Failure to Provide Diabetic Shoes Leads to Amputation
Summary
The facility failed to ensure a resident with a history of bilateral foot diabetic ulcers received diabetic shoes as ordered by the physician. The order for diabetic shoes was placed on 7/10/24, but the facility did not follow up with the shoe vendor to ensure the shoes were ordered and delivered. This oversight continued throughout July, and by 8/30/24, the resident developed a foot ulcer, indicating a lack of preventative foot care measures. The resident, who had a history of Type 2 diabetes with foot ulcers and neuropathy, expressed a desire for diabetic shoes on 8/26/24. Despite this, the facility did not document any communication or follow-up with the shoe vendor between 7/10/24 and 8/30/24. The resident's condition worsened, leading to a wound on the left heel, which eventually required debridement and resulted in a left foot amputation on 10/26/24 and a below-the-knee amputation on 10/31/24. Interviews with facility staff and the shoe vendor revealed that the vendor requested additional paperwork to fulfill the shoe order, but the facility continued to send the same paperwork without addressing the vendor's request. The Director of Nursing stated that follow-up should occur within 24-48 hours, yet there was no evidence of such follow-up. The lack of timely action and communication contributed to the resident's deteriorating condition and subsequent amputations.
Removal Plan
- The DON and designee(s) conducted a full-house audit on diabetic residents to determine at-risk diabetics and ensure proper preventative foot care.
- An audit was conducted to ensure all treatments, supplies, and equipment were readily available for order by the physician and were being followed to ensure residents received the proper preventative foot care.
- DON or designee(s) reviewed the medical records of diabetic residents to ensure that weekly skin assessments were completed and treatment recommendations/orders were in place.
- The DON or designee conducted a care plan audit to ensure that treatment recommendations/orders were included in the care plan and that they were being followed.
- All facility policies and procedures related to podiatry services, skin integrity foot care, and physician orders reviewed and revised as needed.
- Education provided to regional Clinical Manager at Curana to ensure that all practitioners that come to Pine Acres will be collaborating with the IDT team to ensure referrals are made timely and appropriately.
- An audit of orders, interventions, and devices regarding foot care and foot services was conducted by the Nursing Supervisor(s) to ensure proper use.
- The DON/Corporate Nurse/Consultant educated all licensed nurses on facility policies and procedures related to diabetes, foot care, and appropriate wound treatment measures.
- The DON/Corporate Nurse/Consultant educated all licensed nurses on appropriate documentation, which included transcription and entering treatment orders on the physician's order sheet in the EHR and the resident's TAR.
- DON/Corporate Nurse/Consultant educated all nurse aides on preventative diabetic foot care.
- DON/Corporate Nurse/Consultant conducted daily treatment record and nursing documentation audits to ensure accurate and complete documentation of diabetic foot care and preventative measures.
- For residents returning from the hospital, treatment recommendations/orders and wound care appointments will be transcribed and overseen by the DON and Corporate Nurse.
- DON/Corporate Nurse/Consultant Monitoring will continue to monitor/audit the following: Observation of treatments for diabetic foot care prevention and orders, Weekly physician orders, Weekly diabetic skin treatment orders related to diabetics, Treatment recommendations and orders are being added and processed into the EHR and TAR.
- A QAPI PIP has been initiated to report on the above monitoring and auditing procedures. All findings from the PIP will be presented at the monthly QAA meeting. Monitoring/auditing and reporting will continue.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to implement podiatry orders and document refusal for a resident with dementia, muscle weakness, and protein-calorie malnutrition. An LPN observed thick, yellow, irregular toenails and noted the resident was on the podiatry list every 3 months. A podiatry visit included an order for ammonium lactate 12% cream to the feet and callused skin, but the order was not found in the MAR/physician orders, and the CNO stated the resident refused the treatment and the refusal and provider notification were not documented.
A resident with cellulitis, COPD, and GERD had a podiatry order and consent on file, but the chart showed long, mycotic toenails needing trim and repeated podiatry consult notes for nail care. Observation found thickened, yellowed toenails extending past the toes, and the resident said the condition made walking painful and difficult. The NHA stated the resident was missed during two 360 Care podiatry visits and should have received toenail care.
Failure to Complete Ordered Diabetic Shoe Measurement: A resident with DM was ordered diabetic shoes and custom insoles, but therapy never measured him or completed the order. Staff interviews showed the order was passed between LVN, DON, ADON, and the DOR, but no one confirmed the next steps with the podiatrist office, and the resident said he did not recall being contacted by therapy.
A resident with an ingrown great toenail and recurrent toe infections did not receive timely foot care or podiatry follow-up. The resident’s toenails were observed to be long and unkept, and the record lacked a foot care plan when the problem was identified. Despite repeated recommendations from the NP, Wound MD, and ER physicians, podiatry was delayed for months, and the facility did not consistently carry out ER instructions such as podiatry follow-up and toe soaks. The resident required antibiotics more than once for the infected toe before podiatry was finally completed.
A resident with diabetes and dependence for daily care had dry, flaking skin on both lower extremities and very thick toenails, with staff noting a podiatry consult was needed. The record showed repeated references to the consult and the resident requesting podiatry care, but no documented facility follow-up for several weeks, and later the resident complained that toenails had not been clipped and overgrown toenails were observed.
Failure to provide timely foot care and follow a podiatry recommendation for a resident with CVA, hemiplegia, cognitive impairment, and arterial toe ulcers. The resident’s toenails on both feet were observed to be thick and long, and dirt was noted under the fingernails. The NP documented thickened nails and recommended routine in-house podiatry evaluation, but the resident was not on the SW’s podiatry list when interviewed, and the hospice nurse reported no prior facility communication about the nail care need.
Failure to Implement Podiatry Orders and Document Refusal
Penalty
Summary
The facility failed to ensure podiatry treatment orders and care plan interventions were implemented as written for Resident #32, who was admitted with diagnoses including dementia, muscle weakness, and protein-calorie malnutrition. The resident’s care plan, initiated on 4/11/24, directed staff to provide podiatry evaluation and treatment as needed. On 7/9/26, an LPN observed that the resident’s toenails needed trimming and described them as chunky, yellow, and irregular, and later stated the resident was on the podiatry list to be seen every three months. A review of the resident’s podiatry visit dated 5/19/26 documented a physician order for ammonium lactate 12% cream to be applied to bilateral feet and callused skin as needed for 180 days, but the resident’s physician orders from 05/01/26 through 07/09/26 contained no order for ammonium lactate. The CNO stated on 7/10/26 that when the ammonium lactate order was received, the resident was asked if he wanted the treatment and he said no, and that the provider notification of the refusal and the resident’s refusal were not documented in the medical record.
Failure to Provide Timely Podiatry Nail Care
Penalty
Summary
Provide appropriate foot care was not consistently done for one resident who was admitted with diagnoses including cellulitis, COPD, and GERD. The resident had a physician order dated 5/8/26 for a podiatry consult and treat as needed, and a consent for 360 Care podiatry signed on 5/11/26. A clinical record progress note dated 5/8/26 at 18:01 documented that the resident’s toenails were long, mycotic, and in need of trim. Subsequent Skin and Wound notes dated 5/19/26, 5/27/26, 6/3/26, 6/10/26, 6/17/26, 6/24/26, 7/1/26, and 7/8/26 continued to list podiatry toenail care consultations. On 7/7/26, observation showed both feet had thickened, yellowed toenails extending past the tips of the toes with rough and uneven surfaces, and the resident stated the toenail condition made it painful and difficult to walk. The facility’s 360 Care Appointment Listing dated 7/1/26 lacked evidence that the resident was scheduled for nail care, and the NHA stated the resident was missed during 360 Care podiatry visits on 5/18/26 and 7/1/26 and should have been seen and provided toenail care.
Failure to Complete Ordered Diabetic Shoe Measurement
Penalty
Summary
The facility failed to ensure proper foot care for a resident with type 2 diabetes mellitus by not having him measured for diabetic shoes and diabetic insoles as ordered by the physician. Resident #2’s record showed a quarterly MDS indicating he could make himself understood and understand others, with a BIMS score of 9 reflecting moderately impaired cognition. His care plan included diabetes-related interventions, including checking his body for breaks in skin and treating them promptly as ordered by the doctor. The order summary dated 06/09/26 directed physical therapy to measure, order, and dispense diabetic shoes and three pairs of heat molded/custom molded diabetic insoles. During interviews, the resident stated he did not recall anyone from therapy talking to him about diabetic shoes. Staff interviews showed the podiatrist had written the order and it was passed from LVN B to the Director of Rehab and then to the ADON, but the order was not carried out. The Director of Rehab stated there was miscommunication and that she should have contacted the podiatrist office right away to determine how to obtain the custom-fit shoes. The ADON stated therapy did not evaluate residents for diabetic shoes and that she should have followed up to see what needed to be done. The DON and Administrator stated the order should have been followed, and the Administrator stated there was no system for monitoring therapy evaluations to ensure orders were followed through.
Failure to Provide Timely Foot Care and Podiatry Follow-Up
Penalty
Summary
The facility did not ensure proper foot care and treatment for a resident with an ingrown right great toenail and repeated toe infections. The resident was admitted with morbid obesity and peripheral vascular disease, was cognitively intact, and required substantial to maximum assistance with bathing and showering. The resident’s record did not contain a foot care plan or toenail care interventions when the ingrown toenail was identified, and survey observation found the resident’s toenails to be long and unkept, with black scabbing along the right great toe. The resident’s ingrown toenail was first documented when staff noted slight bleeding and an order was entered for bacitracin and a podiatry referral. The resident’s NP and Wound MD also documented the ingrown toenail and recommended podiatry. Despite these recommendations, the resident was not seen by podiatry for several months. During that time, the resident developed toe infections and was treated with antibiotics after ER visits. The ER discharge instructions included follow-up with podiatry and, on one occasion, toe soaks in warm water three times daily, but the facility did not enter the podiatry referral or the toe soak order into the record. The resident continued to have recurrent problems with the right great toe, including swelling, tenderness, and infection, and the Wound MD documented that the wound was exacerbated by infection and again recommended podiatry and oral antibiotics. The resident later reported wanting to see podiatry because of elongated toenails. Podiatry was not completed until more than seven months after the first referral, and the podiatrist stated that if the facility had communicated earlier, the resident could have been seen sooner. The podiatrist also stated that antibiotics treated the infection but not the underlying ingrown toenail problem. After podiatry evaluation, the resident’s toe issue resolved.
Delayed Podiatry Care and Overgrown Toenails
Penalty
Summary
The facility failed to ensure timely foot care for Resident 4, who was alert and oriented, dependent on staff for daily care needs, and had diabetes. Nursing documentation on May 7, 2026 noted excessive dry, flaking skin on both lower extremities and very thick toenails, and staff stated they would email for a podiatry consult. Email correspondence on May 8 showed the facility contacted the podiatry office to add the resident to the podiatry list. Subsequent nursing notes on May 14 and May 21 documented continued dry, flaking skin on both lower extremities, that a podiatry consult had been sent and was awaiting an in-house date, and that the resident was requesting to be seen by the podiatrist. A social service note on June 29 recorded that the resident complained her toenails had not been clipped and that overgrown toenails were observed. Review of the clinical record found no evidence of follow-up by the facility between May 21 and June 26, 2026 regarding the podiatry need, and the Nursing Home Administrator confirmed the findings.
Failure to Provide Timely Foot Care and Follow Podiatry Recommendation
Penalty
Summary
The facility failed to ensure proper foot care for a resident with a history of cerebral infarction and left-sided hemiplegia who was totally dependent on staff for activities of daily living, including dressing, footwear, personal hygiene, and showering. The resident also had moderate cognitive impairment, a left great toe arterial ulcer with eschar noted on admission, and later developed a left 2nd toe arterial ulcer. During observation, the resident’s three middle toes on both feet were found to have thick toenails measuring about 3 mm in length, and the resident also had dirt under his fingernails. Record review showed that on 06/20/2026, the NP documented edema of the left foot, dry skin, insensate lower extremity, and a full-thickness arterial ulcer, and recommended a routine in-house podiatry evaluation for management of thickened nails. The resident and staff verbalized understanding of the wound, dressing care, and treatment recommendations. However, the resident was not on the SW’s podiatry list at the time of interview, and the SW stated that the MDs would usually reach out to her about podiatry orders so she could add residents to the list for the podiatrist’s next visit. The resident, family member, WCNs, SW, DON, and hospice nurse all described that the toenails had remained long and had not been addressed before surveyor intervention. The resident stated someone had cut one toenail but not the rest, and his family member said the toenails were already long the previous week. WCN A and WCN B both observed that the toenails needed trimming, and WCN A stated that if toenails were not clipped they could curl up and break the skin. The DON acknowledged that the resident had long nails upon admission and later stated that the NP had included the long toenails in the wound report, but the task to place the resident on the podiatry list had not been completed. The hospice nurse stated there were no records of the facility calling hospice about the long toenails before the surveyor intervention, and the facility policy stated that the facility is responsible for meeting the resident’s personal care and nursing needs in coordination with hospice and for communicating with hospice to ensure needs are addressed.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release August 26, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.