Edenbrook Of St Cloud
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Cloud, Minnesota.
- Location
- 1717 University Drive Southeast, Saint Cloud, Minnesota 56304
- CMS Provider Number
- 245438
- Inspections on file
- 41
- Latest survey
- June 26, 2025
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Edenbrook Of St Cloud during CMS and state inspections, most recent first.
The facility failed to serve food at a palatable temperature, affecting all residents. Observations and interviews revealed that meals were often cold, with some items undercooked or overcooked. Food was left on carts for extended periods, and staff did not consistently check temperatures during serving. The steam table had issues maintaining adequate temperatures, and the facility's policy for safe food temperatures was not followed, leading to a deficiency.
Two residents experienced neglect in a facility, with one resident left with full urinals and another missing scheduled baths. Despite needing assistance due to cognitive and mobility impairments, staff failed to provide timely help, impacting their dignity and quality of life. Interviews revealed staff did not adhere to facility policies for regular checks and personal hygiene assistance.
A resident with dementia and moderate cognitive impairment fell and sustained a head laceration after being left unattended by a nursing assistant during ambulation. The resident, who required supervision and assistance according to their care plan, reported feeling weak and dizzy. The nursing assistant left the resident to retrieve a wheelchair, resulting in the fall. The incident was captured on video, and staff interviews confirmed the failure to adhere to the resident's care plan, which required continuous assistance.
The facility failed to properly label and date food items, maintain a clean kitchen, and ensure proper hand hygiene and glove use by staff, leading to potential risks for all 65 residents.
The facility failed to submit accurate staffing data for Quarter 1, 2023, to CMS. Discrepancies were found between staff schedules and timecards, leading to inaccuracies in the PBJ report. The DHR confirmed the inaccuracies during interviews.
The facility failed to ensure safe water temperatures in five resident bathrooms and an eye wash station, with temperatures ranging from 121 to 131 degrees Fahrenheit. The maintenance director admitted to not checking the water temperatures, and a resident reported warm water during personal care. The facility's Water Management Program indicated that water temperatures should be kept below 120 degrees Fahrenheit.
The facility failed to ensure proper donning and doffing of PPE for a resident with a urinary catheter and did not implement EBP for 14 other residents with various medical conditions. Additionally, staff did not follow proper hand hygiene and laundry transportation protocols, leading to potential contamination risks. The infection prevention nurse and director of nursing confirmed that EBP had not been implemented per CDC recommendations.
A resident with quadriplegia and traumatic brain injury was observed with a soiled shirt throughout the day, despite expressing discomfort. Nursing staff acknowledged the issue but did not change the shirt promptly, affecting the resident's dignity and comfort. Facility policy emphasized immediate action to maintain dignity, which was not followed.
A resident reported and observations confirmed that her room was filthy, with a soiled privacy curtain and unclean floor. Housekeeping staff acknowledged that the curtain should have been replaced and the floor cleaned more thoroughly, including under the bed. The facility's cleaning policies and procedures were not followed, leading to the deficiency.
The facility failed to change soiled clothing for a resident with quadriplegia and traumatic brain injury, and did not assist another resident with severe cognitive impairment in shaving, despite both being dependent on staff for these activities.
A facility failed to ensure timely assistance with repositioning and did not implement care planned interventions for a resident with pressure ulcers. The resident was not wearing heel protectors, the air mattress was off, and the resident was not repositioned for over three hours. Staff were unaware of the care plan requirements, and the facility's policy on turning and repositioning was not followed.
A facility failed to provide necessary hand splinting and ROM services for a resident with cognitive impairment and hemiplegia, leading to a decline in the resident's ROM. Despite a detailed care plan, staff frequently did not apply the required splints or perform ROM exercises, and documentation showed many instances of non-compliance. Interviews revealed a lack of communication, training, and accountability among staff regarding the resident's restorative program.
The facility failed to ensure that two residents were offered or received pneumococcal and/or influenza vaccinations as per CDC recommendations. Despite having policies in place, the facility lacked a process to ensure immunizations were completed, as confirmed by the infection preventionist and the director of nursing.
The facility failed to maintain safe storage of medications when two out of three medication carts were left unlocked and unattended. LPNs were observed accessing the carts without using keys, despite acknowledging the importance of locking them. The DON confirmed that medication carts should be locked when not in direct attendance, as per facility policy.
The facility failed to maintain proper infection control practices during blood glucose checks for two residents. An LPN placed contaminated lancets in a plastic cup on the medication cart and did not disinfect the glucometer. Another LPN checked a resident's blood glucose without wearing gloves. Staff interviews and document reviews confirmed these deficiencies.
Deficiency in Food Temperature Management
Penalty
Summary
The facility failed to ensure that food was served at a palatable and appetizing temperature for all residents reviewed, with specific concerns raised by six residents. The issues were documented through grievances and resident council meeting minutes, which highlighted ongoing complaints about cold meals. Observations and interviews with residents and family members revealed that meals were often served cold, with some food items being undercooked or overcooked, making them difficult to eat. Residents expressed frustration with the temperature and quality of the food, and some resorted to bringing in outside food or making their own meals. During observations, it was noted that food was left on meal carts in hallways for extended periods before being served, contributing to the temperature issues. Staff interviews revealed that food temperatures were not consistently checked during serving, and there were issues with the steam table not maintaining adequate temperatures. The kitchen manager acknowledged problems with the steam table and the lack of proper temperature monitoring, which led to food being served at unsafe temperatures. The facility's food temperature logs showed discrepancies in recorded temperatures, and staff were using incorrect forms for documentation. The facility's policy required hot foods to be maintained at 150 degrees Fahrenheit or above, but observations showed that many food items were served below this temperature. The kitchen manager admitted that some foods were not safe to serve due to low temperatures and that corrective actions were not consistently taken. The facility's failure to maintain safe food temperatures and address resident complaints resulted in a deficiency that had the potential to affect all residents in the facility.
Failure to Provide Dignified Care and Timely Assistance
Penalty
Summary
The facility failed to ensure dignified and respectful care for two residents, R2 and R4, by not providing necessary services such as emptying bedside urinals and adhering to scheduled bathing routines. R2, who had moderate cognitive impairment and required assistance with mobility and toileting, was left with full urinals on his bedside table, which were not emptied by staff in a timely manner. This neglect led to R2 feeling embarrassed and frustrated, as he had to wait for long periods for assistance, impacting his dignity and quality of life. R4, who had intact cognition but required assistance with personal hygiene and toileting due to limited mobility, experienced similar neglect. Despite being scheduled for baths twice a week, R4 often did not receive them, leading to feelings of embarrassment and discomfort. The facility's failure to update the bath schedule and ensure staff were aware of the changes contributed to this deficiency. R4's care plan indicated a need for regular bathing to maintain hygiene and prevent skin issues, but this was not consistently provided. Interviews with staff revealed a lack of adherence to facility policies regarding resident care and dignity. Staff were expected to perform regular checks and assist with personal hygiene needs, but these duties were not consistently fulfilled. The facility's policies emphasized the importance of treating residents with respect and dignity, yet the actions and inactions observed in the care of R2 and R4 demonstrated a failure to uphold these standards, resulting in a deficiency in the quality of care provided.
Failure to Implement Ambulation Interventions Leads to Resident Fall
Penalty
Summary
The facility failed to implement proper ambulation interventions for a resident with a history of falls, resulting in actual harm. The resident, who had diagnoses of dementia and moderate cognitive impairment, required supervision or touching assistance when ambulating, as indicated in their care plan. On the day of the incident, the resident was being assisted by a nursing assistant (NA) while ambulating in the hallway. The resident reported feeling weak and dizzy, prompting the NA to leave the resident unattended to retrieve a wheelchair, during which time the resident fell and sustained a head laceration. The incident was captured on facility video surveillance, showing the NA leaving the resident alone in the hallway, which was against the care plan that required the resident to have assistance of one staff and a front-wheeled walker. The NA acknowledged being familiar with the resident's care plan and admitted to leaving the resident unattended due to the absence of immediate help and lack of a walkie-talkie. The fall resulted in the resident requiring emergency medical care, including treatment for a 2 cm laceration on the posterior scalp with three staples and a head CT scan to rule out intracranial hemorrhage. Interviews with staff members, including a licensed practical nurse (LPN) and registered nurses (RNs), confirmed that the NA should not have left the resident unattended, especially given the resident's history of falls. The staff acknowledged that the NA should have called for help and maintained support for the resident. The facility's Activities of Daily Living (ADLs) Policy and Procedure emphasized the need for appropriate care and services to prevent a decline in residents' abilities, which was not adhered to in this case.
Failure to Maintain Food Safety and Sanitation Standards
Penalty
Summary
The facility failed to ensure food items were properly labeled and dated after packaging was opened, and did not maintain a clean and sanitary kitchen area. During an initial tour of the kitchen, surveyors observed multiple instances of opened and undated food items in various freezers and refrigerators, including chicken patties, breaded steaks, garlic bread, shredded carrots, orange juice, tarter sauce, and beef base. Additionally, the kitchen had several cleanliness issues, such as spills and crumbs in the freezers, dishes stored on the floor, wet and soiled trays, and a dirty metal fan stored near food items. The registered dietician and kitchen supervisor confirmed these observations and acknowledged that the dietary manager should have been routinely inspecting the kitchen to ensure compliance with food safety standards. Further observations revealed that a cook was not following proper hand hygiene and glove use protocols while serving food. The cook was seen touching various items, including meal tickets, trays, and utensils, without changing gloves or washing hands before handling food. The dietary manager confirmed that staff were expected to use gloves for single use only and to change gloves and wash hands when switching tasks. The facility's policies on food safety and handwashing emphasized the importance of these practices to prevent foodborne illness and maintain resident health, but these protocols were not being followed, leading to potential risks for all 65 residents in the facility.
Inaccurate Staffing Data Submission
Penalty
Summary
The facility failed to submit complete and accurate staffing data for Quarter 1 (October 1-December 31, 2023) to the Centers for Medicare and Medicaid Services (CMS). The Payroll-Based Journal (PBJ) report identified excessively low weekend staffing, specifically on October 14, 2023. During an interview, the administrator confirmed that the director of human resources (DHR) was responsible for submitting the PBJ. A review of staff timecard punches and facility schedules revealed discrepancies, such as a nursing assistant (NA-C) working more hours than scheduled and a licensed practical nurse (LPN-B) working without being scheduled. These discrepancies indicated inaccuracies in the PBJ report submitted to CMS. The DHR explained that the process for submitting the PBJ involved the corporate office running a spreadsheet, which was then sent to the DHR for additional data entry before being sent back to corporate. The DHR also reported that weekend staffing typically consisted of four to six nursing assistants, depending on the facility's census, and two nurses on the night shift and three on the day shift. However, the review of schedules and timecards showed inconsistencies, leading to the verification of inaccuracies in the PBJ report for two staff members on October 14, 2023.
Failure to Maintain Safe Water Temperatures
Penalty
Summary
The facility failed to ensure an environment free of accident hazards related to hot water temperatures in five resident bathrooms and the sink at the eye wash station. During a resident screening, the water temperature in a resident's bathroom felt very hot to the touch after running for only a few minutes. The maintenance director verified the water temperatures in several other resident bathrooms and found them to be excessively high, ranging from 121 to 131 degrees Fahrenheit. These temperatures were confirmed to be too hot and had the potential to cause burns. Additionally, a licensed practical nurse verified that four residents who were independent with mobility on the memory care unit had the potential to turn on these hot water sinks. The maintenance director admitted to not checking the water temperatures and was unaware they were running hot. The facility's Water Management Program indicated that water temperatures should be kept below 120 degrees Fahrenheit, and resident rooms at the end of wings, as well as common area bathrooms, should have been routinely checked and recorded. During a resident council meeting, a resident mentioned that the water in her bathroom had recently felt warm when staff were providing personal care. The administrator stated that his expectation was for water temperatures to remain within State and Federal guidelines.
Failure to Implement Enhanced Barrier Precautions and Proper Hand Hygiene
Penalty
Summary
The facility failed to ensure proper donning and doffing of personal protective equipment (PPE) to prevent the spread of infection for one resident observed for enhanced barrier precautions (EBP). Specifically, a nursing assistant did not wear a gown while performing high-contact activities for a resident with a urinary catheter. The nursing assistant admitted to not receiving clear education on the required PPE for EBP. Additionally, the facility did not identify and implement EBP for 14 other residents who required such precautions due to various medical conditions, including surgical incisions, pressure injuries, and urinary catheters. There was no PPE located near these residents' rooms for staff to use during high-contact care activities, and no signs indicating EBP were posted outside their rooms. The facility also failed to ensure proper hand hygiene and the transportation of personal laundry in a manner that prevented contamination. During observations, a dietary aide touched the tops of drinking glasses with bare hands, and a nursing assistant delivered laundry using an uncovered cart without sanitizing hands between resident rooms. The laundry cart remained uncovered during the entire observation, and the nursing assistant admitted to not following the facility's policy on sanitizing hands and covering the cart. Similarly, a housekeeper was observed delivering laundry with a partially covered cart and did not sanitize hands during the entire process. The infection prevention nurse (IP) and the director of nursing (DON) confirmed that the facility had not implemented EBP per CDC recommendations. The IP stated that she was unaware of the CDC's recommendations for EBP and that the facility had only begun training staff on EBP that day. The DON verified that EBP had not been implemented for residents as per CDC guidelines and confirmed her expectations for staff to follow EBP and PPE recommendations to prevent the spread of infections.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to ensure dignity was maintained for a resident (R54) who had a soiled wet shirt. R54, who was cognitively intact and had diagnoses including quadriplegia and traumatic brain injury, was observed with a wet and brown soiled area on his shirt by the neckline. Despite indicating that the soiled shirt made him feel uncomfortable, the resident remained in the same soiled shirt throughout the day, even during meal times. Nursing staff acknowledged the soiled shirt but did not change it promptly, which affected the resident's dignity and comfort. During interviews, nursing staff and the interim director of nursing confirmed that the expectation was to change a resident's soiled shirt immediately to maintain dignity. The facility's policy on resident rights and dignity emphasized treating each resident with respect and ensuring their quality of life. However, the staff failed to adhere to this policy, resulting in the resident remaining in a visibly soiled shirt for an extended period.
Failure to Maintain Clean Environment for Resident
Penalty
Summary
The facility failed to ensure housekeeping services were provided for a clean environment for a resident (R115) who had a soiled privacy curtain and floor. R115, who was cognitively intact and had diagnoses including anxiety, depression, and joint replacements, reported that her room was filthy. Observations confirmed the presence of brown smears and spots on the privacy curtain, dust, crumbs, plastic medication cups, and a wadded paper towel under the bed. Additionally, a drip/spill was noted on the outside of her wardrobe closet. R115 indicated that it had been four to five days since her floor was mopped and that the area under the bed was not cleaned often. Housekeeping staff confirmed these observations and acknowledged that the curtain should have been replaced and the floor cleaned more thoroughly, including under the bed. The facility's policy and deep clean sheet procedures were not followed as expected, leading to the deficiency in maintaining a clean environment for R115. During interviews, housekeeping staff indicated that their usual practice included sweeping and mopping the room, including under the bed, and replacing soiled curtains. However, the housekeeping lead stated that floors were typically swept and mopped once or twice a week if they appeared clean, and privacy curtains were usually replaced during room turnover. The housekeeping lead was unaware if R115's privacy curtain had been changed before her arrival. R115 reported that her curtain was soiled upon her arrival and expressed concerns about the dust affecting her breathing. The facility's failure to adhere to its cleaning policies and procedures resulted in an unclean environment for R115, as confirmed by multiple observations and staff interviews.
Failure to Change Soiled Clothing and Assist with Shaving
Penalty
Summary
The facility failed to change soiled clothing for a resident (R54) who was dependent on staff for dressing, bathing, and personal hygiene. R54, who has quadriplegia and traumatic brain injury, was observed with a wet and brown soiled area on his shirt that was not changed throughout the day despite expressing discomfort. Nursing assistant (NA)-H admitted to not noticing the soiled shirt and stated that she would have changed it if she had noticed it sooner. The clinical manager confirmed that staff should change soiled clothing immediately. Additionally, the facility failed to assist another resident (R36) with shaving, despite the resident's severe cognitive impairment and dependency on staff for personal hygiene. R36 was observed with long facial hair on multiple occasions, and both the nursing assistant and licensed practical nurse admitted to not assisting with shaving. The interim director of nursing confirmed that R36 required staff assistance with shaving and expected that it should be done daily or when facial hair was present.
Failure to Implement Pressure Ulcer Care Plan
Penalty
Summary
The facility failed to ensure timely assistance with repositioning and did not implement care planned interventions for a resident with current pressure ulcers and at risk for further development of pressure ulcers. The resident, who had diagnoses including cognitive impairment, hypertension, dementia, and anxiety, required total assistance for bed mobility and transfers. The care plan indicated the resident should have heel protectors on while in bed, be repositioned every two hours, and have a special air mattress to relieve pressure. However, observations revealed that the resident was not wearing heel protectors, the air mattress was off, and the resident was not repositioned for over three hours. Interviews with staff confirmed that they were unaware of the care plan requirements, such as the use of heel protectors and the special air mattress. The infection preventionist and the director of nursing both acknowledged that the resident had not been repositioned as required and that the care plan was not followed. The facility's policy on turning and repositioning, which mandates turning dependent residents every two hours and floating the heels off the bed, was not adhered to in this case.
Failure to Provide Hand Splinting and ROM Services
Penalty
Summary
The facility failed to provide hand splinting and range of motion (ROM) services to prevent a potential decrease in ROM for a resident who required these services. The resident had moderate cognitive impairment and diagnoses including stroke, hemiplegia, hemiparesis, and aphasia. The resident's care plan included the use of a resting hand splint in the morning and at bedtime, as well as a passive ROM program. However, documentation and observations revealed that these interventions were not consistently implemented, and the resident was often observed without the required splints or palm protector. The resident's care plan and restorative nursing program outlined specific interventions to maximize ROM and manage contractures, including the application of a blue palm protector during the day and a gray splint at night. Despite these detailed instructions, staff frequently failed to apply the splints or complete the ROM exercises. Documentation showed numerous instances where the interventions were marked as not applicable, refused, or not completed, with many entries left blank. Observations confirmed that the resident was often without the required splints, and staff interviews indicated a lack of awareness and training regarding the resident's restorative program. Interviews with staff, including nursing assistants and therapy personnel, highlighted a lack of communication and accountability in implementing the resident's restorative program. Staff were unsure who was responsible for the program and admitted to not consistently performing the required ROM exercises or applying the splints. The therapy department provided initial training and written instructions but did not offer ongoing education or oversight. The resident's primary care physician and the interim director of nursing were not informed of the resident's refusals or the failure to implement the restorative program, leading to a decline in the resident's ROM and overall condition.
Failure to Ensure Residents Received Recommended Vaccinations
Penalty
Summary
The facility failed to ensure that two residents, aged 77 and 67, were offered or received pneumococcal and/or influenza vaccinations in accordance with CDC recommendations. The review of the immunization reports and medical records for these residents revealed that one resident had not been offered the influenza vaccine for the current seasonal flu year, and the other resident had not received the recommended pneumococcal vaccine. Interviews with the infection preventionist (IP) and the director of nursing (DON) confirmed that the facility lacked a process to ensure immunizations were completed for residents, despite having standing orders for these vaccinations. The facility's policies on seasonal influenza and pneumococcal vaccines indicated that all residents should be assessed for eligibility and offered the vaccines unless medically contraindicated or already vaccinated. The policies also required documentation of education provided to residents or their legal representatives and any refusals of vaccination. However, the facility failed to adhere to these policies, as evidenced by the lack of documentation and confirmation that the residents in question had been offered or received the necessary vaccinations. The IP and DON both acknowledged the oversight and the absence of a systematic process to ensure compliance with vaccination protocols.
Failure to Maintain Safe Storage of Medications
Penalty
Summary
The facility failed to maintain safe storage of medications when two out of three medication carts were left unlocked and unattended. On one occasion, an LPN gathered supplies to check a resident's blood glucose and left the medication cart in the hallway, partially locked, while attending to the resident in their room. The LPN admitted that the lock was in working order and acknowledged the importance of locking the cart to prevent theft, but stated that he trusted the people and residents at the facility. Another LPN was observed accessing a medication cart without using a key, stating that she had a key but habitually did not use it to lock the cart. Both LPNs acknowledged that leaving the carts unlocked was not safe. The Director of Nursing (DON) confirmed that medication carts should be locked whenever a nurse is not in direct attendance. The facility's policy on medication storage, dated 2/12/24, directed that medications and biologicals should be stored securely and that compartments containing these items should be locked when not in use. The policy also specified that carts used to transport medications should not be left unattended. Despite this policy, the observed actions of the LPNs demonstrated a failure to adhere to these safety protocols, posing a risk that unauthorized individuals could access the medication carts.
Infection Control Deficiency During Blood Glucose Checks
Penalty
Summary
The facility failed to maintain proper infection control practices during blood glucose checks for two residents. One resident with diabetes mellitus type 2 had their blood glucose checked by an LPN who placed a contaminated lancet and cotton ball in the cover of a plastic container used to hold the resident's glucometer and other supplies. The LPN then placed the contaminated lancet in a plastic cup on the medication cart, which already contained five used lancets. The LPN did not disinfect the glucometer or the plastic container and stated that glucometers were cleaned only once weekly unless used for another resident. The sharps container on the medication cart was observed to be overfilled, with contents approximately two inches above the full line. Another LPN was observed checking the blood glucose of a second resident with diabetes mellitus type 1 and end-stage renal disease without wearing gloves. This LPN also stated that glucometers were cleaned only once weekly unless visibly dirty and that there was no specific process for the day of the week the glucometers were cleaned. Interviews with other staff members, including another LPN and the Director of Nursing (DON), revealed that gloves should be worn for all glucometer testing, and sharps containers should be replaced when the contents reach the full line. The DON confirmed that glucometers were expected to be cleaned after each use and that it was unacceptable to place contaminated lancets in a plastic cup on the medication cart. Facility documents also directed that blood glucose monitoring procedures include hand hygiene, wearing gloves, and cleaning the glucometer per facility policy after each use. The facility's failure to adhere to these infection control practices was observed and confirmed through staff interviews and document reviews.
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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