Hendricks Community Hospital
Inspection history, citations, penalties and survey trends for this long-term care facility in Hendricks, Minnesota.
- Location
- 503 E Lincoln Street, Hendricks, Minnesota 56136
- CMS Provider Number
- 245467
- Inspections on file
- 17
- Latest survey
- April 30, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Hendricks Community Hospital during CMS and state inspections, most recent first.
The facility did not provide RN coverage for at least 8 consecutive hours on several days, as required by regulation. Staffing records showed gaps in RN coverage, and interviews with the DON, administrator, and HR confirmed ongoing difficulties in hiring and retaining RNs despite recruitment efforts.
The facility did not ensure that data submitted to the QAPI committee was analyzed or documented, and failed to establish goals, action plans, or data collection methods for identified issues such as falls and quality indicators. Leadership confirmed that no thorough analysis or measurable outcomes were completed, affecting all residents.
The facility did not have formal Performance Improvement Projects (PIPs) in place as part of its QAPI program, with no documented goals, action plans, or data analysis for identified high-risk or problem-prone areas. This failure was confirmed by the DON, administrator, and QAPI director, and was not in accordance with the facility's QAPI policy.
The QAPI committee did not document attendance at meetings, failed to ensure regular infection control reports from the IP, and did not review State Agency or incident reports as required. Meeting minutes lacked evidence of required data presentations and discussions, and interviews confirmed the absence of documentation for these critical quality assurance activities.
A resident's Death in Facility MDS assessment was not submitted within the required timeframe. The assessment was completed and locked in the electronic health record, but not validated or transmitted, resulting in it being marked as completed rather than accepted. The new MDS coordinator was unaware of the outstanding assessment due to a lack of review of prior submissions, and the DON expected timely tracking and submission of all MDS assessments as per facility policy.
A resident with severe cognitive impairment and a history of DVT was prescribed Eliquis, but the care plan and EMAR did not include instructions or monitoring for anticoagulant side effects or increased bleeding risk. Staff interviews confirmed the omission, and facility policy required such monitoring to be included in the care plan.
A resident with severe cognitive impairment and multiple diagnoses, including DVT and dementia, was prescribed Eliquis without any documented instructions for monitoring side effects in the EMAR or care plan. Interviews with LPN, DON, and MDS nurse confirmed that monitoring for bleeding and other side effects was not included, despite facility policy requiring such monitoring for anticoagulant use.
The facility did not maintain thorough infection control surveillance, as documentation for three residents with influenza symptoms lacked evidence of implemented precautions or resolution of symptoms. Additionally, two staff members returned to work after illness without proper clearance or follow-up, and one resident did not receive a complete TB screening as required.
The facility failed to maintain the required RN coverage of 8 consecutive hours a day, 7 days a week, as evidenced by gaps in staffing schedules for February, March, and April 2024. Despite efforts by the LPN, administrator, and HR to recruit RNs through job postings and fairs, the facility continued to experience staffing shortages, leading to the need for an RN waiver.
The QAPI committee failed to identify and address specific concerns, affecting the quality of life and care for 46 residents. A PIP for medication administration lacked essential components, and no PIPs were implemented from July 2023 to March 2024. The DON acknowledged the need for improvements in the current PIP.
A facility failed to maintain an effective compliance and ethics program, as evidenced by a registered nurse instructing an LPN to sign a narcotic documentation form for a count he did not witness. The facility's policy requires two nurses or medication aides to verify and sign off on narcotic counts at each shift change, which was not adhered to. Additionally, the RN lacked documentation of ethics training, and the facility did not have an active ethics committee.
A resident experienced a fall while being assisted by a nursing assistant, but the facility failed to notify the resident's family and physician. The incident occurred when the resident attempted to grab a bag containing soiled pants, resulting in a fall. Despite the resident denying injury, no notification was made to the family or physician. Days later, a hip fracture was discovered, and the family expressed concerns about the lack of timely notification and medical assessment.
A resident with severe cognitive impairment and multiple diagnoses was subjected to a seatbelt restraint without a plan for reduction or removal. Despite the care plan's goal to decrease restraint usage, no specific interventions were in place. Observations showed the resident could not remove the restraint independently, and staff confirmed no plan was developed due to staffing issues. The facility's restraint policy was not adhered to, as no systematic reduction plan was implemented.
A resident with a history of congestive heart failure and other conditions did not receive proper oxygen administration due to a lack of specified flow rate in the physician's order. Observations showed inconsistent oxygen delivery, and staff interviews revealed confusion about the resident's current order. The facility's policies requiring specific oxygen order details were not followed, leading to inappropriate reliance on staff judgment for oxygen flow rate.
A resident with moderate cognitive impairment was administered risperidone without a qualifying diagnosis, contrary to the facility's policy. The resident exhibited behaviors such as calling out for help and frequent bathroom requests, but no root cause analysis was conducted to understand these behaviors. Interviews with the DON and administrator confirmed the lack of an appropriate diagnosis for the antipsychotic use.
The facility failed to ensure that one of its emergency kits did not contain expired medications and did not maintain a system for the disposition of controlled substances. Expired medications, including Lorazepam, Hydrocodone/APAP, and Tramadol, were found in the E-kit, and the pharmacist confirmed that the expired medications were not replaced. The director of nursing expected monthly checks by the pharmacy and verification by nursing staff, as per facility policy, but these procedures were not followed.
The facility did not provide mandatory training on its QAPI Program, affecting all 46 residents. Staff interviews revealed a lack of awareness and understanding of the facility-specific QAPI program, with some attending meetings or receiving generalized online training. The Director of Nursing admitted that the training was insufficient and that staff were not adequately educated on the program's requirements or communication processes.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to provide registered nurse (RN) coverage for at least 8 consecutive hours per day, 7 days a week, as required by federal regulation CFR 483.35(b)(1). Review of nursing staff schedules for February, March, and April 2025 revealed that there was no 8-hour consecutive RN coverage on two days in March and one day in April. The deficiency was identified through examination of staffing records, which showed gaps in RN coverage on specific dates. Interviews with the DON, administrator, and human resources officer confirmed ongoing challenges in hiring and retaining RNs to meet the required coverage. The DON stated that the scheduler attempted to fill open shifts and notified management of any call-ins or unfilled shifts, and that an RN was on call or could be assigned as needed. The administrator and HR officer described efforts to recruit RNs through various channels, including online job postings and local advertisements. Despite these efforts, the facility was unable to ensure consistent RN coverage as required by policy and regulation.
Failure to Analyze and Document QAPI Data and Actions
Penalty
Summary
The facility failed to ensure that data submitted to the Quality Assurance Performance Improvement (QAPI) committee was properly analyzed and documented, resulting in a lack of oversight for identified problem areas. Review of QAPI meeting minutes from April 2024 through March 2025 revealed that while issues such as falls, family notification for therapy, completion of forms, resident toileting, and repositioning were identified, there were no documented goals, action plans, methods for data collection, or analysis of the information. Several meetings did not include any review of ongoing projects or associated data, and even when quality indicators were discussed, there was no follow-through with measurable goals or action plans. An interview with facility leadership, including the QAPI director, administrator, and DON, confirmed that a thorough analysis of data, including the establishment of measurable goals, plans, or outcomes, had not been completed. The facility's QAPI policy required tracking and measuring performance, establishing goals, identifying and prioritizing deficiencies, analyzing causes, developing corrective action plans, and monitoring outcomes, but these components were not implemented as required. This deficiency had the potential to affect all 47 residents in the facility.
Lack of Formal Performance Improvement Projects in QAPI Program
Penalty
Summary
The facility failed to provide evidence of an ongoing Performance Improvement Project (PIP) focused on high-risk or problem-prone areas, as required by their Quality Assurance and Performance Improvement (QAPI) program. Review of QAPI meeting minutes from April 2024 through March 2025 showed no PIP projects with documented goals, action plans, data collection, or analysis for areas or issues identified as needing improvement. During an interview, the Director of Aging Services, the facility administrator, and the DON confirmed that while there had been some previous PIP projects, no formal PIP plans had been developed in the past year. The facility's QAPI policy requires the identification and correction of high-risk, high-volume, or problem areas, but this process was not followed, potentially affecting all 47 residents in the facility.
QAPI Committee Lacks Documentation and Required Review Processes
Penalty
Summary
The Quality Assurance and Performance Improvement (QAPI) committee failed to meet several regulatory requirements over four reviewed quarters. Meeting minutes from multiple dates showed that the committee did not document attendance, making it impossible to confirm if required members, such as the DON, medical director, infection preventionist (IP), and administrator, were present. The minutes only included a typed list of members without specifying who attended or was absent. Additionally, there was no evidence that the committee received or reviewed regular reports from the IP regarding infection control activities, process and outcome surveillance, outbreaks, staff illness, or the Antibiotic Stewardship Program (ASP). The QAPI director confirmed that while the IP sometimes gave verbal updates, these were not documented, and there was no record of discussion, goals, or plans for improvement. Furthermore, the committee did not document the review of State Agency (SA) or incident reports, as required by facility policy. Interviews with the QAPI director, administrator, and DON revealed uncertainty about whether these reports were discussed with the medical director and confirmed the absence of documentation regarding their review. The facility's QAPI policy mandates maintaining documentation to confirm compliance with CMS requirements, including the composition of the committee and the review of relevant reports, but these requirements were not met during the period reviewed.
Failure to Timely Submit Death in Facility MDS Assessment
Penalty
Summary
The facility failed to ensure timely submission of a Death in Facility Minimum Data Set (MDS) for one resident. The resident's last scheduled MDS assessment was submitted and validated on 11/26/24. However, the Death in Facility MDS, which was signed and locked by the responsible party on 1/7/25, was not successfully submitted or transmitted. The electronic health record indicated the assessment was marked as completed rather than accepted, showing it had not been submitted as required. A registered nurse (RN) who took over as the MDS coordinator in mid-January 2025 reported that prior to her tenure, multiple individuals had completed MDS assessments. The RN identified that the person responsible for the resident's final assessment failed to validate and submit the assessment, which would have sent it to the submission file in the Meditech system. The RN had not reviewed previous MDS submissions and was unaware of the outstanding assessment until the survey. The director of nursing (DON) stated that her expectation was for the MDS coordinator to track Assessment Reference Dates and ensure completion, validation, and submission of MDS assessments within required time frames. Facility policy required assessments to be completed and submitted according to the MDS ARD and within required time frames.
Failure to Update Care Plan for Anticoagulant Side Effect Monitoring
Penalty
Summary
The facility failed to update and implement a comprehensive care plan for a resident receiving anticoagulant therapy. The resident, who had severe cognitive impairment and multiple diagnoses including a history of stroke, DVT, depression, anxiety, dementia, and Alzheimer's disease, was prescribed Eliquis for DVT. The medication order did not include any special instructions or label comments regarding side effect monitoring. Review of the resident's care plan showed it addressed risks related to falls and side effects of psychotropic medications but did not mention anticoagulant use, increased bleeding risk, or the need for monitoring side effects associated with anticoagulant therapy. Interviews with facility staff, including an LPN, DON, MDS nurse, and consultant pharmacist, confirmed that the care plan and EMAR lacked references to anticoagulant use and side effect monitoring. Staff acknowledged that care plans should include instructions for monitoring for bleeding and other side effects when a resident is on anticoagulant therapy. Facility policies also required assessment and monitoring for adverse drug reactions and complications such as bleeding, but these were not reflected in the resident's care plan or EMAR.
Failure to Monitor Anticoagulant Side Effects
Penalty
Summary
The facility failed to ensure appropriate side effect monitoring for a resident receiving anticoagulant therapy. The resident, who had severe cognitive impairment and a history of stroke, deep venous thrombosis (DVT), depression, anxiety, dementia, and Alzheimer's disease, was prescribed Eliquis for DVT. The medication order did not include any special instructions or label comments regarding side effect monitoring. The resident's care plan identified risks related to other medications but did not address anticoagulant use, increased risk for bleeding, or the need for monitoring side effects associated with anticoagulant therapy. Interviews with facility staff, including an LPN, DON, MDS nurse, and consultant pharmacist, confirmed that instructions for monitoring side effects should be present in the electronic medication administration record (EMAR) and the care plan, but were absent in both for this resident. The facility's own policy required staff to assess for adverse drug reactions and monitor for complications such as excessive bruising or bleeding. Despite this, there was no documentation or instruction in the care plan or EMAR to guide staff in monitoring for anticoagulant side effects for this resident.
Deficient Infection Control Surveillance and Employee Health Monitoring
Penalty
Summary
The facility failed to maintain a comprehensive and ongoing infection control surveillance program, as evidenced by incomplete documentation and lack of implementation of appropriate precautions for residents with respiratory symptoms. For three residents who exhibited symptoms such as fever, cough, myalgia, and were diagnosed with influenza, the surveillance forms did not indicate whether any infection control precautions were implemented, what type of precautions were used, or when these precautions were started or ended. Progress notes for these residents also lacked clear documentation regarding the initiation and duration of quarantine or isolation measures, despite ongoing symptoms and confirmed influenza diagnoses. Additionally, the facility did not adequately monitor or enforce return-to-work protocols for staff members who reported illness. Two staff members called in with symptoms of vomiting, diarrhea, and fever, but the documentation did not consistently include illness forms or appropriate clearance by a licensed nurse before returning to work. In one case, a staff member returned to work the day after reporting gastroenteritis symptoms, contrary to recommended guidelines, and there was no evidence of follow-up or assessment prior to their return. The facility also failed to complete required tuberculosis (TB) screening for one resident. Although a TB skin test was administered upon admission, the results were not read, and a baseline symptom screening was not completed prior to testing. A second TB skin test was later administered and read with a negative result, but the initial lapse in protocol was confirmed by the DON, who acknowledged the oversight in both reading the test and completing the symptom screening.
Non-Compliance with RN Coverage Requirements
Penalty
Summary
The facility was found to be non-compliant with the requirement for registered nurse (RN) coverage for 8 consecutive hours a day, 7 days a week, as per CFR 483.35 (b)(1). The review of nursing staff schedules for February, March, and April 2024 revealed that there were several days in each month where the facility failed to provide the required RN coverage. Specifically, there were 6 days in February, 2 days in March, and 2 days in April where the facility did not have an RN on duty for the required 8 consecutive hours. Interviews with facility staff, including the LPN responsible for scheduling, the administrator, the human resources representative, and the director of nursing (DON), highlighted the ongoing challenges in maintaining adequate RN staffing levels. The LPN reported notifying management of call-ins and attempting to fill open shifts, while the administrator and HR representative described efforts to recruit RNs through various channels, including job postings and job fairs. Despite these efforts, the facility continued to struggle with staffing shortages, necessitating the continuation of an RN waiver to remain in compliance.
QAPI Committee Fails to Address Facility Concerns
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) committee failed to effectively identify and address specific concerns within the facility, impacting the quality of life and care for 46 residents. The committee did not implement an action plan to correct identified issues or ensure the development and oversight of systems to maintain quality standards. A performance improvement plan (PIP) was created to observe medication administrations in the dining room, but it lacked essential components such as a target date, observation dates, and times, as well as interventions to analyze underlying causes and opportunities for improvement. During an interview, the Director of Nursing (DON) revealed that the facility used an online quality scorecard to track PIPs but had not implemented any from July 2023 to March 2024. The DON had encouraged the administration and department heads to identify improvement areas and create PIPs, but only one PIP related to medication administration was added in April. The DON acknowledged that the current PIP needed improvements, including audits and consistent data for performance analysis. The facility's QAPI policy from February 2024 stated that the program was to develop and implement performance improvement activities, which was not effectively executed.
Deficiency in Compliance and Ethics Program
Penalty
Summary
The facility failed to maintain an effective compliance and ethics program, as evidenced by an incident involving a registered nurse (RN) and a licensed practical nurse (LPN). On two occasions, the facility's narcotic documentation forms were missing signatures, indicating a lack of proper verification of controlled substance counts. On May 28, 2024, RN-D instructed LPN-E to sign a narcotic documentation form for a count he did not witness. This action was stopped by a surveyor, highlighting a breach in protocol. The facility's policy requires two nurses or medication aides to verify and sign off on narcotic counts at each shift change, which was not adhered to in this instance. Further investigation revealed that RN-D lacked documentation of ethics training upon hire, despite a facility policy requiring such training. Additionally, the facility did not have an active ethics committee, and the director of nursing (DON) was unaware of any regular meetings or the existence of such a committee. The facility's policies emphasize accurate documentation and ethical conduct, yet these were not followed, leading to the deficiency noted by the surveyors.
Failure to Notify Family and Physician After Resident Fall
Penalty
Summary
The facility failed to notify the resident's representative and physician after a witnessed fall involving a resident. On the morning of December 10, 2023, the resident, identified as R48, was combative towards a nursing assistant while being assisted to the toilet. During the incident, the resident attempted to grab a plastic bag containing his soiled pants, resulting in a fall. Although the resident denied injury and refused vital sign checks, there was no documentation indicating that the resident's physician or family were informed of the fall. The incident report and electronic medical records also lacked evidence of notification to the resident's responsible party or physician. Subsequently, on December 14, 2023, the resident was assessed for hip pain, leading to the discovery of a right hip fracture. The family and physician were notified at this point, and the resident was transferred to a regional hospital for further assessment. An interview with a family member revealed that they were unaware of the fall until visiting the resident on December 14, 2023. The family member expressed concerns about the lack of notification and the delay in medical assessment. The Director of Nursing stated that the expectation was for staff to notify both the physician and family within a reasonable time frame, but no policy for incident notification was provided.
Failure to Develop Restraint Reduction Plan for Resident
Penalty
Summary
The facility failed to develop a plan to reduce or discontinue the use of a seatbelt type of restraint for a resident with severe cognitive impairment and multiple diagnoses, including non-traumatic brain injury, Alzheimer's disease, and dementia. The resident was dependent on staff for activities of daily living and used a wheelchair with a trunk restraint. Despite the care plan identifying a goal to decrease or eliminate restraint usage, no specific plan or interventions were in place to achieve this goal. Observations revealed that the resident was unable to remove the seatbelt independently, indicating a lack of assessment and planning for restraint reduction. Interviews with facility staff, including the assistant director of nursing and the director of nursing, confirmed that no plan had been developed for the removal of the restraint due to staffing limitations and a lack of attempts to use less restrictive measures. The facility's policy on the use of restraints, which requires a written order from a physician and a plan to systematically reduce or eliminate the need for restraint use, was not followed. The resident's medical record indicated that behaviors had improved with medication, but the restraint remained in place without a clear plan for its removal.
Inadequate Oxygen Administration for Resident
Penalty
Summary
The facility failed to ensure proper respiratory care for a resident, identified as R3, by not specifying oxygen flow rate parameters in the physician's order and not delivering supplemental oxygen according to the order. R3's medical history included dementia, anxiety, congestive heart failure, and other conditions. The resident's care plan indicated the use of oxygen as needed to maintain oxygen levels above 90%, but the current order lacked a specified flow rate or range, leading to inconsistent oxygen administration. Observations revealed that R3 was inconsistently provided with oxygen, with varying flow rates of 1L, 1.5L, and 2L, despite the absence of a clear order. Staff interviews indicated confusion regarding the resident's oxygen order, with some staff referencing an outdated order for as-needed oxygen at 1L. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) acknowledged the lack of a specified flow rate and the inappropriate reliance on staff judgment to determine the oxygen flow rate. The facility's policies required oxygen orders to specify the rate of flow, route, and rationale, which was not adhered to in R3's case. The DON admitted that the provider might be unaware of the resident's oxygen use due to inadequate documentation and communication. This deficiency in respiratory care was compounded by the failure to update the medical record with the correct oxygen order, leading to further inconsistencies in care delivery.
Inappropriate Use of Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident had a qualifying diagnosis for the routine use of an antipsychotic medication. The resident, who had moderate cognitive impairment and required extensive assistance for daily activities, was being administered risperidone, an antipsychotic, for agitation. However, the resident's medical record did not contain a diagnosis that justified the use of this medication according to the facility's policy, which aligns with the Diagnostic and Statistical Manual of Mental Disorders. The resident exhibited behaviors such as calling out for help and frequent requests to use the bathroom, but there was no evidence of a root cause analysis to determine the underlying reasons for these behaviors. Interviews with the Director of Nursing and the administrator revealed that the antipsychotic was prescribed for behaviors like yelling out for assistance and toileting issues, or if the resident was unable to sleep at night. The facility's policy on antipsychotic medication use specifies that such medications should only be used for certain documented conditions, which were not present in this case. The Director of Nursing acknowledged the lack of an appropriate diagnosis for the antipsychotic use, and the administrator expected staff to adhere to the policy for antipsychotic use.
Expired Medications Found in Emergency Kit
Penalty
Summary
The facility failed to ensure that one of its two emergency kits (E-kits) did not contain expired medications and did not maintain a system for the disposition of controlled substances to prevent drug diversion. During an observation, interview, and document review, it was found that the large E-kit in the medication room had an unsigned inventory list indicating expired medications, including Lorazepam, Hydrocodone/APAP, and Tramadol, all with an expiration date of 5/16/24. The E-kit contained expired tablets of these medications, and the registered nurse (RN-D) stated that nurses were supposed to verify the E-kit tag each shift, while the local pharmacy was responsible for monthly checks and removal of expired medications. However, the pharmacist confirmed that the expired medications were not replaced and that the E-kit controlled medications were not checked monthly by the pharmacy. The director of nursing (DON) expressed that her expectation was for the pharmacy to check the E-kit medications monthly and for nursing staff to record controlled substances on the log with each shift for verification. The facility's policy from December 2023 stated that the pharmacy was to complete a monthly audit to verify medication counts and expiration dates. The failure to adhere to these procedures resulted in expired medications remaining in the E-kit, indicating a lapse in the facility's medication management system.
Facility Fails to Provide Specific QAPI Training
Penalty
Summary
The facility failed to provide mandatory training on its Quality Assurance and Performance Improvement (QAPI) Program, affecting all 46 residents. Interviews with various staff members, including LPNs, nursing assistants, and housekeeping aides, revealed a lack of awareness and understanding of the facility-specific QAPI program. Some staff members had attended QAPI meetings or received generalized online training, but they were not informed about specific performance improvement projects or long-term goals. The training provided was not tailored to the facility's identified areas for improvement, action plans, or monitoring processes. The Director of Nursing acknowledged that staff were newly introduced to QAPI meetings and training, and that the online training provided during orientation was insufficient. Staff were not adequately educated on the requirements of the QAPI program or how to communicate their concerns effectively. The expectation was for staff to attend future QAPI meetings to better understand the program and its goals, which aim to improve the quality of care for residents.
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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