Resident #16, who has no feeling in her legs due to polyneuropathy, was receiving a bed bath on December 21 when nurses found a wound measuring 2.9 by 2 by 0.2 centimeters on the ball of her left foot. The facility contacted a triage service, which instructed staff to keep a pillow under the resident's foot and contact her primary care provider on Monday.
But the next day, inspectors observed Resident #16 sitting in her wheelchair at 2:00 PM without any pillow under her foot. When interviewed nearly an hour later, the resident confirmed that staff had not started any new interventions to relieve pressure on her left foot.
The resident, who has been at the facility since July and is cognitively intact, told the interdisciplinary team she believes her wheelchair's left footrest caused the wound. "Resident #16 has no feeling in her legs and couldn't tell it was rubbing while up in wheelchair," staff noted on December 22. The team decided therapy would evaluate her wheelchair and adjust the left footrest.
By December 23, the wound had grown to 3 by 3 by 0.1 centimeters and was classified as unstageable during a formal wound evaluation.
The facility's response revealed confusion about the wound's cause and a lack of systematic evaluation. Licensed Practical Nurse #446 told inspectors on December 23 that she believed bolsters on the resident's bed caused the pressure ulcer "due to how the resident prefers to be positioned."
Director of Nursing #423 acknowledged the facility had not evaluated the resident after discovering the pressure ulcer. The nursing director said she wasn't sure whether bed bolsters or wheelchair foot pedals caused the injury, and confirmed that therapy had not yet evaluated the resident despite the team's December 22 plan.
"DON #423 verified that Resident #16 has not been evaluated by therapy and there have not been any new interventions added," inspectors wrote.
The resident was already identified as high-risk for pressure ulcers, with a care plan that included weekly skin checks, floating heels, turning and repositioning, a pressure-reducing mattress, and a wheelchair cushion. But these existing interventions proved insufficient to prevent the new wound.
Federal inspectors found the facility violated requirements for appropriate pressure ulcer care and prevention. The facility's own policy, last revised in March 2014, requires nursing staff and the attending physician to assess and document a resident's significant risk factors for developing pressure sores.
Pressure ulcers are a serious concern for residents with limited mobility and sensation. Resident #16's quadriplegia and polyneuropathy made her particularly vulnerable, as she cannot feel pain or pressure that would normally signal the need to shift position or adjust equipment.
The inspection occurred after a complaint and found the facility failed one of three residents reviewed for pressure wound care. Beavercreek Health and Rehab has a census of 62 residents.
The case illustrates how quickly pressure wounds can worsen without prompt intervention. In just two days, the resident's wound grew from 2.9 centimeters to 3 centimeters in length, despite staff awareness of the problem.
Resident #16 remains dependent on staff for bathing, dressing, and positioning, making proper equipment fitting and pressure relief protocols essential for preventing additional wounds. The facility must now develop a plan to correct the deficiency to maintain its Medicare and Medicaid participation.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Beavercreek Health and Rehab from 2025-12-30 including all violations, facility responses, and corrective action plans.