Carriage Hill Health: Pressure Ulcer Care Failures - VA
The resident arrived at the facility with an open wound on the sacrum. A nursing admission assessment documented the wound's presence but provided no measurements, description of tissue condition, or staging information.
A physician ordered treatment on May 2: cleanse the sacral wound with normal saline, pat dry, and apply foam dressing. But the order never reached nursing staff.
The Director of Nursing explained what went wrong during a November inspection interview. The nurse who entered the doctor's order into the computer system "did not click a schedule for the order so the order did not carry over to the TAR."
TAR stands for treatment administration record — the system nurses use to track which treatments need to be completed each day. Without the order appearing on the TAR, nursing staff had no way to know the wound required daily care.
For three days — May 3, 4, and 5 — no treatment was provided. Daily skilled assessments during this period asked whether the resident had impaired skin or a wound being monitored or treated. Each day, staff answered "No."
The wound remained hidden from proper assessment until May 5, when a body audit revealed the extent of the injury. Staff documented a stage 3 pressure injury measuring 3.9 centimeters in length by 2.2 centimeters in width.
Stage 3 pressure injuries involve full-thickness skin loss with visible fat tissue. According to medical definitions, granulation tissue and rolled wound edges are often present, and dead tissue may be visible.
Licensed Practical Nurse #1 explained proper admission procedures during the inspection. Pressure injuries should be assessed the same day a resident arrives, she said. The assessment should include measurements and descriptions of color, smell, and drainage.
The facility's own wound treatment policy requires comprehensive documentation. Complete assessments must include wound type and location, staging information, precise measurements of height, width, and depth, plus detailed descriptions of wound bed color, tissue types, surrounding skin condition, drainage characteristics, odor presence, and pain levels.
None of these elements were documented in the resident's admission assessment.
Licensed Practical Nurse #2 confirmed how the treatment system normally works. Dressing treatments are communicated to nurses through the TAR, and nurses document completion by signing off on the treatments.
But this system failed when the original order entry lacked proper scheduling. The computer glitch created a gap between physician orders and nursing care that lasted three days.
The inspection found no evidence that anyone noticed the missing treatments during the 72-hour period. Daily assessments continued to indicate no wound monitoring was occurring, even though facility staff knew an open sacral wound existed.
Pressure injuries develop when sustained pressure restricts blood flow to skin and underlying tissue, typically over bony prominences like the sacrum. Stage 3 injuries represent significant tissue damage that requires consistent medical attention to prevent infection and promote healing.
The facility's policy emphasizes proper wound assessment and treatment documentation, but the computer system failure exposed how easily physician orders can disappear from nursing workflows. When the scheduling step was missed during order entry, the treatment essentially vanished from the care plan.
Federal inspectors documented the violation under regulations requiring facilities to provide appropriate pressure ulcer care and prevent new ulcers from developing. The finding was classified as minimal harm or potential for actual harm.
The Administrator and Director of Nursing were notified of the violation on November 19 during the inspection exit conference.
The case illustrates how technology failures in nursing homes can interrupt basic medical care. A simple missed click during computer entry left a resident with an untreated stage 3 pressure injury for three days, despite a doctor's clear orders for daily wound care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Carriage Hill Health & Rehab Center from 2025-11-19 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 20, 2026 · Our methodology
CARRIAGE HILL HEALTH & REHAB CENTER in FREDERICKSBURG, VA was cited for violations during a health inspection on November 19, 2025.
The resident arrived at the facility with an open wound on the sacrum.
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.