Havenwood Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Bemidji, Minnesota.
- Location
- 1633 Delton Avenue Nw, Bemidji, Minnesota 56601
- CMS Provider Number
- 245397
- Inspections on file
- 37
- Latest survey
- January 16, 2026
- Citations (last 12 mo.)
- 5 (1 serious)
Citation history
Health deficiencies cited at Havenwood Care Center during CMS and state inspections, most recent first.
A resident with dementia, dysphagia, severe cognitive impairment, and poor coordination, care-planned to need supervision, cueing, and a covered mug with cooled coffee, sustained first- and second-degree burns after spilling hot coffee that had been brewed and served at high temperatures in an activity kitchen. Staff interviews showed inconsistent practices for identifying which residents required lids or cooled liquids, lack of awareness of the resident’s specific cup requirements, and no formal policy or assessment tool for safe hot liquid service, despite prior coffee-spill incidents involving the same resident.
A nurse administered 20 units of rapid-acting insulin instead of the prescribed long-acting insulin to a resident with diabetes after becoming distracted during medication preparation. The error led to a hypoglycemic reaction requiring emergency treatment, and review found that medication administration protocols and verification steps were not followed.
Staff left a medication cart unlocked and unattended in a hallway with medications and a resident's information exposed, while also failing to ensure that a resident's Baclofen medication was labeled accurately and administered according to current orders. The medication bottle label did not match the provider's order, lacked the required direction change sticker, and contained half pills, leading to repeated medication errors.
Menus were not consistently prepared in advance, followed, updated, or reviewed by a dietician, resulting in failure to meet the nutritional needs of residents as required.
A resident with multiple medical conditions required significant assistance and was reported by family to have received poor care, including inadequate food and fluid intake. The family described the situation as neglect and had the resident transferred to the hospital, where dehydration and vomiting were noted. Despite the family's explicit allegation of neglect, facility staff did not report the incident to the state agency, citing their belief that neglect had not occurred.
Three residents with significant mobility impairments and fall risks were not consistently assisted with transfer belts as required by their care plans, resulting in falls and injuries. Staff failed to follow care instructions, such as keeping bed remotes out of reach and using two-person assistance, and admitted to not always using transfer belts due to inconvenience or unavailability. Observations and interviews confirmed these lapses, and facility policy required the use of transfer belts for safe transfers.
The facility failed to maintain comfortable water temperatures on the Maple Lane unit, affecting two residents directly and potentially impacting all 13 residents on the unit. A resident with severe cognitive impairment had to be taken to another wing for showers due to the lack of hot water, while another resident reported lukewarm water in their sink. The maintenance director acknowledged the issue, noting that a new hot water heater had not resolved the problem, and lacked a consistent monitoring process. Staff reported the issue multiple times, but the maintenance logbook did not reflect these requests, indicating a breakdown in communication and documentation.
A resident with moderate cognitive impairment and non-Alzheimer's dementia was found to be living in a room with a floor covered in a sticky, black substance, posing a safety hazard. Despite regular cleaning, the issue persisted, and the maintenance director attributed it to glue from the tiles. The infection preventionist and administrator acknowledged the problem, but no plan was in place to replace the flooring, and a maintenance policy was not provided.
A resident with severe cognitive impairment and multiple diagnoses experienced an 11.13% weight loss over 180 days, which was not accurately coded on the MDS as a significant weight loss. The registered dietician's report failed to identify the 180-day weight, leading to the oversight. Facility staff, including the MDS coordinator and director of nursing, acknowledged the coding error, emphasizing the importance of accurate coding for reimbursement and care planning.
A facility failed to develop a baseline care plan for a newly admitted resident within 48 hours, as required. The resident, admitted with a foley catheter and a history of falls, did not have a care plan to guide staff in addressing his needs. The DON confirmed the absence of the plan, which is against the facility's policy.
A facility failed to implement enhanced barrier precautions for a resident with a surgical wound, leading to a deficiency. The care plan did not address the need for PPE, and a nurse was observed changing the resident's dressing without wearing a gown, despite signs of potential infection. The omission of EBP in the care plan and lack of PPE use were not addressed.
A resident experienced significant weight loss, dropping from 125 lbs to 110 lbs over three months, without the care plan being updated to reflect the registered dietician's recommendations for high-calorie, high-protein shakes and weekly monitoring. The facility's policy required care plans to be reviewed and updated as needed, but this was not done, leading to a deficiency in care planning.
A resident at high risk for falls, with moderate cognitive impairment and a history of seizures, was left unattended in an elevated bed, contrary to their care plan. The bed was left approximately 3.5 feet high after a transfer, and staff did not immediately lower it, increasing the risk of falls.
The facility failed to prevent significant weight loss in two residents due to inadequate assessment and intervention. One resident lost 25.7 pounds over six months, while another lost 15 pounds over three months. Staff did not consistently assist or encourage eating, and there were discrepancies in documenting meal intakes and weights. The care plans lacked necessary interventions, and facility policies on weighing and documentation were not followed.
A facility failed to maintain a complete medical record for a resident with multiple diagnoses, including epilepsy and diabetes. The Physician Order Report was incomplete, with only two of four pages available and several medication orders illegible due to faded printing. Interviews revealed that the medical records staff missed checking the document's legibility and completeness, contrary to the facility's policy requiring physician's progress notes to be stamped and signed at each visit.
The facility failed to ensure timely physician visits for two residents, one with intact cognition and multiple diagnoses, and another with severe cognitive impairment and dementia. The residents did not receive routine visits every 60 days as required, with gaps of 165 days and 76 days between visits, respectively. The facility's policy was not followed, leading to missed appointments.
A facility failed to comprehensively assess and implement interventions for a resident with dementia, leading to repeated episodes of distress and agitation. The resident exhibited behaviors such as yelling and aggression, but the care plan lacked specific interventions, and staff often resorted to administering PRN Zyprexa without attempting non-pharmacological interventions. Interviews revealed a lack of understanding of the resident's triggers and the absence of individualized interventions, contributing to ongoing distress for the resident.
A resident with mild cognitive impairment was incorrectly administered loperamide on a scheduled basis instead of as needed for loose stools. The medication was transcribed from standing orders incorrectly, leading to multiple refusals by the resident, who stated it was unnecessary after initial doses. Staff interviews confirmed the error, and the medication was discontinued after the director of nursing contacted the resident's primary provider.
A facility failed to act on a consulting pharmacist's recommendations regarding a resident's medication regimen, which included Eliquis and Diltiazem, posing a higher bleeding risk. Despite recommendations to reassess the risks, there was no documented response from the physician, and the resident continued receiving the medication. The DON acknowledged the lack of response and mentioned issues with the process of handling recommendations.
A facility failed to conduct a face-to-face provider evaluation for a resident's continued use of PRN Zyprexa, despite multiple administrations for behavior issues and agitation. The resident's medical records lacked documentation of the physician's rationale and duration for the PRN medication, contrary to the facility's policy requiring re-evaluation every 14 days.
The facility failed to implement enhanced barrier precautions (EBP) for two residents, one with a catheter and another with a surgical wound. Staff did not wear gowns during high-contact care activities, contrary to CDC guidelines. The care plans did not adequately address EBP needs, and there was a lack of PPE carts and signage. This resulted in non-compliance with infection prevention protocols.
A resident with dementia and other health issues experienced increased lethargy and was not eating or taking medications. Despite family concerns and staff observations of the resident's decline, the facility delayed notifying the physician and organizing a care conference. The resident was eventually sent to the hospital with severe dehydration and other complications.
A resident with dementia and other health issues experienced increased sleepiness and missed medications, leading to a decline in health. Despite family concerns and visible deterioration, the facility delayed action, resulting in a hospital transfer where severe dehydration and other conditions were diagnosed. Staff interviews revealed a lack of communication and assessment, violating facility policy.
A facility failed to assess a wedge cushion as a potential restraint for a resident with severe cognitive impairment and a history of falls. The resident experienced an unwitnessed fall with injuries when the wedge cushion and fall mat were not in place. Staff and family indicated the wedge was used to prevent falls, but the facility did not evaluate it as a restraint, contrary to their policy.
The facility failed to provide nutrient and calorie substantive snacks and allowed a 15-hour gap between dinner and breakfast without offering a substantial snack. Residents reported the removal of the snack cart, and staff confirmed that snacks were only available upon request. The administrator acknowledged the issue, which could affect residents' nutritional status.
A resident reported inappropriate touching by a staff member, but the facility failed to investigate or report the allegation. Despite the resident's care plan identifying her as a vulnerable adult, no action was taken to address the issue, and the staff member did not receive remedial training.
The facility failed to verify the registration of a nurse aide before allowing them to work directly with residents after the four-month training period. The nurse aide had taken the skills test but did not take the knowledge test due to a communication misunderstanding. The facility did not adhere to its abuse prevention/prohibition program, which required screening through the State of Minnesota Department of Human Services and the Minnesota Nursing Assistant Registry prior to employment.
A resident reported inappropriate touching by a male nursing assistant during peri-care, but the facility failed to investigate or report the allegation to the State Agency or police. Staff were aware of the complaint but did not follow through with necessary actions, and the nursing assistant received no remedial training.
A resident with severe cognitive impairment and multiple diagnoses was observed self-administering a nebulizer treatment without proper assessment or supervision. The care plan did not address nebulizer treatments, and the facility's policy requiring an interdisciplinary team assessment and a written order for self-administration was not followed.
The facility failed to clarify conflicting directives for a resident's emergency care and treatment. The resident's EMR had inconsistent information regarding her code status, leading to confusion among staff. Despite the resident's clear communication of her wishes, the facility did not promptly update and clarify her code status, resulting in a failure to honor her advanced directives accurately.
The facility failed to notify the long-term care ombudsman of resident transfers for hospitalization. A resident with multiple diagnoses, including dementia and hemiplegia, was transferred to the hospital twice without notification to the ombudsman. An email from the ombudsman confirmed no communications had been received since April 2021. A social worker stated notifications were only made if the hospitalization or discharge was contested. A policy on notifying the ombudsman was requested but not provided.
The facility failed to provide a written bed hold notice to a resident or their representative during two hospitalizations. Despite the resident signing a bed hold form upon admission, the medical record lacked evidence of written notification for either hospitalization, contrary to facility policy.
A resident with severe cognitive impairment and incontinence was not repositioned or checked for incontinence for almost four hours, contrary to her care plan. Staff interactions and observations confirmed the failure to adhere to the care plan directives, leading to a deficiency in care.
The facility failed to ensure timely changes of nebulizer and tubing for a resident with severe cognitive impairment and multiple diagnoses, including asthma. The care plan and physician's orders did not address respiratory care, and there was no documentation of nebulizer and tubing changes, contrary to the facility's policy on Quality of Care.
The facility failed to administer medications according to physician orders for two residents, resulting in a seven percent medication error rate. One resident received a nebulizer treatment without supervision, and another was given medication at an incorrect time due to scheduling conflicts.
The facility failed to label medications with an opened-on date and did not dispose of expired medications properly. An inspection revealed a bottle of Flonase and an albuterol sulfate inhaler without opened-on dates in the North medication cart. The TMA admitted to irregular checks for expired medications, and the ADON confirmed that pharmacy audits were conducted every three months. Guidelines for safe storage and disposal of medications were not followed.
Burn Injury from Hot Coffee Due to Lack of System for Safe Hot Liquid Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision related to hot liquids, resulting in a resident sustaining burns from spilled coffee. The resident had diagnoses including dementia, aspiration pneumonia, dysphagia, and insomnia, and a quarterly MDS identified severe cognitive impairment with a need for setup or cleanup assistance for eating. The care plan documented a self-care deficit related to dementia, poor coordination, and weakness, and indicated the resident was independent with eating but required supervision and cueing at times. The nursing assistant care guide specified that the resident should receive coffee only in a covered mug with cooled coffee and no styrofoam cups. Despite these documented needs and instructions, the resident experienced multiple coffee-related incidents. Progress notes showed that on one earlier occasion the resident spilled coffee on his left foot, causing a burn with minimal redness. Later, the resident again spilled coffee while drinking in his room, resulting in a large reddened area on the left side of his body, including the forearm and abdomen, with peeling skin and subsequent documentation of first- and second-degree burns. Staff noted that the resident would not allow them to touch the affected areas and that pain medication and cold packs were required, with ongoing monitoring and treatment ordered by the NP and physician. Surveyor interviews and observations revealed systemic gaps in how hot beverages were prepared and served. Coffee for early-morning service was brewed in the activity kitchen while the main kitchen was closed, and the dietary manager measured coffee in a cup at 170°F. Staff practices for determining which residents required lids or cooled liquids were inconsistent; some CNAs relied on asking the charge nurse, some believed this should be in the care plan, and one CNA who served the resident on the day of the burn was unaware of the requirement for a specific handled cup with lid and had not seen the care sheet indicating no styrofoam cups. The DON acknowledged there was no policy on safe serving temperatures for hot liquids and no assessment tool to determine which residents were safe to receive hot liquids, while CNAs reported informal methods such as adding cold water or ice and noted that several residents with dementia drank coffee without being identified as needing cooled beverages.
Insulin Administration Error Due to Distraction and Protocol Lapses
Penalty
Summary
A medication administration error occurred when a nurse administered 20 units of Novolog, a rapid-acting insulin, instead of the physician-ordered 20 units of Lantus, a long-acting insulin, to a resident with diabetes. The resident's care plan and physician orders specified the use of Lantus at bedtime and Novolog only per sliding scale or with meals, depending on blood sugar readings and meal intake. On the evening of the incident, the nurse became distracted by questions from other residents and staff while preparing the insulin at the medication cart, leading to the selection and administration of the wrong insulin type and dose. The error was discovered after the insulin was administered, and the nurse realized the mistake upon returning to the medication cart. The resident's blood sugar was monitored, and the nurse contacted the DON and the on-call provider. The resident was subsequently sent to the emergency room for evaluation and treatment. Medical records indicate the resident experienced a hypoglycemic reaction and required administration of dextrose, glucagon, and glucose tablets. The resident remained neurologically intact and was monitored until blood sugar levels stabilized before being discharged back to the facility. Interviews with staff and review of facility policies revealed that the nurse did not follow the rights of medication administration, was distracted during medication preparation, and failed to verify the medication against the EMAR and physician orders. The root cause analysis identified distraction, lack of communication between nurses, and failure to adhere to established medication administration protocols as contributing factors to the incident. The resident, who had a history of diabetes and was cognitively intact, received the incorrect insulin due to these lapses.
Failure to Secure Medications and Ensure Accurate Medication Labeling
Penalty
Summary
Facility staff failed to ensure that medications and resident information were secured at all times. During an observation, a medication cart was left unattended and unlocked in a hallway, with the computer screen displaying a resident's identifying information. On top of the cart, there was a cup containing a clear liquid and a medication cup with three white pills. No staff were present in the hallway, and a resident in a wheelchair passed by the unattended cart. The trained medication assistant (TMA) later returned to the cart after assisting with a resident transfer, confirming that the cart and computer screen had been left unsecured with medications exposed. Additionally, the facility did not ensure that medication labeling was clear and unaltered. A resident with multiple sclerosis had a provider order for Baclofen with specific dosing instructions, but the medication bottle label did not match the current order. The label on the bottle was outdated and had handwritten instructions to refer to the electronic medication administration record (EMAR), but there was no required orange sticker indicating a direction change. The TMA was unaware that incorrect doses had been administered over several days due to the mismatched label and lack of clear instructions. The TMA also found half pills in the bottle, which should not have been present, indicating ongoing medication administration errors. The director of nursing confirmed that the Baclofen dose had been changed, but staff continued to use a bottle with an incorrect label after running out of the correctly dosed medication. The facility's policy required that medication labels be neat, legible, and only changed by the pharmacy, but this was not followed. The failure to secure medications and resident information, as well as the lack of proper medication labeling and administration, resulted in multiple medication errors for the resident.
Deficiency in Menu Planning and Nutritional Compliance
Penalty
Summary
Menus did not consistently meet the nutritional needs of residents as required. The menus were not always prepared in advance, were not consistently followed, and were not regularly updated to reflect residents' current needs. Additionally, menus were not always reviewed by a dietician, and there were instances where the dietary needs of residents were not met as outlined in their care plans. These deficiencies were observed through review of menu documentation and dietary records, which showed lapses in menu preparation, review, and adherence to residents' individualized nutritional requirements.
Failure to Report Allegation of Neglect to State Agency
Penalty
Summary
The facility failed to report an allegation of neglect to the state agency for a resident who was admitted with diagnoses including atrial fibrillation, adult failure to thrive, and hypertension. The resident required assistance with repositioning, toileting, and wheelchair mobility. According to progress notes, the resident's family expressed concerns about poor care, specifically that the resident was not eating or drinking adequately and was refusing medications. The family insisted the resident be sent to the emergency department, and upon arrival at the hospital, the resident was found to be dehydrated and vomiting. The family explicitly described the care as neglect to facility staff. Despite these allegations and the facility's own policy requiring reporting of neglect allegations within specified timeframes, interviews with staff revealed that the allegation was not reported to the state agency. The social services designee and licensed social worker both acknowledged the family's claims but stated the facility did not believe neglect had occurred and therefore did not report the incident. The administrator confirmed that the allegation was not reported, as she was not aware of the concerns until after the family had already removed the resident from the facility.
Failure to Use Transfer Belts and Maintain Hazard-Free Environment Leads to Resident Falls
Penalty
Summary
The facility failed to provide a hazard-free environment and did not utilize required assistance devices, such as transfer belts, as outlined in resident care plans for three of four residents reviewed for falls. One resident with a history of falls, left scapula fracture, and moderate dementia required substantial to maximal assistance for transfers and was care planned for transfer belt use. Despite this, the resident was assisted without a transfer belt and subsequently fell, resulting in visible injuries to the face and head. The resident confirmed that the transfer belt was not used during the incident. Another resident with severe cognitive impairment and a history of fractures was identified as a fall risk and required two-person assistance with a transfer belt. Staff failed to follow the care plan by leaving the bed remote within the resident's reach, which allowed the resident to raise the bed and fall. Observations confirmed the remote was accessible, and staff interviews revealed a lack of awareness regarding the ability to lock the bed remote, contrary to care plan instructions. A third resident with hemiplegia and recent stroke was also care planned for transfer with a belt and two-person assistance. However, staff were observed ambulating the resident without a transfer belt, and the staff member admitted to not using the belt because it was bothersome and unavailable. Interviews with nursing and therapy staff confirmed that the transfer belt was required for safe transfers, and the facility's policy mandated its use for both single and double assist transfers. Family members also reported inconsistent use of transfer belts and adherence to care plans by staff.
Failure to Maintain Adequate Water Temperatures on Maple Lane Unit
Penalty
Summary
The facility failed to maintain a system ensuring comfortable water temperatures for residents on the Maple Lane unit, affecting two residents directly and potentially impacting all 13 residents on the unit. Resident 22, with severe cognitive impairment, was dependent on staff for personal care and had to be taken to another wing for showers due to the lack of hot water. Resident 45, with moderate cognitive impairment, reported that the water in their sink was lukewarm at best, necessitating showers on another wing. Interviews with family members and residents highlighted the inconvenience and discomfort caused by the cold water issue. The maintenance director acknowledged the problem, noting that a new hot water heater installed in November 2024 had not resolved the issue. Water temperatures were recorded between 93 to 98 degrees, below the expected maximum of 115 degrees. The maintenance director admitted to only testing water temperatures when complaints were received and lacked a consistent monitoring process. Staff reported the issue multiple times, but the maintenance logbook did not reflect these requests, indicating a breakdown in communication and documentation. The director of nursing and the administrator were aware of the ongoing issues, which were discussed in quality assurance meetings, but the problem persisted, with no policy on water temperature management provided.
Failure to Maintain Safe Flooring Environment
Penalty
Summary
The facility failed to maintain a safe environment for a resident with moderate cognitive impairment and non-Alzheimer's dementia, as evidenced by the condition of the flooring in the resident's room. Observations revealed a black, sticky substance built up on the seams between the flooring tiles, covering approximately 50% of the floor. This substance adhered to shoes when walked upon, indicating a potential safety hazard. Interviews with housekeeping staff revealed that the room was cleaned about three times a week, but the sticky substance persisted and was difficult to remove. The maintenance director acknowledged the issue, attributing it to glue from the tiles, and noted that the floor had been replaced within the past year. Despite attempts to address the problem by scraping and rewaxing the floor, the issue recurred within a week. The infection preventionist confirmed the floor's condition, stating it was sticky and could not be cleaned thoroughly. The administrator acknowledged the situation as unacceptable and recognized the need for the floor to be replaced. However, there was no current plan in place to replace the flooring, and a policy for maintenance of flooring was requested but not provided. This lack of action and planning contributed to the deficiency in maintaining a safe and clean environment for the resident.
Failure to Accurately Code Significant Weight Loss on MDS
Penalty
Summary
The facility failed to accurately code a significant weight loss on the Minimum Data Set (MDS) for a resident with severe cognitive impairment and multiple diagnoses, including diabetes, hemiplegia, hemiparesis, chronic kidney disease, dysphasia, and aphasia. The resident's weight decreased from 172.5 pounds to 153.3 pounds over 180 days, representing an 11.13% weight loss, which should have triggered a significant weight loss alert on the MDS. However, the registered dietician's initial report did not identify the 180-day weight, leading to the resident not being flagged for significant weight loss. Interviews with facility staff, including the registered dietician, MDS coordinator, director of nursing, and administrator, revealed that the coding error was acknowledged, and the resident's quarterly MDS was incorrectly coded. The MDS coordinator stated that accurate coding is crucial as it affects reimbursement, quality reports, and the implementation of appropriate interventions. The facility's policy requires assessments to be completed by qualified staff and coded accurately to develop person-centered care plans, which was not adhered to in this case.
Failure to Develop Baseline Care Plan for New Resident
Penalty
Summary
The facility failed to develop a baseline care plan for a newly admitted resident, identified as R211, within the required 48-hour timeframe. R211 was admitted to the facility after being hospitalized for acute blood loss anemia and acute knee pain due to gout. Upon admission, R211 had a foley catheter in place, which was to remain until a scheduled urology appointment, and required assistance with ambulation due to a history of falls at home. Despite these needs, the facility did not create a baseline care plan to guide staff in providing appropriate care for R211. During an interview, the Director of Nursing (DON) confirmed the absence of a baseline care plan for R211, acknowledging that it was the facility's practice to complete such plans within 48 hours of admission. The facility's policy mandates that the baseline care plan should include initial goals, physician and dietary orders, therapy services, and instructions for effective, person-centered care. The lack of a baseline care plan meant that staff were not formally informed of R211's care needs, including the management of the foley catheter, enhanced barrier precautions, and assistance with activities of daily living and mobility.
Failure to Implement Enhanced Barrier Precautions for Surgical Wound Care
Penalty
Summary
The facility failed to identify and implement enhanced barrier precautions (EBP) for a resident with a surgical wound, leading to a deficiency. The resident, who was cognitively intact, had been admitted with a surgical wound requiring care. The care plan, revised after the resident's admission, included monitoring for signs of infection and assistance with daily activities but did not address the need for EBP. During observations, it was noted that there was no personal protective equipment (PPE) cart near the resident's room, nor were there signs instructing staff to wear PPE during dressing changes. A registered nurse (RN) was observed changing the resident's dressing without wearing a gown, despite noticing signs that the wound might be getting infected. The RN admitted to not wearing PPE during wound care, based on instructions from the infection preventionist, and acknowledged the risk of spreading bacteria. The facility's care plan policy required updates as needed, but the omission of EBP in the resident's care plan and the lack of PPE use during wound care were not addressed, contributing to the deficiency.
Failure to Update Care Plan for Resident with Weight Loss
Penalty
Summary
The facility failed to revise and update a comprehensive care plan for a resident who experienced significant weight loss. The resident, who was cognitively intact and required set-up assistance for eating, was not on a physician-prescribed weight-loss regimen. Despite recommendations from a registered dietician (RD) to offer high-calorie, high-protein shakes and monitor weekly weights and intake, the care plan did not reflect these individualized interventions. The resident's care plan, dated several months prior, only included general interventions such as offering a regular diet and snacks, without addressing the specific needs identified by the RD. The resident's weight had decreased from 125 lbs to 110 lbs over a three-month period, indicating a significant weight loss. The RD had completed a significant change assessment and discussed a plan to increase the resident's weight, but the care plan was not updated to include these recommendations. The facility's policy required care plans to be reviewed every 90 days and updated as needed, but this was not adhered to in this case. Interviews with the RD and the facility administrator confirmed the expectation for accurate assessments and care planning to prevent weight loss, which was not met for this resident.
Failure to Maintain Bed in Low Position for High-Risk Resident
Penalty
Summary
The facility failed to ensure a bed was kept in the low position to prevent falls for a resident identified as high risk for falls. The resident, who had moderate cognitive impairment and a history of unspecified convulsions, required substantial assistance for mobility and was unable to ambulate. The care plan for the resident included specific fall interventions such as a low bed and floor mats. However, during an observation, the resident was left unattended in an elevated bed position by the nursing staff, which was not in line with the care plan interventions. The incident was observed when a registered nurse and a nursing assistant transferred the resident into bed using a mechanical lift, leaving the bed approximately 3.5 feet high. The bed remained elevated and out of staff view while the nursing assistant attended to the resident's roommate and left the room to gather supplies. The bed was eventually lowered after incontinence care was provided. Interviews with staff, including the director of nursing and the administrator, confirmed that the resident should not have been left unattended in an elevated bed due to the risk of falls, especially considering the resident's history of seizures.
Failure to Prevent Weight Loss in Residents
Penalty
Summary
The facility failed to adequately assess and implement interventions to prevent weight loss for two residents, leading to significant deficiencies in their nutritional care. One resident, who had severe cognitive impairment and multiple medical conditions, experienced a weight loss of 25.7 pounds or 14.89% over six months. Despite the resident's fluctuating weights and inconsistent meal intakes, the registered dietician did not recognize the significant weight loss, and the care plan did not include necessary interventions to stabilize or prevent further weight loss. Observations revealed that staff did not consistently assist or encourage the resident to eat, and there were discrepancies in documenting meal intakes and weights. Another resident, who was cognitively intact, experienced a weight loss of 15 pounds over three months. The resident was identified as malnourished, with a nutritional risk score indicating significant weight loss and a BMI less than 19. Although the registered dietician recommended high-calorie, high-protein shakes and other interventions, the care plan failed to include these individualized interventions. Observations showed that the resident's meal intake was not accurately documented, and the facility's policy on weighing residents was not consistently followed. Interviews with staff, including the registered dietician, nurses, and nursing assistants, highlighted a lack of consistent monitoring and documentation of weights and meal intakes. The facility's policies on weighing residents and documenting meal intakes were not adhered to, contributing to the failure to recognize and address the significant weight loss in both residents. The director of nursing and other staff acknowledged the deficiencies and the need for improved monitoring and intervention strategies.
Incomplete Medical Record for Resident
Penalty
Summary
The facility failed to maintain a complete medical record for a resident, identified as R7, during routine visits. R7's medical history includes epilepsy, diabetes, pain, autistic disorder, fibromyalgia, and chronic kidney disease. The Physician Order Report for R7, covering the period from October 7, 2024, to January 7, 2025, was incomplete. Although the report was supposed to contain four pages, only two pages were available, and of the 12 medication orders listed, only nine were legible due to faded and incomplete printing. Additionally, the order for a non-pharmaceutical intervention for pain was illegible, and pages three and four of the report were missing. Interviews with the medical records staff member and the director of nursing revealed that the full four-page Physician Order Report could not be located. The medical records staff member admitted to missing the check for legibility and completeness after scanning the documents into the resident's medical records. The facility's policy requires that the physician's progress notes be stamped and signed at each visit, confirming the review of the plan of care, medications, treatments, and all other orders. However, this policy was not adhered to in R7's case, leading to the deficiency.
Failure to Ensure Timely Physician Visits for Residents
Penalty
Summary
The facility failed to ensure that long-term residents received routine physician visits every 60 days as required, affecting two residents. Resident R7, who had intact cognition and multiple diagnoses including epilepsy and diabetes, did not have documented physician visits for 165 days between July 26, 2024, and January 8, 2025. The medical record staff noted that visits were scheduled but not completed or billed, and the primary physician had stopped rounding at the facility, leading to missed appointments. R7 eventually changed to a different primary physician and was seen in January. Resident R39, who had severe cognitive impairment and dementia, was not seen by a physician within the required timeframe on two occasions. The resident was seen on August 21, 2024, but not again until November 5, 2024, which was 76 days later, and then again on January 15, 2025, which was 71 days later. The medical record staff, who was new to the role, acknowledged the oversight in scheduling and counting days, resulting in the delay. The facility's policy required residents to be seen by a physician every 60 days, with a 10-day grace period, but this was not adhered to in these cases.
Failure to Address Dementia-Related Behaviors in Resident
Penalty
Summary
The facility failed to comprehensively assess and implement interventions for a resident diagnosed with dementia, leading to repeated episodes of distress and agitation. The resident, who had a severe cognitive impairment and was on antipsychotic medication, exhibited behaviors such as yelling, hallucinations, and aggression towards staff. Despite these behaviors, the resident's care plan lacked specific interventions to address these issues, and staff did not consistently attempt non-pharmacological interventions before administering medication. Observations and interviews revealed that the resident frequently yelled out, especially at night, and had difficulty being consoled. Staff often resorted to administering PRN Zyprexa without documented attempts of non-pharmacological interventions. The resident's care plan directed staff to reorient and validate as needed, but it did not provide specific strategies to manage the resident's behaviors effectively. Interviews with staff indicated a lack of understanding of the resident's triggers and the absence of individualized interventions in the care plan. The facility's failure to provide a comprehensive assessment and implement effective interventions for the resident's dementia-related behaviors resulted in ongoing distress for the resident. Staff interviews highlighted the need for a more resident-centered care plan with specific interventions to prevent or calm the resident's behaviors. The absence of a facility policy regarding dementia care further contributed to the deficiency, as staff were left without clear guidelines to manage the resident's condition effectively.
Medication Transcription Error Leads to Improper Administration
Penalty
Summary
The facility failed to ensure that as-needed medication from facility standing orders was transcribed and administered correctly for a resident experiencing loose stools. The resident, who had mild cognitive impairment and was continent of bowel and bladder, was prescribed loperamide, an antidiarrheal medication, to be administered four times daily for diarrhea. However, the medication was intended to be given only after each loose stool, not exceeding 8 mg in a 24-hour period. The medication was incorrectly scheduled for regular administration times, leading to multiple instances where the resident refused the medication, stating it was unnecessary after initial doses resolved her symptoms. Interviews with staff revealed that the loperamide order was transcribed from standing orders incorrectly, as it should have been recorded as a PRN medication rather than scheduled doses. The director of nursing confirmed that the medication should not have been scheduled and that the resident's primary provider was contacted to discontinue the medication. The facility's policy required notifying the provider if a resident experienced four or more loose stools in a 24-hour period, which was not adhered to in this case. The transcription error led to medication errors each time the medication was administered at scheduled times.
Failure to Act on Pharmacist's Medication Review Recommendations
Penalty
Summary
The facility failed to ensure that consulting pharmacist recommendations were acted upon, addressed, and documented in the medical record for a resident reviewed for unnecessary medication use. The resident, who had intact cognition and diagnoses including paroxysmal atrial fibrillation, heart disease, and secondary hypertension, was on a medication regimen that included Eliquis, aspirin, and Diltiazem. The consulting pharmacist identified an irregularity in the medication regimen, noting that the concomitant use of Diltiazem with oral anticoagulants like Eliquis was associated with a higher bleeding risk. The pharmacist recommended reassessing the risks versus benefits of using Diltiazem, but there was no recorded response from the physician to either accept or reject the recommendation. The deficiency was further highlighted when the consulting pharmacist renewed the recommendation in a subsequent review, again noting the lack of response from the physician. Despite the recommendation being made in both August and October, the resident continued to receive the medication without any documented action or response from the physician. The Director of Nursing (DON) acknowledged the absence of the provider's response and mentioned that the physician sometimes took the recommendation forms back to the clinic for further review without returning them. The facility's policy required that recommendations be acted upon and documented, but this was not adhered to in this case.
Failure to Provide Face-to-Face Evaluation for PRN Psychotropic Medication
Penalty
Summary
The facility failed to provide a face-to-face provider evaluation for the continued use of a PRN psychotropic medication for a resident with severe cognitive impairment and a diagnosis of dementia. The resident was prescribed Zyprexa (olanzapine) 2.5 mg to be taken as needed for behaviors, with the order stating it was acceptable to continue until the next face-to-face visit. However, the resident's medical records from January 22 to February 12 did not include documentation from the physician regarding the rationale and duration of need for the PRN antipsychotic medication. The resident received the PRN medication multiple times in January and February for various reasons, including behavior issues and agitation. Interviews with the Director of Nursing and the administrator revealed that PRN antipsychotic medications should be re-evaluated by the physician every 14 days with documented rationale and duration for use. The facility's policy required a face-to-face assessment by the prescribing provider 14 days after initiating a new PRN psychotropic medication, which was not adhered to in this case.
Failure to Implement Enhanced Barrier Precautions for Residents
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for two residents, one with a catheter and another with a surgical wound. The Centers for Disease Control and Prevention (CDC) guidelines require the use of personal protective equipment (PPE), including gowns and gloves, during high-contact care activities to prevent the spread of multidrug-resistant organisms (MDROs). However, the facility did not adhere to these guidelines for a resident with an indwelling Foley catheter and another resident receiving surgical wound care. For the resident with the Foley catheter, the care plan indicated the need for EBP due to the catheter. Despite this, staff members, including a nursing assistant and a registered nurse, failed to wear gowns during catheter care and toileting activities. The facility's infection preventionist and director of nursing confirmed that EBP was required for residents with catheters, but staff did not consistently follow this protocol, as evidenced by the lack of PPE carts and signage indicating EBP requirements. Similarly, for the resident with a surgical wound, the care plan did not address the need for EBP, and staff did not wear gowns during dressing changes. Observations revealed that a registered nurse assessed and changed the resident's dressing without wearing a gown, despite the presence of a fluid-filled blister and signs of potential infection. The facility's policy required EBP for residents with wounds, but staff were not informed or did not adhere to these requirements, leading to a failure in implementing necessary precautions.
Failure to Notify Physician of Resident's Decline
Penalty
Summary
The facility failed to notify the physician of a change in condition for a resident who was experiencing increased sleepiness, not eating, and not taking medications. The resident, who had a history of dementia with behavioral disturbance, depression, hypertensive kidney disease, and other conditions, was observed by family and staff to be more lethargic and not consuming food or medications. Despite these observations, the facility did not promptly inform the physician or take immediate action to address the resident's declining condition. The resident's family member expressed concerns about the resident's medication and condition, noting that the resident was not eating and was difficult to understand. The family member visited the facility multiple times, observing the resident in a deteriorated state, and communicated these concerns to the staff. However, the facility delayed in organizing a care conference and did not notify the physician until the resident's condition had significantly worsened, leading to an unscheduled hospital discharge. Interviews with facility staff, including a trained medication aide, registered nurse, and the director of nursing, revealed that the resident's decline had been noted but not adequately addressed. The staff had observed changes in the resident's behavior and condition, yet failed to follow the facility's policy of notifying the physician and family in a timely manner. The director of nursing acknowledged that the staff should have updated the provider upon identifying the change in the resident's condition.
Failure to Assess and Respond to Resident's Change in Condition
Penalty
Summary
The facility failed to identify and assess a change in condition for a resident who exhibited increased sleepiness, missed medications, and irregular eating and drinking habits. The resident, diagnosed with dementia, depression, and other health issues, was noted to have severe cognitive impairment and required assistance with mobility and nutrition. Despite these needs, the facility did not adequately respond to the resident's deteriorating condition, which included lethargy and refusal to eat or drink, until the family member insisted on a hospital transfer. The resident's family member expressed concerns about the resident's medication, Zyprexa, and its effects, noting that the resident was not communicating or eating as usual. Despite these concerns and the resident's visible decline, the facility delayed action, opting to schedule a care conference instead of immediate intervention. The family member's insistence led to the resident's transfer to the hospital, where severe dehydration, hypernatremia, and a urinary tract infection were diagnosed. Interviews with facility staff revealed a lack of communication and assessment regarding the resident's condition. The Director of Nursing and the administrator acknowledged the failure to update the provider or conduct an assessment following the change in condition. The facility's policy required notification and evaluation of changes in resident status, which was not followed in this case, leading to the deficiency.
Failure to Assess Wedge Cushion as Potential Restraint
Penalty
Summary
The facility failed to assess the use of a wedge cushion as a potential restraint for a resident with severe cognitive impairment. The resident had a history of multiple falls and was identified as restless and impulsive. The care plan included the use of a wedge cushion to prevent falls, but the facility did not evaluate whether the wedge cushion functioned as a restraint. The resident experienced an unwitnessed fall, resulting in injuries, when the wedge cushion and fall mat were not in place. Interviews with staff and family revealed that the wedge cushion was used to keep the resident positioned in bed and prevent falls. However, the facility's nurse consultant admitted that the resident had not been assessed for a potential restraint, and the type of wedge being used was unfamiliar to her. The facility's policy on physical restraints required an assessment to determine the need and risk/benefit relationship before using a restraint, which was not conducted in this case.
Failure to Provide Substantive Snacks and Prevent Long Gaps Between Meals
Penalty
Summary
The facility failed to ensure nutrient and/or calorie substantive snacks were offered and readily available for three residents who voiced concerns at a resident council meeting. These residents reported that the snack cart, which used to be available, was no longer in use. Interviews with nursing assistants confirmed that the snack cart was no longer available, and residents had to request snacks if they wanted them. The certified dietary manager confirmed that dinner was served at 5 p.m. and breakfast at 8 a.m., resulting in a 15-hour gap between meals without offering a substantial snack in the evening. The administrator acknowledged that the hours between meals were too many and that the snack offerings did not meet the requirements for a substantial snack, which is important for maintaining residents' consistent weights and preventing weight loss. The facility's decision to remove the snack carts was based on concerns about safety and infection control, as noted in the Havenwood Resident Council Meeting Minutes. The dietary staff would lock the snack carts in the kitchenettes after meal service, and residents had to ask staff to get them snacks or drinks. This change led to residents not having access to snacks between meals, particularly in the evening, which could affect their nutritional status. The facility's policy stated that there should not be more than 14 hours between meal services unless a substantial bedtime snack is offered, but this policy was not being followed, leading to the deficiency identified in the report.
Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to ensure allegations of abuse were investigated for a resident who reported inappropriate touching by a staff member. The resident, who had diagnoses including anxiety, depression, bipolar disorder, and secondary Parkinsonism, reported the incident to staff but no investigation was conducted. The resident's care plan identified her as a vulnerable adult and encouraged family involvement in care conferences. Despite this, the allegation was not reported to the State Agency or the police department, and the staff member involved did not receive any remedial training on performing cares after the incident. Interviews with various staff members revealed that the resident had expressed discomfort with the care provided by the nursing assistant and did not want him to provide further care. However, the facility did not follow its policy on abuse prevention and investigation, which required a thorough and objective investigation of all allegations. The failure to investigate and report the allegation, as well as the lack of remedial training for the staff member involved, constituted a deficiency in the facility's handling of the situation.
Failure to Verify Nurse Aide Registration
Penalty
Summary
The facility failed to verify the registration of a nurse aide (NA-A) before allowing them to work directly with residents after the four-month training period. NA-A was hired on 10/23/23 and placed on investigatory suspension on 4/1/24. A review of NA-A's personnel file showed no verification of nursing assistant certification. A search of the nursing assistant registry confirmed that NA-A was not currently registered. During an interview, the administrator revealed that NA-A had taken the skills test on 12/22/23 but did not take the knowledge test due to a communication misunderstanding between the testing site and the facility. The facility's abuse prevention/prohibition program required screening of all applicants through the State of Minnesota Department of Human Services and the Minnesota Nursing Assistant Registry prior to employment, which was not adhered to in this case.
Failure to Report Allegations of Abuse
Penalty
Summary
The facility failed to ensure allegations of abuse were reported for a resident who had diagnoses including anxiety, depression, bipolar disorder, and secondary Parkinsonism. The resident, who was cognitively intact, reported that a male nursing assistant had touched her inappropriately during peri-care, making her uncomfortable. This incident was reported to staff, but no further investigation or reporting to the State Agency or police department occurred. The resident's care plan identified her as a vulnerable adult, but the facility did not follow through with the necessary actions to address her concerns properly. Interviews with staff revealed that the assistant director of nursing and a social worker were aware of the resident's complaint but did not investigate further because the resident stated it wasn't abuse. The nursing assistant involved was not given any remedial training, and there was no documentation of any education or training in his personnel file following the allegation. The facility's policy required prompt reporting of any suspected abuse, but this was not adhered to in this case.
Failure to Assess Resident for Self-Administration of Nebulizer Treatment
Penalty
Summary
The facility failed to ensure nursing staff observed medication administration for a resident who was not assessed to be able to self-administer a nebulizer treatment. The resident, who had severe cognitive impairment and multiple diagnoses including aphasia, asthma, anxiety, depression, and morbid obesity, was observed self-administering a nebulizer treatment without proper assessment or supervision. The resident's care plan did not address nebulizer treatments, and there was no assessment for self-administration of medications. During an observation, a trained medication aide prepared the resident's nebulizer and left the resident alone with the call light within reach, returning only after the treatment was completed. The medication aide was unaware if the resident had been assessed for self-administration. The corporate registered nurse confirmed that the resident had not been assessed for self-administration of medications. The facility's policy required an interdisciplinary team assessment and a written order for self-administration, which had not been followed in this case.
Failure to Clarify Conflicting Advanced Directives
Penalty
Summary
The facility failed to ensure conflicting directives for emergency care and treatment were clarified for a resident (R28) who had advanced directives. R28's electronic medical record (EMR) identified her as do not resuscitate (DNR) on her face sheet, while another document in her EMR indicated she wanted full code status, meaning all available reasonable technology should be used in the event of cardiac respiratory arrest. Despite R28's cognitive intactness and her clear communication that she wanted full code status, the facility's records were inconsistent, leading to confusion among staff about her true wishes in an emergency situation. Interviews with staff revealed that the conflicting information was not promptly addressed. An LPN verified the discrepancy between the face sheet and the scanned document, and a social worker confirmed that the code status should have been updated and clarified during care conferences. Observations showed that the code status information on the clipboard next to the automated external defibrillator (AED) was outdated, listing R28 as DNR. The facility's policy required regular audits to ensure accurate communication of residents' code status, but these audits were not effectively implemented, resulting in the failure to honor R28's wishes accurately.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to ensure the long-term care ombudsman was notified of resident transfers for one of two residents reviewed for hospitalization. The resident, identified as R26, had diagnoses including dementia, hemiplegia, seizure disorder, and depression, and was cognitively intact. The resident's progress notes indicated hospital transfers on two occasions, but the medical record lacked evidence of notification to the state ombudsman's office. An email from the ombudsman confirmed no communications regarding hospitalizations had been received since April 2021. During an interview, a social worker stated the facility only notified the ombudsman's office if the hospitalization or discharge was contested. A policy on notifying the ombudsman's office was requested but not provided.
Failure to Provide Written Bed Hold Notice
Penalty
Summary
The facility failed to provide a written bed hold notice to a resident or their representative during two separate hospitalizations. The resident, who had diagnoses including dementia, hemiplegia, seizure disorder, and depression, was cognitively intact according to the quarterly Minimum Data Set (MDS). The resident's progress notes indicated hospital transfers on two occasions, but the medical record lacked evidence of written notification for either hospitalization. Interviews with facility staff revealed that residents typically sign a bed hold form upon admission, which includes language about holding the bed without charge for up to 18 consecutive days. However, the facility's policy and resident handbook both require written notification at the time of transfer or discharge. The social worker confirmed the importance of this notification to inform residents or their families about potential charges and to determine if they want their bed held.
Failure to Reposition and Check Incontinent Resident
Penalty
Summary
The facility failed to ensure timely repositioning and incontinence care for a resident (R30) who was at risk for pressure ulcers. R30, who had severe cognitive impairment, morbid obesity, and was always incontinent of bowel and bladder, was observed from 8:15 a.m. to 11:54 a.m. without being repositioned or checked for incontinence as per her care plan. Despite multiple interactions with staff and visitors, R30 remained seated in her wheelchair for almost four hours without being repositioned or checked for incontinence, which was against the care plan directives of repositioning and checking every two to three hours. During the observation period, staff failed to offer or perform necessary care actions, such as checking and changing R30's brief or repositioning her, even when prompted by visitors. Interviews with staff confirmed that R30 had not been repositioned or checked for incontinence as required. The facility's Skin Care policy emphasized the importance of individualized care plans to address pressure relief and incontinence, which was not adhered to in this case, leading to a deficiency in care for R30.
Failure to Change Nebulizer and Tubing in a Timely Manner
Penalty
Summary
The facility failed to ensure that the nebulizer and tubing for a resident were changed in a timely manner. The resident, who had diagnoses including aphasia, asthma, anxiety, depression, and morbid obesity, was identified as severely cognitively impaired and receiving oxygen therapy. The resident's care plan did not address respiratory care or nebulizer treatments, and the physician's orders did not include instructions for the care and changing of the nebulizer and tubing. The medical record also lacked documentation for nebulizer and tubing changes. During an observation, the resident's nebulizer setup was found on the bedside table with undated tubing. Interviews with a trained medication aide and a nurse consultant revealed that the nebulizer setup should be rinsed after each use and the tubing should be changed regularly to prevent infection. However, there was no documentation of these changes in the medication administration record. The facility's policy on Quality of Care emphasized the importance of providing respiratory care consistent with professional standards, but this was not followed in the resident's case.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure medications were administered in accordance with physician orders for two residents. Resident R30, who has severe cognitive impairment and multiple diagnoses including asthma and morbid obesity, was observed receiving a nebulizer treatment without supervision. The trained medication aide (TMA) left R30 alone during the treatment, despite R30 not being assessed for self-administration of medications. This action was contrary to the facility's policy and the TMA's training, which required supervision during nebulizer treatments. Resident R39, diagnosed with end-stage renal failure and undergoing hemodialysis, was given calcium acetate at a time not aligned with her meal schedule, contrary to physician orders. The TMA administering the medication acknowledged the error but cited scheduling conflicts with R39's dialysis times. The assistant director of nursing confirmed that the medication should be given as directed with meals. These actions resulted in a medication error rate of seven percent, exceeding the acceptable threshold of five percent.
Failure to Label and Dispose of Medications Properly
Penalty
Summary
The facility failed to ensure medications with a shortened expiration period were labeled with an opened-on date and failed to ensure expired medications were disposed of properly. This was observed during an inspection of the North medication cart, which contained a bottle of Flonase for a resident without an opened-on date and with a manufacturer expiration date of 2/2024. Additionally, an albuterol sulfate inhaler for another resident was found without an opened-on date and with a dose-meter reading of 202. The trained medication aid (TMA) admitted to checking for expired medications only every couple of weeks or whenever time allowed, rather than on a regular basis. The assistant director of nursing (ADON) stated that the pharmacy consultant conducted medication cart audits every three months and that it was expected not to have expired medications in the cart. The ADON also emphasized the importance of dating medications when opened to ensure their effectiveness. A document from Thrifty Pharmacy outlined that medications should be stored safely and securely, and outdated or deteriorated medications should be immediately removed from stock and disposed of according to procedures. However, these guidelines were not followed, leading to the observed deficiencies.
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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