North Valley Nursing Center: Diabetic Toe Infection Risk - CA
The resident, who had been at the facility since February 17, 2026, was lying in bed watching television when inspectors walked into his room on the morning of May 18. He told them the ingrown nail on his right big toe had come back, that it had been there for at least a week, maybe longer, and that it only hurt when someone put pressure on it. He said he remembered telling staff. He did not remember who.
That same morning, at 8:36 a.m., the facility's Infection Preventionist examined the toe. She found what appeared to be an ingrown nail affecting the outside wall of the right big toe, with swelling and a dry crust along the left side. She said treatment should have started as soon as the symptoms returned. She said that after the previous round of treatment ended on May 2, staff should have either obtained an order to continue care or documented that the toe had fully healed. Neither had happened.
The treatment that ended on May 2 had run for thirty days, from April 2 through May 2, addressing the same toe, the same nail, the same problem. When it ended, no one checked whether it had resolved. No follow-up order was written. No note confirmed healing. The toe was simply dropped from the care plan, and sixteen days later, the ingrown nail was back, visibly swollen, and still without a treatment order when inspectors arrived.
For a resident without diabetes, an ingrown toenail is painful and inconvenient. For Resident 25, it was something more. Type 2 diabetes impairs blood sugar control and slows wound healing. Foot wounds in diabetic patients can escalate to infection, tissue death, and in serious cases, amputation, faster and with less warning than in non-diabetic patients. The Director of Nursing acknowledged this directly when inspectors interviewed her on May 22. She said wounds like ingrown toenails should be addressed in diabetic residents as soon as possible. She said the treatment nurses should have followed up after the care orders ended on May 2.
She also said that for diabetic residents, licensed staff should be assessing lower extremities for wounds or suspected wounds every day, and that nursing assistants should be checking residents' skin for wounds or discoloration during showers and personal care. Resident 25 was dependent on staff for bathing, dressing, toileting, and personal hygiene. His feet were not something he could easily monitor himself. That daily assessment, the one the Director of Nursing described as standard practice for diabetic residents, had not caught the returning ingrown nail. The resident caught it himself and reported it. It still went unaddressed for at least a week.
The facility's own written policy on podiatry services, last reviewed in January 2026, states that residents are to receive proper treatment and care within professional standards of practice to maintain mobility and good foot health. A separate policy on nursing care for diabetic residents, also reviewed in January, acknowledges that foot complications may be associated with prolonged, poorly controlled diabetes and directs staff to recognize, manage, and document treatment complications. Both policies were on file. Neither appears to have guided what happened, or did not happen, in the weeks after May 2.
The inspection was part of a review of non-pressure skin conditions. Inspectors sampled two residents for that review. Resident 25 was one of them.
What the inspectors found when they looked at his toe, the swelling, the dry crust, the absence of any current treatment order, was not a complicated clinical situation. The Infection Preventionist said as much herself. The problem was not a failure of medical knowledge. It was a failure of follow-through. A treatment ended, and no one asked whether it had worked.
Resident 25 told inspectors the last time the podiatrist visited the facility, he was not on the list. He did not say it with alarm. He said it the way someone says something they have already accepted. He had been at North Valley since February. He was dependent on staff for the basic tasks of daily life. He had a condition that made his feet one of the most medically significant parts of his body. And when the ingrown nail came back, he told someone. He just did not know who, and whoever it was did not write it down, did not call the doctor, did not get an order.
The toe was still waiting for treatment when the inspection closed on May 22.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for North Valley Nursing Center from 2026-05-22 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
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Last verified: November 3, 2026 · Our methodology
NORTH VALLEY NURSING CENTER in TUJUNGA, CA was cited for violations during a health inspection on May 22, 2026.
He said he remembered telling staff.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.