The resident at Parkridge Specialty Care had been placed on strict non-weight bearing status for her left foot on September 17. Yet for nearly three weeks, staff allowed her to stand flat-footed during transfers, placing full pressure on a wound that measured over three centimeters wide.
By October 1, the wound had grown to 3.5 centimeters by 2.0 centimeters. More critically, it now probed to bone, creating what her podiatrist called "a high risk for underlying osteomyelitis" — a serious bone infection that could require amputation.
The resident told inspectors on October 2 that she "did not wear her shoe unless someone made her." She had just showered and transferred barefoot, she said.
Staff accounts revealed systematic failures to follow medical orders.
A certified nursing assistant who helped the resident shower initially claimed the resident wore her post-operative shoe during the transfer. Then she changed her story, admitting the shoe was in the laundry so the resident wore only "blue gripper socks" instead. When the resident stood up, she placed pressure on both feet.
Another nursing assistant said she helped the resident out of bed on October 6. The resident "stood and pivoted during the transfer and was flat footed with both feet," the assistant said. She did not place pressure on only her heel as ordered.
A third assistant acknowledged that when staff instructed the resident to use only her right foot, "she did place pressure on the left." The resident "was not able to avoid placing pressure on her left toe," the assistant said.
Most troubling, one nursing assistant admitted she "did not know the resident was to only place pressure on her heel during transfers" — despite the medical order being in place for weeks.
The facility's wound nurse acknowledged she never notified the podiatrist when the wound changed on September 5, even though facility policy called for contacting doctors within 24 hours of wound concerns. Her reason: the resident had an upcoming appointment on September 17.
That delay proved costly. During the September 17 visit, the podiatrist found the wound had worsened significantly. His notes stated the wound "probed to the bone" at the base of the big toe. Given the severity, he ordered an MRI scheduled for October 8 and noted that "a biopsy would be considered versus further amputation."
The resident's medical records showed she had not worn her required diabetic shoes and inserts during that critical appointment, though the notes stated staff were "unsure why."
The Director of Nursing told inspectors the resident required two staff members to assist with transfers and strict non-weight bearing on her left foot. But she admitted the facility only changed the resident to mechanical lift transfers on the morning of October 6 — the same day inspectors arrived.
When asked why this change occurred so late, the nursing director said it was her understanding that "the resident completed transfers fairly well before this." She added that if the resident couldn't maintain non-weight bearing during transfers, "they would come up with a different plan."
That plan came three weeks too late.
The podiatrist was direct about the consequences of the facility's failures. If the resident had been bearing weight on her left foot since September 17, or if she wasn't wearing her post-operative shoe, "this could make the ulceration worse," he told inspectors.
He expected the facility to develop "a different plan sooner than after a few weeks" if the resident couldn't maintain the weight restrictions.
Instead, staff continued dangerous transfer practices that violated explicit medical orders. The wound measurements tell the story: what started as a manageable diabetic ulcer became a bone-deep infection requiring possible amputation.
Federal inspectors found no documentation that the facility modified the resident's transfer status before October 6, despite weeks of evidence that current methods were failing.
The resident now faces an MRI to determine the extent of bone involvement and potential surgical intervention that could have been prevented with proper care protocols.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Parkridge Specialty Care from 2025-10-07 including all violations, facility responses, and corrective action plans.