Augustana Chapel View Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Hopkins, Minnesota.
- Location
- 615 Minnetonka Mills Road, Hopkins, Minnesota 55343
- CMS Provider Number
- 245493
- Inspections on file
- 24
- Latest survey
- December 4, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Augustana Chapel View Care Center during CMS and state inspections, most recent first.
During an Influenza A outbreak, the facility did not consistently monitor or screen residents for respiratory symptoms, nor did it promptly implement or document transmission-based precautions for symptomatic individuals. Several residents with complex medical conditions developed influenza, with some requiring hospitalization. Staff were observed entering rooms on contact and droplet precautions without proper PPE, and infection control records were incomplete, contributing to the spread of the virus.
Two residents with complex medical histories experienced changes in condition, including confusion, respiratory symptoms, and signs of infection, but did not receive timely or comprehensive assessment and monitoring as required by facility policy. Despite staff and provider expectations for frequent monitoring and documentation, records lacked evidence of ongoing vital sign checks, respiratory assessments, or prompt provider notification. Both residents were subsequently hospitalized with influenza A and related complications.
A resident with a history of stroke and aneurysm received ibuprofen 66 times on a scheduled basis due to a transcription error, instead of as needed per the physician's order. The error occurred when the order was incorrectly entered into the EHR and subsequently administered by staff according to the MAR. The facility did not promptly notify the physician or family, nor did it document whether the resident experienced any adverse effects.
A resident with multiple complex medical conditions received an excessive dose of hydromorphone after staff administered 4 mg based on a medication card label that conflicted with the MAR. Confusion arose from two different hospital discharge orders and pharmacy deliveries, and staff did not consistently verify the most current physician order or properly mark outdated medication cards. The resident experienced respiratory depression and required emergency intervention for suspected opioid overdose.
The facility did not ensure timely completion of physician-ordered laboratory tests for three residents with acute medical needs. In each case, STAT or urgent lab orders were delayed due to issues such as lack of follow-up with the lab, insufficient supply monitoring, and unclear procedures for specimen collection and pick-up. Providers were not notified of delays, and facility policies for urgent lab processing and supply management were not consistently followed.
A resident tested positive for influenza A, but staff failed to notify the ordering practitioner of the abnormal result. The nurse manager documented the results as negative and was unaware of the positive finding, and both the DON and nurse practitioner confirmed they were not informed. Facility policy required timely notification of abnormal lab results, which did not occur in this case.
A resident's EHR was found to be incomplete, missing a provider visit note and key hospital documents following a hospitalization. Staff interviews confirmed that these documents were not uploaded as required, and there was no clear process for tracking non-routine provider notes, resulting in an inaccurate and incomplete medical record.
Three residents with varying cognitive abilities and respiratory conditions were left unattended during nebulizer treatments after staff set up the equipment, without proper assessment of their ability to safely manage the treatment independently. Despite their preference not to self-administer medications, no further evaluation was conducted to ensure they could complete the treatment safely when left alone, contrary to facility policy.
A resident with moderate cognitive impairment and mobility issues had grab bars installed without comprehensive assessment or documentation of risks and benefits. The facility failed to provide education or obtain informed consent, and staff interviews revealed inconsistencies in the assessment and installation process.
The facility failed to ensure proper use of enhanced barrier precautions (EBP) and personal protective equipment (PPE) during high-contact care for two residents. Staff did not consistently wear gowns and gloves as required, despite signage and training. This non-compliance occurred during care activities for residents with significant medical needs, including catheter care and wound management.
The facility failed to document advance directives for several residents, including those with severe cognitive impairments. Despite care conferences, there was no evidence of offering advance directive planning. The DON admitted reliance on hospital discharge papers for code status, and no policy was provided upon request.
The facility failed to ensure that all licensed staff were properly trained and certified in BLS/CPR, with 18 out of 62 staff lacking valid certifications. Interviews revealed that while BLS classes were offered, there was no system to ensure current certifications, and no disciplinary actions were enforced for non-compliance. The facility also lacked a formal audit and did not provide a BLS/CPR policy.
The facility failed to honor a resident's bathing preferences, leading to inconsistent provision of bed baths and lack of hair washing for ten weeks. Despite the resident's documented preference for bed baths due to medical conditions, staff did not consistently follow up or document these preferences, resulting in a deficiency in resident self-determination and choice.
The facility failed to revise a comprehensive care plan for a resident with multiple severe injuries, resulting in the omission of critical medical instructions from the care plan and electronic health record. The Director of Nursing acknowledged the oversight and breach in protocol, which could potentially lead to harm.
A resident with serious medical conditions did not receive their prescribed total parenteral nutrition (TPN) and lipids on multiple occasions due to unavailability. The facility failed to ensure an adequate supply and timely administration of these medications, as confirmed by the medication administration record and interviews with staff.
Failure to Implement Effective Infection Control During Influenza A Outbreak
Penalty
Summary
The facility failed to implement effective infection prevention and control strategies for respiratory protection, specifically in response to an outbreak of Influenza A. There was a lack of ongoing monitoring and screening of residents with respiratory symptoms, and transmission-based precautions (TBP) were not consistently or promptly implemented for symptomatic residents. Documentation revealed that TBP were often delayed, not initiated at symptom onset, or removed without comprehensive assessment and monitoring for symptom resolution. In several cases, residents with symptoms were not placed on appropriate precautions until days after symptom onset or after laboratory confirmation, and there was no consistent documentation of respiratory assessments or the rationale for removal of precautions. Multiple residents with complex medical histories, including conditions such as hemiplegia, diabetes, COPD, morbid obesity, and immunodeficiency, developed symptoms consistent with influenza and subsequently tested positive. Several residents required hospitalization due to complications. The facility's infection control records did not reflect timely or comprehensive surveillance, and there was no evidence of active respiratory symptom screening for residents who were exposed or symptomatic. Staff interviews confirmed that assessments were not always documented, and infection tracking logs were incomplete, missing key information such as the start and end dates of TBP and not including all symptomatic residents. Direct observations revealed staff entering rooms of residents on contact and droplet precautions without donning the required personal protective equipment (PPE) as indicated by signage. Staff demonstrated inconsistent understanding and adherence to infection control protocols, with some staff only wearing masks when full PPE was required. Housekeeping staff were also observed failing to follow proper PPE and hand hygiene protocols when cleaning rooms of residents on precautions. These failures contributed to the spread of Influenza A within the facility, resulting in an outbreak affecting multiple residents and leading to an immediate jeopardy situation due to the risk of further transmission.
Failure to Monitor and Assess Residents with Acute Illnesses Resulting in Hospitalization
Penalty
Summary
The facility failed to comprehensively assess and appropriately monitor two residents with acute illnesses, including influenza, which resulted in hospitalization. For one resident with a history of COPD, CHF, diabetes, and chronic respiratory failure, staff identified a change in condition marked by confusion, poor appetite, and a cough. Although the provider was notified and laboratory tests were ordered, the resident's records lacked documentation of ongoing assessment and monitoring of vital signs, respiratory status, or infection after the change in condition was noted. There was no evidence of additional monitoring or assessment between the time the change was identified and the resident's transfer to the hospital, despite staff interviews indicating that more frequent monitoring should have occurred. The resident was later hospitalized with diagnoses including influenza A, hypoxia, sepsis, and acute respiratory failure. Another resident with CHF, dementia, and an indwelling catheter experienced a change in condition characterized by foul-smelling urine and altered mental status. The provider was notified via a written message rather than an immediate call, and laboratory tests for infection and influenza were ordered. The resident's records did not show evidence of ongoing assessment or monitoring of vital signs, respiratory status, or urinary symptoms after the change in condition. Despite orders for daily monitoring and documentation, there were no corresponding progress notes or evidence of additional monitoring. The resident was later hospitalized with influenza A, sepsis, and a high fever. Interviews with nursing staff and the DON confirmed that the expected standard of care was not met, as there was a lack of timely and thorough assessment and monitoring following the residents' changes in condition. Facility policies required prompt provider notification and active surveillance for illness, especially during an influenza outbreak, but these were not followed. The records lacked documentation of the required assessments and monitoring, and there was a delay in provider notification and treatment for both residents.
Medication Order Transcription Error Resulting in Incorrect Ibuprofen Administration
Penalty
Summary
The facility failed to ensure accurate transcription of physician orders for a resident with a history of stroke and aneurysm, resulting in a medication error. The resident was prescribed ibuprofen 400 mg every 6 hours as needed (PRN) for pain or fever, but the order was incorrectly transcribed into the electronic health record (EHR) as a scheduled dose every 6 hours. As a result, the resident received ibuprofen 66 times over a period of approximately two weeks, rather than only as needed. The medication administration record (MAR) reflected the incorrect scheduled dosing, and staff administered the medication according to the MAR. The error was identified as a human transcription error, with the health unit coordinator entering the order, the charge nurse checking it, and nursing staff administering the medication based on the MAR. The facility's medication error report noted that the physician and family were not notified in a timely manner, and the resident's record did not document whether the resident experienced any untoward effects from the medication. Interviews with staff confirmed the process and the error, and the facility's policy required prompt reporting, observation for effects, and notification of the physician and family, which was not fully followed in this case.
Significant Medication Error Due to Conflicting Orders and Inadequate Verification
Penalty
Summary
A resident with a history of fractured left femur, status post hemiarthroplasty, acute respiratory failure with hypoxia, and acute bronchitis due to RSV was admitted to the facility with two different Dilaudid (hydromorphone) orders from the hospital. The pharmacy received both orders, leading to confusion and the delivery of medication cards with conflicting dosing instructions. The medication administration record (MAR) and the medication card label did not match, and staff were instructed to follow the MAR if discrepancies arose. However, the medication card with the incorrect dose was not properly marked or removed, and staff did not consistently verify the most current physician order before administration. On the morning in question, an LPN administered 4 mg of hydromorphone to the resident for severe pain, after verifying the medication card label with the MAR. Shortly after, the resident was found to have abnormal, labored breathing and was difficult to arouse. Emergency medical services were called, and the resident was transferred to the hospital, where an opioid overdose was suspected and treated with Narcan. The facility's policies required staff to administer medications as prescribed, verify the six rights of medication administration, and observe and document the resident's response to PRN medications, but these procedures were not fully followed in this case. Interviews with staff revealed that there was confusion regarding which order to follow, and the process for reconciling discrepancies between the MAR and medication card was not consistently implemented. The medication card with the outdated order was not immediately marked to prevent administration, and staff did not always verify the most current physician order when discrepancies were identified. This series of actions and inactions resulted in the resident receiving a significant medication error, specifically an excessive dose of hydromorphone, leading to an adverse clinical event.
Failure to Obtain Timely Laboratory Services for Physician-Ordered Tests
Penalty
Summary
The facility failed to ensure that physician-ordered laboratory studies were obtained in a timely manner for three residents with acute medical needs. For one resident with multiple diagnoses including diabetes, hyperkalemia, and heart failure, a STAT order for CBC and BMP was placed following a change in condition. While some specimens were collected promptly, the blood draws for CBC and BMP were delayed until the following day, despite facility policy and staff expectations that STAT labs be collected within two hours. There was no evidence of additional follow-up with the laboratory or notification to the provider regarding the delay, and the provider only became aware of the delay the next morning when the resident's condition had further declined, resulting in a hospital transfer. Another resident with a history of heart failure, hematuria, and urinary tract infection had laboratory orders for respiratory viruses and urinalysis following an acute episode of confusion and foul-smelling urine. The required swabs were not collected on the day of the order due to a lack of supplies, and the tests were performed the following day. The provider was not notified of the delay, nor of the positive influenza result, contrary to facility policy and provider expectations. Interviews revealed that the system for monitoring and ordering lab supplies relied on nurses to notify health unit coordinators when supplies were low, and there was no routine monitoring in place. A third resident admitted for rehabilitation after hip surgery developed fever and cough, prompting orders for respiratory virus testing. While a COVID-19 test was collected and processed, there was no documentation of results for influenza and RSV, and staff interviews indicated uncertainty about specimen storage and lab pick-up procedures. The laboratory confirmed that STAT orders required direct notification from the facility, which did not occur. Facility policies required immediate action for urgent lab orders and a system for maintaining adequate supplies and timely specimen transport, but these procedures were not consistently followed.
Failure to Notify Practitioner of Abnormal Lab Result
Penalty
Summary
A deficiency occurred when facility staff failed to promptly notify the ordering practitioner of an abnormal laboratory result for a resident who was tested for influenza A, RSV, and COVID-19 following an acute visit for a new problem. The laboratory swab was collected and resulted in a positive influenza A finding, which was marked as abnormal. However, the nurse manager documented in a late entry note that the lab results were negative and later admitted to being unaware of the positive result. The only evidence of the positive result was a scanned copy of the faxed lab report, and there was no documentation confirming that the nurse manager had notified the nurse practitioner of the abnormal finding. Interviews with the DON and the nurse practitioner confirmed that neither was aware of the positive influenza A result until informed by surveyors. The DON stated that she expected the provider to have been notified, and the nurse practitioner indicated she would have treated the resident for influenza A had she been informed. The facility's policies required timely notification of abnormal lab results to the attending physician or designee, but this was not followed in this instance.
Incomplete Medical Record Documentation for Hospitalized Resident
Penalty
Summary
The facility failed to maintain a complete, accurately documented, and readily accessible medical record for a resident who was reviewed for documentation. The resident was admitted to the facility and subsequently sent to the hospital due to confusion, weakness, and distress. Upon return from the hospital, the resident's electronic health record (EHR) was missing key documents, including a provider visit note from the day the resident was sent to the hospital, as well as the hospital discharge summary and physician history and physical (H&P) from the hospitalization period. Interviews with facility staff revealed that while there was a process for uploading provider notes and hospital documents into the EHR, there was a lack of tracking for non-routine provider visits and some hospital documents. The health unit coordinator confirmed that the missing documents were not present in the EHR and should have been uploaded, and the director of nursing acknowledged that the resident's medical record was incomplete and not accurate at the time of review. Facility policy required that such documentation be included in the resident's legal health record.
Failure to Assess Residents' Ability to Self-Administer Nebulizer Treatments
Penalty
Summary
The facility failed to complete thorough self-administration assessments for three residents who did not wish to self-administer their medications but were left unattended during nebulizer treatments. For each of these residents, staff set up the nebulizer treatment, applied the mask, and turned on the machine, then left the room while the treatment was ongoing. No further assessment was conducted to ensure these residents were competent to manage the nebulizer, such as removing the mask or turning off the machine when finished. Observations confirmed that residents were left alone with the nebulizer running, and interviews revealed that some residents did not recall who operated the machine or were not involved in the process beyond receiving assistance from staff. The residents involved had varying levels of cognitive function and medical conditions, including multiple sclerosis, asthma, surgical aftercare, acute respiratory failure, and chronic obstructive pulmonary disease. Despite their preferences not to self-administer medications, the facility did not perform additional assessments to determine their ability to safely complete nebulizer treatments independently when left unattended. Staff interviews indicated inconsistent understanding of the requirements for self-administration assessments and supervision during nebulizer treatments, and the facility's policy required an observation to be completed if a resident was to self-administer medications, including nebulized treatments.
Failure to Assess and Document Risks and Benefits of Grab Bars
Penalty
Summary
The facility failed to comprehensively assess and discuss the risks and benefits prior to the installation of grab bars for a resident identified as R194. The resident had moderate cognitive impairment and required assistance with bed mobility. Despite these needs, the facility did not document a thorough assessment of the resident's condition or the medical symptoms being addressed by the use of grab bars. The assessment lacked documentation of education provided to the resident or his representative, and there was no review of the risks and benefits, including the risk of entrapment. The care plan for R194 indicated the need for assistance with bed mobility and transferring due to impaired functional mobility and a history of falls. However, the documentation did not include any evidence of education or informed consent regarding the use of grab bars. Interviews with staff revealed that while therapy and nursing staff were involved in the decision-making process, there was no formal documentation of the discussions or assessments conducted. The facility's policy required a physical device assessment with input from the interdisciplinary team, but this was not completed or documented. Observations and interviews with the resident and staff further highlighted the lack of communication and documentation. The resident did not recall receiving any education about the grab bars or being informed of the associated risks. Staff interviews indicated a lack of clarity and consistency in the process for assessing and installing bed mobility devices. The interim DON and regional nurse consultant acknowledged the expectations for assessment and monitoring but did not provide evidence of compliance with these procedures.
Inadequate PPE Usage During High-Contact Care
Penalty
Summary
The facility failed to ensure enhanced barrier precautions (EBP) and appropriate personal protective equipment (PPE) were followed during high-contact care for two residents, R193 and R9, who required EBP for infection control. R193, with mild cognitive impairment and a bladder catheter, was observed without proper PPE usage by staff during care activities. LPN-A and NA-A did not wear gowns while assisting R193, despite signage indicating EBP requirements. LPN-A incorrectly believed that PPE was only necessary for catheter care and dressing changes, while NA-A confirmed not wearing PPE for boosting the resident in bed. R9, with significant cognitive impairment and multiple diagnoses, including chronic respiratory failure and pressure ulcers, also experienced inadequate PPE usage. An unidentified staff member and NA-E entered R9's room without donning gowns during high-contact care activities, such as repositioning and providing perineal care. NA-E acknowledged the requirement to wear a gown during such activities but failed to do so, resulting in direct contact between her clothing and R9's body and bedding. The facility's infection preventionist, IP-D, was responsible for training staff on EBP and ensuring compliance. Despite placing PPE carts and signage outside residents' rooms, IP-D was aware of frequent incidents of non-compliance with gown usage. The facility's policy on transmission-based precautions outlined specific high-contact activities requiring gown and glove use, which were not consistently followed by staff, leading to the deficiencies observed.
Failure to Document Advance Directives
Penalty
Summary
The facility failed to identify and document the preferences for health care directives for seven out of ten residents reviewed for advance directives. These residents included individuals with severe cognitive impairments and complex medical conditions such as multiple sclerosis, Alzheimer's disease, and cerebral infarction. Despite having care conferences and assessments, the facility did not ensure that advance directives or POLST forms were properly documented or signed by a provider. Interviews with social services staff revealed that they were responsible for reviewing residents' POLST and advance directives during care conferences. However, there was no evidence that the facility staff offered advance directive planning to the residents or their families. In one instance, a family member reported that attempts to discuss advance directives with the facility's admission staff were unsuccessful, and the resident was unable to communicate her wishes due to cognitive impairment. The Director of Nursing acknowledged that the facility relied on code status from hospital discharge papers and did not have a policy requiring advance directives or POLST forms. The facility lacked documentation of offering advance planning to residents, and there was no advance directive policy provided upon request. This deficiency highlights a significant gap in the facility's process for ensuring residents' rights to participate in their health care decisions.
Deficiency in BLS/CPR Certification Among Staff
Penalty
Summary
The facility failed to ensure that all licensed staff were properly trained and certified in Basic Life Support (BLS) and Cardiopulmonary Resuscitation (CPR), which is essential for providing emergency care to residents. Upon review, it was found that 18 out of 62 licensed staff members, including both Registered Nurses (RNs) and Licensed Practical Nurses (LPNs), did not have valid BLS/CPR certifications on file. Some staff members had expired certifications, and others had taken online courses without hands-on practice or in-person skill assessments. The facility's BLS/CPR book did not contain certificates for several staff members, and one LPN's certification was expired. Interviews with the staff development coordinator (SDC) and the director of nursing (DON) revealed that while BLS classes were offered twice a year, there was no system in place to ensure that staff maintained current certifications. The SDC admitted to reminding staff to submit their certificates but did not enforce any disciplinary actions for non-compliance. The DON and the administrator acknowledged the lack of a formal audit to verify staff certifications. Additionally, the facility did not provide a BLS/CPR policy when requested, indicating a lack of structured oversight in maintaining essential life-saving skills among staff.
Failure to Honor Resident's Bathing Preferences
Penalty
Summary
The facility failed to honor a resident's bathing preferences, leading to a deficiency in resident self-determination and choice. Resident R3, who was admitted with fractures and subsequent surgeries, preferred bed baths due to his medical condition. Despite this preference being documented in his care plan, the facility did not consistently provide bed baths or alternative bathing methods when R3 refused showers. Documentation showed that R3 only received one bed bath since admission, and there were multiple instances where bathing was not recorded or completed as per R3's preference. Observations and interviews revealed that R3 had not had his hair washed in ten weeks and was experiencing visible skin flakes and oily hair. R3 expressed his dissatisfaction with the lack of bed baths and stated that he had not been refusing them but rather requesting them without success. Staff interviews confirmed that R3 preferred bed baths and did not want to use the shower due to his surgical sites. However, there was a lack of consistent follow-up and documentation to ensure R3's preferences were honored. The facility's policies on bathing and resident dignity emphasized the importance of honoring resident preferences and providing at least one bath per week. However, the documentation and staff actions did not align with these policies. The Director of Nursing acknowledged the deficiency, noting that the expectation was for bed baths to be offered if a resident refused a shower, but this was not consistently documented or followed through in R3's case.
Failure to Revise Comprehensive Care Plan
Penalty
Summary
The facility failed to revise a comprehensive care plan for a resident (R3) who was admitted with multiple severe injuries, including fractures and dislocations in both lower extremities, and required specific medical interventions. Despite the resident's complex medical needs and a podiatry clinic note dated 4/1/24 that included critical instructions for wearing a cam boot and night splint, these instructions were not transcribed into the resident's electronic health record (EHR) or care plan. The care plan, initially developed on 3/7/24, did not reflect the updated medical orders, leading to a gap in the resident's care management. During an interview, the Director of Nursing (DON) acknowledged that the podiatry clinic note had not been transcribed into the resident's chart and confirmed that the care plan was not updated to include the new instructions. The facility's policy mandates that care plans be updated routinely to reflect the resident's current condition, but this was not adhered to in R3's case. The DON admitted that this oversight represented a breach in practice and protocol, potentially leading to harm due to the lack of adherence to the provider's instructions for the resident's care.
Failure to Ensure Adequate Supply and Administration of TPN
Penalty
Summary
The facility failed to ensure an adequate supply and administration of ordered medications for a resident diagnosed with multiple serious conditions, including colon cancer and gastro-esophageal reflux disease. The resident required total parenteral nutrition (TPN) and lipids, which were not administered as ordered on several occasions due to unavailability. Specifically, the medication administration record (MAR) indicated that TPN was not administered on the evening and night shifts of one day, and lipids were not administered on the day shift of the following day. Progress notes confirmed that the specialty pharmacy was unable to deliver the TPN on time, resulting in a missed dose. Interviews with the pharmacy technician and the director of nursing (DON) revealed that the facility typically received a seven-day supply of TPN per delivery, and the pharmacy technician would call weekly to check on the supply. However, a breakdown in communication and responsibility led to the TPN running out. The DON confirmed that nurses were responsible for tracking medication refills and ensuring an adequate supply, but in this instance, the TPN ran out, and the next delivery was delayed. Facility policy required reordering medications one week in advance and contacting the resident's family or physician if the medication did not arrive on time, but these steps were not effectively followed.
Latest citations in Minnesota
A resident with dry eye syndrome and degenerative eye disease had orders for cyclosporine ophthalmic emulsion and Refresh Tears, both scheduled at the same time. Medication records and direct observation showed a TMA instilled cyclosporine drops in both eyes and immediately followed with Refresh Tears in both eyes without waiting between medications. This practice conflicted with referenced professional guidance recommending several minutes between multiple eye drops and with the medical provider’s recommendation to wait fifteen minutes between the two ophthalmic medications. No facility policy on ophthalmic medication administration was provided when requested.
A resident with severe cognitive impairment, impaired mobility, and high fall risk was care planned to have wheelchair footrests in place at all times, with staff ensuring proper positioning and monitoring for leaning during transport. A NA transported the resident in a manual wheelchair from the shower without the footrests, and while going through the doorway the wheelchair struck the door frame, causing the resident, who was leaning forward, to fall out. The resident sustained a T12 fracture, head injury with concussion, abrasions and contusions, and multiple right-hand lacerations requiring sutures, and the DON confirmed the care plan had not been followed.
A high‑risk, immobile resident with MS and prior heel DTI developed an avoidable unstageable coccygeal pressure ulcer after staff failed to consistently assess and document skin status, did not transfer or timely provide ordered pressure‑relieving mattresses, and did not reliably perform q2h repositioning. The resident was repeatedly left on a bedpan for prolonged periods despite early reports of this issue, and the toileting care plan was not revised to a bedside commode until after the coccygeal wound had significantly worsened. Wound assessments lacked complete measurements and staging, changes in wound size and color were not promptly recognized as deterioration or reported to providers, and recommended interventions from a wound NP (including an air mattress and offloading) were not promptly implemented. As a result, the coccygeal ulcer rapidly progressed to a large, necrotic, malodorous wound requiring hospital transfer and surgical debridement.
A resident with spastic hemiplegia, muscle weakness, and moderate cognitive impairment was observed using bilateral bed grab bars for bed mobility and transfers, but the care plan did not address grab bar or side rail use. Review of the EMR showed no completed bed mobility device or side rail assessment to determine the necessity or safety of the grab bars, and no documentation that risks and benefits were discussed or that informed consent was obtained. An LPN and the ADON stated that a bed mobility device assessment is required before grab bars are installed and confirmed that no such assessment existed for this resident.
A resident with bilateral heel pressure ulcers and multiple comorbidities received wound care during which an RN removed dressings from both heels, cleansed both wounds, and wiped each heel without changing gloves or performing hand hygiene between wounds or after disposing of soiled dressings. This practice conflicted with the facility’s written wound care procedure, which requires glove removal and hand hygiene after dressing removal and after wound cleansing. In interviews, the RN, NP, and DON/IP acknowledged that hand hygiene and glove changes are expected between dirty and clean tasks and between separate wounds to prevent infection.
A resident with MS, neurogenic bladder, mobility limitations, and existing pressure injuries was identified as dependent for toileting hygiene and at risk for pressure ulcers, yet the care plan lacked an individualized toileting/incontinence plan and a defined repositioning schedule. Despite a new coccyx pressure ulcer and documentation that interventions such as increased repositioning and incontinent care were needed, the care plan was not revised for a period of time to reflect these changes. During this time, the resident sometimes fell asleep on a bedpan and remained on it until staff removed it, and staff were not initially informed that the bedpan should no longer be used. The DON later acknowledged that the care plan revisions for turning, repositioning, and toileting were delayed until after the resident’s coccyx ulcer had significantly worsened.
A resident with diabetes, Crohn’s disease, bowel incontinence, and a history of MASD on the right gluteus developed an open, painful lesion on the right gluteal area that was documented over time without complete wound characteristics, clear etiology, or timely provider notification. Wound care orders were written for a stage 3 pressure ulcer on the left buttocks, while staff reported the wound was only on the right side and applied the left‑sided orders to the right gluteal wound in the absence of specific right‑side treatment orders. The DON acknowledged discomfort with staging the wound, lack of early physician notification, and confusion over wound classification, despite a facility policy requiring comprehensive wound assessment, consistent measurement, and provider notification when treatment orders are absent.
A resident with diabetes, chronic leg ulcer, kidney transplant, and a documented gluteal wound was care-planned for Enhanced Barrier Precautions (EBP), with posted instructions requiring gown and gloves for high-contact care such as transfers and wound care. During a telehealth wound assessment, the DON donned a gown and initially performed hand hygiene but then applied gloves without hand hygiene, removed a soiled dressing from the resident’s gluteal area, discarded it, removed gloves, and applied new gloves again without performing hand hygiene between glove changes. On another occasion, during use of a sit-to-stand lift, an NA wore gown and gloves, but the DON handled the lift harness, the resident’s clothing, and assisted with the transfer and repositioning while wearing a gown but no gloves, despite EBP requirements for transfers. The DON stated EBP was only needed for catheter or wound care and not for transfers, contradicting the posted EBP instructions and facility policy.
A resident with severe dementia, psychiatric disorders, and high dependence for ADLs was verbally abused during evening care when a NA, frustrated with the resident’s crying and resistance, loudly ridiculed her as acting like a two-year-old, threatened to hit her back if struck, told her she would be sent to a locked unit, and questioned who would want to care for her when she cried like a baby. Multiple staff witnessed the loud, stern, and intimidating tone and reported it to an LPN, who recognized it as verbal abuse but did not immediately remove the NA from duty or promptly report the allegation per policy, allowing the NA to continue working on the unit. Following this incident, the resident demonstrated increased crying, combativeness, resistance to care, wandering, self-isolation, and refusal of food, fluids, and medications above baseline, with documentation of significant emotional distress and subsequent ED evaluation for aggressive behaviors and poor intake.
A resident with dementia, bilateral above‑knee amputations, vascular disease, and severe protein‑calorie malnutrition developed a wound on an amputation stump that had a dressing dated several days before any documentation or treatment orders appeared in the record. Although bath audits and nursing notes initially reported no skin issues, a later assessment described a full‑thickness stage 4 ulcer/diabetic ulcer on the stump with exposed bone, erythema/edema, slough, and moderate serosanguineous drainage. Nursing staff interviews showed no one could identify who first discovered the wound or applied the initial dressing, and there was no evidence that the wound was assessed, the provider notified, or standing orders implemented when it was first present, despite facility expectations that new wounds be promptly evaluated and reported.
Failure to Follow Professional Standards for Ophthalmic Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice for administering ophthalmic medications to a resident with dry eye syndrome and degenerative eye disease. The resident was cognitively intact, required assistance with ADLs, and had physician orders for cyclosporine ophthalmic emulsion 0.05% one drop in both eyes twice daily and Refresh Tears ophthalmic solution one drop in both eyes four times daily for dry eyes. The administration summary showed that both eye medications were scheduled for the same time and were documented as being given at the same time on multiple dates. During a medication pass observation, a trained medication aide administered the ordered oral medications, then applied gloves and instilled one drop of cyclosporine in each eye, immediately followed by one drop of Refresh Tears in each eye, without any waiting period between the two medications. The surveyors referenced guidance from the American Academy of Allergy, Asthma, and Immunology stating that when more than one eye drop is ordered, three to four minutes should be allowed between drops in the same eye, and five to fifteen minutes should be allowed between different eye medications to prevent dilution. Interviews with the DON, pharmacy consultant, and medical provider confirmed that best practice and the provider’s recommendation were to wait between administration of cyclosporine and Refresh Tears, with the medical provider specifying a fifteen-minute interval. The facility did not provide a policy on ophthalmic medications when requested. The observed practice and documented administration times demonstrated that staff did not follow these professional standards or the medical provider’s recommended interval between the two eye medications.
Failure to Follow Wheelchair Transport Care Plan Leads to Fall With Injuries
Penalty
Summary
The deficiency involves the facility’s failure to implement care-planned fall prevention interventions for a resident at high risk for falls, resulting in a fall with injury. The resident had diagnoses including aphasia, dysphagia, muscle weakness, traumatic brain injury, and impaired mobility, with severe cognitive impairment documented on the MDS and dependence on staff for transfers and wheelchair transport. A care plan addressing wheelchair transport safety and positioning directed staff to ensure the resident was fully positioned and supported in the wheelchair prior to transport, verify footrests were in place prior to transport, and monitor for leaning, sliding, or unsafe positioning. An additional care-planned approach required wheelchair pedals to be on at all times. On the date of the incident, a nursing assistant transported the resident in a manual wheelchair from the shower room to the resident’s room without the foot pedals in place, contrary to the care plan. While being wheeled through the doorway, the wheelchair struck the door frame, causing the chair to stop and the resident, who had begun leaning forward, to fall out of the wheelchair onto the floor. Progress notes and ED documentation identified that the resident sustained a T12 vertebral fracture, a head injury with concussion, an abrasion and contusion to the head, a bruise to the left knee, and multiple lacerations to the right hand requiring sutures. The nursing assistant later acknowledged awareness that the foot pedals should have been on but did not apply them because the transport was only from the shower to the room. The DON confirmed that the resident’s care plan had not been followed when the fall occurred.
Failure to Implement and Update Pressure Ulcer Prevention and Treatment Led to Avoidable Unstageable Coccygeal Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, monitor, and implement individualized pressure ulcer prevention and treatment interventions for multiple high‑risk residents, resulting in an avoidable, unstageable coccygeal pressure ulcer for one resident that required surgical debridement and hospitalization. The resident had primary progressive multiple sclerosis, hereditary spastic paraplegia, obesity, and pre‑existing pressure‑related deep tissue injury to the left heel, and was identified as high risk for pressure ulcers on the Braden Scale due to constant moisture, chairfast status, very limited mobility, inadequate nutrition, and friction/shear risk. Hospital records on readmission documented irritant contact dermatitis of the bilateral gluteal cleft with specific cleansing and barrier cream orders, and facility documentation showed the resident could not reposition in bed or chair and required assist of two and a full‑body mechanical lift for transfers. Despite this, the admission/readmission skin assessment and weekly skin checks lacked measurements and detailed wound characteristics for the heel ulcer and gluteal dermatitis, and the care plan did not include comprehensive, individualized interventions beyond generic repositioning and wound care orders. After a new coccyx pressure ulcer was identified and documented as a stage 2 lesion, the facility failed to promptly and accurately update the care plan and implement recommended pressure‑relieving interventions. The wound nurse practitioner on 3/5 ordered coccyx wound care, an air mattress, pressure offloading, and a dietician consult, but the care plan was not revised and there was no evidence that an air mattress was placed on the bed for nearly two weeks. The environmental services director later confirmed that when the resident was moved to a new room, the gel mattress was not transferred, and the air mattress requested on 3/17 was not actually placed until the following day, despite being marked as completed. During this period, TAR documentation showed gaps in the every‑2‑hour repositioning order, and staff interviews revealed that CNAs were unaware of which residents were on repositioning programs, were not consistently repositioning residents, and had not received recent education on pressure ulcer prevention. The DON and RN case manager acknowledged that the coccyx wound increased in size and changed color between assessments, that the bed lacked the ordered gel mattress, and that the physician was not notified of the wound’s deterioration at that time. The facility also failed to timely modify toileting and incontinence care practices despite knowledge that the resident was being left on a bedpan for extended periods. The DON reported hearing before an IDT meeting that the resident had fallen asleep on a bedpan for an undetermined amount of time, but the care plan was not revised to discontinue bedpan use and implement a bedside commode until after the coccyx wound had significantly worsened. CNAs confirmed that the resident sometimes fell asleep on the bedpan and that they were not informed she should no longer use it until after the sore had worsened. Subsequent wound assessments documented rapid progression of the coccyx wound from a small stage 2 ulcer to a large, malodorous, necrotic wound with eschar, slough, erythema, and purulent drainage, ultimately classified as an unstageable pressure ulcer. The DON, NP, PA, and medical director all indicated that the lack of a pressure‑relieving mattress, failure to adjust pressure‑reducing interventions, and prolonged time on a bedpan likely contributed to the development and deterioration of the resident’s pressure ulcer, which was determined to be avoidable and resulted in hospitalization and surgical debridement. Additional documentation and interviews showed systemic assessment and communication failures related to pressure ulcer management. Weekly skin checks and wound assessments often omitted complete measurements, staging, and wound characteristics, and changes in wound size and appearance were not consistently recognized as deterioration or communicated to providers. The DON acknowledged that a 3/12 assessment showing increased wound size and purple discoloration should have been identified as a deep tissue injury and reported to the physician, but this did not occur. When nursing later documented foul odor, increased pain, and expanding necrotic tissue, telemedicine and PA responses deferred in‑person evaluation and ED transfer despite earlier recommendations that the resident be sent to the ED if an in‑person provider could not assess the wound. The NP ultimately found a large, malodorous, purulent wound with expanding eschar and ordered transfer to the hospital, where imaging and surgical findings confirmed a large necrotic sacral wound requiring extensive debridement. Throughout this sequence, the facility did not consistently follow its own pressure ulcer protocols, did not ensure ordered pressure‑relieving equipment was in place, and did not promptly revise care plans or interventions in response to known risk factors and documented wound changes. The report also notes that other residents reviewed for pressure ulcers were affected by similar failures in monitoring and individualized intervention, though detailed narratives focus primarily on this resident. Staff interviews revealed that CNAs relied on paper care guides that did not clearly identify residents on repositioning programs or at risk for skin breakdown, and that they were unaware of some residents’ special mattress orders or toileting restrictions. The DON and medical director stated that residents at risk for pressure ulcers should have immediate pressure‑relieving interventions and that existing ulcers require ongoing evaluation to prevent deterioration, but the documented practices for this resident did not align with those expectations. These combined actions and inactions—insufficient assessment detail, delayed or missing care plan revisions, failure to implement ordered support surfaces and repositioning, and delayed response to wound deterioration—constituted the deficiency in providing appropriate pressure ulcer care and preventing new ulcers from developing.
Failure to Assess, Care Plan, and Obtain Consent for Bed Grab Bar Use
Penalty
Summary
The deficiency involves the facility’s failure to follow required procedures before installing and using bed grab bars for a resident. The resident had diagnoses including spastic hemiplegia affecting the left side and muscle weakness, and an admission MDS indicating moderate cognitive impairment. During observation, the resident was seen in a power chair with bilateral grab bars on the bed and reported using them to roll in bed and for transfers. The resident’s care plan, dated 1/23/26, documented a need for assistance with bed mobility and independence with transfers but did not mention or address the use of grab bars or side rails. Review of the electronic medical record showed no completed grab bar/side rail or bed mobility device assessment to determine the necessity of the grab bars or whether the resident could safely use them. There was also no evidence that the resident or the resident’s representative had been educated on the risks of having a grab bar on the bed or that informed consent had been obtained. In interviews, an LPN and the ADON both stated that a bed mobility device assessment was required to determine need and safety prior to installing grab bars, and both confirmed that no such assessment was present in the resident’s record.
Failure to Perform Hand Hygiene and Change Gloves During Wound Care
Penalty
Summary
Surveyors observed that a registered nurse (RN) and a nurse practitioner (NP) did not follow the facility’s established infection control practices during wound care for one resident. During a wound treatment, the RN wore gloves while removing the dressing from the resident’s left heel, then removed the dressing from the right heel, sprayed both wounds with wound cleanser, wiped the left heel with gauze, and then used a clean gauze pad to wipe the right heel. The RN did not remove her gloves or perform hand hygiene after disposing of the soiled dressings or between cleaning the left and right heel wounds, contrary to the facility’s written wound care procedure, which requires glove removal and hand hygiene after removing the previous dressing and again after cleaning the wound. The resident’s admission MDS documented diagnoses including multiple rib fractures, heart failure, dementia, anxiety, and the presence of a pressure ulcer, and indicated the resident was cognitively intact and required staff assistance with care and transfers. The resident’s care plan identified pressure ulcers on both heels requiring wound care. In interviews, the RN, NP, and the DON/infection prevention nurse each stated that gloves should be changed when moving from dirty to clean areas and that hand hygiene is expected after glove removal and between wounds to prevent infection, confirming that the observed practice did not align with facility policy or expected infection control standards.
Failure to Timely Revise Care Plan for Toileting and Skin Integrity
Penalty
Summary
The deficiency involves the facility’s failure to timely revise and individualize a resident’s care plan to address toileting and incontinence needs in relation to impaired skin integrity. The resident had diagnoses including primary progressive multiple sclerosis, hereditary spastic paraplegia, obesity, and a pressure-induced deep tissue injury to the left heel. A Significant Change MDS identified the resident as dependent for toileting hygiene, with lower extremity range-of-motion limitations, wheelchair use, dependence for transfers, occasional urinary incontinence, intact cognition, and at risk for pressure ulcers with existing unhealed pressure injuries and MASD. The resident’s skin-focused care plan, revised on various dates, included skin inspections, wound care orders, weekly skin checks, pressure ulcer care to the left heel, nutritional supplements, and a gel mattress, but did not include an individualized toileting or incontinence plan. On a weekly skin check dated 3/3/26, nursing staff identified a new Stage 2 pressure ulcer on the coccyx and contact dermatitis on both gluteal folds. An IDT Final Post Review Follow Up dated 3/10/26 (signed 3/23/26) documented that a new skin issue had occurred and that interventions after the incident included wound care treatment orders, increased repositioning, and increased incontinent care. However, the resident’s care plan from 3/3/26 through 3/16/26 did not show revisions reflecting increased incontinence care or a repositioning schedule, and the care plan was not updated to include these elements until 3/17/26. During this period, the care plan still lacked an individualized toileting plan despite the resident’s identified incontinence and new coccyx pressure ulcer. Progress notes on 3/17/26 documented that the resident’s coccyx wound had declined, with an evaluation describing a deteriorating wound characterized as a Kennedy terminal ulcer/End of Life, staged as a Stage 4 pressure ulcer, in-house acquired, with increased size, exudate, odor, pain, and surrounding erythema. On that same date, the skin focus care plan was revised to include prompt incontinence care and keeping the skin clean and dry, and the elimination focus care plan was revised to address incontinence due to neurogenic bladder with use of a bedside commode offered every 2–3 hours. A nursing assistant reported that when working with the resident, the resident would sometimes fall asleep on the bedpan and forget to ask staff to remove it, and that she was not aware the resident was not supposed to use the bedpan until after the sore had worsened. The DON stated that the resident’s care plan had not been revised earlier to include a turning and repositioning schedule or toileting changes, and that it should have been revised as soon as staff learned the resident was falling asleep on the bedpan, rather than waiting until after the pressure ulcer worsened.
Failure to Assess and Notify Provider for Right Gluteal Wound
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess and appropriately manage a non‑pressure skin issue on a resident’s right gluteal area, and to notify the physician in a timely manner. The resident had diagnoses including diabetes, Crohn’s disease, and a kidney transplant, and the MDS indicated occasional bowel incontinence, no pressure ulcers, and no moisture‑associated skin damage at that time. Earlier documentation identified a resolved MASD to the right gluteus, and a progress note later described a sacral wound with creams applied, noting that sores were still open and painful during application, but without any measurements, wound characteristics, or evidence of physician notification. Subsequent wound assessments documented an open lesion on the right gluteus with specific measurements on multiple dates, but did not identify the wound type or other characteristics, and the record did not show physician notification or treatment orders for the right gluteal lesion. Provider orders in place initially addressed cleansing the buttocks and applying barrier cream, and later included a detailed wound care order for a stage 3 pressure ulcer documented on the left buttocks. However, the resident’s record did not contain a specific treatment order for the right gluteal wound, despite the ongoing documentation of an open lesion in that area. Interviews revealed confusion and inconsistency in wound identification and classification. The DON stated that the right gluteal wound was documented as an open lesion because she did not feel comfortable determining the wound type, and acknowledged that the physician should have been notified when the wound was first identified. The DON was unaware that the NP had documented the wound as being on the left buttocks and as a stage 3 pressure ulcer, while the RN reported that the wound had never been on the left buttocks and that she had been applying the left‑sided wound orders to the right gluteal area because there was no open area on the left. The resident reported a recurring painful area on the right buttocks and chronic stool leakage since prior anal fistula surgery. The facility’s own wound treatment policy required comprehensive assessment of wound etiology and characteristics, consistent measurement and documentation, and provider notification in the absence of treatment orders, which were not followed for this resident’s right gluteal wound. The deficiency centers on the lack of a comprehensive wound assessment for the right gluteal lesion, incomplete documentation of wound characteristics, failure to clearly determine and document the wound etiology, and failure to notify the physician and obtain appropriate treatment orders when the wound was identified and remained open. These actions and inactions resulted in a discrepancy between the documented wound location and type and the actual clinical presentation, as well as a period during which the right gluteal wound had no specific, clearly ordered treatment despite being open and painful.
Failure to Perform Hand Hygiene and Implement Enhanced Barrier Precautions During Wound Care and Transfers
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper hand hygiene during wound care and to consistently implement Enhanced Barrier Precautions (EBP) for a resident requiring such measures. The resident had diagnoses including diabetes, a non-pressure chronic ulcer of the right lower leg, and a kidney transplant, and a wound assessment documented an open lesion on the right gluteal area. The resident’s care plan and a sign posted outside the room specified that EBP, including gown and gloves, were required for high-contact care activities such as dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, catheter care, and wound care. During one observation, the DON performed hand hygiene and donned a gown before entering the resident’s room for a telehealth wound assessment. Inside the room, the DON went into the bathroom, applied gloves without performing hand hygiene, removed the resident’s brief, and removed a foam dressing from the right gluteal area that had stool on one corner. After discarding the soiled dressing, the DON removed gloves and then applied new gloves without performing hand hygiene between glove changes. When questioned, the DON stated that hand hygiene should be done when hands or gloves are visibly soiled and before and after removing or applying gloves, and acknowledged that hand hygiene had not been performed each time gloves were removed and reapplied. In a separate observation, the resident was transferred using a sit-to-stand mechanical lift while EBP requirements were not fully followed. An NA entered the room wearing a gown and gloves with the lift, and the DON applied the lift harness under the resident’s arms and cinched the waist strap, encountering the resident’s clothing, while not wearing gloves. After the transfer to bed, the DON pulled down the resident’s pants and removed the harness while touching the resident’s clothes. Following wound care by a CNP-WOC, the DON again assisted the resident by sitting the resident on the edge of the bed, applying the lift harness, and adjusting the resident’s pants and shirt while wearing a gown but no gloves. The DON stated that EBP was only needed for catheter or wound care and not for transfers, and only upon reading the posted EBP sign acknowledged that EBP was required for all high-contact resident care activities, including transfers.
Failure to Protect Resident From Verbal Abuse and Delay in Removing Alleged Perpetrator
Penalty
Summary
The deficiency involves the facility’s failure to protect a vulnerable resident from mental abuse and to respond appropriately to an allegation of abuse. The resident had severe cognitive impairment, Alzheimer’s disease, dementia, anxiety, depression, psychotic disorder, and significant functional dependence, including frequent incontinence and the need for extensive assistance with ADLs and transfers. Her care plan identified behavioral and mood issues such as wandering, yelling, combative behavior, and calling staff names, with interventions including calm approaches, emotional support, redirection, and monitoring for emotional distress and mood/behavior changes. She was identified as a vulnerable adult, with instructions to monitor for signs of emotional distress and to follow the facility’s abuse reporting policy. On the evening in question, while the resident was crying on the phone with her son and expressing a desire to leave, NA-A and NA-B entered to provide evening care using an EZ stand lift. After the resident ended the phone call, multiple staff reported that NA-A spoke to the resident in a loud, stern, and frustrated tone, telling her to stop crying and that she was acting like a two-year-old. When the resident swatted at NA-A, NA-A stated, “If you hit me, I’m going to hit you back,” and later told the resident she was “in trouble now.” Staff reported that NA-A told the resident she would be sent to a locked unit so she could not get out, and questioned who would want to care for her when she cried like a baby, and that nobody would want to keep working with her. NA-C described NA-A yelling commands such as “HOLD ON!” and “Stop crying! Where would you be if you were not here? Probably lying on the floor,” and felt NA-A was obviously upset and overwhelmed. These statements were made in the presence of the resident while she was already distressed and crying. Following this interaction, the resident exhibited crying, yelling, combativeness, resistance to care, wandering into other residents’ rooms, self-isolation, and refusal of food, fluids, and medications above her prior baseline, as documented in behavior charts, target behavior monitoring, and nursing progress notes. Staff documented that she cried most of the morning, was very restless, difficult to redirect, hit and pinched staff, called staff names, and refused care and meals. She required repeated redirection, 1:1 attention, and non-pharmacological interventions, and was ultimately sent to the ED for evaluation of combativeness and emotional distress, where she was treated for dementia with aggressive behavior and hypoglycemia related to poor intake. The report identifies that the resident’s actual response and the reasonable person concept showed serious psychosocial harm, including increased crying and combative behavior above baseline, fear/anxiety manifested as combativeness, resistance to care and social interaction, and self-isolation. The facility also failed to immediately remove the alleged perpetrator from resident care and to promptly report and investigate the allegation in accordance with its abuse policy. After NA-B and NA-C reported to LPN-A that NA-A had yelled at and threatened the resident, LPN-A acknowledged it as verbal abuse but did not initiate immediate protective measures or timely reporting. LPN-A stated she believed she had 24 hours to report because there was no injury, despite facility policy requiring reporting within two hours. NA-A remained on the unit and continued working until the end of her shift, including after staff had clearly communicated their concerns to LPN-A. TMA and NA staff described uncertainty about their authority to remove NA-A and reliance on the nurse to act, while the DON later informed LPN-A that NA-A should have been removed from the floor to prevent further danger to residents. The Immediate Jeopardy was determined to have begun when NA-A’s derogatory, intimidating, and threatening statements were made and continued while she remained on duty with access to the resident and other vulnerable residents.
Failure to Timely Assess and Treat Newly Discovered Stump Wound
Penalty
Summary
The deficiency involves the facility’s failure to provide timely treatment and care for a newly discovered wound on a resident’s above‑knee amputation stump. The resident was admitted with diagnoses including unspecified dementia with behavioral disturbances, vascular dementia, bilateral above‑knee amputations, vascular disease, reduced mobility, and severe protein‑calorie malnutrition, and had no documented ulcers or skin problems on admission or on the most recent MDS. A weekly bath audit on 3/17/26 documented only non‑tender lymph nodes on the right upper hip and did not identify any open areas. However, when the wound was later assessed, the dressing on the stump was dated 3/16/26, indicating that a wound and dressing existed at that time, even though no corresponding assessment, provider notification, or treatment orders were documented. On 3/23/26, nursing staff documented a new skin issue above the resident’s knee at the amputation site, describing a stage 4 pressure ulcer/injury with full‑thickness skin and tissue loss, exposed bone, erythema/edema, and moderate serosanguineous exudate. The wound measured 1.56 cm by 1.64 cm, with 20–29% granulation tissue and 80% slough. A progress note and skin issues assessment on that date confirmed the wound characteristics and staging, and the NP, after reviewing a picture, determined the wound to be a diabetic ulcer with peripheral vascular disease and severe protein‑calorie malnutrition as contributing factors. On that same date, the NP was notified, antibiotic therapy (doxycycline) was ordered for possible cellulitis, and specific wound care orders were initiated, with documentation on the MAR that these treatments were carried out beginning 3/23/26. Multiple interviews with nursing staff revealed that no one could identify who discovered the wound or who applied the initial dressing dated 3/16/26, and there was no documentation of a wound assessment, provider notification, or interim treatment between 3/16/26 and 3/22/26. Several RNs and LPNs who worked shifts from 3/16/26 through 3/20/26 stated they did not notice a wound on the stump and that, per their usual practice, they would have contacted the provider and initiated treatment if they had found one. One LPN recalled seeing a band‑aid with a date on the stump but could not recall the date, and another LPN stated she did not see the wound because she was not looking for one. The facility’s standing orders required staff to assess all wounds daily, change dressings every three days and as needed, treat with normal saline or non‑cytotoxic cleanser and appropriate dressings, and notify the provider the next business day when a new wound or injury was found. Despite these expectations, the wound identified by the dated dressing on 3/16/26 was not assessed, reported, or treated according to orders and facility policy until 3/23/26.
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