A Highlands care home was reported to the Care Commission by a specialist nurse concerned over their treatment of patients' bed sores.
Vascular nurse Delia Law expressed concerns over practices at Wyvis House Care Home when she examined patient Jamesina MacKenzie in May 2009.
The 87-year-old patient later died from an infection she got as a result of the sores, one of which had decayed the flesh through to the hip-bone.
Ms Law visited the patient two weeks later and discovered her sores had "deteriorated tremendously", a fatal accident inquiry heard at Dingwall Sheriff Court on Thursday.
She told the nursing staff that she was reporting the home to the Care Commission about the treatment of the pressure sores.
The Care Commission later ruled that the standard of care at the home was "unacceptable".
The inquiry heard that Miss MacKenzie's notes were not updated regularly by nursing staff and a wound chart to monitor her ulcers was not introduced until weeks after the problem was first noticed.
When asked why the chart was not started sooner, general nurse Lani Velasco said she could not remember.
The inquiry is expected to end on Friday.