Good Samaritan Society - Windom
Inspection history, citations, penalties and survey trends for this long-term care facility in Windom, Minnesota.
- Location
- 705 Sixth Street, Windom, Minnesota 56101
- CMS Provider Number
- 245558
- Inspections on file
- 22
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 23 (1 serious)
Citation history
Health deficiencies cited at Good Samaritan Society - Windom during CMS and state inspections, most recent first.
The facility failed to consistently identify, comprehensively assess, and manage pressure ulcers for a high‑risk, paraplegic resident with diabetes, an indwelling catheter, and an ostomy. An existing heel wound was incompletely documented and not incorporated into the care plan, and later sacral and buttock skin changes, urinary meatus breakdown, and foot wounds were recorded with inconsistent locations, no staging, and missing measurements. Wound clinic records showed detailed staging and treatment recommendations that were not timely or fully reflected in the care plan, including catheter and brief management and measures to prevent recurrent shearing. The resident was not placed on a formal turning/repositioning schedule despite dependence for mobility, and staff documentation of refusals to get out of bed was repetitive and not linked to new interventions, while nursing assistants reported the resident usually accepted care when re‑approached. In late stages, buttock wounds with extensive eschar and slough and a dark lateral foot lesion were present without clear physician notification or evidence‑based treatment orders, and the resident ultimately required hospitalization for advanced, infected pressure ulcers with osteomyelitis and cellulitis.
A resident with paraplegia, diabetes, obesity, and existing right heel skin breakdown was admitted with high risk for pressure ulcers, but the initial care plan did not include a skin integrity focus or the documented heel wound, and the admission wound form lacked required descriptive details. Later, an RN wound assessment identified an unstageable right heel ulcer and subsequent documentation noted a new buttock pressure sore and a stage 3 ulcer at the urinary meatus related to catheter tension and incontinent brief use, yet the care plan was not promptly revised to include these new wounds or the wound clinic’s specific interventions for off-loading boots, catheter device positioning, brief removal, and barrier cream, despite the DON’s expectation that RN leaders update care plans with changes.
Two residents were not afforded appropriate dignity during care. One resident with cognitive impairment and a urinary catheter was twice observed with the catheter bag exposed and improperly placed, once hanging from a trash can and later on the floor in a wash basin, both times without a dignity cover despite staff acknowledging that covers should be used. Another resident who required assistance for bed mobility was left sitting on the edge of the bed in only a brief with pants at the knees, yelling for help, while the room door remained open and the privacy curtain was not drawn as staff provided support. Staff and leadership later confirmed expectations for covered catheter bags and closed doors during care, consistent with the facility’s dignity policy.
A resident with paraplegia and known risk for skin breakdown developed worsening shearing and open areas on the buttocks and impaired skin integrity at the coccyx/sacrum, while documentation of Wound Data Collections lacked measurements and wound type descriptions. Nursing orders and skin observations showed evolving buttock wounds, discoloration, and a left lateral foot issue, but there was no evidence that the physician was notified of new wounds or treatment changes, nor that the care plan was revised to address refusals and repositioning. The resident’s emergency contact reported not being informed of the buttock wounds and learned of their severity from a visitor, despite a facility policy requiring immediate notification of the resident, MD, and representative when treatment must be significantly altered.
A resident with paraplegia and type 2 DM, who was cognitively intact and had no documented dental issues on admission assessments, expressed a desire to pursue dental care, which was noted in the Nursing Admit/Re-admit Data. The resident later reported that no one had assisted in arranging a dental appointment, despite having informed the clinical care leader RN. The CCLRN stated that county case workers and the DON would need to approve dental appointments and described it as a process but could not explain the process or identify who should initiate it. Record review showed no documentation of any attempts to arrange dental services, contrary to facility policy that requires providing or obtaining routine and emergency dental services and assisting residents with making appointments and arranging transportation.
Two residents received wound care, catheter care, and personal care during which staff did not consistently follow infection prevention and control practices. For one resident with paraplegia, multiple pressure ulcers, an indwelling catheter, and an ostomy, nurses performed wound and wound vac care without reliably sanitizing hands between glove changes, placed supplies on undisinfected surfaces, reused gauze from an open package after contact with blood and other contaminated items, and allowed wound vac tubing to fall to the floor and leak secretions. Another nurse then provided IV care wearing gloves but no gown and left the room without hand hygiene. For a second resident with dementia, edema, and a history of pressure ulcers, a nursing assistant performed toileting, perineal care, catheter manipulation, and equipment handling while wearing the same gloves throughout, including into the hallway and bathroom. A nurse conducted leg wound care after dropping gauze on the floor and placing dressings on an uncleaned chair, with inconsistent hand hygiene. Later, a hospice nurse and an LPN performed buttock wound and catheter care without changing gloves or sanitizing hands between contact with the resident’s buttocks and clean supplies, despite staff acknowledging in interviews that such glove use and infection control lapses were problematic.
The facility failed to maintain a comprehensive infection prevention and control program, as the infection preventionist did not conduct formal surveillance or analyze infection data for trends. The DON confirmed the lack of comprehensive infection surveillance, which is crucial for identifying trends and implementing preventive interventions.
A resident with impaired cognition and incontinence was denied timely assistance to use the commode by an NA, leading to embarrassment due to incontinence. Other staff members confirmed that residents should be assisted when requested, and if busy, staff should seek help. The incident highlighted a failure in providing dignified care.
A resident with Parkinson's disease and other conditions experienced a deficiency in care as the facility failed to consistently implement a care plan for maintaining range of motion (ROM). Observations showed the resident's hands were often without the prescribed splint, and staff interviews revealed inconsistencies in applying passive range of motion (PROM) exercises. The occupational therapist confirmed the need for PROM and splinting, but documentation was insufficient to assess changes in the resident's condition.
A facility failed to follow standards of care for a resident with an indwelling catheter. The resident, with a history of UTIs and diagnoses including ulcerative proctitis, had a catheter placed without a clear medical justification. Staff were uncertain about the catheter's necessity, and the facility's policy requiring an order and indication was not met. The catheter was used as a permanent solution for incontinence without further evaluation or a urology consult.
Failure to Assess and Manage Pressure Ulcers Leading to Severe Wound Infection
Penalty
Summary
The deficiency involves the facility’s failure to identify, comprehensively assess, monitor, and implement effective interventions to prevent and manage pressure ulcers for multiple residents, with Immediate Jeopardy for one resident. One resident with paraplegia, diabetes, obesity, an indwelling catheter, and an ostomy was dependent for lower body care and transfers and was identified as at risk for pressure ulcers. On admission, the resident’s right heel wound was noted but not staged or fully described despite form instructions to document blanchability, size, color, odor, and discharge. The initial care plan did not include a skin integrity problem or the right heel wound, and subsequent skin checks failed to mention the heel wound. For an extended period after admission and readmission, the care plan was not revised to reflect existing and newly identified skin issues, including sacral redness, and pressure-relieving interventions were delayed or incompletely incorporated into the care plan. As time progressed, the resident developed multiple additional areas of impaired skin integrity, including buttocks, coccyx/sacrum, urinary meatus, and foot wounds. Wound clinic records showed comprehensive staging and measurements of the right heel and urinary meatus pressure ulcers and later buttock shearing injuries, while facility documentation (RN wound assessments, skin observations, and progress notes) was inconsistent and often lacked measurements, staging, wound type, and detailed descriptions. New wounds and changes in condition, such as buttock shearing and coccyx pressure areas, were not consistently or comprehensively assessed, and physician notification for new or worsening wounds was not evident for several documented changes. The care plan was not timely updated to include wound clinic recommendations, such as catheter and brief management for the urinary meatus ulcer and interventions to prevent recurrent shearing injuries to the buttocks. In the weeks leading up to the Immediate Jeopardy period, documentation of the resident’s buttock and coccyx wounds remained inconsistent, with alternating descriptions of coccyx versus buttock involvement and characterizations as shearing or pressure sores, without comprehensive wound assessments or clear identification of wound type. Skin observations and wound data collections around the end of the year showed black and blue tissue on the buttocks and new left lateral foot involvement, yet there was no documented physician notification or change in treatment orders for these developments. Wounds were not measured until early January, at which time large buttock wounds with significant eschar and slough, macerated and erythematous margins, and drainage were finally documented. Interviews with nursing staff revealed reliance on a clinical care lead RN to measure wounds and obtain orders, acknowledgment that wounds had not been measured for weeks, and use of treatments such as hydrofera blue and cleansing with soap and water or wet wipes without clear physician authorization or articulated evidence-based rationale. Throughout this period, the resident was not placed on a formal turning and repositioning schedule despite being at risk for pressure ulcers and dependent for repositioning. Staff and interdisciplinary team notes repeatedly referenced the resident’s refusals to get out of bed or reposition, but these notes were often verbatim over multiple entries and did not reflect new assessments or individualized interventions to address refusals. Nursing assistants reported that the resident rarely refused care and would usually accept care when re-approached, while a nurse later stated the resident had not received education on the risks of not repositioning prior to hospitalization. The clinical care lead RN stated that shearing was not a form of pressure, that the resident’s discolored buttocks were “always” monitored, and that larger protective dressings such as Mepilex were sometimes not used due to size or payor concerns, leading to use of ABD pads instead. By the time the resident was evaluated at the wound clinic in January, the buttock and foot wounds were classified as unstageable and stage 3 pressure ulcers, with the gluteal wound described as very advanced and infected, and subsequent hospital records documented sacral decubitus ulcer with osteomyelitis and cellulitis. Additional observations after the resident’s return from the hospital showed ongoing gaps in wound management and monitoring. Nursing staff could not initially locate dressing change orders, and the resident reported that no care had been provided to his heels over the weekend and that wedges for repositioning were only used if he requested them. On examination, facility leadership identified a dark, non-blanching area on the right lateral foot that was questioned as an unstageable pressure ulcer or suspected deep tissue injury, while the clinical care lead RN initially characterized it as a blister and a diabetic wound. Toenails pressing into adjacent toes and causing skin indentations were discovered only during surveyor observation, and improvised measures such as placing gauze between toes were initiated at that time. These documented inactions and inconsistent assessments, monitoring, and interventions for existing and developing wounds contributed to the progression of the resident’s buttock wound to a severe, infected pressure injury requiring hospitalization for osteomyelitis, cellulitis, and soft tissue infection.
Failure to Timely Update Care Plan for Multiple Pressure Ulcers and Catheter-Related Wound
Penalty
Summary
The deficiency involves the facility’s failure to timely and comprehensively update a resident’s care plan to reflect existing and newly developed pressure ulcers and related interventions. The resident was admitted with paraplegia, type 2 diabetes, obesity, and a documented right heel wound on the Nursing Admit/Re-admit Data Collection, but that form lacked required descriptive details such as staging, blanchability, size, color, odor, or discharge. The admission MDS identified the resident as at risk for pressure ulcers, with significant lower extremity impairment, dependence for lower body care and transfers, and use of pressure-reducing devices, but no pressure ulcers were documented at that time. The initial care plan dated the day after admission did not include a skin integrity focus or identify the right heel wound, although it did address assistance needs for turning and transfers. A subsequent care plan identified only potential for pressure ulcer development and general preventive interventions, without specifically addressing the existing right heel wound. As the resident’s condition evolved, the facility did not revise the care plan to reflect new pressure ulcers and specific wound-related interventions in a timely manner. An RN wound assessment later identified an unstageable right heel pressure ulcer, but the assessment did not address a red sacrum noted on the same date, and the care plan was not updated at that time to include off-loading boots, which were only added months later. A progress note documented a new pressure sore on the right buttock and the resident’s refusal to get up in a chair at mealtimes despite education on repositioning, yet there was no indication the care plan was revised to address this new wound. A wound clinic report then identified a stage 3 right heel ulcer and a stage 3 ulcer at the urinary meatus related to catheter tension and incontinent brief use, with specific directions regarding catheter device positioning, removal of the brief, and use of barrier cream. The record showed no corresponding care plan revisions to include the new urinary meatus ulcer or the clinic’s catheter and incontinent garment interventions until a later date, and interventions for prevention/minimization of recurrent buttock shearing injuries were also delayed, contrary to the DON’s stated expectation that RN nurse leaders update care plans with changes.
Failure to Maintain Resident Dignity for Catheter Care and Privacy During Personal Care
Penalty
Summary
The deficiency involves failure to maintain resident dignity related to catheter management and privacy during personal care for two residents. One resident with Alzheimer's disease and dementia, who had a urinary catheter placed by hospice on 1/2/26, was observed on two separate occasions with the catheter collection bag exposed and improperly positioned. On one occasion, the catheter bag was hanging from a garbage can next to the resident's recliner without a dignity cover, despite the resident's care plan identifying self-care deficits and the need for staff assistance. On another occasion, the same resident was observed in bed with the catheter bag placed on the floor in a wash basin, again without a dignity cover, even though a dignity bag was available in the closet. Staff, including an RN and an LPN, acknowledged that urine collection bags should be covered for dignity and should not be hung from garbage cans. The second resident, who had anxiety disorder and required two staff for bed mobility, was left without adequate privacy during care. During morning care, a nursing assistant exited the resident's room without shutting the door, leaving the resident sitting on the edge of the bed wearing only a brief secured at the waist with pants pulled down to the knees, while two other nursing assistants supported the resident in a seated position. The resident was yelling for help while the door remained open and the privacy curtain was not drawn. Staff later stated that the door should have been shut during this care. The DON reported that she expected doors to be shut during cares and that catheter bags should have covers, and the facility's Resident Dignity policy directed staff to maintain the dignity of every resident.
Failure to Notify Physician and Representative of Wound Changes and Inadequate Wound Assessment
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician and the resident’s representative of changes in a resident’s skin integrity and related treatment orders, and failure to comprehensively assess new and evolving wounds. The resident, who was paraplegic and chair/bedbound, had a care plan identifying shearing on both buttocks and high risk for skin breakdown, with interventions including barrier cream, dressings when areas were open and draining, and monitoring for signs of shearing and infection with reporting of abnormalities to the health care provider. Early faxed communications to the physician noted intermittent shearing on the buttocks and later increased skin breakdown and open sores associated with the resident’s refusal to get out of bed, but there was no evidence that the care plan was revised to address refusals or a repositioning program. Wound Data Collections from mid-December documented impaired skin integrity at the coccyx/sacrum but were not comprehensive, lacking wound measurements and type descriptions, and a physician note during this period did not mention shearing injury. Subsequent nursing orders directed cleansing of the buttocks and application of zinc oxide and ABD pads, and later documentation described shearing on both buttocks, darkened and reddened areas, and black and blue tissue, as well as a dried calloused area on the left lateral foot treated with iodine. However, between early and late December, records did not show that the physician was notified of new wounds or changes in treatment orders, and from late December through the end of the month there was no indication that the buttock wounds and left lateral heel were comprehensively assessed. The resident’s family member, listed as emergency contact, reported not being informed by the facility about the buttock wound and instead learning of its severity from a visitor who assisted with care. A certified wound NP reported that all prior wounds had been healed and that the wound clinic later received a referral for pressure ulcers on the right lateral foot and both buttocks. The DON stated that nurses should notify the physician of any change in condition, and the facility’s Notification of Change policy required immediate notification of the resident, physician, and resident representative when treatment needed to be significantly altered, but the records did not show such notifications occurred for these wound changes.
Failure to Assist Resident in Obtaining Requested Dental Services
Penalty
Summary
The deficiency involves the facility’s failure to assist a resident in obtaining requested dental services, as required by facility policy. The resident, who had paraplegia and type 2 diabetes, was cognitively intact and had no documented dental issues such as cavities, broken teeth, dentures, or bridges on the admission MDS and Nursing Admit/Re-admit Data collection. However, the Nursing Admit/Re-admit Data form included a comment that the resident would like to pursue dental care. Despite this documented request, there was no evidence in the medical record of any attempts to arrange a dental appointment. During interviews, the resident reported that no one at the facility had worked with him to make a dental appointment, although he stated he had informed the clinical care leader RN. The clinical care leader RN confirmed she completed the Nursing Admit/Re-admit Data and acknowledged that county case workers managed the resident and that either they or the DON would have to approve a dental appointment, describing it as a process. She was unable to articulate the process for obtaining a dental appointment when requested by a resident and was unsure who was responsible for initiating it. Review of the resident’s record by the clinical care leader RN did not reveal any documentation of efforts to set up a dental visit, despite the facility’s policy stating that the location provides or obtains routine and 24-hour emergency dental services and assists residents, when necessary, in making appointments and arranging transportation and referrals.
Failure to Follow Infection Control Practices During Wound, Catheter, and Personal Care
Penalty
Summary
The deficiency involves the facility’s failure to follow infection prevention and control practices during wound care and other direct care for two residents. For one resident with paraplegia, multiple pressure ulcers, an indwelling catheter, and an ostomy, staff performed extensive wound and wound vac care without consistently sanitizing hands between glove changes, moved and placed wound supplies on undisinfected surfaces, and handled clean and dirty items interchangeably. During the wound care, staff removed and applied dressings to multiple wounds, manipulated the wound vac, and cleaned blood using gauze taken repeatedly from the same package, sometimes after touching contaminated items, and without always performing hand hygiene between glove changes. The suction tubing from the wound vac fell to the floor and leaked secretions, and the canister was discarded, while staff continued to work in the area. After this care, another nurse entered the room wearing gloves but no gown, removed IV medication, flushed the IV, and left the room without performing hand hygiene. For a second resident with Alzheimer’s, dementia, edema, and a history of pressure ulcers, staff also failed to adhere to infection control practices during toileting, catheter care, and wound care. A nursing assistant performed perineal care, manipulated the mechanical lift, wheelchair, catheter bag and tubing, moved equipment in and out of the room, handled a blanket and pillow, and went into the bathroom and hallway, all while wearing the same pair of gloves and without changing them until the end of the sequence. During wound care to the resident’s legs, a nurse removed heel protectors soaked in bodily fluids, dropped gauze on the floor and picked it up, and placed dressings on a chair that had not been disinfected, while intermittently changing gloves and sometimes sanitizing hands, but not consistently between all clean and dirty contacts. In a subsequent wound assessment of the second resident’s buttocks, a hospice nurse and an LPN initially provided care such as obtaining vital signs and administering medications without gowns or gloves, then donned gowns and gloves to perform wound care and catheter care. During this care, they removed dressings, washed the buttocks with wet wipes obtained from the bathroom sink, applied cream, and handled wound care supplies and the catheter cover without removing gloves or sanitizing hands between touching the resident’s buttocks and clean surfaces. Staff interviews confirmed awareness that gloves should be changed when soiled, between different tasks, and that wearing dirty gloves was an infection control issue. The DON stated that following enhanced barrier precautions and infection control was confusing.
Inadequate Infection Surveillance and Data Analysis
Penalty
Summary
The facility failed to maintain a comprehensive infection prevention and control program, as evidenced by the lack of analysis of monthly surveillance data for trends and patterns. The infection preventionist, RN-B, was responsible for overseeing the infection control program and maintaining the surveillance log. However, RN-B admitted that while infections were tracked and documented, there was no formal surveillance or monitoring of trends and breaks in infection practices. The infection data was reviewed informally and not tracked or analyzed comprehensively, which was confirmed by RN-B during an interview. The Director of Nursing (DON) verified that the facility's infection surveillance was not comprehensive, and residents were not tracked or compared for trends or patterns. The DON acknowledged the importance of monthly analysis to identify trends and implement interventions to prevent infections, including staff education and system process review. Despite the facility's policy indicating the need for a robust infection prevention and control program, the facility had not completed the necessary infection surveillance, data collection, analysis, or tracking and trending of infections among residents or staff.
Failure to Provide Dignified Care for Resident's Toileting Needs
Penalty
Summary
The facility failed to provide care in a dignified and respectful manner to a resident with moderately impaired cognition and a history of bowel incontinence. The resident, who was dependent on staff for toilet transfers and hygiene, requested to use the commode but was denied assistance by a nursing assistant (NA-E) who stated she was too busy. NA-E told the resident she should have asked to use the commode earlier and accused the resident of seeking attention out of jealousy. As a result, the resident was taken to the dining room without being assisted to the commode, leading to embarrassment due to incontinence. Interviews with other staff members, including another nursing assistant (NA-D), a registered nurse (RN-C), a licensed practical nurse (LPN-A), and the director of nursing (DON), revealed that the facility's expectation was for residents to be assisted to use the commode when requested. They indicated that if a staff member was too busy, they should seek help from another NA or a nurse. The incident was observed when NA-D later assisted the resident to the commode, where it was noted that the resident had been incontinent of urine in her brief. NA-E's training record showed she had been trained in person-centered care and effective communication.
Failure to Maintain Resident's Range of Motion
Penalty
Summary
The facility failed to provide adequate services to maintain and prevent the loss of range of motion (ROM) for a resident diagnosed with Parkinson's disease, dementia, polyneuropathy, and peripheral vascular disease. The resident, identified as having severely impaired cognition and limited ROM in both upper and lower extremities, was dependent on staff for all activities of daily living. The care plan required passive range of motion (PROM) exercises and the use of a palm splint for the resident's left hand to prevent complications related to immobility. Observations revealed that the resident's left hand was often found without the prescribed splint, and both hands were noted to be in a contracted position. Interviews with nursing assistants and licensed practical nurses indicated a lack of clarity and consistency in the application of the resident's care plan. The nursing assistant responsible for restorative duties reported being frequently pulled from these duties, resulting in inconsistent application of PROM exercises and splinting. Additionally, there was confusion among staff regarding the resident's need for a splint and ROM exercises for the right hand, which was also observed to be contracted. The occupational therapist confirmed that the resident should receive PROM for both hands and wear a splint on the left hand throughout the day. However, the therapist noted a lack of documentation on the progression of the resident's condition, making it difficult to assess changes in the resident's ROM. The facility's failure to consistently implement the care plan and provide necessary interventions contributed to the deficiency in maintaining the resident's ROM.
Failure to Justify Indwelling Catheter Use for Resident
Penalty
Summary
The facility failed to adhere to standards of care and practice for the use of an indwelling catheter for a resident with a history of urinary tract infections (UTIs). The resident, who has diagnoses including ulcerative proctitis, insomnia, and hypothyroidism, was found to have an indwelling catheter without a clear medical diagnosis justifying its use. The resident's care plan indicated the catheter was related to an overactive bladder and hygiene issues, but there was no documentation of post-void residuals or a urology consult to support the necessity of the catheter. Interviews with staff revealed uncertainty about the reason for the catheter, and the resident reported frequent UTIs despite the catheter placement. The facility's urinary catheter policy requires an order and indication for an indwelling Foley insertion, with consideration of alternatives. However, the resident's documentation lacked a specific indication for the catheter, and the director of nursing acknowledged that the resident's diagnosis did not meet the standard of care for a Foley catheter. Despite this, the catheter was placed as a permanent solution to the resident's incontinence, based on a provider's note and order, without further evaluation or consultation with a urologist.
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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