Resident 4, who has Parkinson's disease and dementia, refused podiatrist care throughout 2024 at Glendora Grand on West Arrow Highway. The resident's toenails became discolored, elongated, ingrown, deformed, thickened and painful with fungal buildup underneath, according to podiatric consultation notes from January through December.
Nobody told the family. Nobody informed the resident's physicians. Licensed nurses conducting weekly assessments documented the infected toenails but failed to notify doctors on January 14, January 22, January 28 and February 5.
The resident's care plan from December specifically identified risk for clinical decline due to treatment refusals. It required staff to monitor noncompliance episodes, notify physicians for possible treatment, and refer for psychological consultation. None of this happened.
On February 10, nursing assistant CNA 8 finally reported the condition to licensed vocational nurse LVN 9 after showering the resident. "Resident 4's toenails were thick and long, and the big toenails on Resident 4's right foot was curving up," CNA 8 told investigators.
LVN 9 assessed the toenails and found them "long, thick, and dark yellowish green in color." The nurse called nurse practitioner NP 1, who ordered X-rays of both feet and a podiatry consultation.
The X-rays revealed possible osteomyelitis in multiple toes of both feet. Osteomyelitis is inflammation of bone or bone marrow, usually caused by infection.
Three days later, the facility transferred the resident to a hospital for intravenous antibiotics to treat right toe osteomyelitis.
Social Service Director admitted during the inspection that she never informed licensed nurses about the resident's repeated treatment refusals, despite facility policy requiring such notification after three refusals. "The SSDR stated the SSDR did not inform the licensed nurses of Resident 4's repeated refusal for podiatry care," the inspection report states.
Director of Nursing said she was completely unaware the resident had refused podiatry care for the entire year. "The DON stated the DON was unaware Resident 4 had refused podiatry care for the whole year of 2024," according to the inspection.
The nursing director explained that licensed nurses should have tried alternative interventions, such as having staff with good rapport present during treatment, notifying physicians and mental health professionals, and coordinating with family members.
LVN 9 acknowledged failing to document the change in condition properly. The nurse should have completed an SBAR communication form on February 10 when first assessing the infected toenails, but waited until February 13 to document the resident's deteriorating condition.
"Long nails could cause residents discomfort and pain and put residents at risk for infection," LVN 9 told investigators.
The facility's own policies required immediate physician notification for treatment refusals and significant condition changes. The comprehensive care plan policy mandated attempting alternative methods when residents refuse treatment and documenting such attempts in clinical records.
During the inspection, the Director of Nursing could not recall whether the resident's family was ever informed about the repeated podiatry refusals. After reviewing the last four care plan conferences, no documentation existed showing family notification.
"After a resident refused treatment three times, the primary physician, the psychologist/psychiatrist, and the family must be informed," the Director of Nursing told investigators. "Licensed nurses were not aware Resident 4 was refusing podiatry care and probably did not inform (Resident 4's) physicians."
The Social Service Director acknowledged the dangerous consequences of ignoring treatment refusals. "The facility could not let residents refuse for too long because it could cause residents to sustain an injury," she said.
The resident's medical history showed moderate cognitive impairment requiring supervision with eating, oral hygiene and personal care. The resident could express needs but could not make medical decisions, making staff oversight crucial for preventing complications like bone infection.
Federal inspectors cited the facility for failing to provide appropriate foot care and ensure proper treatment when residents refuse medical services. The violations resulted in actual harm to the resident, who required hospitalization and intravenous antibiotics that could have been prevented with earlier intervention.
The case illustrates how communication breakdowns in nursing homes can escalate minor conditions into serious medical emergencies requiring acute care hospitalization.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Glendora Grand, Inc from 2025-02-26 including all violations, facility responses, and corrective action plans.
