Hospital staff discovered the maggots on September 27 when the confused resident arrived at the emergency department. The facility's own wound care nurse later confirmed to inspectors that nursing staff should have been assessing the area but had no evidence anyone monitored the right heel wound from the time of admission until a wound physician finally examined it on September 15.
The resident had arrived at Divine Rehabilitation with multiple wounds. Staff were supposed to apply skin prep daily to the right heel because the area was soft, according to wound care nurse LPN #303. But the facility couldn't prove the treatment happened on August 14, August 15, August 20, September 1, September 4, and September 10.
Nobody documented assessing the wound on September 11, even though that's when everything went wrong.
A nurse aide tried to remove the resident's sock that day and watched the skin peel away with the fabric. LPN #303 removed the sock completely, exposing a large open area on the right heel. She called the wound physician and received new orders, but the facility had no evidence the ordered treatment actually started until September 13 — two days later.
"Most likely what happened was the skin prep did not completely dry and the sock stuck to the heel, removing a layer each time his socks were removed," Wound Physician #400 told inspectors. The doctor explained that staff should have allowed the skin prep to completely air dry before putting socks back on the resident.
The physician said the resident likely had a deep tissue injury on the right heel before it opened into a wound. Necrosis can set in within hours if not properly treated, the doctor warned.
Weekly skin checks were supposed to happen on the resident's shower days, set up by unit managers. The resident never received orders for these weekly checks, LPN #303 confirmed. The facility had no evidence any skin checks occurred between August 22 and September 24.
Even when skin checks did happen on August 8, August 15, August 22, and September 24, nursing staff failed to identify or assess the heel wound.
Pressure-relieving boots were supposed to protect the resident's heels, but the facility couldn't document they were in place on multiple occasions: the night of August 6, during the day on August 14 and August 15, the night of August 16, and during the day on August 20.
The wound physician saw the resident on September 22 and debrided the heel wound, though this wasn't documented in wound care notes. The doctor told inspectors the resident may have had slough — a buildup of dead tissue — on the right heel when first admitted to the facility. The physician couldn't recall any assessment, monitoring, or treatments other than skin prep and pressure-relieving boots.
Five days later, emergency room staff found the maggots.
The facility's administrator confirmed that weekly skin checks should have been completed for the resident. The documented skin checks that did occur made no mention of any skin issues on the right heel.
Divine Rehabilitation's own wound treatment policy, dated 2024, required staff to monitor treatment effectiveness through ongoing wound assessment. The policy specifically called for modifications when wounds showed "lack of progression towards healing" and "changes in the characteristics of the wound."
The inspection arose from two separate complaints filed against the facility. Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents.
The wound physician's assessment proved prescient. What started as preventable skin breakdown from improperly dried skin prep and stuck socks deteriorated into an infected wound severe enough to attract maggots — a sign of advanced tissue death that typically occurs when wounds remain untreated and unmonitored.
Hospital staff noted the resident seemed confused during the emergency department visit, adding another layer of vulnerability to someone who depended entirely on nursing staff to notice, assess, and treat a wound that was literally consuming itself.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Divine Rehabilitation and Nursing At Toledo from 2025-10-27 including all violations, facility responses, and corrective action plans.
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