Coryell Health Rehab: Tennis Shoes Worsened Wound - TX
Resident #1 developed a fluid-filled blister on her left heel sometime in April 2025 at Coryell Health Rehabliving at the Meadows. The wound progressed to a deep tissue injury requiring specialized dressing changes three times a week with lidocaine spray to control pain.
The resident's family discovered the tennis shoes on her feet during a visit and immediately questioned staff. A licensed vocational nurse confirmed the resident wasn't supposed to wear the shoes. The certified nursing assistant on duty said she didn't know about the restriction.
"The family was visiting and saw the shoes on the resident," the Assistant Director of Nursing told state inspectors during a September complaint investigation.
The wound care nurse said putting tennis shoes on a foot with a pressure area "would cause discomfort." She explained there should have been an order for the resident to wear only socks or open-back house shoes to prevent further damage.
Three days earlier, the Assistant Director of Nursing had discussed the tight-fitting shoes with the family as a possible cause of the heel blister. The family agreed to switch to house shoes, and the nursing supervisor said she communicated the change to staff.
But an agency worker ignored those instructions. The family took the tennis shoes home after finding them on their relative's feet.
The resident died in July 2025, three months after the heel wound first appeared.
Federal inspectors found the facility failed to provide adequate staff training about the resident's specific care needs. Despite discussions in care plan meetings about avoiding tennis shoes, no formal in-service training occurred for nursing assistants in May, June, or July.
"I believe there was a missed communication with the CNAs, the charge nurse was supposed to notify the CNA," the Director of Nursing admitted to inspectors. "I will have to check with the ADON to find out if there was an in-service with the staff not to put the tennis shoes on Resident #1."
The facility had ordered special heel boots to offload pressure from the wound site and was repositioning the resident every two hours. Staff were following physician orders for wound care that included cleaning with Vashe solution, applying betadine, and covering with specialized dressings.
But the communication breakdown meant the most basic protection failed. The wound care nurse acknowledged that either she or the Assistant Director of Nursing should have entered a formal order specifying appropriate footwear.
The physician's wound care orders were explicit: "USE HEEL BOOT AT ALL TIMES TO OFFLOAD PRESSURE." The directive came after the tennis shoe incident, when the pressure area had already developed into a painful wound requiring lidocaine spray before each dressing change.
Inspectors requested the facility's skin and wound care policy during their September visit. Administrators never provided it.
The family's vigilance caught the violation during their visit, but the damage was already done. The Assistant Director of Nursing confirmed this was the only time shoes were placed on the resident after the heel wound developed, but acknowledged the harm it caused.
"Once it was agreed upon not to put the shoes on Resident #1, the staff shouldn't have put the shoe on the resident," the Director of Nursing told inspectors.
The case illustrates how basic communication failures can worsen preventable injuries in nursing homes. The resident's heel wound progressed from a simple blister to a deep tissue injury requiring three-times-weekly professional wound care and pain medication.
Agency staffing complicated the situation. The worker who put on the tennis shoes wasn't a regular employee familiar with the resident's specific care plan restrictions. The facility's failure to conduct formal training meant temporary staff had no way to learn about individual resident needs.
The wound care nurse heard about the tennis shoe incident "in conversation" rather than through official channels. The Director of Nursing wasn't certain whether any in-service training had occurred. The Assistant Director of Nursing relied on informal communication that clearly failed to reach frontline workers.
State inspectors classified the violation as causing minimal harm to few residents. But for the family watching their relative's condition deteriorate, the preventable discomfort represented a fundamental failure of care coordination.
The resident's family had already identified the tight shoes as problematic and agreed to the footwear change. Staff had the information needed to prevent further injury. The facility had specialized equipment and wound care protocols in place.
None of it mattered when a single worker, uninformed about the care plan, put tennis shoes on a wounded heel.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Coryell Health Rehabliving At the Meadows from 2025-09-09 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
CORYELL HEALTH REHABLIVING AT THE MEADOWS in GATESVILLE, TX was cited for violations during a health inspection on September 9, 2025.
Resident #1 developed a fluid-filled blister on her left heel sometime in April 2025 at Coryell Health Rehabliving at the Meadows.
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.