Ohio Living Swan Creek: Heel Pressure Ulcer - OH
Ohio Living Swan Creek managers confirmed the pressure sore was facility-acquired when it was discovered on June 14, according to federal inspection records from a complaint investigation completed in August.
The breakdown began May 19 when an MDS nurse created a care plan to offload Resident 31's heels — a standard prevention measure to keep pressure off vulnerable areas. But no physician order accompanied the plan.
Nine days later, on May 28, staff switched the resident from a Hoyer lift to a different mobility device called a Steady lift. Only then did managers request a physician's order for heel offloading, according to Unit Manager 113's interview with inspectors.
The resident developed the pressure ulcer 17 days later.
Administrator interviews revealed the gap between planning and action. The facility's MDS nurse, described as "relatively new to her role," had placed the preventative care plan without securing the required physician order that would have activated the protection measures.
"When a preventative care plan is put in place, there needs to be a physician order that is written so that the preventative measures are enacted by the treatment team," the administrator told inspectors during a September 4 interview.
The administrator confirmed there was no documented evidence of heel offloading from May 19 through June 14 — the entire period when the care plan existed but couldn't be implemented without the physician's order.
Manager 113 initially told inspectors there was no need for heel offloading on admission. But the administrator's verification painted a different picture: the facility had identified the need for prevention measures but failed to follow through with proper authorization.
The timing proved critical. The resident's equipment change from the Hoyer lift to the Steady lift on May 28 coincided with finally obtaining the physician's order for heel protection. But by then, nearly three weeks had passed since the original care plan identified the risk.
Quality Departmental Management Coordinator 203 joined the unit manager in confirming the pressure ulcer was facility-acquired during the inspection process.
Federal inspectors cited the facility for failing to prevent the development of pressure ulcers, noting the violation affected few residents but represented minimal harm or potential for actual harm.
The facility's own policy, updated July 25, defines pressure ulcers as localized injuries to skin and underlying tissue, usually over bony prominences, caused by pressure combined with shear or friction. The policy specifically identifies suspected deep tissue injuries as purple or maroon discolored areas that may be preceded by tissue that feels painful, firm, boggy, or temperature-different compared to surrounding skin.
The inspection occurred as part of complaint number 2566353, suggesting someone reported concerns about the facility's pressure ulcer prevention practices.
The case illustrates a common breakdown in nursing home care: identifying risks through assessment and care planning, but failing to bridge the gap to actual implementation of protective measures. The resident's heel remained vulnerable for nearly a month while paperwork requirements prevented staff from acting on their own prevention plan.
The administrator's acknowledgment that the facility has since educated the MDS nurse about proper procedures suggests recognition that the system failure was preventable. But for Resident 31, that education came too late.
The pressure ulcer developed exactly where the original care plan had identified vulnerability, during the exact timeframe when protection measures existed on paper but not in practice.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ohio Living Swan Creek from 2025-08-27 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
OHIO LIVING SWAN CREEK in TOLEDO, OH was cited for violations during a health inspection on August 27, 2025.
But no physician order accompanied the plan.
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.