Colonial Manor Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Lakefield, Minnesota.
- Location
- 403 Colonial Avenue, Lakefield, Minnesota 56150
- CMS Provider Number
- 245572
- Inspections on file
- 20
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Colonial Manor Nursing Home during CMS and state inspections, most recent first.
The facility failed to ensure the dietary manager was certified to oversee nutrition and food services in the absence of a full-time RD, potentially affecting all 25 residents. The DM, employed since December 2023, was not certified and had not started certification classes. The administrator was aware but believed weekly RD visits were adequate until certification was obtained.
The facility failed to submit accurate staffing data to CMS for Q3 2024, indicating insufficient licensed nursing coverage on multiple days. Despite schedules and timecards showing coverage, the PBJ report triggered a deficiency. Staff responsible for data entry could not identify the cause, and the facility followed CMS policy.
The facility failed to ensure the acting infection preventionist (IP) had completed specialized training, affecting all 25 residents. The DON, who started in July 2024, had only completed one module of the CDC course, while RN-A, the MDS coordinator, had no training. Both were enrolled in the necessary courses, but the facility lacked a trained IP, contrary to its Infection Prevention and Control Program requirements.
The facility failed to implement a process for reviewing antibiotic use, affecting several residents. Infection control logs lacked information on antibiotic dosages and infection resolution. The newly assigned Infection Preventionist had not started training, and the facility's policies on antibiotic stewardship were not adequately enforced.
A resident with moderately impaired cognition reported missing handkerchiefs and shirts, but the facility failed to follow its grievance process. Despite informing staff, no formal report was completed, and confusion among staff about the procedure was evident. The absence of a social worker and a missing belongings binder contributed to the breakdown in handling the grievance.
A facility failed to accurately code a resident's hospice status on the MDS assessment. The resident, with diagnoses of protein-calorie malnutrition and receiving palliative care, was enrolled in hospice care, but this was not reflected in the quarterly MDS. The MDS nurse acknowledged the oversight after reviewing the resident's EMR and admitted to inadvertently missing the hospice status. The facility's policy for MDS accuracy was requested but not provided.
A facility failed to update a resident's care plan to include hospice care, despite the resident being enrolled in hospice services. The resident had diagnoses of protein-calorie malnutrition and was receiving palliative care. Although a provider had ordered hospice admission and the hospice agency confirmed enrollment, the care plan did not reflect these services. The MDS nurse acknowledged the oversight, which was contrary to the facility's care planning policy requiring updates with any changes.
A resident was discharged without a complete recapitulation of stay, as required by facility policy. The resident, with conditions including a pressure ulcer and paraplegia, was discharged home with their spouse. Despite discharge orders being reviewed, the medical record lacked a discharge summary due to staff turnover and lack of awareness by the MDS coordinator.
The facility failed to accurately monitor and document the weights of two residents, leading to a deficiency in providing adequate nutrition. One resident experienced significant weight loss without proper documentation or physician notification, while another had inconsistent weight records that were not addressed. The facility's policy for weight monitoring was not followed, contributing to the deficiency.
A facility failed to follow enhanced barrier precautions (EBP) for a resident with a urinary ostomy. The resident required assistance for daily activities, including toileting. An NA was observed assisting the resident without donning the required PPE, despite an EBP sign on the door. The NA believed PPE was unnecessary as she did not touch the resident directly. The DON confirmed that the facility's policy required PPE during toileting for residents under EBP, and the infection preventionist noted that EBP had been reviewed in a staff meeting attended by the NA.
The facility failed to document and administer pneumococcal and influenza vaccines for residents, despite having policies in place. A resident's record lacked documentation of receiving vaccines or education on risks/benefits, while another resident's record showed consent but no administration of the influenza vaccine. The RN confirmed delays in obtaining consents and that no influenza vaccines had been given, despite availability.
A facility failed to report a verbal abuse allegation involving a resident to the administrator and State Agency (SA) in a timely manner. The incident, where a nursing assistant allegedly threatened a resident, was delayed in reporting due to the absence of key staff and unsuccessful attempts to delegate reporting duties. The facility's policy requires immediate reporting, but the incident was not reported to the SA until the following day.
The facility failed to provide sufficient staffing, resulting in delayed assistance with personal care needs for several residents. Residents reported extended wait times for toileting and other care, leading to incontinence and missed baths. Staff interviews confirmed the shortage, and administration acknowledged the issue but lacked a process to track call light response times.
A resident with severe cognitive impairment and Alzheimer's disease experienced a change in their ADLs, including coughing or choking during meals and weight loss. Despite these changes, the care plan was not updated to include the Speech Language Pathologist's orders for staff assistance with feeding and cues to sit up. Interviews with staff confirmed the resident ate better with assistance, but the care plan remained unchanged, leading to a deficiency.
A resident entered the facility without a pressure ulcer but later developed one due to inadequate assessment and intervention. The facility failed to update the care plan, conduct comprehensive assessments, and follow physician orders for dressing changes. The resident was not placed on the wound clinic list, and the facility's actions did not align with their policy to prevent and treat pressure ulcers.
A resident with severe cognitive impairment experienced a decline in continence due to the facility's failure to implement an effective toileting program. Despite being identified as a good candidate for retraining, the resident's care plan was not consistently followed, and no causal analysis was conducted. The DON acknowledged the decline but lacked a treatment plan, contributing to the deficiency.
Deficiency in Dietary Manager Certification
Penalty
Summary
The facility failed to ensure that the dietary manager (DM) was certified to oversee nutrition and food services in the absence of a full-time registered dietician (RD). This deficiency had the potential to affect all 25 residents residing in the facility. During an interview, DM-J, who had been employed since December 2023, admitted she was not a certified dietary manager and had not started any certification classes. Although she held a Food Safety Certificate from 2019, she was only notified on the day of the interview that the administrator would enroll her in the certification class. The administrator acknowledged awareness of DM-J's lack of certification and believed that the RD's weekly visits would suffice until DM-J obtained her certification. However, DM-J had not yet been signed up for the dietary certification classes. The job description for the dietary manager required knowledge of state and federal food regulations, Serv-Safe Certification, and a current certification as a Certified Dietary Manager (CDM) or dietician, or a willingness to obtain such certification.
Inaccurate Staffing Data Submission to CMS
Penalty
Summary
The facility failed to submit accurate and complete staffing data to the Centers for Medicare and Medicaid Services (CMS) for Quarter 3 of 2024. The CMS payroll-based journal (PBJ) staffing data report indicated that there were four or more days within the quarter where the facility had less than 24 hours per day of licensed nursing coverage. The specific dates identified were 5/25/24, 6/8/24, 6/9/24, 6/16/24, 6/1/24, 6/22/24, 6/23/24, 6/24/24, 6/29/24, and 6/30/24. However, upon review of the nursing staff schedules and daily staffing postings for these dates, it was found that a licensed nurse was scheduled for each shift, and timecards confirmed that all shifts were worked by either an employed nurse or an agency nurse. Interviews with the nursing department coordinator and the business office manager revealed that there was always a licensed nurse working each shift, and all nursing staff, including management and agency staff, were entered into the PBJ report. Despite this, the report still triggered for insufficient coverage. The business office manager, who was responsible for entering the data, and the administrator could not determine why the report indicated a deficiency. The facility stated that they followed the CMS PBJ - LTC policy manual, but the issue with the report remained unresolved.
Lack of Trained Infection Preventionist in Facility
Penalty
Summary
The facility failed to ensure that the acting infection preventionist (IP) had completed specialized training in infection prevention and control, which had the potential to affect all 25 residents residing in the facility. The Director of Nursing (DON), who started her employment in July 2024, assumed the infection control role in October but had only completed one module of the CDC infection preventionist course. The role was intended to be shared with RN-A, the Minimum Data Set (MDS) coordinator, who had no training at the time of the survey. RN-A, who began working at the facility in June 2024, was initially focused on MDS training and had not yet started the CDC infection preventionist course, although she was enrolled. The facility's administrator acknowledged the lack of a trained infection preventionist but noted that both the DON and RN-A were enrolled in the necessary training. The facility's Infection Prevention and Control Program, dated December 2022, outlined the need for effective oversight and training in infection prevention and control practices, which was not being met at the time of the survey.
Failure to Implement Antibiotic Review Process
Penalty
Summary
The facility failed to implement a comprehensive process for reviewing antibiotic use, which affected four out of five residents reviewed for antibiotics. The monthly infection control logs from July to November 2024 identified residents with infections who were administered antibiotics, but these logs lacked critical information such as antibiotic dosages and whether the infections had resolved. For instance, one resident with a urinary tract infection (UTI) was prescribed Macrobid, but the surveillance log did not indicate the dosage or resolution of the infection. Similarly, other residents with UTIs were prescribed antibiotics like ampicillin and cefdinir, yet the logs did not document the resolution of their infections. Interviews revealed that the facility's registered nurse, who was newly assigned as the Infection Preventionist (IP), had not yet started her IP training and was unaware of the existing processes for antibiotic use identification. The facility's administrator expected the nursing team to track and maintain monthly updates on antibiotic use, but this was not consistently enforced. The facility's Antibiotic Stewardship Policy required follow-up on pending cultures and monitoring of antibiotic usage patterns, but these procedures were not adequately implemented, leading to the deficiency in antibiotic management.
Failure to Follow Grievance Process for Missing Personal Property
Penalty
Summary
The facility failed to adhere to its grievance process regarding missing personal property for a resident identified as R19, who reported missing handkerchiefs and shirts. R19, who has moderately impaired cognition, stated that multiple packs of handkerchiefs and a couple of shirts have been lost since his admission in January 2024. Despite informing multiple staff members about the missing items, no formal grievance process was initiated. Interviews with nursing assistants and the nursing department coordinator revealed confusion and lack of clarity about the procedure for handling missing belongings, with some staff unsure of the next steps after reporting to the charge nurse. Further investigation showed that the facility's policy required a missing or damaged item report to be completed and submitted to social services, who would maintain a file of such reports. However, the administrator confirmed that no form was completed for R19's missing items, indicating a failure to follow the grievance process. The laundry staff was aware of the missing handkerchiefs but not the shirts, and no resolution was reached. The absence of a social worker further complicated the process, as the missing belongings binder was not maintained, leading to a breakdown in the facility's grievance handling procedure.
Failure to Accurately Code Hospice Status on MDS
Penalty
Summary
The facility failed to accurately code a resident's hospice status on the Minimum Data Set (MDS) assessment. The resident, identified as R15, had diagnoses of protein-calorie malnutrition and was receiving palliative care. Despite being enrolled in hospice care on July 8, 2024, as confirmed by the hospice agency, the quarterly MDS assessment did not reflect this status. The MDS nurse, RN-A, acknowledged during an interview that hospice was not marked in Section O of the MDS assessment, which should indicate special treatments, procedures, and programs. This oversight was identified when RN-A reviewed the resident's electronic medical record and admitted to inadvertently missing the hospice status. The facility's policy for the accuracy of MDS assessments was requested but not provided.
Failure to Update Care Plan for Hospice Services
Penalty
Summary
The facility failed to revise the care plan for a resident, identified as R15, to include hospice care, despite the resident being enrolled in hospice services. R15's facesheet, printed on 11/20/24, listed diagnoses of protein-calorie malnutrition and an encounter for palliative care. The quarterly Minimum Data Set (MDS) assessment indicated that R15 had moderately impaired cognition but could communicate effectively. Progress notes from 7/3/24 showed that a provider had faxed an order for hospice admission, and the hospice agency confirmed R15's enrollment in hospice services on 7/8/24. However, R15's care plan, initiated on 5/1/23, did not reflect the inclusion of hospice or palliative care. During an interview, the MDS nurse acknowledged the omission and stated that the care plan should have been updated to reflect the resident's hospice status. The facility's care planning policy, revised in 8/23, requires care plans to be updated with any changes throughout a resident's stay.
Incomplete Discharge Documentation for Resident
Penalty
Summary
The facility failed to document a complete recapitulation of stay for a resident reviewed for discharge. The resident, who was admitted to the facility with diagnoses including a pressure ulcer, depression, osteomyelitis, and paraplegia, was discharged to home with their spouse. Although discharge orders were signed by the provider and reviewed with the resident and spouse, the medical record lacked a discharge summary. Interviews with facility staff revealed that there was confusion regarding the responsibility for completing the discharge summary. The regional director of skilled care confirmed the absence of the discharge summary and attributed it to staff turnover. The MDS coordinator, who was handling the discharge process for the first time, was unaware of the requirement to complete a discharge summary, resulting in its omission. The facility's policy required nursing staff to complete the discharge summary in the electronic health record, but this was not adhered to in this instance.
Failure to Accurately Monitor and Document Resident Weights
Penalty
Summary
The facility failed to document and monitor weight loss for a resident, R24, who experienced significant weight loss. R24 had a history of stroke, Parkinsonism, dementia, and dysphagia, which placed her at risk for nutritional compromise. Despite these risks, the facility did not accurately monitor her weight changes, as evidenced by inconsistent weight records and a lack of reweighs when discrepancies were noted. The registered dietician (RD) and licensed practical nurse (LPN) both identified inaccuracies in the weight records, but reweighs were not conducted, and the physician was not notified of the significant weight loss. Additionally, the facility failed to obtain accurate weights for another resident, R4, who had severe protein-calorie malnutrition and dysphagia. R4's weight records showed inconsistencies, with an aberrant weight recorded that was not addressed. The RD noted the inaccuracies in her reports, but there was no communication with the nursing staff or director of nursing (DON) to rectify the issue. The DON was aware of the inaccuracies but relied on verbal communication to address the problem, which did not effectively resolve the issue. The facility's policy required weekly weights to be taken by nursing staff and entered into the electronic medical record, with reweighs requested for significant changes. However, this policy was not followed, as evidenced by the lack of reweighs and physician notification for significant weight changes. The facility's failure to adhere to its policy and ensure accurate weight monitoring contributed to the deficiency in providing adequate nutrition and monitoring for residents at risk of malnutrition.
Failure to Follow Enhanced Barrier Precautions for Resident with Urinary Ostomy
Penalty
Summary
The facility failed to ensure that enhanced barrier precautions (EBP) were followed for a resident with a urinary ostomy. The resident, who had diagnoses including neuromuscular dysfunction of the bladder and bladder-neck obstruction, required staff assistance for most activities of daily living, including toileting. An observation revealed that a nursing assistant (NA) entered the resident's room and assisted with toileting without donning the required personal protective equipment (PPE), despite an EBP sign on the door indicating the need for gown, gloves, and mask. During interviews, the NA admitted to not wearing PPE while assisting the resident, believing it was unnecessary as she did not touch the resident directly. The director of nursing (DON) was uncertain about the distance requirement for PPE use and later confirmed that the facility's policy required PPE during toileting for residents under EBP. The infection preventionist confirmed that EBP had been reviewed in a staff meeting, and the NA had attended. The facility's policy indicated that EBP should be used for residents with indwelling medical devices during high-contact care activities such as toileting.
Deficiency in Vaccination Documentation and Administration
Penalty
Summary
The facility failed to maintain proper records and documentation for pneumococcal and influenza vaccinations for residents, leading to a deficiency in their immunization protocol. Specifically, one resident's medical record lacked documentation of receiving any pneumococcal or influenza vaccines, as well as documentation of education on the risks and benefits or declination of these vaccines. Additionally, another resident's record showed consent for the influenza vaccine, but there was no documentation of the vaccine being administered, despite the COVID vaccine being given. Furthermore, the facility did not document that the influenza vaccine had been offered or that education on risks and benefits was provided for another resident. The registered nurse (RN) confirmed that the facility had not administered influenza vaccines for the current year, citing delays in receiving consent forms from families. The RN also acknowledged that the influenza vaccines had been available at the facility for several months but had not been administered. The facility's policies on resident vaccinations and infection control outlined the procedures for offering and documenting vaccinations, including providing educational handouts and obtaining consent. However, these procedures were not followed, resulting in the deficiency.
Delayed Reporting of Verbal Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of verbal abuse involving a resident to the administrator and the State Agency (SA) in a timely manner. The incident occurred when a nursing assistant allegedly threatened a resident by saying that her husband would yell at her if she did not cooperate. This event was reported internally by another nursing assistant who witnessed the incident, but the report was delayed due to the absence of the charge nurse, the Director of Nursing (DON), and the administrator. The business office manager was informed later in the day, but the report to the SA was not made until the following day. The facility's Abuse Prevention Plan requires that all allegations of abuse be reported immediately, but not later than two hours after the allegation is made. In this case, the report was delayed beyond the required timeframe, as the administrator was out of the building and the DON was unavailable to report the incident. The delay in reporting was further compounded by unsuccessful attempts to grant another staff member the privileges needed to report to the SA, resulting in a failure to comply with the facility's policy and regulatory requirements.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient staffing to meet the needs of residents, resulting in delayed assistance with personal care needs. Seven residents reported concerns about inadequate staffing, leading to extended wait times for assistance with toileting and other personal care tasks. For instance, one resident experienced a 1.5-hour wait for assistance, resulting in incontinence due to diarrhea. Another resident reported sitting on the commode for an hour, causing discomfort and increasing the risk of urinary tract infections due to delayed catheter drainage. The call light logs for the residents indicated numerous instances of prolonged wait times, with some residents experiencing waits of over an hour. Interviews with family members and residents highlighted the impact of these delays, including embarrassment, frustration, and anxiety. Residents expressed concerns about missed baths and the inability to receive timely assistance, which affected their dignity and personal hygiene. The facility's staff also acknowledged the staffing shortages, with some employees stating that they were unable to respond to call lights promptly due to other responsibilities. The facility's administration recognized the staffing challenges but did not have a clear process for tracking and addressing call light response times. The Director of Nursing was unaware of a specific time frame for what constituted a timely response, and the interim case manager noted that staffing was based on census rather than the acuity of residents' needs. Despite efforts to recruit new staff, the facility continued to struggle with providing adequate care, as evidenced by the residents' complaints and the documented call light wait times.
Failure to Revise Care Plan for Resident with ADL Changes
Penalty
Summary
The facility failed to revise the care plan for a resident who experienced a change in their activities of daily living (ADLs). The resident, who had severe cognitive impairment due to Alzheimer's disease and anxiety, initially required partial to substantial assistance with ADLs and showed no signs of a swallowing disorder. However, a significant change in the resident's condition was noted, including coughing or choking during meals and a weight loss from 178 to 160 pounds. Despite these changes, the care plan was not updated to reflect the new needs identified by the Speech Language Pathologist (SLP), which included staff assistance with feeding at every meal and frequent cues to sit up. Interviews with facility staff, including a Licensed Practical Nurse (LPN) and a Nursing Assistant (NA), revealed that while the resident could feed themselves, they ate better when assisted by staff. The Director of Nursing (DON) acknowledged that the care plan had not been revised to include the SLP's orders and noted the resident's weight loss. The facility's care plan policy requires that care plans be revised as necessary to reflect changes in a resident's condition, but this was not done in this case, leading to the deficiency.
Failure to Prevent and Address Pressure Ulcer Development
Penalty
Summary
The facility failed to comprehensively assess, monitor, and implement person-centered interventions to prevent a pressure ulcer for a resident who entered the facility without a pressure ulcer. Initially, the resident was assessed with a Braden Scale score indicating no risk for pressure ulcers, but later assessments showed an increased risk. Despite this, the care plan did not adequately address the resident's needs, and interventions such as a pressure-reducing device were not effectively implemented. The resident developed a pressure ulcer on the coccyx, which was not promptly or adequately addressed. There was a lack of comprehensive pressure ulcer assessments, including staging, characteristics, and signs of infection. The facility also failed to conduct a tissue tolerance test to determine repositioning frequency and did not perform daily skin monitoring or weekly comprehensive wound assessments. The care plan was not updated to reflect the development of the pressure ulcer or to prevent further occurrences. The facility's policy required individualized repositioning programs and regular monitoring of skin conditions, but these were not followed. The resident's dressing was not changed according to physician orders, and the resident was not placed on the wound clinic list for weekly measurements. The Director of Nursing acknowledged the need for improvement in pressure ulcer care, but the facility's actions did not align with their policy to prevent and treat pressure ulcers effectively.
Failure to Implement Effective Toileting Program
Penalty
Summary
The facility failed to develop an individualized toileting program for a resident with severe cognitive impairment, Alzheimer's disease, and anxiety, leading to a decline in continence. The resident required partial to moderate assistance with toileting and was frequently incontinent of bladder but always continent of bowel upon admission. Despite being identified as a good candidate for a bowel/bladder retraining program, the facility did not implement an effective toileting plan, and the resident's continence declined over time. The resident's care plan included a toileting schedule to prevent bladder incontinence, but the plan was not consistently followed. The resident was supposed to be toileted three times a day, but records showed inconsistencies in adherence to this schedule. Additionally, the facility did not maintain a voiding diary or conduct a causal analysis to understand the resident's baseline toileting routine, which could have informed a more effective care plan. The Director of Nursing (DON) acknowledged the resident's decline in continence but was unable to articulate a treatment plan to address the issue. The facility's policy required a comprehensive assessment and care plan to maintain the highest practicable level of continence, but this was not achieved. The lack of a revised toileting plan and failure to notify the physician of the resident's decline contributed to the deficiency.
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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