The resident reported that another resident had backed over their toe in a wheelchair on September 14 or 15. Despite the resident asking nurses each day about getting an X-ray, staff waited until September 18 to contact a physician, who immediately ordered the imaging and started antibiotics.
But even after the doctor's order, the facility failed to arrange the X-ray promptly. The resident continued asking about treatment daily while their condition worsened.
By September 22, when inspectors arrived, the resident's right fourth toe showed extensive damage. A registered nurse removing the dressing described "macerated toe, with the toenail coming loose at the base, and an open necrotic area to the underside of the toe, approximately 1.0 centimeter in size."
The nurse admitted the resident had asked earlier that day for a dressing change, "but the nurse did not have time until now."
A certified medication technician who examined the toe on September 18 told inspectors it "looked like a chewed up hot dog." The toe was swollen, with the top appearing white and the underside open.
Over the weekend of September 20-21, an LPN finally sent the resident to the hospital after discovering the toe had "a black area on the underside and the toe was draining yellow and green odorous drainage." Hospital staff confirmed the toe was broken.
The delay violated the facility's own policies. The Senior Director of Regulatory Affairs told inspectors that when physicians order X-rays, "facility staff should contact the mobile X-ray company the same day. The resident should have his/her X-ray the day ordered or the next day, if ordered late in the day."
The Administrator and an LPN both confirmed nurses should obtain physician-ordered X-rays within 24 hours.
But the breakdown extended beyond just delayed imaging. An LPN who had recently returned to work discovered systematic failures in wound care. Over three to four shifts, the nurse found that "nurses were not completing the resident wound assessments and were not consistently completing the resident skin assessments."
When the LPN attempted to identify residents with open wounds and measure them over the weekend, they couldn't find where to document the measurements. No wound assessments had been entered in the resident's electronic health record.
"He/she was unable to determine if resident's wounds were better or worse, due to not being able to find recent wound or skin assessments in the medical records," inspectors noted.
The LPN told inspectors they were "unsure who was responsible for wound assessments in the past, but did not think the facility staff were completing the wound assessments."
This confusion about basic responsibilities appeared widespread. When inspectors asked the charge nurse on September 24 who was responsible for resident skin assessments, the LPN replied they were "unsure."
The Administrator also told inspectors "he was unsure who was responsible for completing weekly skin assessments."
The Senior Director of Regulatory Affairs acknowledged the facility "did not think the facility had completed weekly skin or wound assessments consistently."
The resident's family member, who served as their responsible party, expressed worry about the toe's condition during the week-long delay. The family member watched their loved one speak to nurses each day about needing the X-ray while the infection progressed.
A certified medication technician involved in the case told inspectors they were "unsure why the facility delayed in obtaining an X-ray of the resident's foot." The technician noted the resident "had asked the nurse to do a treatment to his/her toe, but was still waiting on his/her treatment."
The cascade of failures began with a simple wheelchair accident but escalated through delayed medical response, absent wound monitoring, and confused staff responsibilities. What should have been routine imaging and treatment stretched into a week-long ordeal that ended with emergency hospitalization for an infection that had progressed to tissue death.
The resident who asked for help each day while their toe deteriorated now faces the consequences of a broken bone that went untreated while dead tissue spread beneath loose toenails.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cassville Health Care Center from 2025-09-24 including all violations, facility responses, and corrective action plans.