Flagstone
Inspection history, citations, penalties and survey trends for this long-term care facility in Eden Prairie, Minnesota.
- Location
- 12500 Castlemoor Drive, Eden Prairie, Minnesota 55344
- CMS Provider Number
- 245312
- Inspections on file
- 21
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Flagstone during CMS and state inspections, most recent first.
Staff failed to perform hand hygiene before and after administering medications to multiple residents. Observations showed that medication assistants and an RN did not sanitize their hands as required, even after touching residents and objects in resident rooms. Interviews with staff and a resident confirmed that hand hygiene was not consistently practiced during medication passes, contrary to facility policy.
The facility failed to provide a private meeting space for resident council meetings, holding them in the dining room during lunch without informing residents. This affected all residents who regularly attended, as they were not aware these were council meetings. The activity director and administrator did not ensure proper communication or privacy, contrary to facility policy.
The facility failed to assist residents with personal hygiene, as observed in three residents who required varying levels of assistance with ADLs. One resident with severe cognitive impairment was not shaved despite a care plan indicating a preference for it. Another resident, who needed moderate assistance, had significant facial hair and reported issues with obtaining a working shaver. A third resident, requiring maximal assistance, was not shaved regularly despite expressing a preference for frequent shaving. Staff interviews confirmed inconsistencies in providing shaving assistance.
The facility failed to assess the ability of three residents to self-administer medications before leaving medications with them. One resident had Nystatin powder on the bedside table without an order or assessment. Another resident had multiple medications, including eye drops and Tums, without orders for them to be left at the bedside. The third resident had Aspercream with lidocaine on the bedside table, despite the care plan indicating no self-administration except for Aspercream, but lacked an assessment. The director of nursing confirmed the absence of self-administration assessments for all three residents.
A resident with depression and malnutrition was not assisted into a wheelchair for meals as required by their care plan. Staff acknowledged the expectation but did not comply, assuming the resident would refuse. Interviews confirmed the care plan's importance for repositioning and quality of life, but no refusal was documented, and a care plan policy was not provided.
A resident receiving hospice services, who required assistance with daily activities, was not provided with meaningful and engaging activities as per her care plan. She reported not receiving an activities calendar or being invited to activities, which was confirmed by staff interviews. The life enrichment director and DON acknowledged the lack of documentation and engagement, leaving the resident feeling sad and isolated.
A resident with severe cognitive impairment and a recent fall resulting in a fracture was not provided with adequate fall prevention interventions. Despite being at high risk for falls, the resident's wheelchair was not placed next to the bed as required by the care plan, leading to a deficiency in the facility's fall prevention measures.
A newly admitted resident with chronic kidney disease and other conditions did not receive the required 30-day physician visits for the first 90 days. Despite being seen by a nurse practitioner, the resident's medical record lacked evidence of physician visits, contrary to the facility's policy. The administrator and DON confirmed the deficiency.
The facility failed to ensure medications were available and administered as ordered for two residents. One resident did not receive Creon for several days due to unavailability, and the provider was not notified. Another resident missed doses of Zoloft, with the medication initially not found in the cart. The facility's medication administration policy was not adequately followed, contributing to the deficiency.
A LTC facility experienced a 7% medication error rate due to two incidents involving incorrect medication administration. One resident with Crohn's disease did not receive their prescribed Creon due to unavailability, while another resident received a 4% Lidocaine patch instead of the ordered 5% due to pharmacy supply issues. The facility's medication administration policy, which includes the eight rights of drug administration, was not adhered to, resulting in these errors.
The facility failed to maintain a resident's room in good repair, with visible scuff marks, plaster coming off the walls, and dents present for over a month. Despite the facility's system for reporting maintenance issues, no work order was submitted to address the damage, compromising the resident's homelike environment.
The facility failed to develop a comprehensive care plan for a resident with severe cognitive impairment and psychotropic medication use. The care plan lacked resident-specific goals and interventions, despite the resident's history of hallucinations and agitation. Interviews confirmed the care plan was general and did not meet the facility's policy requirements.
The facility failed to provide adequate grooming and shaving for a resident with moderate cognitive impairment and multiple health conditions. Despite the care plan and facility policy requiring daily grooming, observations over several days showed that the resident's facial hair was not addressed. Staff acknowledged the need for shaving and the availability of necessary supplies, but the task was not completed, leading to a deficiency in providing proper grooming care.
A resident with severe cognitive impairment, diabetes, and multiple pressure ulcers did not receive consistent care as outlined in the care plan. Despite the requirement to use blue heel boots and elevate legs with pillows at all times, staff failed to implement these interventions, leading to inadequate pressure ulcer management.
The facility failed to adequately monitor orthostatic blood pressures and weight changes for a resident using antipsychotic drugs and a diuretic. The resident experienced significant weight fluctuations and symptoms like dizziness and wheezing, which were not properly documented or reported to the provider. The facility did not follow the care plan and physician's orders for monitoring side effects and fluid status.
The facility failed to ensure appropriate follow-up on wound culture results for a resident with a stage 4 pressure ulcer, leading to potential inappropriate use of antibiotics and lack of special precautions. The resident's care plan and medical records lacked documentation of the wound infection, and staff interviews revealed inconsistencies in tracking and following up on culture results.
Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to ensure proper hand hygiene was performed during medication administration for five residents. Observations revealed that trained medication assistants and a registered nurse did not sanitize their hands before or after administering medications, despite handling residents, touching personal items in resident rooms, and preparing medications. For example, one medication assistant assisted a resident to stand, touched the resident's fridge, and administered medications without hand sanitization before or after the process. Another medication assistant and a registered nurse also failed to perform hand hygiene before entering resident rooms or after administering medications. Interviews with residents and staff confirmed that hand hygiene was not consistently practiced during medication passes. One resident reported rarely seeing staff sanitize their hands before or after giving medications. Both a registered nurse and a medication assistant acknowledged that hand sanitizer should be used before and after medication administration. The interim director of nursing also stated that hands should be sanitized between medication passes. Facility policy directs staff to perform hand hygiene before and after contact with residents and after contact with objects in resident rooms.
Lack of Private Meeting Space for Resident Council Meetings
Penalty
Summary
The facility failed to ensure that residents were provided a private meeting place without staff present for resident council meetings, affecting all five residents who regularly attended these meetings. Interviews with residents revealed that they were not aware of the resident council meetings, as they were not invited or informed about them. The activity director conducted the meetings during lunch in the dining room, which was not communicated as a resident council meeting to the residents. This practice did not allow for a private setting where residents could freely express their concerns. The review of the resident activity calendar showed that the location of the meetings was not specified, and the activity director was unable to explain how residents who did not eat in the dining room were invited to the meetings. The administrator believed that residents could discuss concerns privately with the activity director or fill out a grievance form, but did not see an issue with the meetings being held in the dining room with staff present. The facility's policy stated that residents should have the opportunity to meet in a private space, which was not adhered to in this case.
Failure to Assist Residents with Personal Hygiene
Penalty
Summary
The facility failed to provide adequate assistance with personal hygiene for four residents, all of whom required varying levels of assistance with activities of daily living (ADLs). Resident R7, who had severe cognitive impairment and required staff assistance for personal hygiene, was observed with long facial hair despite the care plan indicating a preference for being shaved when facial hair was visible. Staff interviews revealed that R7 had not been shaved recently, and there was uncertainty about the last time shaving assistance was provided. Resident R33, who had no cognitive impairment but required moderate assistance with personal hygiene, was observed with significant facial hair over multiple days. R33 reported that his shaver was not working and was under the impression that residents needed to purchase their own shavers. Staff confirmed that shaving tasks were not completed daily, and there was a lack of readily available shavers for residents. Resident R267, who required maximal assistance with personal hygiene, was also observed with long facial hair over several days. Despite expressing a preference for being shaved often, R267 was not shaved regularly, and staff were unclear about the frequency of shaving required. The facility's policy indicated that ADL care should be provided based on resident preferences, but observations and interviews demonstrated a failure to adhere to this policy.
Failure to Assess Residents' Ability to Self-Administer Medications
Penalty
Summary
The facility failed to ensure that residents' ability to self-administer medications was assessed before leaving medications with them. Three residents were involved in this deficiency. The first resident, identified as R33, had no cognitive impairment but required moderate assistance with personal hygiene. Despite this, Nystatin powder was found on the resident's bedside table without an order to leave it there or an assessment for self-administration. The care plan for R33 lacked information regarding self-administration of medication, and the registered nurse confirmed the medication should not have been left at the bedside. The second resident, R267, also had no cognitive impairment and required maximal assistance with personal hygiene. This resident had several medications, including eye drops and Tums, on the bedside table without orders for them to be left there. The care plan indicated that R267 chose not to self-administer medications, and there was no assessment for self-administration. A licensed practical nurse confirmed the presence of these medications and the lack of orders for them to be left at the bedside. The third resident, R9, had no cognitive impairment and needed moderate assistance with activities of daily living. Aspercream with lidocaine was found on the bedside table, although the care plan indicated that R9 chose not to self-administer medications except for Aspercream. However, there was no assessment for self-administration, and the registered nurse confirmed the lack of an order for self-administration. The director of nursing verified that none of the three residents had self-administration assessments completed, which was against the facility's medication administration policy.
Failure to Follow Care Plan for Resident's Meal Positioning
Penalty
Summary
The facility failed to adhere to the comprehensive care plan for a resident identified as R62, who was diagnosed with depression and malnutrition and required extensive assistance with activities of daily living. The care plan, revised on 12/30/24, specified that R62 should be up in her wheelchair for all meals due to limited physical mobility and self-care deficits. However, during an observation on 1/28/25, a nursing assistant (NA-F) delivered R62's meal tray to her bedside and did not assist R62 into her wheelchair, contrary to the care plan instructions. NA-F acknowledged the expectation to get R62 up for meals but did not do so, assuming R62 would refuse. Interviews with staff, including a registered nurse (RN-C), a household coordinator (HC), and the director of nursing (DON), confirmed that R62 was supposed to be in her wheelchair for meals to aid in repositioning and quality of life. The DON emphasized the expectation for staff to follow care plans and report any refusals. Despite these expectations, the care plan was not followed, and no documentation of refusal was noted. Additionally, the facility was unable to provide a care plan policy when requested.
Failure to Provide Meaningful Activities for Resident
Penalty
Summary
The facility failed to provide meaningful and engaging activities for a resident, identified as R62, who was reviewed for activities. R62, who had no cognitive impairment and was receiving hospice services, required extensive assistance with activities of daily living. Her care plan indicated a preference for visits from her daughter, talking with staff, watching television, one-to-one visits, and group activities. However, R62 reported not being offered any activities or visitors since her admission and did not have an activities calendar in her room, which was confirmed by observations and interviews. The life enrichment director confirmed that activity calendars were supposed to be distributed to each resident at the beginning of the month and that staff were expected to invite residents to group activities. However, there was no documentation to confirm that R62 had been invited to or participated in any activities. The director of nursing corroborated these findings, acknowledging the lack of documentation and stating that staff were expected to engage all residents in daily activities. Despite the facility's procedures, R62 was left without engagement, leading to feelings of sadness and isolation.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement necessary interventions for a resident who had a recent fall resulting in a significant injury and remained at high risk for falls. The resident, identified as having severe cognitive impairment and diagnoses including anxiety disorder, dementia, and a left humerus fracture, required extensive assistance with activities of daily living. Despite being identified as high risk for falls, the resident's care plan was not adequately followed, as evidenced by the improper placement of the resident's wheelchair, which was supposed to be next to the bed as a fall prevention measure. Observations and interviews revealed that the resident's wheelchair was found five feet away from the bed and in the bathroom, contrary to the care plan's instructions. Nursing staff, including a nursing assistant, nurse manager, and the director of nursing, confirmed the resident's recent fall and the expectation that the wheelchair should have been placed next to the bed. The facility's Fall Prevention and Management Program Policy required that all residents be assessed for fall risk and that interventions be implemented according to specific risk factors, which was not adhered to in this case.
Failure to Provide Required Physician Visits for New Resident
Penalty
Summary
The facility failed to ensure that a newly admitted resident received the required 30-day physician visits for the first 90 days after admission. The resident, identified as R30, was admitted with no cognitive impairment and had diagnoses including chronic kidney disease, an indwelling catheter, and a history of urinary tract infections. R30 required moderate assistance with activities of daily living such as bathing, transfers, and toileting. Despite these needs, R30's medical record showed no evidence of being seen by a physician since admission. During interviews, R30 confirmed not having seen a physician and expressed that staff avoided him when he requested a visit. Although R30 had been seen by a nurse practitioner three times, the facility's policy required physician visits every 30 days for the first 90 days, which was not met. The administrator and director of nursing confirmed these findings and acknowledged the failure to adhere to the facility's policy.
Medication Availability and Administration Deficiency
Penalty
Summary
The facility failed to ensure that medications were available and administered as ordered for two residents, R61 and R57. R61, who had moderate cognitive impairment and diagnoses including Crohn's disease, heart failure, and chronic kidney disease, did not receive Creon, a medication necessary for pancreatic insufficiency, from January 22 to January 28. The medication was not available, and the facility's process to reorder it was not effectively implemented. The pharmacy was contacted, but the provider was not notified of the unavailability of the medication, which was a critical step missed in the process. R57, who had moderate cognitive impairment and diagnoses including hypertension, depression, Alzheimer's, aphasia, and seizure disorder, did not receive Zoloft, a medication for depression, on January 26 and 27. The medication was not found in the medication cart initially, but was later located in the medication room. The facility's process for reordering medications was not followed, and the physician was not informed of the missed doses, which was a necessary action to ensure continuity of care. The facility's medication administration policy, revised in May 2021, was not adequately followed. The policy required the eight rights of drug administration to be adhered to and included instructions to contact the pharmacy if medications were unavailable. However, it lacked specific guidance on notifying the resident's provider if a medication was not available, which contributed to the deficiency in ensuring medications were administered as ordered.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility had a medication error rate of 7%, exceeding the acceptable threshold of 5%, due to errors in medication administration for two residents. One resident, identified as R61, who had moderate cognitive impairment and diagnoses including Crohn's disease, heart failure, and chronic kidney disease, did not receive their prescribed Creon medication from 1/22/25 because it was unavailable. The trained medication aide (TMA) responsible for administering the medication indicated that the Creon was not available and planned to reorder it from the pharmacy. The clinical coordinator confirmed the medication had not been administered since 1/22/25, and the director of nursing (DON) later discovered the issue was due to an insurance problem. Another resident, R44, who was cognitively intact and had diagnoses including arthritis and sciatica, received an incorrect dosage of Lidocaine patch. The order was for a 5% Lidocaine patch, but a 4% patch was administered instead because the pharmacy did not have the 5% version. The TMA acknowledged the discrepancy, and the clinical coordinator confirmed the error. The facility's usual process for handling unavailable medications was not followed, as the physician was not contacted to determine if an alternative medication should be administered. The facility's policy requires adherence to the eight rights of drug administration, which was not followed in these instances, leading to the medication errors.
Failure to Maintain Resident Room in Good Repair
Penalty
Summary
The facility failed to ensure that a resident's room walls were in good repair, compromising the homelike environment for a resident with severe cognitive impairment who required extensive assistance with mobility and daily living activities. The resident's room had visible scuff marks, plaster coming off the walls, and dents, which had been present for more than a month. Family members and nursing assistants confirmed that the damage was likely caused by the resident's wheelchair and mechanical lift used by staff. Despite the facility's system for reporting maintenance issues, no work order had been submitted to address the wall damage in the resident's room. Interviews with staff, including the environmental services director, nursing assistants, and the director of nursing, revealed that maintenance issues should be reported immediately and addressed within 24 hours. However, the system failed in this instance, as no work order was found for the resident's room repairs. The facility's administrator confirmed that there was no specific policy on maintaining a homelike environment, although residents were provided with a rights booklet upon admission, which included the right to a safe, clean, and comfortable environment.
Failure to Develop Comprehensive Care Plan for Psychotropic Medication Use
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident (R54) who was taking psychotropic medications, including an antipsychotic. The resident had severe cognitive impairment, Alzheimer's disease, psychotic disorder, and legal blindness. The care plan lacked resident-specific goals and interventions for psychotropic medication use, including person-centered goals and resident-specific interventions to address target behaviors. The care plan identified the use of antidepressant, antianxiety, and antipsychotic medications but did not provide details about the medications and resident-specific behaviors and interventions. The resident's Care Area Assessments (CAAs) indicated restlessness, agitation, and a history of hallucinations treated with psychotropic drugs. Despite this, the care plan did not include non-pharmacologic interventions or specific details about the resident's previous favorite activities. Interviews with the hospice case manager, a registered nurse, and the director of nursing confirmed that the care plan was general and lacked the necessary specifics. The facility's policies on psychotropic and unnecessary medication use and care planning required individual interventions, which were not reflected in the resident's care plan.
Failure to Provide Adequate Grooming and Shaving for Resident
Penalty
Summary
The facility failed to provide adequate grooming and shaving for a resident (R22) who was dependent on staff for activities of daily living (ADLs). R22 had moderate cognitive impairment and required assistance with personal hygiene due to conditions such as depression, anxiety, dementia, and psychosis. Despite the care plan indicating that R22 should be clean and well-dressed daily with staff assistance for personal hygiene, observations over several days showed that R22 had significant facial hair that was not addressed. Nursing assistants and other staff members were observed interacting with R22 multiple times without addressing the facial hair, and it was noted that the electric razor might need new batteries, which were readily available in the supply room. The director of nursing confirmed that shaving should occur every bath day, and there were no special preferences for R22 regarding facial hair. However, the facial hair remained unchanged throughout the observations, indicating a failure to follow the care plan and facility policy for daily grooming and shaving. The observations and interviews revealed that the nursing assistants and other staff members did not adequately perform grooming tasks, specifically shaving, for R22. Despite the care plan and facility policy requiring daily morning and bedtime care, including shaving, R22's facial hair was not addressed over several days. The nursing assistant acknowledged the need for shaving and the availability of batteries for the electric razor, but the task was not completed. The registered nurse and director of nursing both confirmed the expectation for staff to assist with shaving, highlighting a lapse in the execution of these duties, leading to the deficiency in providing proper grooming care for R22.
Failure to Implement Pressure Ulcer Interventions
Penalty
Summary
The facility failed to ensure proper interventions were in place for a resident with pressure ulcers. The resident, who had severe cognitive impairment, diabetes, peripheral vascular disease, and dementia, was frequently incontinent and required extensive assistance with mobility and toileting. The resident had multiple pressure ulcers, including a stage three pressure ulcer on the left heel, an unstageable pressure ulcer, a diabetic foot ulcer, and moisture-associated skin damage. The care plan indicated the use of blue heel boots and pillows to elevate the legs at all times, both in bed and in the wheelchair, to reduce pressure and promote healing. However, observations revealed that the resident did not have a pillow under her legs while in the wheelchair on multiple occasions. Despite the care plan and task forms indicating the need for leg elevation, staff failed to consistently implement this intervention. Interviews with staff, including a licensed practical nurse (LPN) and a nursing assistant (NA), confirmed that the resident was supposed to have pillows under her legs at all times. The LPN and NA acknowledged the oversight and verified that the care sheet required leg elevation, but the intervention was not consistently followed. The facility's Skin Integrity Management Policy emphasized the importance of implementing preventative measures and appropriate treatment modalities for pressure ulcers. Despite this policy, the staff did not adhere to the care plan's interventions, resulting in the resident not receiving the necessary care to prevent further skin breakdown. The director of nursing (DON) and other staff members acknowledged the deficiency and the expectation that the care plan should be followed to ensure the resident's well-being.
Failure to Monitor Orthostatic Blood Pressures and Weight Changes
Penalty
Summary
The facility failed to ensure adequate monitoring of orthostatic blood pressures for a resident using antipsychotic drugs and did not adequately monitor weights and fluid status for the same resident. The resident, who had moderate cognitive impairment, received a diuretic, an antidepressant, and an antipsychotic on a routine basis. The resident's diagnoses included high blood pressure, high cholesterol, peripheral vascular disease, edema, depression, anxiety, insomnia, dementia, and psychosis. Despite the care plan indicating the need for monitoring side effects and targeted behaviors, the facility did not document orthostatic blood pressures as required by the physician's orders and the facility's policy on psychotropic and unnecessary medication use. The resident's electronic health record (EHR) lacked documentation of orthostatic blood pressures, and the treatment administration record (TAR) only showed completion for side effect monitoring on two specific dates. Additionally, the resident's EHR revealed significant weight fluctuations that were not reported to the provider as required. The resident's weights showed differences of more than 5 pounds on multiple occasions, but there was no documentation that the provider was updated regarding these changes. The resident's care plan identified the need to monitor weights and fluid status due to the use of a diuretic and the risk of dehydration or fluid deficit. During observations and interviews, it was noted that the resident experienced dizziness, leg tenderness, and audible wheezing, which were not adequately addressed by the staff. The nursing assistant and registered nurse acknowledged the resident's symptoms but did not follow through with proper documentation or notification to the provider. The director of nursing confirmed that the facility did not follow up on the provider's plan to monitor weight and fluid status and acknowledged the lack of documentation and provider notification for the resident's weight changes and orthostatic blood pressures.
Failure to Follow Up on Wound Culture Results
Penalty
Summary
The facility failed to implement a system to ensure appropriate follow-up on wound culture results for a resident with a stage 4 pressure ulcer, leading to potential inappropriate use of antibiotics and lack of special precautions. The resident had multiple diagnoses, including multiple sclerosis, paraplegia, and a history of urinary tract infections. Despite having a wound culture obtained at a wound clinic, the facility did not follow up on the culture and sensitivity report in a timely manner, resulting in a delay in appropriate treatment and precautions for the resident's wound infection, which included MRSA and mixed flora bacteria. The resident's care plan and medical records lacked documentation of the wound infection and the necessary follow-up on the wound culture report. The facility's antibiotic tracking log indicated the presence of a wound infection but did not document the follow-up of the culture results. Interviews with staff revealed inconsistencies in the process of tracking and following up on culture results, with the infection preventionist and registered nurse acknowledging the lack of documentation and follow-up on the wound culture report. The facility's policy on infection prevention and control, including antibiotic stewardship, emphasized the importance of tracking and reporting antibiotic use and outcomes. However, the facility failed to adhere to these guidelines, resulting in a deficiency in ensuring appropriate follow-up on wound culture results and the implementation of necessary precautions for the resident's wound infection.
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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