Carriage Hill Health: Care Quality Deficiencies - VA
The resident arrived with an open wound on the sacrum that staff documented only as "open wound" without any detailed assessment. A physician ordered treatment on May 2: cleanse the wound with normal saline, pat dry, and apply foam dressing.
The order never reached the nurses.
"The nurse who entered the 5/2/25 physician's order for R2's treatment into the computer system did not click a schedule for the order so the order did not carry over to the TAR," Director of Nursing ASM #2 told inspectors on November 19.
Without the treatment appearing on the Treatment Administration Record, nurses had no way of knowing the resident needed wound care. The resident received no treatment on May 3, 4, or 5.
During those three days, nurses completing daily skilled assessments repeatedly answered "No" to the question: "Does the resident have impaired skin and/or a wound that is being monitored or treated?"
The wound was actually a stage 3 pressure injury.
By May 5, when staff finally conducted a proper body audit, they discovered the sacral pressure wound measured 3.9 centimeters in length by 2.2 centimeters in width. Stage 3 pressure injuries involve full-thickness skin loss where fat tissue becomes visible, often accompanied by granulation tissue and rolled wound edges.
Licensed Practical Nurse #1 explained to inspectors that pressure injuries should be assessed the same day a resident is admitted. The assessment should include measurements and descriptions of color, smell, and drainage.
"Dressing treatments that need to be done are communicated to nurses via the TAR and nurses evidence treatments are done by signing them off on the TAR," Licensed Practical Nurse #2 told inspectors.
The facility's own wound treatment policy requires comprehensive documentation including wound type and location, stage classification, precise measurements of height, width, depth, and any undermining or tunneling. Staff must also document wound bed color, tissue type, surrounding skin condition, drainage characteristics, odor presence, and pain levels.
None of this detailed assessment occurred when the resident was admitted with the open sacral wound.
The inspection revealed a cascade of failures: inadequate initial assessment, improper computer entry of physician orders, and three days of missed treatments while nurses incorrectly documented that no wounds required monitoring or treatment.
Pressure injuries develop when sustained pressure reduces blood flow to tissue, typically over bony prominences like the sacrum. Stage 3 injuries represent serious tissue damage that requires prompt, consistent treatment to prevent infection and further deterioration.
The resident's wound went from basic documentation as an "open wound" to a measured stage 3 pressure injury spanning nearly four centimeters during the period when no treatment was provided.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm. The Administrator and Director of Nursing were notified of the findings on November 19 during the inspection's exit conference.
The case illustrates how technology failures in nursing homes can directly impact resident care. When physician orders don't properly transfer to nursing staff through electronic systems, residents suffer the consequences of missed treatments and inadequate monitoring.
For this resident, three days without wound care meant three days of potential infection risk, increased pain, and delayed healing of an already serious pressure injury that had penetrated through all layers of skin.
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: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Last verified: November 3, 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 with an open wound on the sacrum that staff documented only as "open wound" without any detailed assessment.
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.