The resident told federal inspectors on October 27 that he had been at Amberwood Care Centre for about six months and had not seen a podiatrist yet. He said he had told several staff members about needing foot care, and their response was always that he would get put on the list to be seen.
When inspectors examined the man's feet, they found his left big toenail was extremely overgrown, curved, thickened and jagged. The resident had already lost his left third toe to amputation, and his remaining toenails were also long and overgrown.
The resident's medical conditions made proper foot care critical. His diagnoses included type 2 diabetes with diabetic peripheral angiopathy with gangrene, peripheral vascular disease, and hemiplegia following a stroke. These conditions significantly increase the risk of serious foot complications and infections.
A licensed practical nurse confirmed she had received the resident's request for podiatry care months earlier. She said she called the front desk to have him put on the list to be seen by the podiatrist, but she was not sure if he had been seen or not.
The nurse acknowledged that the resident's toenails were indeed overgrown and long when inspectors showed them to her.
The facility's Director of Nursing explained that Amberwood sends a census to the podiatrist before their bimonthly visits and notifies them of new admissions so they can be seen on the next visit. She confirmed the resident had not been seen by the podiatrist yet.
The podiatrist comes every other month. The last podiatry visit was on September 8, nearly two months before the inspection.
The Director of Nursing confirmed the resident should have been seen and said she was not sure why he was not seen.
Amberwood's own foot care policy, dated March 2018, states that residents will receive appropriate care and treatment to maintain mobility and foot health. The policy specifically addresses residents with medical conditions associated with foot complications, including diabetes and peripheral vascular disease.
The policy requires that residents with foot disorders or medical conditions associated with foot complications will be referred to qualified professionals.
Despite having this policy in place for over seven years, the facility failed to ensure the diabetic resident received timely podiatry care even as his condition visibly deteriorated.
For diabetic patients with peripheral vascular disease and existing gangrene, delayed foot care can lead to serious infections, additional amputations, or life-threatening complications. Overgrown, thickened toenails can cause pressure sores, ingrown nails, and provide entry points for bacteria.
The resident's case illustrates a breakdown in the facility's referral system. While staff acknowledged his requests and claimed to put him on a list, no one followed up to ensure he actually received care over a six-month period.
The inspection found that communication between nursing staff and administration failed to result in actual podiatry services. The licensed practical nurse made the referral request months ago but never confirmed whether the resident was scheduled or seen.
Meanwhile, the resident's toenails continued growing unchecked, creating an increasingly dangerous situation for someone already at high risk for foot complications due to diabetes and vascular disease.
The facility's bimonthly podiatry schedule meant missed appointments could result in four-month delays between opportunities for care. For high-risk diabetic residents, such delays can have serious consequences.
Federal inspectors cited Amberwood for failing to provide appropriate foot care, finding minimal harm or potential for actual harm. The violation affected one of three residents reviewed for foot care during the inspection.
The resident remains at the facility, still waiting for the podiatry appointment he requested six months ago.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Amberwood Care Centre from 2025-10-27 including all violations, facility responses, and corrective action plans.