Franciscan Health Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Duluth, Minnesota.
- Location
- 3910 Minnesota Avenue, Duluth, Minnesota 55802
- CMS Provider Number
- 245258
- Inspections on file
- 28
- Latest survey
- February 27, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Franciscan Health Center during CMS and state inspections, most recent first.
The facility failed to report an allegation of sexual assault to the State Agency within the required 2-hour timeframe after a male resident groped a female resident’s breasts without consent in the dining room while approaching his wife. A RN observed the incident, redirected the involved resident, and notified law enforcement and responsible parties, while the affected resident showed no visible distress and later had little recall of the event. The incident was not reported to the State Agency until several hours later, after most of the internal investigation had been completed, and the social worker acknowledged she was unaware that the allegation needed to be reported first and within 2 hours, contrary to facility policy and regulatory requirements.
The facility experienced significant staffing shortages, resulting in delayed medication administration for several residents and inadequate care for a resident with pressure ulcers. Nurses were overwhelmed with responsibilities, leading to late medication passes, while nursing assistants struggled to provide timely repositioning for residents. Interviews and reports confirmed ongoing staffing deficiencies, particularly on weekends and certain shifts, impacting the quality of care.
The facility failed to ensure medications and supplies in the medication storage room were not expired, affecting all 39 residents. Observations revealed expired blood tubes, viral panel swabs, Hibiclens, and Bacitracin ointment. The DON acknowledged the issue, noting the night shift's responsibility to check for expired items, but no check-off sheet was in place to ensure completion.
The facility failed to post ombudsman information at an accessible level for residents, particularly those in wheelchairs. During a resident council meeting, residents expressed difficulty in accessing state inspection postings due to their height. A review confirmed that the ombudsman information was placed too high, approximately six inches from the ceiling, making it inaccessible. The DON verified this issue, which violates resident rights requiring accessible information posting.
A facility failed to maintain a medication error rate below five percent, resulting in a 13.79% error rate. A resident with multiple diagnoses, including anxiety and dysphagia, received medications late due to a nurse's heavy workload. The nurse was responsible for administering medications to 23-24 residents, including those requiring special precautions, leading to delays in medication delivery.
The facility failed to ensure that call lights in resident bathrooms were accessible from the floor, affecting five residents. Observations showed that cords were either too short or had knots, preventing them from reaching the floor, and one call light was non-functional. Staff interviews revealed a lack of awareness about regulations for call light cord length, and the maintenance director was not informed of the issues.
A facility failed to provide a newly admitted resident with a copy of their baseline care plan, which included essential care needs and interventions. Despite the care plan being developed, neither the resident nor their representative received a copy, as confirmed by interviews with the resident, family, and staff.
A resident with pressure ulcers was not repositioned timely, as required by their care plan, leading to a deficiency in care. The resident, dependent on staff for bed mobility, was left in the same position for over three hours, resulting in an uncovered and actively bleeding wound. The facility's policy required repositioning based on individual assessments, which was not followed in this instance.
A facility failed to establish an effective communication system with an outside dialysis center for a resident with end-stage renal disease and type 2 diabetes mellitus. The resident's care plan required dialysis on specific days and included staff responsibilities for monitoring and communication. However, the dialysis agreement lacked essential information, and the facility's policy on Dialysis Management was not followed, leading to a deficiency in ensuring continuity of care.
A facility failed to investigate and analyze the underlying causes of a resident's delusions, leading to a deficiency in behavioral health care. The resident exhibited hallucinations and delusions, such as seeing people and animals in her room, over several months. Despite staff training on mental health conditions, the facility did not adequately address these symptoms or adjust the care plan, resulting in insufficient behavioral health services.
A facility failed to ensure proper PPE use when staff exited a Covid-19 positive resident's room. Staff removed N-95 masks inside the room and replaced them with surgical masks, contrary to facility policy and CDC guidelines. Interviews revealed staff were misinformed about proper doffing procedures, leading to potential exposure risks.
The facility failed to maintain up-to-date immunization records and provide vaccine education for new admissions. Two residents lacked immunization histories, and another was not offered a pneumococcal vaccine despite eligibility. Additionally, three residents were not educated or offered the influenza vaccine, with no documentation of vaccine declinations. Staff interviews revealed uncertainty about vaccination status and procedures for handling refusals.
The facility failed to educate and offer COVID-19 vaccinations to residents upon admission. A resident with chronic heart failure and other conditions had a record of a past COVID-19 vaccine, but staff were unsure if vaccines were offered upon admission. Another resident with hypertensive heart disease and other conditions had no immunization history, and staff assumed the resident was anti-vaccine without documentation. A third resident with spastic hemiplegia and stroke also lacked an immunization history, and staff were unsure if follow-up occurred. The facility's policy to document and offer vaccines upon admission was not followed.
A resident with severe cognitive impairments and multiple mental health disorders was involved in an inappropriate sexual encounter with a housekeeper, who was unaware of the prohibition against relationships with residents. The incident was documented by a nurse but not reported for investigation, despite the resident's care plan indicating a history of inappropriate behavior. An occupational therapy assistant assessed the resident as not cognitively intact enough to consent, highlighting the facility's failure to protect the resident from potential abuse.
A resident with severe cognitive impairments reported a romantic and physical encounter with a housekeeper, which was documented by an RN but not reported to the State Agency within the required two-hour timeframe. The facility's policy mandates immediate reporting of suspected maltreatment, which was not followed, resulting in a deficiency.
The facility did not ensure that a housekeeper received required training on abuse, neglect, and exploitation. The housekeeper could not recall the last training, and records showed no training since 2021. The DON and administrator confirmed that training should occur upon hire and annually, as per the facility's policy.
Failure to Timely Report Alleged Sexual Assault to State Agency
Penalty
Summary
The facility failed to timely report an allegation of sexual assault to the State Agency within the required 2-hour timeframe after an incident in which one resident groped another resident’s breasts without consent in the dining room. On the morning of 1/20/26 at approximately 9:15 a.m., a registered nurse (RN-A) observed that a male resident (R1) approached the dining room to greet his wife (R3), moved around a table when asked by an aide, and then came behind another resident (R2) and groped her breasts without her consent. R1 was redirected to his room and educated, and he demonstrated little to no remorse for his actions. RN-A reported that R2 was aware the incident occurred but soon closed her eyes and showed no visible negative reaction or distress, and later staff interviews found R2 had slight to no recall of the incident. Police and the responsible parties for R1 and R2 were notified, and RN-A, who had not worked at the facility for long and was unfamiliar with the residents’ plans of care, stated that the plan of care was nonetheless followed. The facility’s incident report shows that the allegation was reported to the State Agency at 4:25 p.m. on 1/20/26, more than 2 hours after the incident. During an interview on 1/29/26, the social worker stated that the decision was made to report to the State Agency after most of the investigation had been completed and acknowledged she was not aware that the report should have been made first. She agreed that the incident was reported late and not within the 2-hour requirement set by regulations and the facility’s “Maltreatment Reporting Guidelines” policy, which requires immediate reporting, but no later than 2 hours after an allegation of abuse, neglect, financial exploitation, injuries of unknown source, or misappropriation of property.
Staffing Shortages Lead to Delayed Care and Medication Administration
Penalty
Summary
The facility failed to provide sufficient nursing staff to ensure timely completion of resident care, resulting in delayed administration of morning medications for several residents. Specifically, four residents received their medications late, with one resident receiving their morning medications as late as 1:15 p.m. despite being scheduled for administration between 7:00 a.m. and 10:00 a.m. The registered nurse responsible for medication administration was overwhelmed with the task of passing medications to 23-24 residents, including those requiring additional time for medication crushing and enhanced barrier precautions. In addition to medication delays, the facility also failed to provide adequate assistance for a resident with pressure ulcers who required regular turning and repositioning. The resident, who was dependent on staff for bed mobility, was not repositioned for several hours, leading to a worsening of their wound condition. The nursing assistant responsible for the resident's care was unable to attend to the resident in a timely manner due to a busy morning, resulting in the resident's wound being left uncovered and actively bleeding. Interviews with staff revealed ongoing issues with staffing levels, with nurses and nursing assistants frequently unable to complete their duties within their shifts. The facility's staffing levels were consistently below the planned numbers, particularly on weekends and during certain shifts, leading to increased workloads for the remaining staff. The facility's assessment and payroll-based journal report confirmed these staffing deficiencies, highlighting a pattern of insufficient staffing that impacted the quality of care provided to residents.
Expired Medications and Supplies Found in Medication Room
Penalty
Summary
The facility failed to ensure that medications and supplies in the medication storage room were not expired, potentially affecting all 39 residents. During an inspection of the locked medication room, it was observed that the lab cart for blood draws contained nine yellow top blood tubes with an expiration date of 10/31/24, all four respiratory viral panel swabs were expired, two bottles of Hibiclens had expiration dates of 8/2024 and 11/2024, and two tubes of Bacitracin ointment had expiration dates of 11/2023. The Director of Nursing (DON) acknowledged that expired medications should not be used due to concerns about potency and efficacy. It was noted that the night shift was responsible for checking for outdated supplies, but there was no check-off sheet to ensure this task was completed. The facility's Night Nurse Weekly Duties document indicated that each Tuesday, the night nurse was to check for dates on opened medications and expired medications on both medication carts, treatment carts, and the medication room, highlighting any dates that expire within the current month.
Inaccessible Posting of Ombudsman Information
Penalty
Summary
The facility failed to ensure that current contact information for all pertinent State Agency and advocacy groups was posted at a level accessible to all residents, particularly those in wheelchairs or with poor eyesight. During a resident council meeting, four residents, all requiring the use of a wheelchair, expressed that they were unaware of where state inspections were posted and noted that some postings were too high to read. A review of the bulletin board in the main dining room revealed that the poster with information regarding the ombudsman was placed approximately six inches from the ceiling, making it inaccessible to residents in wheelchairs. The Director of Nursing confirmed the inaccessibility of the ombudsman information, which is a violation of the Combined Federal and State Resident Rights that require such information to be posted in a form and manner accessible and understandable to residents and their representatives.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 13.79% with four errors out of 29 opportunities. This deficiency involved a resident who was observed during medication passes. The resident, who was moderately cognitively intact, had multiple diagnoses including anxiety, depression, and dysphagia, and required medications to be administered through a gastric tube. The errors were primarily due to the late administration of medications, which were given significantly past their scheduled times. The registered nurse responsible for administering the medications was handling a large workload, passing medications for 23-24 residents, including those requiring crushed medications and enhanced barrier precautions. This workload contributed to the delay in medication administration. The director of nursing confirmed that nurses were responsible for half of the residents in the building and acknowledged the importance of timely medication delivery. The facility's medication delivery schedule was not adhered to, leading to the observed deficiencies.
Inaccessible Call Lights in Resident Bathrooms
Penalty
Summary
The facility failed to ensure that resident call lights were accessible from the bathroom floor in multi-resident bathrooms for five residents. Observations revealed that call light cords in several rooms were either too short or had knots, preventing them from reaching the floor. In one instance, a call light did not function when pulled. Interviews with nursing staff and the maintenance director indicated a lack of awareness regarding the required length of call light cords in bathrooms. Measurements confirmed that the cords were significantly above the floor, with some cords having knots that further reduced their length. The nursing assistant and registered nurses interviewed were not aware of any specific regulations concerning the length of call light cords in resident bathrooms. The maintenance director was not informed of the non-functioning call light and had not received any repair requests. The director of nursing acknowledged the importance of having call lights reach the floor to ensure residents could access them in case of a fall. The facility's call light policy, dated 2017, did not address the required length of call lights in resident bathrooms.
Failure to Provide Baseline Care Plan to Resident
Penalty
Summary
The facility failed to ensure that a copy of the baseline care plan was provided to a newly admitted resident, identified as R40, or their representative. R40 was admitted with spastic hemiplegia affecting the right dominant side and a nontraumatic intracerebral hemorrhage. The baseline care plan, dated 11/19/24, included short-term goals, health maintenance needs, pain intervention, safety concerns, medication concerns, and designated representative, as well as needs and interventions for eating, toileting, bathing, grooming, dressing, bed mobility, and transfers. However, there was no indication that R40 or their representative had been offered or received a copy of this care plan. Interviews conducted with R40 and their family member revealed that they were not aware of any meetings regarding care plans. The Director of Nursing (DON) stated that the baseline care plan should be reviewed and a copy offered to the resident or their representative. A registered nurse confirmed that while the care plan was developed with the resident, it was not offered to them or their representative. The corporate RN also verified the importance of providing a copy of the baseline care plan to ensure the resident and their family are aware of the plan of care.
Failure to Reposition Resident with Pressure Ulcers
Penalty
Summary
The facility failed to ensure timely repositioning for a resident with pressure ulcers, leading to a deficiency in care. The resident, identified as R25, had intact cognition and was diagnosed with Parkinson's with dyskinesia, diabetes mellitus, stage two pressure ulcers in the sacral region and left buttock, dermatitis due to friction or contact with body fluids, and a non-pressure chronic ulcer. R25 was dependent on staff for bed mobility and required repositioning every two to three hours as per the care plan. However, during an observation, R25 was left in the same position from shortly after 7 a.m. until 10:02 a.m., exceeding the recommended repositioning interval. When the nursing assistant (NA-D) finally attended to R25, they discovered the wound was not covered with a dressing and was actively bleeding. The registered nurse (RN-D) was called to clean and dress the wound, noting that it appeared worse than the previous day. RN-D had been conducting weekly wound assessments since the facility's rounding wound provider stopped visiting. Despite the worsening condition of the wound, the resident's provider was aware and visited the facility weekly. The facility's repositioning policy required residents to be repositioned based on individual assessments, but this was not adhered to in R25's case, contributing to the deficiency.
Failure to Implement Effective Dialysis Communication System
Penalty
Summary
The facility failed to establish an effective communication system with an outside dialysis facility, which is crucial for ensuring continuity of care and reducing the risk of complications for a resident requiring dialysis services. The resident, who had intact cognition and was diagnosed with end-stage renal disease and type 2 diabetes mellitus, was receiving dialysis care while residing at the nursing facility. The resident's care plan indicated that dialysis was scheduled for Monday, Wednesday, and Friday, and included staff responsibilities such as assessing the dialysis site for bleeding or drainage, updating the provider or dialysis unit with any concerns, recording weights from the dialysis unit, and observing for signs of infection. During interviews, it was revealed that the health unit coordinator stated that a dialysis communication sheet was supposed to accompany the resident to the dialysis center and be returned to the facility, but the resident did not have a dialysis agreement in their electronic medical record. The director of nursing emphasized the importance of a dialysis agreement for better communication and continuity of care. The dialysis agreement, dated after the deficiency was noted, lacked critical information such as the dialysis contact person and the name and address of the hospital for emergency dialysis. The facility's policy on Dialysis Management required a comprehensive agreement to manage the resident's care, including details on medical and non-medical emergencies and the process for information exchange, which was not adhered to in this case.
Failure to Investigate Resident's Delusions
Penalty
Summary
The facility failed to investigate, review, and analyze the underlying causes of a resident's delusions, leading to a deficiency in providing necessary behavioral health care and services. The resident, identified as R11, exhibited behaviors of hallucinations and delusions, as documented in her quarterly Minimum Data Set (MDS). Despite having no cognitive impairment diagnosis, R11 displayed significant behavioral changes, including hallucinations of people and animals in her room, confusion, and delusional thoughts about children and animals. These behaviors were consistently documented by staff over several months, yet there was no evidence of a thorough investigation or analysis of these symptoms. R11's care plan included interventions such as monitoring for cognitive changes, orienting her to time and place, and providing redirection as needed. However, the progress notes revealed ongoing episodes of delusions and hallucinations, such as seeing babies and cats in her room, believing her teddy bear was a real baby, and expressing a desire to leave the facility due to perceived intrusions. Despite these documented behaviors, the facility did not adequately address the underlying causes or adjust the care plan to better meet R11's needs. Interviews with staff, including registered nurses and nursing assistants, indicated that they received training on dementia and mental health conditions. However, there was uncertainty about R11's diagnoses, and the interventions identified by staff were limited to redirection, reassurance, and reorientation. The director of nursing emphasized the importance of understanding mental health conditions, yet the facility's actions did not reflect a comprehensive approach to managing R11's behavioral health needs. This lack of investigation and analysis contributed to the deficiency in providing necessary behavioral health care and services to R11.
Improper PPE Use in Covid-19 Isolation Room
Penalty
Summary
The facility failed to ensure the appropriate use of personal protective equipment (PPE) when exiting a resident's room with a Covid-19 positive diagnosis. The resident, identified as R32, was severely cognitively impaired and had a diagnosis of Covid-19. On December 11, 2024, two staff members were observed outside R32's room donning isolation gowns and N-95 masks before entering. However, upon exiting, they were seen wearing surgical masks, having removed their N-95 masks inside the room and replaced them with surgical masks stored inside. This practice was contrary to the facility's policy and the Centers for Disease Control (CDC) guidelines, which state that all PPE except the respirator should be removed before exiting the room. Interviews with staff revealed a misunderstanding of the proper procedure for doffing PPE in an airborne isolation room. Nursing assistants reported being instructed by nurse managers to remove their N-95 masks inside the room, a practice confirmed by RN-B, who stated that staff were educated on PPE procedures during orientation and annually. However, the Director of Nursing (DON) clarified that N-95 masks should not be removed until outside the Covid-19 room to prevent exposure. The facility's policy, dated July 25, 2023, also directed staff to discard disposable respirators after exiting the resident room and performing hand hygiene, which was not followed in this instance.
Failure to Ensure Up-to-Date Immunization Records and Vaccine Education
Penalty
Summary
The facility failed to ensure that immunization records were up to date for two residents who were new admissions. Resident 13, who was over the age of 50 and had multiple diagnoses including hypertensive heart disease and atrial fibrillation, did not have a Minnesota Immunization Information Connection (MIIC) report, and the facility could not provide any immunization history. Similarly, Resident 40, also over the age of 50 with conditions such as spastic hemiplegia and nontraumatic intercerebral hemorrhage, lacked an MIIC report and immunization history. Interviews with registered nurses revealed uncertainty about the residents' vaccination status and whether follow-ups had been conducted. The facility also failed to educate and offer pneumococcal vaccines to residents upon admission. Resident 17, who had a history of cerebrovascular disease and diabetes mellitus, was eligible for a pneumococcal vaccine according to CDC guidelines but was not offered one. The registered nurse was unaware of the CDC's PneumoRecs VaxAdvisor and relied solely on the MIIC for vaccine status, without consulting the resident's provider about vaccine eligibility. The director of nursing expected staff to review CDC guidelines and offer vaccines appropriately, which was not done in this case. Additionally, the facility did not provide education or offer the influenza vaccine to three residents. Resident 11, with chronic heart failure and other conditions, had an outdated influenza vaccine record, and there was no documentation of the vaccine being offered to Residents 13 and 40. The facility could not provide evidence of education about the influenza vaccine or signed declinations from the residents or their representatives. The director of nursing was unsure of the process if a resident declined the vaccine, indicating a lack of clear procedures for handling vaccine refusals.
Failure to Educate and Offer COVID-19 Vaccinations
Penalty
Summary
The facility failed to ensure that residents were educated on and offered COVID-19 vaccinations upon admission, as evidenced by the cases of three residents. Resident 11, who was admitted with chronic heart failure, hypertension, multidrug-resistant organism, diabetes mellitus, and depression, had a record of a COVID-19 vaccine received on 10/19/23. However, there was uncertainty from the staff regarding whether Resident 11 had been offered any vaccines upon admission. Resident 13, admitted with hypertensive heart disease, anxiety disorder, atrial fibrillation, and adult failure to thrive, had no immunization history available, and the staff assumed the resident was anti-vaccine without documented evidence of education or declination. Resident 40, admitted with spastic hemiplegia and nontraumatic intracerebral hemorrhage, also lacked an immunization history, and the staff was unsure if the resident or their representative had been followed up on regarding vaccination status. Interviews with the nursing staff revealed a lack of clarity and follow-through in documenting and offering COVID-19 vaccinations to these residents. RN-B was unaware of any immunization history for Resident 40 and unsure if any follow-up had occurred. RN-A assumed Resident 13 was anti-vaccine but had no documentation to support this belief. The Director of Nursing expected staff to identify a resident's vaccine status upon admission to ensure proper education and offering of vaccines, but this expectation was not met. The facility's policy required an immunization history to be taken upon admission and documented in the resident's medical record, with any unknown histories shared with the attending physician, but this process was not followed for the residents in question.
Failure to Protect Resident from Sexual Abuse by Staff
Penalty
Summary
The facility failed to protect a resident's right to be free from sexual abuse by staff, as evidenced by an incident involving a resident with severe cognitive impairments and multiple mental health disorders, including schizoaffective disorder, autism, bipolar disorder, intellectual disabilities, Alzheimer's disease, dementia, and schizophrenia. The resident, who had a court-appointed guardian due to his inability to make decisions, was reported to have engaged in inappropriate sexual contact with a housekeeper. The resident's care plan noted a history of making inappropriate sexual comments and touching others inappropriately, with interventions in place to manage these behaviors. Despite these interventions, the resident reported to a registered nurse that he had a romantic relationship with a housekeeper, which included inappropriate touching. The nurse documented the incident but did not report it for investigation. The housekeeper confirmed the encounter, stating she was unaware of the prohibition against relationships with residents. An occupational therapy assistant assessed that the resident was not cognitively intact enough to consent to a relationship, highlighting the resident's vulnerability and the facility's failure to protect him from potential abuse.
Failure to Timely Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident with severe cognitive impairments, including schizoaffective disorder, autism, bipolar disorder, intellectual disabilities, Alzheimer's disease, dementia, and schizophrenia. The resident, who required extensive assistance with daily activities, informed a registered nurse (RN-A) that he had a romantic relationship with a housekeeper and that they had engaged in physical contact. Despite documenting the incident in the resident's medical record, RN-A did not report the allegation to the State Agency within the required two-hour timeframe. The housekeeper confirmed the resident's account, stating that she was unaware of the prohibition against relationships with residents until after the encounter. The facility's policy mandates that any suspected maltreatment be reported within two hours, a guideline reiterated by both RN-B and the director of nursing. The administrator also emphasized the importance of timely reporting. The failure to report the incident promptly constitutes a deficiency in the facility's adherence to its maltreatment reporting guidelines.
Failure to Provide Required Abuse Training
Penalty
Summary
The facility failed to ensure that required training on abuse, neglect, and exploitation was completed for a housekeeper, identified as H-A, whose personnel records were reviewed. During an interview, H-A stated she could not recall the last time she received such training. A review of her personnel file revealed that she had not undergone training on abuse, neglect, and exploitation since June 7, 2021. The Director of Nursing (DON) confirmed that all staff should receive this training upon hire, annually, and as events occur. The facility's Maltreatment Prohibition policy, reviewed on October 18, 2021, also directed that employees be trained on these policies and procedures during orientation and annually. However, the administrator acknowledged that H-A had not received the required education since 2021.
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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