Friendship Village Of Bloomington
Inspection history, citations, penalties and survey trends for this long-term care facility in Bloomington, Minnesota.
- Location
- 8130 Highwood Drive, Bloomington, Minnesota 55438
- CMS Provider Number
- 245229
- Inspections on file
- 15
- Latest survey
- March 27, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Friendship Village Of Bloomington during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple psychiatric diagnoses was prescribed Lexapro, a psychotropic medication, without documented informed consent from the resident or their representative. Staff interviews and facility policy confirmed that informed consent should have been obtained and documented prior to starting the medication, but no such documentation was found in the resident's record.
A resident with multiple risk factors for skin breakdown developed several wounds, including a stage 2 pressure ulcer, but staff failed to consistently assess, document, and report changes in the wounds. Nursing staff were unaware of the current wound status, the wound care team did not include the resident in weekly rounds, and the nurse practitioner was not informed of wound deterioration. Facility policies for prompt notification and evidence-based wound care were not followed.
Staff failed to consistently perform hand hygiene and follow enhanced barrier precautions during personal and wound care for a resident with complex medical needs, including a venous ulcer and indwelling catheter. Nursing assistants did not change gloves or perform hand hygiene when moving from dirty to clean tasks, and a nurse did not wear a gown or consistently perform hand hygiene between glove changes during wound care, contrary to facility policy.
A resident with severe cognitive impairment and a need for assistance with personal hygiene was not properly assisted with shaving, despite documentation indicating the task was completed daily. Observations showed the resident was unshaven for several days, and staff interviews confirmed the task was not performed as required by the care plan and facility policy.
The facility failed to thoroughly investigate injuries of unknown origin for four residents with suspicious bruises. The injuries were not witnessed, and the residents could not explain how they occurred. The facility did not conduct thorough investigations or document the incidents properly, leading to unverified rationales and a failure to implement corrective actions.
The facility failed to recognize and report injuries of unknown origin for four residents with suspicious bruises. Despite multiple staff members identifying the bruises as suspicious, they were not reported to the State Agency as required by the facility's policies.
The facility's administration failed to take timely and appropriate action to address injuries of unknown origin and bruises for four residents. Despite being informed, the DON and administrator did not report the injuries to the state agency, conduct thorough investigations, or implement preventive measures. The facility lacked a formal tool for investigating incidents, and responsibilities were unclear among staff members.
The facility failed to accurately identify a resident's status on the MDS assessment. Despite the resident displaying behaviors such as repetitive calling out and receiving Lorazepam for anxiety, the MDS did not reflect these behaviors. Documentation and interviews confirmed the discrepancy, highlighting a failure in accurately assessing and documenting the resident's behavioral symptoms.
The facility failed to consistently implement transfer interventions for a cognitively impaired resident and did not properly monitor and document bruising for two residents, leading to discrepancies in care and incomplete documentation.
The facility failed to properly assess and monitor bruises on multiple residents, leading to inconsistencies in documentation and lack of follow-up care. For one resident, the measurements and location of a bruise were inconsistent among different nursing staff, and there was no further investigation to determine the cause. Another resident had multiple bruises that were not properly documented or monitored, and the care plan was not revised to address risks. A third resident had a bruise that was not consistently assessed or monitored, and the facility lacked a policy for monitoring bruises.
The facility failed to provide timely assistance with repositioning for a resident with severe cognitive impairment and multiple diagnoses, leading to a risk of pressure ulcer development. The care plan directed repositioning every two hours while in bed but did not specify frequency while in a chair. Observations and staff interviews confirmed that the resident was not repositioned as required.
The facility failed to provide adequate supervision and appropriate transfer techniques for a resident with severe cognitive impairment, resulting in a significant bruise. Another resident at high risk of falls experienced multiple falls due to an unlocked wheelchair, with inconsistent use of an anti-rollback device. The facility's failure to adhere to care plans and ensure proper transfer methods led to injuries and potential harm.
A resident with severe cognitive impairment and multiple diagnoses did not receive timely incontinence care as per their care plan, resulting in a period of four hours and thirty minutes without assistance. Staff interviews confirmed the resident should have been assisted every 2-3 hours.
The facility failed to provide nonpharmacological interventions before administering as-needed antianxiety medications to a resident with severe cognitive impairment and multiple diagnoses. The care plan and clinical records lacked documentation of such interventions, and staff did not consistently implement or document them, despite the resident frequently calling out and displaying distress.
The facility failed to notify the Office of Ombudsman for Long-Term Care (OOLTC) of facility-initiated transfers for 12 residents who had been hospitalized. The deficiency was identified through an email correspondence with the OOLTC, which indicated that the facility had not completed monthly reporting of transfers and discharges as required. Interviews with the director of health center sales and services (DHCSS) and the administrator confirmed that the notifications had not been sent and that the facility policy did not include a timeframe for reporting emergency transfers to the OOLTC monthly or within 30 days prior to the discharge or as soon as practicable.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to inform a resident or their representative in advance and obtain consent for the use of a psychotropic medication, specifically Escitalopram Oxalate (Lexapro). The resident in question had severe cognitive impairment, a history of depression, Alzheimer's, dementia, and hallucinations, and was taking both antipsychotic and antidepressant medications. The care plan and medication administration record documented the use of Lexapro for anxiety and related symptoms, with the medication originally started several months prior to the review. Upon review of the resident's electronic medical record, there was no evidence of informed consent for Lexapro. Interviews with facility staff, including an LPN, the DON, and the consultant pharmacist, confirmed that informed consent should have been obtained and documented prior to starting the psychotropic medication. The facility's own policy required that residents or their representatives be informed of the recommendation, risks, benefits, purpose, and potential adverse consequences of antipsychotic medication use, but this process was not followed in this case.
Failure to Accurately Assess and Report Wound Deterioration
Penalty
Summary
The facility failed to ensure that wounds were accurately assessed and reported for a resident with multiple risk factors, including severe cognitive impairment, immobility, incontinence, diabetes, congestive heart failure, and kidney disease. The resident was identified as being at moderate risk for pressure ulcers and had a care plan instructing staff to monitor, document, and report any changes in skin status. Despite this, documentation showed inconsistencies and a lack of clarity regarding the identification, assessment, and monitoring of wounds, including a stage 2 pressure ulcer and other skin issues such as bruising, skin tears, and abrasions. Observations and interviews revealed that staff were not consistently aware of the resident's current wound status, with some staff unable to explain missing dressings or the duration of open wounds. Nursing staff admitted to not having recently assessed the resident's wounds and were unaware of open areas, while the wound care team had not included the resident in weekly rounds or provided documentation of wound assessments. The treatment administration record lacked evidence of updated or discontinued wound care orders for the resident's ongoing skin issues. Further, the nurse practitioner was not notified of changes or deterioration in the resident's wounds, and the director of nursing was unaware of open areas that required attention. Facility policies required prompt notification of changes in a resident's condition and evidence-based wound care practices, but these were not followed, resulting in a failure to provide appropriate treatment and care according to orders, resident preferences, and goals.
Failure to Perform Hand Hygiene and Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to ensure proper hand hygiene and adherence to enhanced barrier precautions (EBP) during personal and wound care for a resident with significant medical needs. During personal care, two nursing assistants wore gowns and gloves but did not change gloves or perform hand hygiene when moving from dirty to clean areas, such as after cleansing the peri-area and before assisting with other tasks. One assistant applied cream and handled linens with the same gloves, and after removing gloves, donned new gloves without performing hand hygiene. The resident was only given a washcloth to wash his own hands at the end of care. During wound care, a registered nurse did not wear a gown as required for EBP and inconsistently performed hand hygiene between glove changes. The nurse handled wound dressings, performed wound cleansing, and assisted the resident with personal items such as a water pitcher, all while wearing the same gloves. At one point, the nurse picked up a dressing that had fallen on the floor and continued care without changing gloves. Hand hygiene was not performed between all glove changes, and the nurse acknowledged missing these steps during an interview. The resident involved had a history of kidney failure, hypertension, depression, chronic pain, an indwelling urinary catheter, and a venous ulcer. The care plan specified the need for EBP and extensive assistance with personal hygiene due to limited mobility and a left leg amputation. Facility policy required hand hygiene before and after resident contact, between glove changes, and the use of appropriate PPE for residents on EBP, but these protocols were not consistently followed during the observed care events.
Failure to Provide Required Assistance with Grooming for Cognitively Impaired Resident
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment, Alzheimer's disease, dementia, and impaired balance was not assisted with shaving as required by his care plan and personal preferences. The resident's care plan and Kardex both indicated the need for staff assistance with personal hygiene, including shaving, and instructed staff to maintain a consistent routine. Documentation in the resident's task sheets and treatment administration record (TAR) showed that staff had marked the shaving task as completed daily, despite observations on two consecutive days revealing the resident had several days' growth of facial hair and was not clean shaven. Interviews with nursing staff and the director of nursing confirmed that nursing assistants were responsible for assisting with shaving and that tasks should only be signed off as completed if actually performed. Staff could not explain why the task was documented as completed when it had not been done, and there was no documentation of care refusal or other reasons for the omission. Facility policy required that residents unable to perform activities of daily living independently receive necessary services to maintain good grooming and personal hygiene.
Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate injuries of unknown origin for four residents who had suspicious bruises. These residents included one with mild cognitive impairment and dementia, another with severe cognitive impairment and Parkinson's disease, a third with severe cognitive impairment and Alzheimer's disease, and a fourth with severe cognitive impairment and dementia. The injuries were not witnessed, and the residents could not explain how they occurred. The facility's failure to investigate these injuries constituted an immediate jeopardy situation, which began when the first resident was identified with a bruise on the inner thigh and continued as additional residents were found with unexplained bruises on their face, calf, and wrist. For each resident, the facility did not conduct a thorough investigation to determine the root cause of the injuries. For example, one resident was found with multiple bruises after a fall, but no investigation was done to rule out the cause. Another resident had a large facial bruise, but the facility did not interview staff or investigate the possibility of abuse. Similarly, a resident with a wrist bruise and another with a calf bruise did not have their injuries thoroughly investigated, and the facility did not use a formal tool to document or analyze the incidents. The facility's policies required a thorough investigation of injuries of unknown origin, including reviewing documentation, interviewing staff and residents, and observing interactions. However, these steps were not followed, and the facility did not document the investigations properly. The lack of thorough investigations and documentation led to unverified rationales for the injuries and a failure to implement corrective actions to protect residents from further harm. The immediate jeopardy was removed after the facility took corrective actions, but non-compliance remained at a lower scope and severity level.
Removal Plan
- Conducted interviews with all interviewable residents regarding their perception of safety in the facility
- Completed a physical assessment of all residents to identify any injuries of unknown origin
- Nursing leadership, including the facility unit managers, DON and administrator, were educated on investigating injuries of unknown origin by the facility's regional director of health services
- Reviewed the facility's policy regarding injuries of unknown source
- Educated all staff on identification of injuries of unknown source
- Administrator will monitor compliance to ensure complete investigation practices are followed
- Administrator will complete an audit of incidents of unknown source or bruising
- Any identified concerns will be addressed
- If trends or patterns are identified, the facility will conduct an ad-hoc Quality Assurance and Performance Improvement meeting to address any additional interventions needed to ensure compliance
Failure to Report Injuries of Unknown Origin
Penalty
Summary
The facility failed to recognize and report injuries of unknown origin to the administrator and/or the State Agency (SA) for four residents with suspicious bruises. Resident 18 was observed with a large bruise on the left side of the chin and neck area, which was not reported to the SA despite being identified as suspicious by multiple staff members. The facility's investigation concluded that the bruise was likely due to dental issues or the resident's habitual head positioning, but this was not verified, and the injury was not reported to the SA as required. Resident 57 was found with a bruise on the left wrist, which was not reported to the SA. The bruise was initially assessed by an LPN who did not find it suspicious, but a nursing assistant later described the bruise as looking like thumb marks. Despite this, the bruise was not reported to the SA, and the facility's incident report did not identify the bruise as suspicious. The DON confirmed that such a description should have prompted a report to the SA. Resident 30 had a bruise on the left lower extremity, which was not reported to the SA. The bruise was believed to be caused by the resident kicking or bumping into something, but there was no incident report to support this. Similarly, Resident 46 was found with multiple bruises after a fall, but the cause of the bruises was unknown, and they were not reported to the SA. The facility's policies directed staff to report injuries of unknown origin immediately, but this was not followed in these cases.
Failure to Address Injuries of Unknown Origin
Penalty
Summary
The facility's administration failed to take timely and appropriate action to address injuries of unknown origin and bruises for four residents. For Resident 18, a facial bruise was reported by a nursing assistant and confirmed by a registered nurse. Despite the Director of Nursing (DON) and the administrator being informed, the incident was not reported to the state agency, and no thorough investigation or preventive measures were taken. The DON did not assess the resident, and the facility lacked a formal tool for investigating the root causes of incidents. Resident 30's progress notes revealed a bruise on the left calf and foot, reported by the resident's daughter and confirmed by a nurse. The DON and administrator were notified, but the injury was not reported to the state agency, and no thorough investigation or preventive actions were implemented. Similarly, Resident 46 was found on the floor with multiple bruises, and although the DON and administrator were aware, the facility failed to report the injury to the state agency and did not conduct a thorough investigation or take preventive measures. Resident 57 sustained a bruise around the left wrist, which was reported by a nurse's aide and assessed by a nurse manager. The DON and administrator were informed, but the injury was not reported to the state agency, and no thorough investigation or preventive actions were taken. The facility's process for identifying, reporting, and investigating injuries of unknown origin was inadequate, with no formal tool or process in place, and responsibilities were unclear among staff members.
Inaccurate MDS Assessment for Resident with Behavioral Symptoms
Penalty
Summary
The facility failed to ensure the resident status was accurately identified on the Minimum Data Set (MDS) assessment for one resident (R18) reviewed for behaviors. R18, who had moderate cognitive impairment and diagnoses including dementia, Parkinson's disease, and anxiety disorder, was noted to have received Lorazepam for anxiety. Despite the care plan indicating behaviors such as pulling hair, biting nails, and yelling out, the MDS assessment did not reflect any behaviors during the seven-day look-back period. Documentation in the progress notes and interviews with staff and family members confirmed that R18 frequently called out repetitive phrases and displayed behaviors that required intervention, which were not accurately captured in the MDS assessment. Observations and interviews revealed that R18 repeatedly called out phrases like 'Please help me, I am stuck,' and staff responded by offering comfort measures and administering Lorazepam as needed. However, the Behavior Monitoring and Intervention Reports did not document these behaviors, leading to an inaccurate MDS assessment. The facility's MDS coordinator and licensed social workers acknowledged the discrepancy, confirming that the MDS did not accurately reflect R18's behaviors during the look-back period. The administrator verified that the MDS should be completed according to CMS instructions, highlighting a failure in accurately assessing and documenting the resident's behavioral symptoms.
Failure to Implement Transfer and Bruising Interventions
Penalty
Summary
The facility failed to ensure transfer interventions were consistently implemented for a resident with severe cognitive impairment and multiple diagnoses, including dementia and Parkinson's disease. The resident's care plan required extensive assistance of two staff members for transfers. However, observations revealed that staff members frequently transferred the resident without using a gait belt or the assistance of a second staff member, contrary to the care plan directives. Interviews with staff confirmed these deviations from the care plan, with some staff members stating they believed the resident was light enough to transfer alone without a gait belt. Additionally, the facility failed to implement interventions for monitoring and documenting bruising for two residents. One resident, who was on anticoagulant therapy, had a bruise identified by a family member, but the facility did not document the bruise's width or color, nor did they monitor and document the bruise until it resolved. Another resident with fragile skin had multiple bruises documented, but the facility failed to record the color of the bruises, and the size of the bruises remained unchanged over several weeks without resolution. Interviews with staff and review of care plans revealed discrepancies in the implementation of care directives, including the use of gait belts and the number of staff required for transfers. The facility's documentation practices for monitoring and documenting bruises were also found to be inconsistent and incomplete, failing to adhere to the care plans established for the residents. These deficiencies were confirmed through observations, interviews, and record reviews conducted by the surveyors.
Failure to Properly Assess and Monitor Resident Bruises
Penalty
Summary
The facility failed to properly assess and monitor bruises on multiple residents, leading to inconsistencies in documentation and lack of follow-up care. For Resident 30, a bruise was noted on the left lower extremity, but the measurements and location of the bruise were inconsistent among different nursing staff. There was no further investigation to determine the cause of the bruise, and the facility failed to monitor the bruise over time, making it unclear when the bruise resolved. Additionally, the care plan related to anticoagulant therapy required monitoring and documenting bruising, which was not adequately followed. Resident 46 was found with multiple bruises on the right forearm, lower arm, anterior elbow, and medial thigh. The color of the bruises was not documented, and the size of the bruises remained the same over time without resolving. The facility did not revise the care plan to address the risks associated with the use of a Hoyer lift sling, which was suspected to cause some of the bruises. The facility also failed to monitor and document the bruises consistently, leading to a lack of clarity on the resident's condition. Resident 18 had a bruise on the left side of the chin and neck area, but the facility did not continue to assess and monitor the bruise for healing, worsening, or pain. The care plan required monitoring and documenting the location, size, and treatment of skin injuries, but this was not followed. The facility's internal incident report suggested possible causes for the bruise, but there was no routine monitoring or assessment documented. The facility did not have a policy for monitoring resident bruises, leading to inconsistent care and documentation.
Failure to Provide Timely Repositioning for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to provide timely assistance with repositioning to minimize the development of pressure ulcer risk for a resident with severe cognitive impairment and multiple diagnoses, including dementia, Parkinson's disease, and anxiety disorder. The resident's care plan directed staff to reposition the resident every two hours while in bed, but did not specify the frequency for repositioning while in a chair. Observations revealed that the resident was seated in a Broda chair for over four hours without being repositioned, contrary to the care plan's directives. Interviews with staff confirmed that the resident had not been repositioned as required during this period. The resident's skin was observed to be bright pink and blanchable, indicating adequate blood perfusion, but the lack of timely repositioning posed a risk for pressure ulcer development. The facility's wound care policy did not provide specific guidance on the frequency of repositioning for dependent residents, contributing to the deficiency. The administrator and staff acknowledged that repositioning should be done in accordance with the care plan, but this was not consistently implemented, leading to the observed deficiency.
Inadequate Supervision and Transfer Techniques Lead to Resident Injuries
Penalty
Summary
The facility failed to provide adequate supervision and appropriate transfer techniques for a resident (R18) with severe cognitive impairment and multiple diagnoses, including dementia and Parkinson's disease. Despite the care plan directing staff to provide extensive assistance of two staff members for transfers, observations revealed that a nursing assistant (NA-A) transferred R18 alone without using a gait belt. This inappropriate transfer method was confirmed by multiple staff members, including a registered nurse (RN-A) and a licensed practical nurse (LPN-A), who acknowledged that the care plan was not followed. Additionally, the facility did not conduct a comprehensive transfer assessment for R18, and the origin of a significant bruise on R18's chin remained undetermined despite an investigation and nurse practitioner assessment ruling out dental issues as the cause. The facility's director of nursing (DON) admitted that discrepancies in transfer styles among staff could have contributed to the injury and that the facility would have approached the investigation differently if they had been aware of these discrepancies earlier. Another resident (R46) was identified as being at high risk of falls and had a care plan in place for fall prevention, which included reminders to lock the wheelchair when completing activities of daily living (ADLs) independently. Despite this, R46 experienced multiple falls due to an unlocked wheelchair. On one occasion, R46 was found on the floor after attempting to self-transfer, and the wheelchair was found unlocked. The facility staff documented reminders to lock the wheelchair but did not implement additional preventative measures until an anti-rollback device was installed. However, observations revealed that the anti-rollback device was not consistently used, and R46 continued to use a wheelchair without the device, leading to further falls and injuries. The facility's failure to adhere to individualized care plans and ensure consistent use of assistive devices and proper transfer techniques resulted in injuries and potential harm to residents. The discrepancies in staff practices and lack of comprehensive assessments and investigations highlight significant deficiencies in the facility's supervision and care provision. The DON acknowledged the potential for personal injury due to improper transfer methods and the need for consistent adherence to care plans to prevent accidents and injuries.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely assistance with incontinence care for a resident (R18) who was identified with severe cognitive impairment and diagnoses including dementia, Parkinson's disease, and anxiety disorder. The resident was dependent on staff for toileting hygiene, frequently incontinent of bowel and bladder, and required substantial assistance with transfers. The care plan directed staff to check the resident every two hours and assist with toileting as needed. However, observations on the specified date revealed that the resident was not assisted with toileting for a period of four hours and thirty minutes, contrary to the care plan directives. During the observation period, the resident was seen in various locations within the facility, including the dining room, her room, and the activity room, without receiving the required incontinence care. Interviews with the nursing assistant (NA-A) and licensed practical nurse (LPN-A) confirmed that the resident was supposed to receive assistance with incontinence care every 2-3 hours. The administrator also confirmed that staff were expected to follow the care plan. Despite these directives, the resident was found to be incontinent of urine when finally assisted with incontinence care after the prolonged period without assistance.
Failure to Implement Nonpharmacological Interventions Before Administering Antianxiety Medications
Penalty
Summary
The facility failed to provide nonpharmacological interventions prior to administering as-needed antianxiety medications to a resident with severe cognitive impairment and multiple diagnoses, including dementia, Parkinson's disease, and anxiety disorder. The resident's care plan and clinical records lacked documentation of nonpharmacological interventions attempted before administering Lorazepam, despite the resident frequently calling out repetitive phrases and displaying behaviors such as pulling hair, biting nails, and yelling out. Observations and interviews with staff confirmed that nonpharmacological interventions were not implemented or documented as required. The resident's medication administration records indicated multiple instances of Lorazepam administration without prior nonpharmacological interventions from January to April. The resident's behavior monitoring reports also lacked evidence of nonpharmacological interventions before medication administration. Interviews with family members and staff revealed that the resident frequently called out for help and displayed distress, but staff did not consistently provide or document nonpharmacological interventions to address these behaviors. The facility's behavior committee meetings discussed the resident's medication but did not include specific nonpharmacological interventions in the meeting minutes. The administrator and director of health services confirmed that nonpharmacological interventions were not included in the care plan or implemented before administering antianxiety medications. The facility also lacked a policy related to antianxiety medication, further contributing to the deficiency in care for the resident.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the Office of Ombudsman for Long-Term Care (OOLTC) of facility-initiated transfers for 12 residents who had been hospitalized. The deficiency was identified through an email correspondence with the OOLTC, which indicated that the facility had not completed monthly reporting of transfers and discharges as required. Specific instances included residents being transferred to the hospital for various medical reasons such as unresponsiveness, low oxygen saturation, family requests, infections, falls with injury, increased respirations, pleural effusion, pneumonia, low hemoglobin, and chest pain. The medical records for these residents lacked evidence that notice of the transfers was provided to the OOLTC. Interviews with the director of health center sales and services (DHCSS) and the administrator confirmed that the notifications had not been sent and that the facility policy did not include a timeframe for reporting emergency transfers to the OOLTC monthly or within 30 days prior to the discharge or as soon as practicable. During the interviews, the DHCSS admitted that she had let the notifications accumulate for about three months before sending them and was not aware that they should be sent monthly. The administrator verified that transfer notices should be sent to the OOLTC monthly and acknowledged that the facility policy needed to be updated to include a specific timeframe for reporting. The facility's Transfer and Discharge (30 Day Notice) policy dated 1/13/20 directed that a copy of the notice be sent to a representative of the Office of the State Long-Term Care Ombudsman before transferring or discharging a resident, but it lacked a specific timeframe for reporting emergency transfers and facility-initiated transfers to the OOLTC.
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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