Villa Maria Nursing: Wound Care Failures Exposed Tendon - CT

Nobody had told her anything was wrong.

What the nursing assistant found on February 28, 2026, was the end of a chain that had started at least four days earlier. At least five nurses had removed that brace, looked at the skin underneath, and decided not to tell anyone what they saw.

LPN #1 performed a skin assessment on February 24 and found bruising running from the resident's right mid-calf to her ankle. She did not notify the physician. She performed another skin check two days later, on February 26, during the morning shift. The bruising was still there. The skin had gone soft. She still did not call the physician or a supervisor, because, she told inspectors on April 6, the area was not open.

That reasoning, applied across multiple nurses over multiple days, is how a bruise becomes an exposed tendon.

LPN #3 documented on February 25 and 26 that the right leg skin was "clean, dry and intact with baseline discoloration." LPN #4 removed the brace on February 27 during the morning shift, saw no open area, and applied skin prep to the heels and toes. LPN #5, working the evening shift that same day, removed the brace, saw bruised skin, and decided the bruising was an existing impairment. He did not report it to a supervisor.

The contracted wound physician, MD #1, told inspectors on March 30 that if anyone had called him about soft skin, redness, or bruising before the skin broke open, he would have recommended padding between the brace and the skin as a barrier. The resident's age and weight meant skin breakdown could happen fast, he said. A device-associated pressure injury, in his words.

What he did not know until inspectors told him was that there was already an order for padding from the orthopedic physician, written when the resident was discharged from the hospital. The facility had not followed it. He said the facility should have.

The Director of Nursing confirmed to inspectors that the standard process for skin checks involving a medical brace was to remove the brace, look at the skin, and report any changes, including discoloration, to the physician. That process, by the accounts of the nurses themselves, was not followed.

LPN #2, LPN #3, and LPN #4 all provided written statements but did not speak to inspectors directly. The report notes that multiple attempts were made to interview each of them and none was obtained.

The facility's corrective action plan, dated February 28, the same day the wound was discovered, called for staff education on skin assessments and change-in-condition reporting, a facility-wide audit of residents wearing braces, and weekly audits going forward to confirm braces were being removed, skin was being inspected, and any changes were being documented and reported. The compliance date listed was March 5.

State inspectors accepted the corrective action plan during their on-site visit on March 30.

The inspection classified the violation as causing actual harm to a small number of residents. That classification, in the language of federal inspection reports, means the harm was not theoretical.

The nursing assistant who found the wound had never cared for this resident before. She noticed the odor. She felt the moisture. She took off the brace. What she found there had been building for days, visible to anyone who looked, unreported by everyone who did.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Villa Maria Nursing and Rehabilitation Community from 2026-03-30 including all violations, facility responses, and corrective action plans.

Additional Resources

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