Resident #16 discovered the injury herself on December 21 during a bed bath. The wound measured 2.9 by 2 by 0.2 centimeters on the ball of her left foot. She has polyneuropathy and no feeling in her legs.
"I believe my wheelchair's left foot rest caused the wound," she told the interdisciplinary team the next day. "I have no feeling in my legs and couldn't tell it was rubbing while up in wheelchair."
But Licensed Practical Nurse #446 disagreed. She believed the bolsters on the resident's bed caused the pressure ulcer because of how the resident prefers to be positioned.
Director of Nursing #423 admitted she wasn't sure which piece of equipment injured the resident. "They were not sure if the bolsters on the bed or the wheelchair foot pedals caused the pressure injury," according to the inspection report.
The resident had been admitted in July with quadriplegia and polyneuropathy. Her care plan already identified her as at risk for pressure ulcers, with interventions including weekly skin checks, floating heels, turning and repositioning, a pressure-reducing mattress, and wheelchair cushion.
None of it prevented the wound.
After discovering the injury, facility staff received instructions to keep a pillow under the resident's foot to relieve pressure and contact her primary care provider on Monday for evaluation. The interdisciplinary team noted that therapy would evaluate the resident in her wheelchair and adjust the left footrest to prevent further rubbing.
But when inspectors observed the resident on December 22 at 2:00 PM, she sat in her wheelchair without a pillow under her foot.
The resident confirmed during an interview that afternoon that staff had not started any new interventions to alleviate pressure from her left foot. This was one day after the wound was discovered and documented.
By December 23, the wound had grown. The wound evaluation measured it at 3 by 3 by 0.1 centimeters and classified it as unstageable, meaning the full depth couldn't be determined due to tissue coverage.
Director of Nursing #423 verified during the inspection that staff had not evaluated the resident after finding the pressure ulcer. She confirmed the resident had not been evaluated by therapy and no new interventions had been added.
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.
Resident #16 was cognitively intact and dependent for bathing, dressing, and positioning. She relied entirely on staff to protect her from equipment-related injuries she couldn't feel developing.
The inspection occurred as part of a complaint investigation at the 62-bed facility. Federal inspectors classified the violation as causing minimal harm or potential for actual harm.
The contradiction between the resident's explanation and the nurse's theory left staff paralyzed. While they debated whether her wheelchair footrest or bed bolsters caused the injury, the resident continued using both pieces of equipment without modifications.
The wound grew larger during the days of inaction. What started as a 2.9-centimeter injury became a 3-centimeter unstageable ulcer while staff remained uncertain about basic protective measures.
Resident #16 understood her vulnerability better than her caregivers. She correctly identified the wheelchair component that injured her foot, but staff couldn't act on her assessment. The therapy evaluation she requested never happened during the inspection period.
The facility failed to implement the pillow placement ordered after the wound's discovery. The resident sat in her wheelchair on December 22 with her injured foot unprotected, exactly as it had been when the wound developed.
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.