I think you are right. If it hadn't been for visiting angels, the wound wouldn't have been brought to anyone's attention. The facility staff is supposed to dress P every day but half the time, they don't do it. That's how S caught it--by changing P's socks.
Very few others have outside caregivers so I know that things go on way too long ... and then it's too late.
I will explain that to the ombudsman.