The resident developed the sacral pressure ulcer while at the facility in late August. After a hospital stay from September 11 to September 12, nursing staff failed to resume wound care from September 12 through September 24.
Treatment gaps continued sporadically through early October. The resident missed additional wound care on September 27, 28, and 29, plus October 2 and October 5.
The pressure ulcer finally healed on October 6, when treatments were discontinued. But facility administrators acknowledged during the inspection that the wound could have been prevented entirely.
LPN (B) told inspectors on October 22 that the pressure ulcer "was not present on admission to this facility and occurred after the Resident was admitted." She maintained tracking documents for all facility wounds that were separate from the resident's official clinical record.
When asked about inconsistent nursing notes, some documenting the wound and others showing no wound at all, LPN (B) called it "an error."
The facility's own policy requires weekly skin assessments for all residents, documented in clinical records. But no skin assessments were recorded for this resident until September 5, when a nurse practitioner wound specialist conducted an evaluation.
Staff completed only two Braden skin assessments during the resident's entire stay. These assessments measure pressure ulcer risk and are typically done on admission. The first wasn't completed until October 14 — scoring 10, indicating high risk. The second came October 22, scoring 12, also high risk.
Both assessments were completed months after admission, well past their intended purpose of preventing wounds.
LPN (B) claimed staff documented skin checks on "weekly skin integrity review sheets." When inspectors asked for wound measurements, she said they were recorded "on the pressure ulcer records" in centimeters. But when pressed to provide all documentation since admission, she could only produce her personal tracking document created with the nurse practitioner.
The document existed outside the resident's official medical record.
During an end-of-day conference on October 22, facility leadership gathered to address the inspection findings. The administrator, director of nursing, corporate registered nurse consultant, and corporate administrator of operations attended.
Inspectors presented evidence of missing skin assessments, inadequate prevention measures, and inconsistent wound monitoring and treatment.
The corporate team acknowledged the failures. Since the pressure ulcer healed once proper treatment resumed, they agreed the wound was avoidable with appropriate care.
Federal regulations require nursing homes to provide necessary care to prevent pressure ulcers in residents at risk and to promote healing for existing wounds. Facilities must also maintain accurate, complete medical records.
The inspection classified the violation as causing minimal harm or potential for actual harm to few residents.
When facility staff were asked if they had additional documentation or explanations, they stated "they had nothing further to provide."
The case illustrates how documentation gaps and treatment interruptions can compromise resident care, even when facilities eventually provide effective treatment. The resident's wound healed once consistent care resumed, but only after weeks of missed opportunities for prevention and treatment.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Regency Health and Rehabilitation Center from 2025-10-22 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Regency Health and Rehabilitation Center
- Browse all VA nursing home inspections