Edenbrook Pine Haven
Inspection history, citations, penalties and survey trends for this long-term care facility in Pine Island, Minnesota.
- Location
- 210 Northwest 3rd Street, Pine Island, Minnesota 55963
- CMS Provider Number
- 245359
- Inspections on file
- 31
- Latest survey
- August 28, 2025
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Edenbrook Pine Haven during CMS and state inspections, most recent first.
A resident with dementia reported being physically abused by a staff member, but the LTC facility failed to report the allegation to the State Agency within the required 2-hour timeframe. The delay was due to communication failures between the RN and DON, resulting in the report being made several hours late, contrary to the facility's policy.
A resident with moderately impaired cognition reported physical abuse, resulting in bruises on the inner thigh. Despite multiple staff observations, the facility failed to conduct a comprehensive skin assessment or establish a monitoring plan, as the existing policy did not address non-pressure skin concerns.
A resident with respiratory issues did not receive oxygen therapy as ordered due to inaccurate transcription and administration of physician orders. The resident experienced low oxygen saturation levels, and staff sometimes forgot to reapply oxygen after removing the CPAP machine. Facility policies on oxygen administration and medication orders were not followed, leading to inconsistent care.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with extensive wounds, leading to a deficiency in infection prevention. Despite the presence of an EBP sign, an LPN was observed not wearing a gown during wound care, contrary to policy. Staff were trained on EBP and PPE use, but adherence was not maintained during the observed care.
The facility failed to ensure staff donned appropriate PPE for two residents on contact and enhanced barrier precautions, leading to potential infection risks. One resident with a history of Clostridium difficile and MRSA was not properly protected by staff, and another resident with a urinary catheter was transferred without PPE. Additionally, the facility did not maintain a clean laundry area and improperly stored ice packs with food, lacking a policy for laundry cleanliness.
The facility failed to ensure proper sanitization of dishware due to a dishwasher not reaching the required rinse temperature of 180 degrees F, with only three out of 36 entries meeting the standard. Additionally, mineral buildup was observed on water/ice machines in two care units, with unclear responsibility for cleaning. These deficiencies potentially impacted all 29 residents in the affected units.
A resident with interstitial pulmonary disease was left unsupervised to self-administer a nebulizer treatment, despite a discrepancy in their self-administer medications assessment indicating a need for assistance. Facility staff inconsistently applied the policy on self-administration, leading to the resident incorrectly handling the medication. Interviews revealed a lack of proper assessment and understanding of the policy requirements.
A facility failed to create a comprehensive care plan for a resident with bipolar disorder receiving psychotropic medications. The care plan lacked specific non-pharmacological interventions to support the resident's mood and reduce self-isolation and lethargy. Staff interviews revealed a lack of awareness and guidance on managing the resident's behaviors, and the interim DON confirmed the care plan was not adequately individualized.
The facility failed to monitor and document skin conditions for two residents. One resident with dementia had an undocumented bruise, while another with MASD had open wounds that were not properly assessed or measured. Nursing staff interviews revealed communication and documentation lapses, and facility policies did not adequately address these issues.
A facility failed to ensure proper catheter management for a resident with an indwelling catheter. The care plan lacked details on catheter type, change schedule, and removal plan, and there was no evidence of education on catheter risks. Staff interviews revealed a lack of awareness and documentation regarding the catheter's necessity and the resident's refusal to remove it. The facility's catheter care protocol was undated and lacked guidance on timely removal and resident education.
A facility failed to deliver supplemental oxygen according to physician orders and did not maintain oxygen tubing per standards for a resident with respiratory needs. The resident's care plan lacked documentation of oxygen requirements, and observations showed inconsistent oxygen administration and tubing on the floor. Staff interviews revealed uncertainty about tubing change protocols, and the facility's policy required weekly changes and proper storage, which were not documented or consistently practiced.
A facility failed to ensure proper collaboration with a dialysis facility for a resident requiring dialysis. The resident's medical records lacked critical contact information for the dialysis facility, leading to communication failures, such as not notifying the facility about new antibiotics or missed appointments. Interviews revealed staff were unaware of the dialysis facility details, and policies were outdated, compromising the resident's care.
A pharmacist failed to report an increase in a psychotropic medication for a resident with bipolar disorder, missing the change in monthly reviews. The resident's care plan required monitoring of behaviors, but no behaviors were documented to justify the increase. Interviews revealed a lack of communication among the healthcare team, with the nurse practitioner and clinical pharmacist unaware of the medication change, highlighting a breakdown in the medication review process.
A resident with bipolar disorder experienced an unjustified increase in Depakote dosage after a GDR, despite stable mood and no documented behaviors. The increase was due to inadequate communication among healthcare providers, including a lack of awareness by the psychiatrist of the recent GDR. Interviews revealed gaps in the medication review process and communication, with leadership changes possibly contributing to the oversight.
The facility failed to offer the PCV20 pneumococcal vaccine to two residents, despite CDC guidelines recommending it for adults aged 65 and older. Both residents had received previous pneumococcal vaccinations, but their records lacked evidence of being offered PCV20 or any shared clinical decision-making. Interviews with staff confirmed the oversight, and the facility's policy did not include information on PCV20, contributing to the deficiency.
Failure to Timely Report Resident Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of staff-to-resident physical abuse to the State Agency (SA) within the required 2-hour timeframe. A resident with moderately impaired cognition and a diagnosis of dementia reported to a registered nurse (RN-D) that she had been physically abused by a staff member approximately two weeks prior. The resident described being kicked in the leg, pinched in the groin area, and slapped on the cheek, which resulted in her glasses being knocked off. Despite the resident's report at 4:10 p.m., the incident was not reported to the SA until 9:27 p.m., exceeding the 2-hour reporting requirement. The delay in reporting was due to a series of communication failures. RN-D attempted to contact the Director of Nursing (DON) shortly after the resident's report but was unable to reach her immediately and left a voicemail. The DON did not receive the message until later and instructed RN-D to gather more information before reporting to the SA. The DON and other staff members, including the Director of Social Services and the Administrator, acknowledged the reporting delay and the facility's policy requiring immediate reporting of abuse allegations within 2 hours. The facility's policy on abuse, neglect, and misappropriation of resident property mandates that all allegations be reported per federal and state law, which was not adhered to in this instance.
Failure to Monitor and Document Non-Pressure Skin Injuries
Penalty
Summary
The facility failed to assess and monitor non-pressure related skin injuries, specifically bruises, for a resident who was reviewed for abuse. The resident, who had moderately impaired cognition, reported allegations of physical abuse, including being pinched and kicked, resulting in bruises on the inner thigh. Despite these allegations and visible bruises, the facility did not conduct a comprehensive skin assessment or establish a monitoring plan for the bruises, as evidenced by the lack of documentation in the resident's medical record. Interviews with staff revealed that the bruises were observed by multiple staff members, including a registered nurse and the director of nursing, but were not properly documented or monitored. The facility's existing skin ulcer policy did not address the process for monitoring non-pressure skin integrity concerns, contributing to the deficiency. The director of nursing acknowledged the absence of a comprehensive skin assessment and monitoring in the resident's medical record, which should have been in place according to facility policy.
Failure to Accurately Transcribe and Administer Oxygen Orders
Penalty
Summary
The facility failed to ensure accurate transcription and administration of a physician's order for oxygen therapy for a resident with respiratory issues. The resident, who had intact cognition and diagnoses of respiratory failure and obstructive sleep apnea, was supposed to receive oxygen therapy. However, the facility did not clearly document whether the oxygen therapy was to be administered continuously or as needed. This lack of clarity led to inconsistent oxygen administration and monitoring. On several occasions, the resident's oxygen saturation levels were not adequately monitored or recorded, and the oxygen was not administered as ordered. For instance, after a bathing session, the resident's oxygen level dropped to 82% on room air, prompting the initiation of standing house orders for hypoxia. Despite this, there were instances where the resident was left without oxygen, leading to low oxygen saturation levels, such as 84% when checked by a nursing assistant. The resident reported that staff sometimes forgot to put the oxygen back on after removing the CPAP machine in the morning. The facility's staff, including a registered nurse and the director of nursing, acknowledged that the oxygen orders were not transcribed correctly and that there was a failure to clarify the orders with the provider. The director of nursing stated that the resident's oxygen order should have been to ensure the resident was receiving 1-2 liters to keep saturations above 90%. The facility's policies on oxygen administration and medication orders were not followed, contributing to the deficiency in care.
Failure to Implement Enhanced Barrier Precautions for Wound Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with extensive wounds, leading to a deficiency in infection prevention and control. The resident, identified as R6, had multiple diagnoses including bullous pemphigoid, chronic venous hypertension with ulcers, and subacute osteomyelitis, requiring complex wound care. Despite the presence of an EBP sign outside the resident's room, a Licensed Practical Nurse (LPN) was observed not wearing a gown while performing wound care, contrary to the facility's infection prevention policy. The resident's care plan and physician orders detailed specific wound care treatments, including the use of various dressings and ointments. The facility's policy required staff to wear gowns and gloves during high-contact activities, such as wound care, to prevent the spread of infections. However, during an observation, the LPN was only wearing gloves and not a gown, as required by the EBP sign and facility policy, citing discomfort due to heat as the reason for not wearing the gown. Interviews with staff, including a Nursing Assistant (NA) and a Registered Nurse (RN), revealed that staff were trained on EBP and the use of personal protective equipment (PPE) through online education and in-services. The Director of Nursing (DON) confirmed that staff were expected to follow the EBP policy, which included wearing gowns, gloves, masks, and eye protection when necessary. Despite this training, the failure to adhere to EBP during wound care for the resident was identified as a deficiency.
Inadequate PPE Use and Infection Control Lapses
Penalty
Summary
The facility failed to ensure staff donned appropriate personal protective equipment (PPE) for enhanced barrier precautions (EBP) and contact precautions for two residents. One resident, identified as R207, had a history of Clostridium difficile and methicillin-resistant Staphylococcus aureus (MRSA) and was on contact precautions. However, a nursing assistant entered the resident's room without donning gloves or a gown, despite signage indicating the need for such precautions. The care plan for R207 lacked evidence of any precautions, and there was confusion among staff about the necessity of PPE, with some staff members incorrectly stating that PPE was only required for certain procedures. Another resident, R48, was on enhanced barrier precautions due to having a urinary catheter. Despite this, a nursing assistant transferred the resident to bed without wearing a gown, contrary to the signage outside the resident's door. The staff member acknowledged the oversight and mentioned a misunderstanding of the regulations. The facility's infection preventionist confirmed the need for PPE during such interactions to prevent infections. Additionally, the facility failed to maintain a clean laundry area, with observations of dust and lint blowing onto clean linens. The facility also improperly stored resident ice packs alongside food items in unit refrigerators, posing a risk of contamination. The facility lacked a policy for laundry cleanliness, and the director of nursing acknowledged the need for in-house education to prevent the spread of infection.
Dishwasher and Ice Machine Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure that the high-temperature sanitizing dishwasher reached the required rinse temperature of 180 degrees Fahrenheit to properly sanitize dishware used for resident service. Observations revealed that the dishwasher in the 500/600 wing kitchenette consistently recorded rinse temperatures below the required threshold, ranging between 161 degrees F and 177 degrees F, with only three out of 36 documented entries meeting the necessary temperature. The dietary aide was unaware of the correct temperature requirements and relied on an electronic temperature gauge that was set to alarm only if temperatures fell below 160 degrees F. Additionally, the dishwasher exhibited significant white crusty mineral-like buildup, indicating a lack of regular cleaning and maintenance. The facility also failed to maintain cleanliness of the resident water/ice machines in two care units, with observations noting white and brownish mineral buildup on the machines. Interviews with staff revealed a lack of clarity regarding responsibility for cleaning these machines, with maintenance staff unaware of the last cleaning date and stating that cleaning was done quarterly. The facility's policies directed more frequent cleaning and maintenance, which was not adhered to, potentially impacting all 29 residents in the affected care units.
Failure to Assess Appropriateness of Self-Administration of Medication
Penalty
Summary
The facility failed to appropriately assess and determine the clinical appropriateness of self-administration of medication for a resident, identified as R25, who was left alone to administer a nebulizer treatment without staff supervision. R25's quarterly Minimum Data Set (MDS) assessment indicated intact cognition and a diagnosis of interstitial pulmonary disease, requiring assistance for activities of daily living and mobility. Despite a care plan allowing R25 to self-administer inhalers, there was a discrepancy in the self-administer medications (SAM) assessment, which indicated a need for assistance with inhalant medications. During an observation, R25 was seen administering a nebulizer treatment alone, incorrectly handling the medication, and expressing a lack of understanding about the medication being used. Interviews with facility staff, including a trained medication assistant (TMA), a licensed practical nurse (LPN), a registered nurse (RN), and the director of nursing (DON), revealed inconsistencies in the understanding and implementation of the facility's policy on self-administration of medication. The TMA and LPN admitted to setting up nebulizer treatments and leaving the resident unsupervised, while the RN and DON emphasized the need for a SAM assessment and a physician's order for self-administration. The facility's policy required an interdisciplinary team assessment to ensure safe self-administration, which was not adequately followed, leading to the deficiency.
Failure to Develop Individualized Care Plan for Resident on Psychotropic Medications
Penalty
Summary
The facility failed to develop a comprehensive and individualized care plan for a resident receiving psychotropic medications. The resident, who had mild cognitive impairment and a diagnosis of bipolar disorder, was noted to receive psychotropic medications routinely. However, the care plan lacked specific non-pharmacological interventions to support the resident's mood and minimize self-isolation, lethargy, and refusals of care. The care plan included outdated interventions and did not address the resident's current needs effectively. Interviews with staff revealed a lack of awareness and guidance regarding the resident's behaviors and mood management. Nursing assistants and LPNs were not informed of effective interventions for the resident's mood changes or delusions. The interim DON confirmed that the care plan was not adequately individualized and did not meet the facility's expectations for monitoring and addressing the resident's behaviors and mood changes. The deficiency was identified during a review of the resident's care plan and staff interviews.
Deficiencies in Monitoring and Documenting Skin Conditions
Penalty
Summary
The facility failed to properly identify and monitor bruising for a resident with dementia and severe cognitive impairment. The resident, who required assistance with activities of daily living and mobility, was observed with a golf ball-sized bruise on her left forearm on two separate occasions. Despite physician's orders for weekly skin inspections and a care plan requiring daily observations for skin changes, the bruise was not documented or reported by the nursing staff. Interviews with nursing assistants and licensed practical nurses revealed a lack of communication and documentation regarding the bruise, which was not noted in the resident's medical record. Additionally, the facility did not routinely assess or document the healing progress of open wounds related to moisture-associated skin damage (MASD) for another resident. This resident, who was cognitively intact and had a history of diabetes and chronic skin breakdown, had open areas on the buttocks that were not measured or properly documented. Despite the presence of bleeding and drainage, the nursing staff failed to include necessary wound assessments and measurements in the medical record or in communication with the provider. Interviews with nursing staff and the interim director of nursing highlighted inconsistencies in wound care documentation and assessment practices. The facility's policies on skin alterations and pressure ulcers did not adequately address the monitoring and documentation of bruises or non-pressure wounds. The lack of proper documentation and monitoring of skin conditions for both residents indicates a deficiency in the facility's adherence to care protocols, potentially compromising resident safety and care quality.
Deficiency in Catheter Management and Resident Education
Penalty
Summary
The facility failed to ensure proper catheter management for a resident, identified as R207, who was reviewed for catheter care. R207's admission Minimum Data Set (MDS) assessment indicated that the resident had an indwelling catheter and was dependent on staff for toileting hygiene and transfers. However, the facility did not attempt a trial of a toileting program. The care area assessment (CAA) noted that R207 had a diagnosis of urinary retention requiring a Foley catheter and had been treated for a urinary tract infection upon admission. Despite these conditions, the facility's documentation lacked critical information regarding the catheter's management, such as when it was last changed, when it should be removed, and the type of catheter used. The care plan for R207 was insufficient, as it only included monitoring for signs and symptoms of a urinary tract infection without detailing the type of catheter, its change schedule, or removal plan. There was also no evidence of education provided to R207 about the risks and benefits of catheter use or interventions to restore urinary function without a catheter. Interviews with staff revealed a lack of awareness and documentation regarding the catheter's necessity and the resident's refusal to have it removed. The physical therapist assistant working with R207 noted the absence of bladder retraining efforts, and the LPN acknowledged the lack of education and documentation about the catheter. The facility's catheter care protocol was undated and lacked guidance on the timely removal of catheters, care plan interventions for resident education, and documentation of the implications of continued catheter use. Interviews with the director of nursing highlighted the expectation for staff to provide education to residents about the risks of catheter use, but this was not reflected in R207's care plan or medical record. The deficiency in catheter management and resident education contributed to the facility's failure to prevent potential complications such as infections.
Failure to Maintain Proper Oxygen Administration and Tubing Maintenance
Penalty
Summary
The facility failed to ensure that supplemental oxygen was delivered according to physician orders and did not maintain oxygen tubing per professional standards for a resident with respiratory care needs. The resident, who had a medical history including acute systolic congestive heart failure, unspecified dementia, and chronic obstructive pulmonary disease, was observed with inconsistent oxygen administration. The physician's orders specified supplemental oxygen at 2 to 3 liters via nasal cannula to maintain oxygen saturations of 90% or higher, but the orders lacked information on when to change the oxygen tubing. The resident's care plan also did not reflect the need for oxygen, and the medication and treatment administration records lacked documentation on tubing changes. Observations revealed that the resident's oxygen tubing, including the nasal cannula, was frequently found on the floor, and the oxygen was not consistently administered as ordered. Interviews with staff indicated a lack of clarity on when to change the tubing, and the facility's policy required weekly changes and proper storage of the tubing. The director of nursing confirmed that the nasal cannula should not be on the floor and emphasized the importance of following oxygen orders for infection control. Despite the facility's policy, there was no documentation or consistent practice to ensure the oxygen tubing was changed weekly or stored correctly.
Failure in Dialysis Coordination and Communication
Penalty
Summary
The facility failed to ensure proper collaboration with the dialysis facility for a resident who required dialysis services. The resident, identified as R14, had multiple medical conditions including acute kidney failure, chronic kidney disease, and peripheral vascular disease, necessitating regular dialysis. Despite having physician orders for pre- and post-dialysis assessments and monitoring of the hemodialysis catheter, the facility's documentation lacked critical information such as the contact details of the dialysis facility and instructions on when to contact them. The resident's medical records, including the medication administration record (MAR), treatment administration record (TAR), and electronic medical record (EMR), were incomplete, missing essential details about the dialysis facility. This lack of information led to communication failures, such as the dialysis facility not being notified when the resident started a new antibiotic or when the resident refused dialysis due to feeling unwell. The facility's care plans also did not include necessary contact information for the dialysis facility, which was crucial for coordinating care and ensuring the resident's medical stability. Interviews with nursing staff revealed a lack of awareness about which dialysis facility the resident attended, further highlighting the communication breakdown. The facility's policies on dialysis care were outdated and did not address the need for notifying the dialysis facility about medication changes or appointment cancellations. This deficiency in communication and documentation compromised the resident's care and the facility's ability to manage the resident's dialysis needs effectively.
Pharmacist Fails to Report Psychotropic Medication Increase
Penalty
Summary
The pharmacist failed to identify and report an increase in a psychotropic medication for a resident without implementing non-pharmacological interventions or confirming the clinical significance of the increased dose after a gradual dose reduction (GDR). The resident, who had mild cognitive impairment and a diagnosis of bipolar disorder, was receiving psychotropic medications routinely. Despite the care plan's directive to monitor behaviors and mood, the medical record lacked evidence of behaviors that would justify the medication increase. The pharmacist's medication regimen reviews from October 2023 to June 2024 did not identify any irregularities, missing the increase in Depakote dosage ordered by a psychiatrist in November 2023. Interviews revealed a lack of communication and awareness among the healthcare team regarding the medication changes. The nurse practitioner was unaware of the previous GDR and the subsequent increase in Depakote, which was not communicated by the clinical pharmacist or nursing staff. The clinical pharmacist admitted to missing the increased dose in subsequent reviews and acknowledged that it should have been brought to the team's attention. The interim Director of Nursing noted leadership changes and expected the team to be aware of medication changes, highlighting a breakdown in communication and oversight in the medication review process.
Inadequate Communication Leads to Unjustified Psychotropic Medication Increase
Penalty
Summary
The facility failed to ensure that an increased dose of a psychotropic medication was clinically indicated for a resident after a gradual dose reduction (GDR). The resident, who had mild cognitive impairment and a diagnosis of bipolar disorder, was receiving psychotropic medications on a routine basis. Despite the absence of behaviors such as delusions, refusal of care, or increased self-isolation, the resident's Depakote dosage was increased from 250mg to 375mg daily without clear clinical justification. This increase occurred after a previous GDR had reduced the dosage, and there was no documentation explaining the rationale for the increase. The report highlights a lack of communication and coordination among the healthcare providers involved in the resident's care. The nurse practitioner who initially reduced the Depakote dosage was not aware of the subsequent increase, and there was no progress note or communication from the psychiatrist regarding the change. The clinical pharmacist, who tracks GDRs, was also unaware of the dosage increase and noted that the psychiatrist's progress note did not acknowledge the recent GDR. This lack of communication led to the resident receiving a higher dosage of Depakote than was previously deemed necessary. Interviews with facility staff, including a licensed practical nurse, a nurse practitioner, and the interim Director of Nursing, revealed gaps in the medication review process and communication among the care team. The interim DON acknowledged that leadership changes might have contributed to the oversight. The facility's expectation was for nursing, pharmacy, and providers to be aware of any changes in psychotropic medication dosages to ensure appropriate administration, which was not met in this case.
Failure to Offer Pneumococcal Vaccination per CDC Guidelines
Penalty
Summary
The facility failed to ensure that two residents, identified as R48 and R36, were offered or received the pneumococcal vaccination in accordance with CDC recommendations. The CDC guidelines specify that adults aged 65 years and older should receive either the PCV20 vaccine or a combination of PCV15 followed by PPSV23. However, the facility's documentation and interviews revealed that these residents were not offered the PCV20 vaccine, nor was there evidence of shared clinical decision-making regarding this vaccination. Resident R48, who was admitted to the facility with intact cognition and a history of malignant neoplasm of the colon, anemia, and hemiplegia following a stroke, had received PPSV23 in 2012 and PCV13 in 2017. Despite this, the resident's medical records and consent forms lacked any mention of PCV20, and there was no documentation of shared clinical decision-making. Similarly, Resident R36, with diagnoses including chronic kidney disease and type 2 diabetes, had received PPSV23 in 2011 and 2016, and PCV13 in 2015. Like R48, R36's records did not indicate that PCV20 was offered or that any clinical decision-making discussions took place. Interviews with the facility's infection preventionist and director of nursing confirmed the oversight. The infection preventionist acknowledged that the consent forms did not include information about PCV20 and that discussions regarding clinical decision-making had not occurred for these residents. The director of nursing noted the need for a short-term program for pneumococcal vaccines due to the risk of pneumonia. The facility's policy, dated February 2020, followed CDC guidelines for PCV13 and PPSV23 but did not address PCV20 or shared clinical decision-making, contributing 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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