Eventide Lutheran Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Moorhead, Minnesota.
- Location
- 1405 7th Street South, Moorhead, Minnesota 56560
- CMS Provider Number
- 245461
- Inspections on file
- 34
- Latest survey
- November 13, 2025
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Eventide Lutheran Home during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a recent right great toe amputation did not consistently have a post-op shoe applied as ordered by the physician. The post-op shoe was omitted from the care plan, and staff were unclear about its use, resulting in the shoe being incorrectly placed or not used at all. Observations and interviews confirmed the lack of proper documentation and communication, leading to the resident's surgical site not being protected as prescribed.
A resident with severe cognitive impairment and on hospice care, who required total assistance with eating, was fed by a hospice RN who stood beside her in the dining room rather than sitting. Interviews with the family, nursing staff, and DON confirmed that standing while feeding does not maintain resident dignity, and facility policy requires dignified care during such assistance.
A resident who was cognitively intact but dependent on staff for certain activities was observed independently using a nebulizer without staff present or proper assessment. Facility records lacked documentation of a self-administration assessment, physician order, or care plan entry authorizing self-administration, despite staff confirming the resident was self-administering after setup. This was not in accordance with the facility's self-medication policy.
A resident with severe cognitive impairment and left-sided weakness did not consistently have her water mug placed within reach, despite care plan instructions and staff awareness of her needs. Multiple observations and interviews confirmed that the water mug was often left out of reach, preventing the resident from accessing fluids independently.
A resident with severe cognitive impairment and dysphagia, able to verbalize food preferences, was not offered meal choices and consistently received a predetermined pureed meal. Staff and dietary personnel confirmed that residents on mechanically altered diets were not given options, and the facility's policy did not address meal choice for these diets.
A resident with severe cognitive impairment and multiple diagnoses was admitted to hospice, but the facility did not complete a Significant Change in Status Assessment (SCSA) as required. The MDS coordinator missed the assessment due to a miscalculation, and only a quarterly and death MDS were completed. The DON confirmed that timely completion of MDS assessments is expected.
A resident with significant cognitive and physical impairments, identified as at risk for pressure ulcers, was observed in bed without the required Prevalon boots on multiple occasions. Despite care plan directives and staff expectations, nursing assistants did not apply the boots, leaving them on a bedside table. Nursing and administrative staff confirmed the boots should have been used whenever the resident was in bed, but this was not done, resulting in a deficiency in pressure ulcer prevention.
A resident with dementia and a known risk for elopement exited the facility undetected after multiple WanderGuard alarms were triggered. Staff response to the alarms was delayed and incomplete, with searches limited to certain areas and failure to check outside promptly. The resident was missing for several hours before being found by police several miles away, highlighting a breakdown in supervision and adherence to elopement protocols.
Staff did not consistently perform proper hand hygiene or use required PPE during high-contact care activities for two residents on enhanced barrier precautions with indwelling urinary catheters. Observations showed lapses such as not sanitizing hands between glove changes and failing to wear gowns during catheter care, despite facility policy and posted instructions. Staff interviews confirmed these steps were missed, and facility policy required these infection prevention measures.
A resident with impaired cognition and a history of falls fell from a wheelchair and sustained a left humerus fracture due to the facility's failure to follow care plan interventions. The care plan required the removal of foot pedals from the wheelchair and not leaving the resident alone, but these were not adhered to, resulting in the resident attempting to self-transfer and falling.
A resident with dementia and osteoporosis fell from a mechanical lift during a transfer in an LTC facility, resulting in a scalp laceration and sacrum contusion. The incident occurred due to improper securing of the lift sling and failure to position the lift's legs widely for stability. The resident was sent to the ED for treatment.
The facility failed to ensure that food and beverages stored in the refrigerators and freezers were labeled, dated, and discarded properly. Several items were found without proper labeling or dating, and some had visible signs of spoilage. The culinary coordinator and registered dietician confirmed these findings, indicating that the residents had recently been served these items, which should have been discarded according to facility policy.
The facility failed to maintain wheelchairs and a standing lift in a clean and sanitary manner for a resident with moderate cognitive impairment and multiple diagnoses. Observations revealed dried brown food-like substances on the resident's wheelchair pedal and the standing lift. Staff interviews confirmed the presence of the substances and revealed uncertainty about cleaning responsibilities and processes. The facility did not provide a policy on cleaning wheelchairs and lifts when requested.
The facility failed to ensure proper PPE use and hand hygiene per CDC guidelines for two COVID-19 positive residents and did not prevent a catheter drainage bag from being placed on the floor for another resident. Staff did not follow the facility's policies, leading to potential infection risks.
Failure to Follow Physician Orders for Post-Op Shoe After Toe Amputation
Penalty
Summary
A deficiency occurred when the facility failed to ensure physician orders were followed for a resident who had recently undergone a right great toe amputation. The resident, who had severely impaired cognition and a history of physical and verbal behavioral symptoms, returned from surgery with post-operative instructions that included weight bearing as tolerated in a post-op shoe to protect the surgical site. However, the post-op shoe was not included in the resident's care plan or the nursing assistant care plan, and staff were unclear about when and how the shoe should be used. Multiple observations showed the resident without the post-op shoe on the right foot, and at times, the shoe was incorrectly placed on the left foot instead. Interviews with staff revealed confusion and lack of knowledge regarding the post-op shoe order, with some staff believing the shoe should not be used or not knowing which foot it belonged on. The resident's medical history included non-traumatic brain dysfunction, peripheral vascular disease, diabetes mellitus, and Alzheimer's disease, all of which increased the risk for poor wound healing and skin breakdown. The care plan identified risks for skin breakdown and previous pressure ulcers, but did not address the need for the post-op shoe following the amputation. Observations documented the resident sitting in various locations without the protective shoe on the surgical foot, and staff interviews confirmed that the care plan had not been updated to reflect the post-surgical needs. Family members also reported that during their visits, the resident's right foot was not protected as instructed by the post-op orders. Staff interviews further highlighted the lack of communication and documentation regarding the post-op shoe. Nursing staff and nursing assistants were unsure about the presence of an order for the shoe, its purpose, or the correct application. The facility's policy required care plans to be updated with changes in the resident's condition, but this was not done after the resident's surgery. As a result, the resident's surgical site was not consistently protected as prescribed, and staff actions did not align with the physician's post-operative instructions.
Failure to Provide Dignified Dining Assistance
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, dementia, hypertension, and anemia, who was receiving hospice care and required total staff assistance with eating, was not provided a dignified dining experience. The resident was observed in the dining room seated in a reclining wheelchair while a hospice registered nurse (H-RN) stood beside her and assisted her with eating by feeding her with a spoon. This practice was observed on multiple occasions during the meal. Interviews with the resident's family member, the H-RN, another registered nurse (RN-A), and the director of nursing (DON) confirmed that standing while feeding a resident is not considered a dignified practice. The family member expressed dissatisfaction with the staff standing while feeding, and both RN-A and the DON stated that staff are expected to sit while assisting residents with eating to maintain dignity and promote safety. Facility policy also indicated that all residents should receive safe and dignified care.
Failure to Assess and Authorize Self-Administration of Nebulizer Medication
Penalty
Summary
The facility failed to ensure that a resident was properly assessed and authorized to self-administer nebulizer medications. The resident, who was cognitively intact but dependent on staff for transfers and toileting due to a hip fracture and right ankle fracture, was observed on multiple occasions independently using a nebulizer in her room without staff present. Documentation review revealed that the resident's care plan and electronic health record did not include any assessment or authorization for self-administration of medications, nor was there a physician's order permitting this practice. The resident's medication orders directed staff to administer the nebulizer treatments, but there was no documentation supporting self-administration. Interviews with facility staff, including an LPN, resident care manager, and DON, confirmed that the required self-administration assessment had not been completed, and the process outlined in the facility's self-medication policy was not followed. The policy required a provider's order, a completed assessment to determine appropriateness, and care plan documentation for self-administration, none of which were present for this resident. Staff acknowledged that the resident was self-administering her nebulizer after staff set it up, despite the lack of required assessments and documentation.
Failure to Ensure Hydration Within Reach for Resident with Cognitive and Physical Impairments
Penalty
Summary
A deficiency occurred when staff failed to ensure that a resident with severe cognitive impairment and left-sided weakness consistently had access to adequate hydration within reach. The resident, who required partial assistance with eating and had a care plan specifying the need for tray setup and placement of items on her right side, was observed multiple times with her water mug placed out of reach. Family members and staff interviews confirmed that the water mug was often left across the room or on the resident's left side, which she could not access due to hemiparesis from a stroke. The resident herself reported being unable to reach her water mug and experiencing thirst as a result. Observations on several occasions showed the water mug placed behind the resident, across the room, or on the left side, all out of her reach. Staff acknowledged that the standard practice was to keep the water mug next to her, but this was not consistently followed. The facility's policy directed staff to offer fluids during scheduled care but did not specify the need to keep water within reach when appropriate. The director of nursing stated that her expectation was for staff to place water within reach to prevent dehydration, but this was not consistently implemented for the resident.
Failure to Offer Meal Choices to Resident on Pureed Diet
Penalty
Summary
The facility failed to honor a resident's right to make choices about food at meals for a resident with severe cognitive impairment and dysphagia requiring a pureed, nectar-thick diet. Despite the resident's ability to verbalize preferences, staff did not offer meal options, instead providing the same predetermined pureed meal to all residents on similar diets. Interviews with staff, dietary personnel, and family confirmed that the resident was not asked for meal preferences, and the kitchen routinely pureed only the first menu option for these diets. The care plan indicated the resident could feed herself with assistance and had specific beverage preferences, but these were not consistently honored. Observations and interviews revealed that while residents on regular diets were offered meal choices, those on mechanically altered or pureed diets were not, regardless of their ability to express preferences. Staff and dietary management acknowledged this practice, citing concerns about food waste and assumptions about residents' decision-making abilities. The facility's policy on diets did not address the provision of meal choices for residents on modified diets, contributing to the lack of individualized meal options for the affected resident.
Failure to Complete Significant Change MDS Assessment After Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) using the Resident Assessment Instrument (RAI) process after a resident was admitted to hospice care. The resident, who had severe cognitive impairment and diagnoses including Alzheimer's disease, dementia, and traumatic brain injury, required extensive assistance with activities of daily living. Documentation showed that the resident was admitted to hospice, but the electronic medical record did not contain a significant change MDS assessment following this event. Instead, only a quarterly MDS and a death MDS were completed. During interviews, the MDS coordinator acknowledged that the significant change MDS was missed due to a miscalculation of days, and the DON confirmed the findings, stating that MDS assessments are expected to be completed in a timely manner. Facility policy requires initiation of a significant change assessment when the interdisciplinary team determines there has been a significant change in condition.
Failure to Implement Pressure-Relieving Device for Pressure Ulcer Prevention
Penalty
Summary
A resident with severe cognitive impairment, hemiplegia, aphasia, and Parkinson's Disease was identified as being at risk for pressure ulcers and required extensive assistance with activities of daily living, including bed mobility and repositioning. The resident's care plan and treatment administration record specified the use of Prevalon boots while in bed to prevent skin breakdown. Observations on two separate occasions revealed that the resident was in bed without the prescribed Prevalon boots, which were instead found on a bedside table across the room. Nursing assistants did not apply the boots during care, stating they believed the boots were only required at night. Interviews with nursing staff and the DON confirmed that the resident was at risk for pressure ulcers and that the expectation was for the Prevalon boots to be applied whenever the resident was in bed, as outlined in the care plan. Facility policy required necessary treatment and services to prevent new pressure ulcers, but staff failed to implement the prescribed pressure-relieving device as directed, resulting in a deficiency in pressure ulcer prevention care.
Failure to Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
A deficiency occurred when a resident with moderately impaired cognition, dementia, and a history of wandering and elopement risk exited the facility without staff knowledge or intervention. The resident was equipped with a WanderGuard device, and his care plan included supervision, frequent checks, and specific interventions to address his elopement risk. Despite these measures, the resident was able to trigger multiple door alarms and exit the building, remaining missing for approximately five hours before being located by police several miles away from the facility after dark. The sequence of events leading to the deficiency involved several lapses in staff response and supervision. When the resident's WanderGuard triggered alarms at multiple exit points, the receptionist received the alerts and attempted to notify the charge nurse. However, the response was delayed, and staff did not immediately conduct a thorough search of the property or check outside the building. The receptionist missed a critical alarm while away from her desk, and staff searches were limited to certain areas inside the building. Camera footage later confirmed the resident had exited the building, but this was not reviewed in time to prevent his departure. Interviews with staff revealed that expected protocols, such as immediate response to alarms and comprehensive searches, were not fully followed. Staff acknowledged that they should have checked outside as soon as the alarms were triggered and that more proactive measures could have prevented the resident from leaving the premises. The facility's elopement prevention policy required immediate and thorough searches, but these actions were not effectively implemented during the incident, resulting in the resident's prolonged absence and exposure to potential harm.
Removal Plan
- Facility began immediate investigation.
- Upon R1's return to facility a complete head to toe assessment was completed and every 30-minute safety checks were implemented due to risk of reoccurrence.
- All staff mandatory meetings have been held. Education included: elopement, missing resident, facility policies and procedures, and this specific incident and interventions had been discussed.
- Frequent checks will be completed if statements are made about leaving.
- Elopement checks will be completed if R1 makes statements about leaving.
- Elopement drills will be conducted.
- Wander guard system was checked and in working order.
- Policies were reviewed, elopement and missing resident. no changes needed.
- Other high elopement resident charts and care plans were reviewed, and triggers and interventions were added as needed.
- Pictures of high-risk elopement residents had been dispersed to all departments to review routinely. Pictures updated with any changes.
Failure to Follow Hand Hygiene and PPE Protocols During Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure proper hand hygiene and personal protective equipment (PPE) practices during high-contact care activities for two residents who were under enhanced barrier precautions (EBP) due to indwelling urinary catheters. Observations revealed that staff did not consistently follow established protocols for hand hygiene and PPE use during catheter care and related activities. Specifically, one nursing assistant, after removing gloves post-catheter care, did not sanitize her hands before donning a new pair of gloves and continued to provide care to the resident. Another nursing assistant failed to wear an isolation gown while emptying a urinary catheter, despite facility signage and policy requiring gown and glove use for such high-risk activities under EBP. The residents involved had significant medical histories, including neurogenic bladder, congestive heart failure, and other chronic conditions, and both required substantial assistance with activities of daily living. Their care plans identified them as being at increased risk for infection due to the presence of indwelling urinary catheters and directed staff to use EBP, including proper hand hygiene and PPE, during all catheter-related care. Despite these directives, staff actions did not align with facility policy or posted instructions, as evidenced by the observed lapses in hand hygiene and PPE use. Interviews with staff and facility leadership confirmed that the expected procedures were not followed. Staff acknowledged the importance of hand hygiene between glove changes and the necessity of wearing gowns and gloves during high-risk care activities, but admitted to forgetting or neglecting these steps during the observed incidents. Facility policies reviewed also emphasized the need for hand hygiene before and after resident contact, before clean procedures, and after dirty procedures, as well as the use of gowns and gloves for EBP residents during high-risk activities.
Failure to Follow Care Plan Leads to Resident Injury
Penalty
Summary
The facility failed to follow care planned interventions to ensure the safety of a resident with a history of falls, resulting in actual harm. The resident, who had moderately impaired cognition and required extensive assistance with activities of daily living, fell from a wheelchair and sustained a left humerus fracture. The care plan directed staff to remove foot pedals from the resident's wheelchair when in the room and not to leave the resident alone in the wheelchair, but these interventions were not followed. On the day of the incident, the resident was found on the floor with the wheelchair next to the bed, foot pedals still attached, and the catheter bag in the holder below the wheelchair. The resident attempted to self-transfer back to bed, which led to the fall. The resident was sent to the emergency department and diagnosed with a left proximal humerus fracture. Previous progress notes indicated a history of falls and a high fall risk score, but the care plan interventions were not consistently implemented. Interviews with facility staff confirmed that the care plan required the removal of foot pedals from the wheelchair while the resident was in the room. However, the pedals were not removed at the time of the fall, contributing to the incident. The facility's policy on falls required comprehensive assessments and individualized interventions, but these were not adequately followed, leading to the resident's injury.
Unsafe Mechanical Lift Transfer Results in Resident Injury
Penalty
Summary
The facility failed to ensure a safe transfer using a full body mechanical lift for a resident, resulting in harm. The resident, who had a history of dementia, recurrent hip dislocation, and osteoporosis, fell from the lift during a transfer. This incident led to a laceration on the back of her scalp and a contusion of the sacrum. The resident was sent to the emergency department and required four staples to the scalp. The incident occurred when two nursing assistants were transferring the resident from her bed to a wheelchair using a mechanical lift. The lift's sling was not properly secured, as one of the loops was not fully nested in the hook, causing the resident to slip out of the sling. Additionally, the mechanical lift's legs were not in the wide position, which is necessary to ensure stability during the transfer. The nursing assistants did not double-check the strap placement before proceeding with the lift, which contributed to the resident's fall. The resident's family had a camera in the room that recorded the fall, showing that the straps were not checked by the second nursing assistant who entered the room. The resident began to lean and fall to the right side, and despite attempts by the nursing assistants to hold her, she slipped out of the sling and hit her head on the floor. The facility's investigation confirmed that the sling was not appropriately hooked up, leading to the resident's fall and subsequent injuries.
Removal Plan
- Recertification of mechanical lift usage for all nursing staff.
- Immediate education and demonstration of mechanical lift competencies for all nursing staff involved in the incident.
- All nursing staff required to complete a mechanical lift competency prior to their next shift.
- Email sent to all nursing staff with mechanical lift competency instructions and pictures of correct and incorrect sling positioning.
- Mechanical lift audits conducted to ensure correct usage.
- Immediate staff education and audits initiated after the fall.
- Plan to provide education to approximately five to seven PRN staff prior to their next shift.
Failure to Properly Label, Date, and Discard Food and Beverages
Penalty
Summary
The facility failed to ensure that food and beverages stored in the refrigerators and freezers were labeled, dated, and discarded properly. During an initial tour of the kitchen area, several items were found without proper labeling or dating, including hard-boiled eggs, enchilada sauce, mustard, whipped topping, cherries, butter, summer sausage, Swiss cheese, gluten-free bread, and nectar thick ice cubes. Additionally, various items in the juice cooler, main freezer, hall freezer, basement freezer, first-floor kitchen refrigerator, and first-floor kitchen freezer were also found without proper labeling or dating, and some items had visible signs of spoilage such as ice crystals and crusty flakes around the lids. The culinary coordinator confirmed these findings and indicated that the residents had recently been served these items, which should have been discarded according to facility policy. The registered dietician also confirmed that the expectation was for all food to be dated when opened and discarded per facility policy. The facility's policy on cold storage, revised in January 2018, indicated that all perishable refrigerated and frozen items were to be stored according to state and federal regulations, and all food must be labeled, dated, and properly sealed. The failure to adhere to these standards had the potential to affect all 116 residents who received food and beverages from the facility's refrigerators and freezers.
Failure to Maintain Clean and Sanitary Equipment
Penalty
Summary
The facility failed to maintain wheelchairs and a standing lift in a clean and sanitary manner for a resident with moderate cognitive impairment and multiple diagnoses, including hypertension, non-traumatic brain dysfunction, and arthritis. The resident required staff assistance with activities of daily living and used a manual wheelchair for mobility. Observations revealed a large dried brown food-like substance on the left foot pedal of the resident's wheelchair on two consecutive days. Additionally, a standing lift in the hallway had a similar dried brown food-like substance on its lower end. Interviews with staff, including a nursing assistant, housekeeper, and the director of nursing, confirmed the presence of the dried brown substance on both the wheelchair pedal and the standing lift. The nursing assistant and housekeeper were unsure of the cleaning responsibilities and processes for wheelchairs and lifts. The director of nursing indicated that the night shift was responsible for cleaning resident wheelchairs on their bath day and as needed, while housekeeping was responsible for cleaning the lifts. However, the facility did not provide a policy on cleaning wheelchairs and lifts when requested.
Deficiencies in PPE Use and Catheter Care
Penalty
Summary
The facility failed to ensure proper use of personal protective equipment (PPE) and hand hygiene as per CDC guidelines to prevent the spread of COVID-19 for two residents who tested positive for the virus. Observations revealed that a nursing assistant (NA) did not wear an N95 mask or eye protection while transporting a COVID-19 positive resident and failed to perform hand hygiene. Another NA improperly doffed an N95 mask and placed it on a clean box of gloves without sanitizing her hands. Additionally, a third NA was observed wearing an N95 mask incorrectly before entering a COVID-19 positive resident's room. These actions were contrary to the facility's policy and CDC guidelines, which require the use of an N95 mask, gown, gloves, and eye protection when caring for COVID-19 positive residents and proper hand hygiene practices when donning and doffing PPE. The infection preventionist and director of nursing confirmed these observations and stated that the staff did not meet the expected standards for PPE use and hand hygiene. The facility's policy on COVID-19 and CDC guidelines were not followed, leading to potential risks of infection transmission among residents and staff. The facility also failed to ensure that a resident's urinary catheter drainage bag was not placed on the floor, which could lead to contamination and infection. The resident, who had severe cognitive impairment and required extensive assistance with activities of daily living, was observed with the catheter drainage bag resting directly on the floor. Both a nursing assistant and a licensed practical nurse confirmed that the bag should have been placed in a dignity bag or basin to prevent contamination. The infection preventionist and director of nursing reiterated that the facility's policy required catheter drainage bags to be kept off the floor to prevent infection. The facility's failure to adhere to these policies and guidelines resulted in deficiencies in infection prevention and control practices.
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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