Good Samaritan Society - International Falls
Inspection history, citations, penalties and survey trends for this long-term care facility in International Falls, Minnesota.
- Location
- 2201 Keenan Drive, International Falls, Minnesota 56649
- CMS Provider Number
- 245318
- Inspections on file
- 25
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Good Samaritan Society - International Falls during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and dependence on staff for personal hygiene did not have their shaving preferences assessed or documented. Staff only provided shaving on bath days or upon request, and the care plan did not address the resident's grooming preferences, despite family input that daily shaving was preferred. Facility policy required grooming services based on assessment, but this was not reflected in the resident's records.
A resident with multiple diagnoses, including anemia and long-term anticoagulant use, had an abnormally high ferritin level identified in lab results. Facility staff did not document the lab draw or results in the medical record, nor was there evidence that the provider was notified of the abnormal finding, despite facility policy requiring timely reporting of such results.
Staff did not perform required hand hygiene after providing perineal care and handling bodily fluids for two residents who needed substantial assistance with ADLs. In both cases, staff failed to wash hands or use sanitizer after glove removal and before moving to another resident, despite facility policy and staff awareness of proper procedures.
The facility's assessment failed to include specific staffing levels for different shifts and did not identify residents requiring oxygen supplementation or those with PTSD. The current administrator had not reviewed the assessment completed by the previous administrator, and a policy on the facility assessment was not provided.
The facility failed to develop action plans for identified monitoring areas and did not implement any process improvement projects (PIPs), potentially affecting all 50 residents. Meeting minutes showed reviews of various topics, but no action plans with measurable goals were documented. The RN responsible for the QAPI program was unfamiliar with PIPs, and the DON was unaware of the lack of PIPs. The facility's policy required at least one PIP annually, focusing on high-risk or problem-prone areas.
The facility failed to implement an effective infection control program, including inadequate tracking and reporting of infections, and did not conduct COVID-19 testing per CDC guidelines. Enhanced barrier precautions were not implemented for a resident with pressure ulcers, and a nurse did not wear a mask during a PICC line dressing change. The facility's system for tracking illness and testing was inadequate, leading to a system failure in preventing illness transmission.
A resident with paraplegia and autonomic dysreflexia was left without a functional motorized wheelchair after a lightning strike, despite the facility's knowledge of the issue. The resident's care plan required the use of a motorized wheelchair for independence, but the facility failed to repair it, leaving the resident with an unsuitable manual wheelchair. Staff interviews revealed a lack of communication and follow-up, and the facility did not adhere to its policy on accommodating resident needs.
A facility failed to accurately code medications on the MDS for a resident with severe cognitive impairment and multiple diagnoses. The resident was incorrectly documented as receiving an antianxiety medication, while the MAR indicated they were receiving Trazodone, an antidepressant, for anxiety-related symptoms. An RN admitted to reviewing medications by their use rather than class, leading to the error. The DON expected the MDS to be accurate for comprehensive care planning.
A resident with severe cognitive impairment and incontinence was not provided necessary assistance with toileting and repositioning over a period of several hours. Despite multiple staff interactions, the resident was not checked for incontinence or repositioned according to the care plan, which required checks every two hours. The resident was observed in a slouched position with the call light on for an extended period before staff finally attended to her.
A resident with severe cognitive impairment and a stage two pressure ulcer was not repositioned as required by their care plan, despite being at risk for further ulcer development. During a period of observation, the resident remained in the same position for over two hours, with multiple staff entering the room but failing to reposition them. The facility's policy required repositioning every two hours, which was not followed.
A facility failed to provide trauma-informed care for a resident with PTSD, who exhibited aggressive behaviors and had a history of serving in the Vietnam War. The care plan lacked individualized interventions and did not identify potential triggers, contrary to the facility's policy requiring a trauma assessment within five days of admission.
The facility failed to ensure proper monitoring of high-risk and psychotropic medications for two residents. One resident, with cognitive impairment and behavioral issues, was not monitored for adverse effects of antidepressant and chemotherapy medications. Another resident, on multiple medications, lacked evidence of necessary blood work to assess treatment effectiveness. Interviews revealed a lack of documentation and consideration of pharmacist recommendations, despite facility policies requiring regular monitoring.
The facility failed to monitor adverse effects of high-risk medications for two residents. One resident, with chronic myeloid leukemia, received Gleevec without documented monitoring for side effects. Another resident, with multiple diagnoses, was on anticoagulant and diuretic medications without evidence of monitoring or annual lab work. The facility's policy to monitor high-risk medications every shift was not followed.
The facility failed to monitor adverse effects and behaviors related to psychotropic medication use for two residents. One resident with cognitive impairment and behavioral issues was not monitored for side effects of antidepressants, while another resident on lorazepam and Lexapro was not monitored for adverse effects or behavioral symptoms. The facility's policy required monitoring, but errors in order entry and staffing issues led to non-compliance.
A facility failed to label insulin pens with a resident's name, as required for drugs and biologicals. An LPN administered Humalog and Toujeo insulin to a Type 2 diabetic resident without labeled pens, relying on the fact that the resident was the only diabetic on the unit. Interviews revealed that the pens should have been labeled by the pharmacy or staff, and the RN noted the infection control issue and the resident's right to labeled medication. The facility's policy mandates labeling with specific information, including the resident's name.
A facility failed to establish a process for antibiotic review for a resident with renal insufficiency, diabetes, Alzheimer's, and dementia. The resident was prescribed cefdinir for a UTI with hematuria, but the urine culture showed mixed microflora, suggesting contamination. The facility used McGreer Criteria for antibiotic use, but there was confusion about actions at the unit level and communication issues with ED providers who frequently prescribed antibiotics inappropriately.
The facility failed to post accurate and timely nurse staffing information, with outdated postings and missing dates. Staff were unaware of the requirement to update postings for call-ins and shortages, and the facility lacked a policy on nurse staff postings.
Failure to Assess and Provide Shaving Preferences for Dependent Resident
Penalty
Summary
The facility failed to assess and provide for the shaving preferences of a resident with severe cognitive impairment and multiple diagnoses, including dementia and a traumatic brain injury. The resident required substantial to maximal assistance for personal hygiene, yet his medical record did not contain documentation of his shaving preferences. The care plan, while addressing the need for assistance with ADLs due to physical and cognitive limitations, did not specify shaving preferences. Observations revealed that the resident had significant beard growth and was not offered shaving assistance during care routines. Interviews with staff indicated that shaving was typically performed only on bath days or upon resident request, and if a resident was unable to request, shaving was not routinely provided outside of scheduled bath days. A family member reported that the resident had previously shaved daily and expressed difficulty in getting staff to maintain this routine. The facility's policy required necessary services to maintain grooming based on comprehensive assessment, but there was no evidence in the medical record to support that the resident's shaving preferences were assessed or addressed.
Failure to Notify Provider of Abnormal Lab Result
Penalty
Summary
The facility failed to promptly notify the primary care provider of an abnormal laboratory result for one resident who was cognitively intact and required significant assistance with daily activities. The resident had diagnoses including atrial fibrillation, anemia, depression, long-term use of anticoagulants, and dysphagia. Orders were in place for annual blood tests, including a comprehensive blood count, basic metabolic panel, thyroid stimulating hormone, prothrombin time, and ferritin level. The medical record did not contain documentation of the lab work being drawn or the results, despite the resident receiving iron supplementation for anemia. Laboratory results from November showed an abnormally high ferritin level, but there was no documentation in the resident's progress notes or provider visit notes indicating that the results were reviewed or that the provider was notified. Interviews with nursing staff and the DON revealed that it was not the facility's practice to document labs drawn or lab results in the resident charts, and that nurse managers were responsible for reviewing and scanning lab results into the medical record. However, it was acknowledged that it would be difficult to determine if results had been reviewed or if the provider had been notified of abnormal findings. The facility's policy required timely reporting of lab findings to the ordering provider, but this was not followed in the case of the resident's elevated ferritin level, as there was no evidence of provider notification or review.
Failure to Perform Hand Hygiene After Personal Care
Penalty
Summary
Staff failed to perform appropriate hand hygiene during and after providing personal care to two residents requiring substantial or maximal assistance with activities of daily living (ADLs). One resident with severe cognitive impairment, dementia, and a traumatic brain injury required assistance with personal hygiene and toileting, including the use of a mechanical lift and catheter care. During observed care, staff donned gowns, gloves, and masks but did not use hand sanitizer before gloving. After performing perineal care and handling bodily fluids, staff continued to wear the same gloves, did not perform hand hygiene after glove removal, and exited the resident's room without washing hands or using hand sanitizer. In a separate instance, staff entered another resident's room—who had left-sided hemiplegia and required assistance with toileting—without performing hand hygiene. The staff member applied gloves, assisted with perineal care, and then removed gloves without washing hands or using hand sanitizer before leaving the room. Interviews with staff confirmed awareness of the hand hygiene requirements, and facility policy mandated hand hygiene at specific moments, including after glove removal and before entering another resident's room. These actions and inactions directly led to the identified deficiency in infection prevention and control.
Facility Assessment Lacks Staffing and Resource Details
Penalty
Summary
The facility failed to review and update its facility-wide assessment to incorporate minimal staff requirements and all necessary resources and conditions to care for the resident population. The assessment, dated on an unspecified date, identified the need to determine resources necessary for competent care during both day-to-day operations and emergencies. However, it did not include specific staffing levels needed for different shifts based on resident population and acuity. Additionally, the assessment did not identify residents requiring oxygen supplementation or the minimal equipment and supplies needed for their care. It also lacked an assessment of the resident population with a diagnosis of PTSD. During an interview, the current administrator admitted that the facility assessment was completed by the previous administrator and had not been reviewed by him. He stated that minimum staffing was based on the facility census, with a bare minimum of one nurse and aide on each wing during the day and evening shifts, and one aide on each wing with a nurse float for the overnight shift. The administrator was unsure about the level of detail required for documenting oxygen needs in the assessment but acknowledged that PTSD should be covered. Furthermore, a policy on the facility assessment was required but was not provided.
Failure to Develop Action Plans and Implement PIPs
Penalty
Summary
The facility failed to develop action plans for identified areas of monitoring and did not implement at least one process improvement project (PIP), which had the potential to affect all 50 residents. The Quality Assurance, Action Committee Meeting Minutes from various dates showed that the team reviewed several topics, including infection control, emergency operation plans, dietary concerns, and more. However, the data did not show any facility-developed and implemented action plans with measurable goals or actions taken. Additionally, the facility could not provide evidence of any PIP project focusing on high-risk or problem-prone areas identified through data collection and analysis. Interviews revealed that the registered nurse responsible for the facility's QAPI program had not fully addressed the facility's response to a recent COVID-19 outbreak and was unfamiliar with PIPs. The director of nursing was unaware that no PIPs were in place and stated that there should be performance improvement projects. The facility's Quality Assurance and Performance Improvement policy required at least one PIP to be in development, ongoing, or completed annually, focusing on high-risk, high-volume, or problem-prone areas. The QAPI committee was responsible for tracking and analyzing quality deficiencies, developing action plans, and monitoring effectiveness and sustainability.
Inadequate Infection Control and COVID-19 Testing in LTC Facility
Penalty
Summary
The facility failed to develop and implement an effective infection control surveillance plan, which included identifying, tracking, monitoring, and reporting infections and communicable diseases. The reports for several months did not adequately document whether infections were treated, nor did they identify residents with symptoms of viral infections other than COVID-19. The facility's antimicrobial usage rate was higher than the enterprise average, and there was no written summary of the analysis of actual or potential infections. Additionally, the facility did not have a policy related to infection surveillance, tracking, and trending. The facility also failed to conduct COVID-19 testing of staff and residents according to CDC guidelines. There was a lack of documentation and tracking of staff testing, with several staff members not testing according to the guidelines during a COVID-19 outbreak. The facility did not maintain a COVID-19 Testing Roster for residents, and there was no documentation of when residents were placed into transmission-based precautions. The facility's system for tracking staff and resident illness and testing was inadequate, leading to a system failure in preventing the transmission of illness. Furthermore, the facility did not implement enhanced barrier precautions (EBP) for a resident with pressure ulcers and failed to wear a mask during a peripherally inserted central catheter (PICC) line dressing change for another resident. The infection preventionist did not require EBP for the resident with chronic wounds, and staff were not informed when EBP was needed. During a PICC line dressing change, a nurse did not wear a mask, and another nurse assisting was not trained on the procedure, which was against the facility's policy for sterile technique during such procedures.
Failure to Maintain Resident's Motorized Wheelchair
Penalty
Summary
The facility failed to maintain an electric wheelchair in working order for a resident with paraplegia and autonomic dysreflexia, who relied on the motorized wheelchair for independent mobility. The resident's motorized wheelchair became non-functional after a lightning strike hit the facility, and despite being reported to maintenance, no effective action was taken to repair it. The resident was left with a manual wheelchair that was uncomfortable and did not meet his needs, particularly during autonomic dysreflexia episodes when he needed to recline immediately. Interviews with staff revealed a lack of communication and follow-up regarding the wheelchair's repair. The maintenance staff was aware of the issue but did not take appropriate steps to resolve it, and the director of nursing was unaware of the problem. The facility's policy on accommodating resident needs was not adhered to, as there was no evidence of assessment or discussion with the resident about the broken wheelchair. The resident's care plan emphasized the importance of the motorized wheelchair for maintaining independence, yet the facility did not ensure its functionality.
Inaccurate Medication Coding on MDS
Penalty
Summary
The facility failed to ensure accurate coding of medications on the Minimum Data Set (MDS) for a resident reviewed for unnecessary medications. The resident, who had severe cognitive impairment and diagnoses including Alzheimer's, non-Alzheimer's dementia, diabetes, and depression, was identified on the MDS as receiving an antianxiety medication. However, the medication administration report (MAR) for October 2024 showed the resident was receiving Trazodone, an antidepressant, for generalized anxiety disorder, restlessness, and agitation. During an interview, a registered nurse (RN) responsible for the MDS admitted to reviewing medications based on their use rather than their class, leading to the incorrect entry of the antidepressant as an antianxiety medication. The director of nursing (DON) expressed the expectation that the MDS should be complete and accurate to provide a comprehensive picture of the resident's care needs.
Failure to Assist Resident with Toileting and Repositioning
Penalty
Summary
The facility failed to provide necessary assistance with toileting for a resident, identified as R203, who was dependent on staff for activities of daily living. R203 had severe cognitive impairment, was bedfast, and was always incontinent of bowel and bladder. The care plan required staff to check and change R203 every two hours and as needed. However, during a continuous observation period from 4:30 p.m. to 7:10 p.m., R203 was not checked for incontinence despite multiple staff interactions. Nursing assistant NA-N and LPN-C entered the room at different times but did not check R203 for incontinence or reposition her, even though the resident's call light was on for an extended period. R203 was observed in a slouched position in bed, with her head hanging to the right side and her chin on her chest, indicating a lack of repositioning. The call light remained on from 5:57 p.m. until 7:06 p.m., when NA-M and NA-N finally entered the room, lowered the head of the bed, and checked R203 for incontinence, finding her dry. Interviews with staff revealed that they were aware of the requirement to check and change R203 every two hours, but this was not adhered to during the observation period. The director of nursing confirmed that the facility's expectation was for staff to follow the care plan directives.
Failure to Reposition Resident at Risk for Pressure Ulcers
Penalty
Summary
The facility failed to provide timely repositioning for a resident identified as R203, who was at risk for pressure ulcer development and had a stage two unhealed pressure ulcer upon admission. R203 required substantial to maximum assistance with mobility and was dependent on staff for toileting and transfers. The care plan directed staff to turn and reposition R203 every two hours and as needed, but during an observation period from 4:30 p.m. to 7:10 p.m., R203 was not repositioned despite multiple staff interactions. R203 remained in the same position, slouched in bed with her head hanging to the side, and the call light was on for an extended period without response. Staff members, including a homemaker and an LPN, entered the room but did not attempt to reposition R203. It was not until 7:06 p.m. that two nursing assistants entered the room, noticed R203's precarious position, and repositioned her. The director of nursing later confirmed that the facility's expectation was for staff to check and change residents every two hours if directed by the care plan. The facility's policy on Activities of Daily Living also required necessary services to maintain residents' well-being, which was not adhered to in this instance.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to comprehensively assess and care plan for trauma-informed care for a resident with a history of trauma, specifically post-traumatic stress disorder (PTSD). The resident, who had moderate cognitive impairment, exhibited behaviors such as verbal and physical aggression, and rejection of care. Despite having a care plan that addressed some behavioral symptoms, it lacked individualized trauma-informed approaches or interventions and did not identify potential triggers to avoid re-traumatization. The resident's medical record also lacked a comprehensive assessment for PTSD, potential triggers, and interventions. Interviews with staff and family members revealed that the resident had served in the Vietnam War and had a career as a fire chief, with experiences that could potentially trigger PTSD symptoms. Staff noted that the resident would become angry if others mentioned military service without having served in war. The facility's policy required a trauma assessment within five days of admission, but this was not completed for the resident. The director of nursing acknowledged the importance of assessing and care planning for PTSD to alert staff to potential triggers.
Failure to Monitor High-Risk and Psychotropic Medications
Penalty
Summary
The facility failed to ensure that the consulting pharmacist identified and communicated the need for monitoring potential adverse events for high-risk medications for two residents. One resident, who had moderate cognitive impairment and exhibited behavioral issues, was receiving antidepressant and chemotherapy medications. The medical record lacked evidence of monitoring for adverse effects as ordered by the physician. The consulting pharmacist had recommended adjustments to the resident's medication regimen but did not identify the need for monitoring psychotropic medication side effects. Another resident, with intact cognition and no behavioral symptoms, was on antidepressant, anticoagulant, and diuretic medications. The medical record lacked evidence of annual blood work to assess the effectiveness of hyperthyroid treatment and monitor therapeutic dosages. The consulting pharmacist had recommended a review of the resident's medications, but the physician refused the recommendation. The pharmacy reviews did not show evidence of recommendations for monitoring psychotropic medication side effects or adverse behaviors. Interviews with facility staff revealed that there was a practice to monitor high-risk and psychotropic medications every shift, but documentation was lacking. The consulting pharmacist stated that they checked for side effects and behavior monitoring during monthly reviews but felt that recommendations were not considered. The facility's policy required regular pharmacist services, but the pharmacist noted that recommendations for lab work were not made, and the facility had been short-staffed, affecting the monitoring process.
Failure to Monitor Adverse Effects of High-Risk Medications
Penalty
Summary
The facility failed to ensure proper monitoring for adverse events related to high-risk medications for two residents. One resident, with moderate cognitive impairment and diagnosed with chronic myeloid leukemia and dementia, was prescribed Gleevec. Although the medication was administered daily as ordered, there was no evidence in the Medication Administration Record (MAR) or Treatment Administration Record (TAR) of monitoring for side effects as required. The registered nurse acknowledged the oversight, noting that the order to monitor for side effects was not correctly transferred to the MAR or TAR, and lab work was often missed due to reliance on primary physicians to order it. Another resident, with intact cognition and diagnosed with chronic obstructive pulmonary disease, atrial fibrillation, and kidney disease, was on anticoagulant and diuretic medications. Despite receiving these medications daily, the MAR and TAR lacked documentation of monitoring for adverse effects. Additionally, there was no evidence of annual lab work to assess the effectiveness and therapeutic levels of the medications. The registered nurse and consultant pharmacist both recognized the need for routine lab work, which had not been conducted, and the facility's policy to monitor high-risk medications every shift was not followed.
Failure to Monitor Adverse Effects of Psychotropic Medications
Penalty
Summary
The facility failed to ensure proper monitoring for adverse events and behaviors related to psychotropic medication use for two residents. One resident, identified as R22, had moderate cognitive impairment and exhibited behaviors such as verbal and physical abuse, as well as care rejection. Despite receiving daily antidepressant medication, the facility did not document monitoring for adverse effects as ordered by the physician. The Medication Administration Record (MAR) and Treatment Administration Record (TAR) lacked evidence of monitoring for side effects, which was confirmed by a registered nurse who noted an error in the order entry process. Another resident, R37, who had intact cognition and no identified behavioral symptoms, was also not monitored for adverse effects of their psychotropic medications. The resident received daily doses of lorazepam and Lexapro, but the MAR and TAR did not reflect any monitoring for adverse effects or behavioral symptoms. The director of nursing and a registered nurse confirmed that the facility's practice was to monitor psychotropic medications every shift, which was not done in this case. The consultant pharmacist acknowledged the oversight in monitoring and noted that the facility had been short-staffed, which affected their ability to conduct monthly behavior monitoring meetings. The facility's policy required continuous documentation of mood and behavior to monitor the effects of psychotropic medications, but this was not adhered to for the residents in question. The pharmacist had planned to review the residents' charts but had not yet made specific recommendations for monitoring side effects or adverse behaviors.
Unlabeled Insulin Pens for Diabetic Resident
Penalty
Summary
The facility failed to ensure that two insulin pens were labeled with the resident's name, which is a requirement for drugs and biologicals used in the facility. This deficiency was observed during the administration of insulin to a resident identified as R154, who was a Type 2 diabetic. The insulin pens, Humalog and Toujeo, were not labeled with the resident's name, although the boxes they came in were labeled and stored in the fridge in the medication room. The LPN administering the medication knew the pens belonged to R154 because they were the only diabetic resident on the unit receiving injectable medication. Interviews with the LPN and RN revealed that the pens should have been labeled either by the pharmacy or by the staff with a sticker containing the resident's information. The RN acknowledged that an unlabeled medication pen posed an infection control issue and noted that the resident had paid for the medication, which should have been labeled with their name. The facility's policy on medication labeling requires each prescription medication to be labeled with specific information, including the resident's name, which was not adhered to in this case.
Failure to Establish Antibiotic Review Process
Penalty
Summary
The facility failed to establish a process for antibiotic review to determine appropriate indications for use of an antibiotic for a resident reviewed for antibiotic use. The resident, who had diagnoses including renal insufficiency, diabetes, Alzheimer's disease, and dementia, was identified with a urinary tract infection (UTI) with symptoms of gross hematuria and flank pain related to kidney stones. However, the facility's report did not specify if the resident was treated with an antibiotic or if a urinalysis or urine culture were obtained. The resident was prescribed cefdinir for acute cystitis with hematuria, but the urine culture later identified mixed microflora, indicating possible contamination rather than infection. The registered nurse responsible for the infection control program stated that the facility used McGreer Criteria to determine if an antibiotic was warranted, but noted that the criteria were stringent and residents often had severe infections by the time they met the criteria. The facility reviewed antibiotic orders during morning meetings, but there was a lack of clarity on the actions taken at the unit level. The nurse expressed concerns about the emergency department (ED) providers who frequently prescribed antibiotics for conditions not typically treated with them, such as kidney stones, and mentioned that discussions with the medical director about these concerns had not progressed. The director of nursing acknowledged that antibiotic stewardship was reviewed on a case-by-case basis, but highlighted difficulties in communicating with ED providers due to their rotating schedules. The facility's policy indicated that McGreer Criteria should be used to determine appropriate antibiotic treatment, and in cases of contaminated urine samples, another sample should be collected to potentially stop antibiotic treatment. However, there was no follow-up to determine if the antibiotic should have been discontinued when the resident returned from the ED.
Failure to Maintain Accurate and Timely Nurse Staffing Postings
Penalty
Summary
The facility failed to consistently post accurate nurse staffing information daily, as required. During an observation, it was noted that the staff posting was outdated, showing a date from several days prior, and did not reflect actual staff working hours due to call-ins, vacations, or staff shortages. The facility was unable to provide an updated working staff schedule that accounted for these changes. Additionally, there were several dates where the nurse staff postings were missing entirely, and the postings did not indicate if any corrections had been made to reflect staffing changes. Interviews with facility staff revealed a lack of awareness and understanding of the requirements for nurse staff postings. The household coordinator, responsible for the staff schedule and postings, admitted to not updating the postings to reflect changes and was unsure of the retention period for these records. The DON confirmed that the postings should be retained for 18 months and updated daily but was unaware that they should reflect actual working staff changes. The administrator expected the census to be recorded and posted daily, but a policy regarding the nurse staff posting was not provided.
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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