Belmont Health & Rehab: Wound Care Documentation Failures - IN
Inspectors documented the failure following a complaint investigation completed September 30, 2025.
The wound was identified on February 11, 2025. It measured 1.5 centimeters by 2 centimeters, with a depth of 0.1 centimeters. A Wound Management Report wasn't created until February 14. The facility's own clinical record contained no documentation of the wound's existence before that date.
The resident's shower sheets — the daily records completed by certified nursing aides during bathing — showed no indication of any wound on February 3, February 6, or February 10. The electronic medication and treatment administration records showed no documentation that the ankle treatment had been completed at any point before February 14.
There was a physician order already in place. It had been active since June 2024, directing staff to perform a weekly skin inspection every Friday and to open a new skin impairment event if any new areas were found. A second order, dated February 12, laid out a specific treatment protocol: cleanse the right lateral ankle with normal saline, pat dry, apply skin prep around the wound, apply moistened Prisma dressing to the wound base, cover with gauze, wrap with conforming rolled gauze, and secure with tape. That order was written the day after the wound was identified. The records showed it wasn't followed until two days after that.
The event reports created around the time of the wound's identification lacked any assessment of the right lateral ankle.
A licensed practical nurse interviewed on September 29 described how the system was supposed to work. Nurses assessed residents' skin weekly and documented it in the electronic record. Aides checked skin daily, completed shower sheets, and notified nurses of anything new. Once a new wound was identified, the nurse was supposed to measure it, document it in wound management and in a nurse's note, alert the wound nurse, and get a treatment order.
The wound nurse confirmed the ankle wound was already a Stage 3 when it was first identified on February 11. She said that if a new wound appeared, it should have been documented in a skin event and a progress note. She said the CNAs would document skin impairments on shower sheets and notify the nurse.
Then she said something that cut to the center of the problem: the resident's ankle wound should have been identified before it reached Stage 3.
A Stage 3 pressure ulcer doesn't appear overnight. It represents a progression through earlier stages of skin damage — redness, then partial thickness loss — before breaking through to the full wound depth inspectors found documented on February 14. The facility's own skin management policy, revised in 2025 and provided by the Regional Director of Operations on the last day of the inspection, stated that residents who receive bathing assistance would be observed daily by nursing staff, and that any red areas or open areas would be reported to a licensed nurse for further assessment.
The shower sheets from February 3, February 6, and February 10 recorded nothing. The weekly skin inspection that should have occurred on a Friday in early February left no trace in the record. Whatever was happening to that resident's ankle during those days, it wasn't being written down.
By the time anyone documented it, the skin was already gone.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Belmont Health & Rehabilitation, The from 2025-09-30 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 26, 2026 · Our methodology
BELMONT HEALTH & REHABILITATION, THE in COLUMBUS, IN was cited for violations during a health inspection on September 30, 2025.
Inspectors documented the failure following a complaint investigation completed September 30, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.