Resident #16 discovered the wound herself during a bed bath on December 21. The 2.9 by 2 inch wound on the ball of her left foot had already penetrated deep enough that nurses couldn't determine how far it extended into tissue.
She has no feeling in her legs due to quadriplegia and polyneuropathy. The wound likely developed while she sat in her wheelchair, unaware that something was rubbing against her foot.
"Resident #16 believes her wheelchair's left foot rest caused the wound," inspectors noted after interviewing her December 22. "Resident #16 has no feeling in her legs and couldn't tell it was rubbing while up in wheelchair."
The facility's triage notes from December 21 instructed staff to keep a pillow under her foot to relieve pressure and contact her doctor Monday for evaluation. But when inspectors observed the resident the next day at 2:00 PM, she was in her wheelchair without any pillow under her foot.
The resident confirmed to inspectors that afternoon that "the facility had not started any new interventions to alleviate pressure from her left foot."
By December 23, the wound had grown to 3 by 3 inches and was classified as unstageable, meaning tissue damage extended so deep that the full extent couldn't be determined.
Licensed Practical Nurse #446 told inspectors she believed bed bolsters caused the pressure ulcer "due to how the resident prefers to be positioned." But Director of Nursing #423 wasn't sure whether bolsters or wheelchair foot pedals were responsible.
"DON #423 verified that they were not sure if the bolsters on the bed or the wheelchair foot pedals caused the pressure injury," the inspection report stated.
More troubling, the director of nursing admitted the facility had done nothing to address the problem. "DON #423 verified that Resident #16 has not been evaluated by therapy and there have not been any new interventions added."
The resident's care plan already acknowledged she was at risk for pressure ulcers. Existing interventions included weekly skin checks, floating heels, turning and repositioning, a pressure-reducing mattress, and a wheelchair cushion.
None of that prevented the wound from developing.
The facility's interdisciplinary team notes from December 22 indicated therapy would evaluate the resident's wheelchair and adjust the left footrest "to not rub against her foot." But three days after the wound was discovered, that evaluation still hadn't happened.
The resident had been admitted to Beavercreek Health and Rehab in July. Her quarterly assessment showed she was cognitively intact but completely dependent on staff for bathing, dressing, and positioning.
Federal regulations require nursing homes to provide appropriate pressure ulcer care and prevent new ulcers from developing. The facility's own policy, last revised in March 2014, requires nursing staff and physicians to assess and document risk factors for pressure sores.
But when a resident who couldn't feel her own feet developed a serious wound, staff failed to follow through on basic interventions like keeping pressure off the affected area.
The wound grew larger over two days while different staff members offered conflicting theories about its cause. Meanwhile, the resident remained at risk for further tissue damage from the same source that created the original injury.
Resident #16 was one of three residents inspectors reviewed for pressure wounds during the December 30 complaint investigation at the 62-bed facility.
The inspection classified the violation as causing minimal harm or potential for actual harm to residents. But for a quadriplegic resident who relies entirely on staff to protect her from injuries she cannot feel, the failure to implement immediate protective measures left her vulnerable to complications that could prove far more serious.
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.