Resident 128's family discovered the undocumented wound only when they took their loved one to the emergency room on July 21. By then, the right plantar diabetic ulcer measured 1.5 centimeters wide and nearly a centimeter deep, according to hospital records reviewed by inspectors.
The family told inspectors the wound "was so deep the bone was almost visible" when emergency room staff finally examined it that day. They said they had grown concerned because the resident had become increasingly confused over several days, and they weren't sure if nursing home staff were performing wound care as prescribed.
Emergency room physicians immediately started the resident on three medications to fight what they determined was a grossly infected wound. IV vancomycin, IV cefepime, and flagyl were all needed to combat the worsening infection, hospital notes show.
The wound required immediate surgical debridement. What started as a 1.5-by-1.5-centimeter opening became a 4.5-by-1.6-centimeter cavity after surgeons removed infected tissue at the bedside, according to the podiatric surgery consultation from July 21.
Five days later, vascular surgeons delivered devastating news. The non-healing right foot wound would require either a below-the-knee or above-the-knee amputation.
On July 29, surgeons amputated Resident 128's right leg below the knee.
The resident never recovered. After a brief return to Ranchwood, they were readmitted to the hospital and then transferred to a hospice house, where they died on August 6 — just 16 days after the wound was first discovered.
The family told inspectors their loved one had been sent back to the nursing home for less than a week before requiring hospital readmission that led to the amputation.
When inspectors arrived at Ranchwood in September to investigate the family's complaint, they found a facility that had failed to follow its own wound monitoring procedures. The Director of Nursing admitted that the resident's foot wound was not documented before the July 7 emergency room visit.
More troubling, the resident's last skin assessment had been completed on June 24 — more than two weeks before the family discovered the infected wound. Charge nurses were supposed to conduct weekly skin assessments on all residents, the Director of Nursing told inspectors, but acknowledged they were "working on a process to ensure skin assessments were conducted every week."
The Director of Nursing reported that an employee had been terminated over issues with skin assessments not being completed accurately. The family said they had called the nursing home and were told an investigation had been conducted and changes had been made, with staff being terminated.
Yet when inspectors asked the regional director about incident reports related to Resident 128, they were told there were no reports other than a fall that did not require state notification.
The case represents an immediate jeopardy violation — the most serious finding federal inspectors can make, reserved for situations where residents face immediate threat of serious injury, harm, impairment, or death.
For diabetic residents like 128, foot wounds require constant monitoring because poor circulation and nerve damage can prevent healing and mask serious infections. What might appear as a minor sore can quickly become life-threatening without proper care and documentation.
The inspection found that Ranchwood's failure to conduct required weekly skin assessments left a vulnerable diabetic resident's deteriorating condition undetected for weeks. By the time the family intervened, the infection had progressed beyond what antibiotics and surgery could address.
Resident 128's death occurred just eight days after the amputation, suggesting the infection had spread throughout their body despite aggressive hospital treatment with multiple antibiotics and surgical intervention.
The family's account reveals the human cost of missed assessments and inadequate wound monitoring. They watched their loved one endure increasing confusion, emergency hospitalization, multiple surgeries, amputation, and ultimately death — all from a wound that nursing home staff never documented or reported.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ranchwood Nursing Center from 2025-09-17 including all violations, facility responses, and corrective action plans.