The resident, identified as #30 in inspection records, told investigators on September 18 that facility staff hadn't placed the Prevalon boots on him "in over one month." The padded boots are designed to keep heels elevated and relieve pressure on wounds.
His physician had ordered the boots to be applied every shift to prevent further skin breakdown. The resident already suffered from an unstageable pressure ulcer on his left heel — meaning the wound involved full-thickness skin and tissue damage so severe that inspectors couldn't determine its depth.
State inspectors observed the 58-bed facility over two days in September following complaints. They found the resident without his ordered boots during five separate observations: at 12:30 p.m. and 3:15 p.m. on September 17, and at 7:45 a.m., 12:11 p.m., and 3:03 p.m. on September 18.
The resident was admitted to Buckeye Terrace with acute kidney failure, muscle weakness, bladder dysfunction, and paraplegia. His care plan from July 14 specifically addressed his "multiple pressure ulcers due to immobility as a result of his paraplegia."
According to facility records, interventions were supposed to include helping him turn and reposition regularly, plus weekly monitoring and treatment of his skin breakdown areas.
Unit Manager #105 confirmed to inspectors on September 18 that the resident wasn't wearing the Prevalon boots as ordered by his physician.
The resident's cognitive abilities remained intact, with assessment scores showing he understood his situation and required assistance with self-care. His quarterly evaluation revealed he scored 13 on the Brief Interview for Mental Status, indicating normal cognitive function.
Pressure ulcers represent one of the most preventable yet serious complications in nursing home care. For immobilized residents like those with paraplegia, consistent use of pressure-relief devices becomes critical to prevent existing wounds from deepening and new ones from forming.
The inspection findings emerged from two separate complaints filed against the facility, numbered OH00167373 and OH00166868. State investigators determined the facility failed to ensure pressure relief interventions were administered as ordered.
Buckeye Terrace's violation affected one of three residents reviewed for pressure ulcer care during the September inspection. The facility received a citation for failing to provide appropriate pressure ulcer care and prevent new ulcers from developing.
The resident's case illustrates how seemingly simple oversights can compound serious medical conditions. Without the protective boots, his unstageable heel ulcer remained vulnerable to additional pressure and friction that could worsen the existing tissue damage.
For a resident already dealing with paraplegia and multiple health complications including kidney failure, the absence of basic pressure relief measures represented a fundamental breakdown in prescribed care protocols.
The facility's care plan acknowledged the direct connection between the resident's immobility and his pressure ulcers, yet staff failed to implement the specific medical equipment ordered to address this known risk.
State inspectors classified the violation as causing minimal harm or potential for actual harm. However, for the resident living with the untreated pressure ulcer, the month without protective boots meant continued exposure to the very conditions his doctor had tried to prevent.
The inspection report provides no indication of why staff consistently failed to apply the boots or whether the facility has since corrected the deficiency. The resident remains at Buckeye Terrace, where his heel ulcer continues healing without the protection his physician determined necessary for proper wound care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Buckeye Terrace Rehabilitation and Nursing Center from 2025-09-22 including all violations, facility responses, and corrective action plans.
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