The wound went undetected at Douglas Cove Health and Rehabilitation until an outside provider discovered it during a routine visit and alerted facility staff. By then, Resident 104 required antibiotic treatment for a skin infection.
Director of Nursing B acknowledged the facility's failure during a September 5 interview with state inspectors. She said the nursing home received updated wound orders on September 3 from a community day center provider, who reported discovering "a wound that the facility did not have in their records."
The resident had a diabetic ulcer on the bottom of his left foot that "had not been assessed, monitored or had wound care treatments on record," the director said. She confirmed the facility is responsible for the resident's care and should ensure weekly wound assessments and skin observations are completed.
Federal inspectors found no wound assessments for the left foot in the resident's records. A weekly skin review dated September 1 asked whether any new skin issues were identified. Staff marked "No" and left the sites section blank. The progress note stated "no new skin impairments observed."
Yet community day center records told a different story.
Visit notes from August 18 documented multiple concerning findings during the resident's day program visit. Staff observed a pressure injury on his left ankle with an intact dressing, but also found a "diabetic ulcer with thick scab" on the bottom of his left foot. The area around the wound felt warm to the touch and appeared pink.
The day center's registered nurse noted the resident's left fifth toe was also "scabbed and open to air." She checked with the facility's licensed practical nurse to report her concerns about "slight redness to left foot" and emphasized the need to keep a sock on for protection.
The facility's nurse "verbalizes understanding and states they will assess left foot routinely," according to the day center's documentation.
One week later, the day center's August 25 visit notes showed the problems persisting. Staff found a dressing on the resident's left lower extremity dated August 23. When the registered nurse removed all dressings, she again documented the diabetic ulcer on the bottom of his left foot and provided wound care.
Despite these external observations and the facility nurse's stated commitment to routine assessment, Douglas Cove's own records contained no mention of the foot wound. The September 1 skin review occurred just days before the facility learned about the infection, yet staff documented finding no skin problems.
The case highlights a breakdown in the facility's skin monitoring system. Federal regulations require nursing homes to conduct comprehensive skin assessments and document all wounds, particularly for diabetic residents who face elevated risks of foot complications.
Diabetic ulcers on the feet represent serious medical concerns that can lead to severe infections, hospitalization, and in extreme cases, amputation if left untreated. The warm, pink appearance noted by the day center nurse suggested possible early signs of infection.
The resident ultimately required cephalexin, an antibiotic medication, to treat the skin infection that developed while the wound went unmonitored. The director of nursing's admission that the facility "did not have" the wound "in their records" despite outside documentation raises questions about communication protocols between the nursing home and external healthcare providers.
The inspection occurred following a complaint about the facility's care practices. State investigators classified the violation as causing minimal harm or potential for actual harm to few residents, but the case demonstrates how documentation failures can compromise resident safety.
The facility's repeated assertions of "no new skin impairments" while an ulcer deteriorated on a diabetic resident's foot illustrates the gap between required assessments and actual clinical observation. When external providers must alert a nursing home to wounds on their own residents, the fundamental care monitoring system has failed.
By the time Douglas Cove learned about the diabetic ulcer, the resident was already fighting an infection that proper wound care might have prevented.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Douglas Cove Health and Rehabilitation from 2025-09-05 including all violations, facility responses, and corrective action plans.
Additional Resources
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