The resident, identified as R2 in inspection records, developed the pressure injury by July 19. Staff began treating the wound on his right buttock the next day with dressing changes every other day. But the facility's wound care protocols broke down completely.
V3, the designated wound care nurse, told inspectors on September 30 that she had never assessed R2's wound. "She would have to look at R2's wound to know what type of wound it is," inspectors wrote. "R2's wound was not brought to her attention, and the wound care doctor has not seen it either."
The wound care doctor, V4, confirmed he had never seen R2. "It would be new to him if R2 had a pressure wound," according to inspection records.
This represented a fundamental breakdown in the facility's own wound care system. V3 told inspectors that all skin abnormalities should be reported to her and that she assesses wounds weekly, communicating with the wound care doctor to get treatment orders. She said the wound care doctor "sees all pressure wounds in the facility."
None of that happened for R2.
The Director of Nursing, V2, confirmed the facility's protocols during interviews. When nursing staff identify skin alterations, they should notify the wound care nurse. Pressure wounds should be assessed weekly or more often, with measurements, tissue appearance, undermining, tunneling, odor, and drainage documented. The wound care nurse sees all pressure wounds and involves the doctor as needed.
R2's case revealed how completely these systems failed. His care plan contained no mention of skin alterations or wounds despite the documented Stage 2 pressure injury. No interventions appeared to treat or prevent further wounds. The facility could not provide weekly assessments of his pressure injury.
During the inspection, V6, a registered nurse, performed R2's wound care. She cleaned the right buttock wound with normal saline and gauze, changed gloves, then applied xeroform and foam dressing. The routine dressing changes had continued for months without specialist oversight.
R2's medical conditions increased his vulnerability to pressure injuries. His admission record showed diagnoses including Type 2 diabetes mellitus, hypertension, and anemia. Diabetic patients face heightened risks for wound complications and delayed healing.
Treatment records showed R2 received wound care from July 20 through September 30, a span of more than 10 weeks. Throughout this period, the wound care nurse who was supposed to assess all pressure wounds never examined him.
The facility's own Pressure Injury Prevention and Management Policy, reviewed June 17, required licensed nurses to conduct full body skin assessments after any newly identified pressure injury. The policy mandated that assessments be performed by licensed nurses and documented. After thorough evaluation, the interdisciplinary team should develop relevant care plans with measurable goals for prevention and management.
None of this occurred for R2.
V7, another registered nurse, confirmed that the wound care nurse typically performs weekly wound measurements and treatments. This made the complete absence of specialist care for R2 even more striking.
The inspection found the facility failed to assess and implement prevention interventions for R2, one of three residents reviewed for pressure wounds. Inspectors classified the violation as causing minimal harm or potential for actual harm.
Federal regulators require nursing homes to provide appropriate pressure ulcer care and prevent new ulcers from developing. The standard exists because pressure injuries can worsen rapidly without proper assessment and treatment, potentially leading to serious infections or deeper tissue damage.
R2's case demonstrated how a facility's wound care system can exist on paper while failing completely in practice. The wound care nurse worked in the building. The wound care doctor made rounds. Treatment orders existed and staff followed them. But the resident with a Stage 2 pressure injury remained invisible to the specialists responsible for his care.
The breakdown occurred despite active treatment. Staff changed R2's dressings regularly and followed doctor's orders. But without specialist assessment, the facility could not determine if treatments were effective, if the wound was healing, or if interventions needed adjustment.
R2 continued receiving wound treatments as of the inspection date, still without evaluation by the wound care specialists who were supposed to oversee all pressure injuries in the facility.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Park Place of Belvidere from 2025-11-18 including all violations, facility responses, and corrective action plans.