Glenburnie Rehab: Wound Care Orders Ignored for Resident - VA
The specialist, identified in inspection records as ASM #3, had recommended Manuka honey dressing for a resident referred to as R3, who had an abrasion in the gluteal fold. The specialist noted the abrasion could develop into a pressure injury. The treatment was never ordered. It was never entered into the resident's care plan. There was no evidence it was ever implemented at all.
That finding emerged from a complaint inspection completed October 29, 2025.
What inspectors uncovered when they started asking questions was not a single point of failure. It was a facility where the physician, the nurse practitioner, the wound nurse, and the unit manager had each drawn their own boundaries around what they considered their responsibility, and the resident's wound treatment had fallen into the space between them.
The attending nurse practitioner told inspectors she does not review the wound specialist's recommendations. Her explanation: ASM #3 is the wound expert, and facility staff should follow those recommendations at all times. The attending physician said the same thing from the opposite direction. He told inspectors he does not review the wound practitioner's recommendations either, describing wound treatments as entirely at ASM #3's discretion.
Both the doctor and the nurse practitioner, in other words, believed someone else was responsible for making sure the wound specialist's orders were carried out. Neither had taken any steps to verify that they were.
The regional director of clinical operations, ASM #4, told inspectors she saw no evidence the Manuka treatment had ever been implemented for R3. She confirmed the gluteal fold injury did not appear anywhere in the resident's care plan. She raised the possibility that the attending physician had reviewed ASM #3's recommendations and decided against implementing them, but the inspection record contains no documentation to support that explanation, and the physician himself told inspectors he does not review those recommendations.
The unit manager, LPN #1, described the process that was supposed to move a wound specialist's recommendations from a progress note into an actual treatment order. After ASM #3 evaluates a resident, she enters her findings directly into the facility's electronic medical record. The wound nurse, LPN #2, is then responsible for translating those notes into the resident's order set and updating the care plan. LPN #1 said it was her job to follow up and confirm that orders and interventions had been entered and implemented correctly.
She then said something that cuts to the center of what inspectors found. Sometimes, she told them, ASM #3's recommendations get lost in translation because not everyone is clear about their role in this process.
That is a significant admission. The unit manager responsible for following up on wound care orders acknowledged that the system for carrying out those orders was unclear enough that recommendations routinely disappeared before reaching the patient.
For R3, that is exactly what happened. A wound specialist identified an injury, recommended a specific treatment designed to reduce wound bed pH, promote healing, and prevent the abrasion from deepening into a pressure injury, and the recommendation sat in an electronic record while the resident's care plan reflected none of it.
Manuka honey dressings of the type recommended are designed for daily changes, with the honey releasing into the wound bed while the dressing absorbs drainage and dead tissue. The specialist had determined this was the appropriate intervention. Nobody ordered it.
The administrator and the director of nursing were notified of the findings at 12:20 p.m. on the day of the inspection. No additional information was provided before inspectors left the building.
R3's abrasion, the one the wound specialist said had the potential to become a pressure injury, remained undocumented in the care plan as of the date of the inspection.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Glenburnie Rehab & Nursing Center from 2025-10-29 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 23, 2026 · Our methodology
GLENBURNIE REHAB & NURSING CENTER in RICHMOND, VA was cited for violations during a health inspection on October 29, 2025.
The specialist noted the abrasion could develop into a pressure injury.
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.