Resident 16 was admitted to the facility on February 27, 2025, from a hospital with diagnoses of severe obesity and type 2 diabetes. The resident had no pressure ulcers at admission.
Eleven days later, on March 10, the resident developed an unstageable pressure ulcer on the sacral area measuring 2.40 centimeters long, 0.80 centimeters wide, and 0.20 centimeters deep. The wound covered 1.92 square centimeters and was 100% slough, according to wound physician notes reviewed by federal inspectors.
The facility's own assessment at admission had rated the resident at mild risk for developing pressure sores. Using the Braden Scale, an evidence-based prediction tool, staff scored the resident 15 out of 23. Scores below 19 indicate some level of risk for developing facility-acquired pressure injuries.
Two weeks after the ulcer appeared, on March 24, the wound had grown worse. A wound assessment report showed the unstageable pressure ulcer now measured 2.60 centimeters long and 1.90 centimeters wide, covering 4.94 square centimeters — more than doubling in size.
Staff never completed a change in condition assessment for the pressure ulcer development, a required evaluation when residents experience significant health changes during their stay.
Director of Nursing confirmed during an October 8 interview that the resident acquired the pressure ulcer while in the facility's care. When asked about family notification, she told inspectors: "I do not see family or resident notification."
The nursing director acknowledged that facility policy requires nurses to complete change in condition assessments and notify residents or their representatives when health conditions deteriorate. Neither step was taken for this resident's pressure ulcer.
Pressure ulcers that develop in nursing facilities indicate failures in preventive care or delayed intervention. These injuries occur from prolonged pressure, friction, shear forces, or other risk factors that proper nursing protocols are designed to prevent.
The resident had been admitted with some existing skin conditions, including incontinence-associated dermatitis on the left buttock, right abdominal fold issues, and a blister on the right thigh. However, the sacral pressure ulcer was a new injury that developed during the facility stay.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm to residents. The inspection was conducted in response to a complaint filed against the facility.
The nursing director acknowledged receipt of inspectors' concerns about the assessment and notification failures on October 8, according to the federal report.
Layhill Nursing and Rehabilitation Center is located at 3227 Bel Pre Road in Silver Spring. The facility was required to submit a plan of correction addressing how it would prevent similar assessment and notification failures in the future.
The inspection found that facility staff had the tools and knowledge to assess pressure ulcer risk properly — they used the evidence-based Braden Scale at admission and correctly identified the resident as having mild risk for developing wounds. Despite this early warning system, preventive measures failed to stop the pressure ulcer from developing and growing significantly larger over two weeks of care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Layhill Nursing and Rehabilitation Center from 2025-10-09 including all violations, facility responses, and corrective action plans.
Additional Resources
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