Belmont Health & Rehabilitation: Wound Care Failure - IN
The wound was identified on February 11, 2025. It wasn't entered into the clinical record until February 14. By then, it was already Stage 3.
Shower sheets from February 3, February 6, and February 10 showed no wounds noted for this resident. The Event Reports written around the time of identification contained no assessment of the right ankle at all. The electronic medication and treatment records showed no documentation that the ankle wound treatment ordered by a physician on February 12 had been completed before February 14.
The physician had already ordered weekly skin inspections every Friday since June 2024, with instructions to open a new skin impairment event whenever something new appeared. Nobody did.
The facility's own wound nurse, interviewed on September 29, 2025, said the ankle wound should have been caught before it reached Stage 3. She described the system that was supposed to prevent exactly this: CNAs check skin daily, document impairments on shower sheets, and notify the nurse. Nurses assess weekly, measure new wounds, document them in wound management and a progress note, and alert the wound nurse. LPN 9, interviewed the same morning, described the same process in nearly identical terms.
The process existed. The wound did not appear in any record until it had already become a serious injury.
A Stage 3 pressure ulcer involves full-thickness skin loss. Tissue damage extends through the outer layers of skin into the fat beneath. It is not a wound that develops overnight and goes unnoticed by chance. It is the result of pressure building over time without relief or intervention.
The facility's skin management policy, revised in 2025 and provided by the Regional Director of Operations on September 30, requires daily observation of residents who receive bathing assistance and immediate reporting of any open areas to a licensed nurse.
The resident's ankle wound was measured at 1.5 centimeters by 2 centimeters when it finally entered the record on February 14. What it measured before that, nobody wrote down.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Belmont Health & Rehabilitation, The from 2025-09-30 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
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.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 23, 2026 · Our methodology
BELMONT HEALTH & REHABILITATION, THE in COLUMBUS, IN was cited for violations during a health inspection on September 30, 2025.
The wound was identified on February 11, 2025.
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.