Luther Haven
Inspection history, citations, penalties and survey trends for this long-term care facility in Montevideo, Minnesota.
- Location
- 1109 East Highway 7, Montevideo, Minnesota 56265
- CMS Provider Number
- 245259
- Inspections on file
- 26
- Latest survey
- August 20, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Luther Haven during CMS and state inspections, most recent first.
Two residents with documented mental illness were not accurately identified as such in their MDS assessments, despite PASRR findings and diagnoses. Staff interviews confirmed the omission, and facility policy lacked details on ensuring assessment accuracy or staff training.
A resident's personal refrigerator was found without temperature monitoring, a thermometer, or maintenance logs, and contained expired and improperly stored food items. Facility staff confirmed that there was no process in place to ensure food safety in personal refrigerators, despite the vulnerability of residents and the facility's responsibility to provide care.
A resident with Parkinson's disease, dementia, and depression experienced multiple falls resulting in serious injuries due to the facility's failure to analyze fall trends, determine root causes, and consistently implement or document effective interventions. Staff were often unaware of the resident's care plan requirements, and recommendations for medication review and monitoring were not followed, leading to continued falls and harm.
A resident with severe cognitive impairment and diagnosed with RSV was not properly isolated, as staff failed to implement full transmission-based precautions. The resident was observed without a mask in the hallway, and staff did not wear gowns when entering the resident's room. The infection control preventionist identified incorrect signage and missing gowns, indicating a lapse in following CDC guidelines.
A resident with a history of exit-seeking behavior and cognitive impairment eloped from a facility through a window due to the facility's failure to complete a timely comprehensive elopement risk assessment. Despite known risk factors, the resident was not identified as an elopement risk upon admission, and inadequate interventions were in place. The resident was found by police and family an hour later, having been exposed to the elements.
A facility failed to follow care plans for mechanical lift transfers, resulting in falls for two residents. One resident fell from an EZ-Stand due to a nurse aide's lack of awareness of the two-staff requirement, while another passed out during a transfer and was hospitalized for a leg fracture. A third resident was transferred without clear parameters for using a full lift, highlighting inadequate training and care plan adherence.
The facility failed to prevent staff from storing personal food and effects in a kitchen refrigerator meant for resident food, potentially affecting all 54 residents. A refrigerator in the baking area contained staff items like drink cups and Tupperware with personal food, alongside resident food items. The dietary manager acknowledged the issue, noting that staff should use designated areas for personal storage according to policy.
The facility failed to analyze and document data submitted to the QAPI committee, affecting areas such as UTIs, infection control, grievances, and falls. Despite concerns being raised, there was no evidence of data analysis, root cause identification, or action plans. The ongoing performance improvement project for pressure ulcers also lacked analysis and a clear action plan.
The facility failed to implement its grievance policy effectively, impacting all residents. The grievance policy was not posted throughout the facility, and forms for anonymous submissions were unavailable. Documentation of grievances and resolutions was lacking, with several residents reporting long call light wait times without follow-up. Interviews revealed residents' uncertainty about reporting complaints, and staff acknowledged the need for improvement in grievance documentation.
The facility failed to ensure that nursing assistants, RNs, the infection preventionist, and an LPN were competent in using mechanical lifts and following care plans. Interviews and record reviews showed no competency evaluations were conducted upon hire or annually, affecting 54 residents who might use mechanical lifts. The DON acknowledged the need for improved orientation and training processes.
The facility did not implement its facility-wide assessment protocol, leading to a mismatch between listed competency requirements and actual staff training practices. Recent changes to the assessment, mandated by new regulations, were not communicated to all staff, leaving them uninformed. The QAA committee was tasked with approving revisions and communicating operational goals related to person-centered care, staffing, and resources. The assessment tool highlighted the need for staff education, training, certifications, and policies to support resident care and planned for annual resource reviews and evaluations of daily operations, including emergencies.
The facility failed to remove and destroy discontinued medications promptly, leading to their co-mingling with active medications in the carts. Observations revealed that several residents, including those deceased or discharged, still had their medications stored in the carts. Staff confirmed the need for timely removal and destruction, but staffing challenges delayed the process. The DON acknowledged the issue, and the facility's policy requires timely medication destruction.
The facility failed to respond to call lights promptly, affecting four residents who required assistance with ADLs. Residents experienced significant delays, with call light wait times ranging from 41 to 189 minutes. Despite having intact cognition, residents reported long waits for help, impacting their care and safety. Staff interviews revealed awareness of the issue but highlighted challenges in addressing it, including workload documentation and staffing levels.
A resident with dementia and other conditions fell while being transferred by a nursing assistant using the EZ-Stand, resulting in a head laceration. The nursing assistant, new to the facility and from a staffing agency, was unaware that two staff members were required for transfers, as she had not received proper orientation. The incident was not reported to the State Agency, and no thorough investigation or fall analysis was conducted.
A resident with dementia and other health issues fell during a transfer using an EZ-Stand, resulting in a head injury. The nursing assistant, new to the facility and unaware of the care plan requiring two staff for transfers, attempted the transfer alone. The facility failed to conduct a thorough investigation to determine the root cause and adherence to the care plan, as confirmed by the clinical nurse manager and director of nursing.
Failure to Accurately Document Mental Illness in MDS Assessments
Penalty
Summary
The facility failed to ensure that resident status was accurately identified in the Minimum Data Set (MDS) assessments for two sampled residents. For one resident, documentation showed diagnoses of altered mental status, social phobia, depression, hallucinations, and psychotic disorder with delusions. This resident's Level I PASRR indicated a referral for a Level II assessment for mental illness, which was completed and confirmed the presence of mental illness. However, the resident's admission MDS and subsequent MDS assessments did not document the mental illness in Section A, despite the PASRR findings. Interviews with the social worker revealed that the omission occurred because the resident was not eligible for additional services, but the social worker acknowledged that the MDS should have been coded to reflect the mental illness diagnosis. The DON also agreed that the MDS should accurately reflect the resident's condition. Review of the facility's policy showed requirements for timely completion of assessments but did not specify procedures to ensure accuracy, staff training, or oversight for MDS completion.
Failure to Monitor Personal Refrigerators for Food Safety
Penalty
Summary
The facility failed to implement a process for monitoring personal refrigerators located in resident rooms, as evidenced by the lack of temperature monitoring, absence of thermometers, and no documentation of maintenance or food checks. During an observation, a small dorm-style refrigerator in a resident's room was found to contain various food items, including sausage, sliced cheese, bottles of nutritional supplement, soft chocolate candy, and a meat product labeled with a freeze-by date that had already passed. Neither the refrigerator nor the freezer compartment had a thermometer, and there was no log or record indicating that staff were monitoring the appliance or its contents. Interviews with the facility administrator and the infection preventionist confirmed that the facility was not monitoring personal refrigerators and acknowledged that this was a concern due to the potential for food-borne illness. The facility's policy stated that residents or their families were responsible for maintaining the refrigerator and ensuring safe temperatures, but staff recognized that residents in the facility require care and should not be expected to manage this responsibility themselves. The lack of monitoring and maintenance of personal refrigerators led to the deficiency identified during the survey.
Failure to Analyze Fall Trends and Implement Effective Interventions
Penalty
Summary
The facility failed to assess or analyze trends of falls to determine causal factors or root causes and did not implement effective interventions to prevent or reduce the risk of falls with major injury for a resident with a history of multiple falls. The resident, who had diagnoses of Parkinson's disease, dementia, and depression, experienced seven falls over a period of several months, resulting in significant injuries including spinal compression fractures and a rib fracture. Despite being identified as high risk for falls and having a care plan with various interventions, there was no evidence that these interventions were consistently implemented or that their effectiveness was evaluated. Documentation revealed gaps in the recording of ambulation and toileting schedules, with several months showing no documentation of required ambulation or toileting times. Staff interviews indicated a lack of awareness or understanding of the resident's care plan interventions, such as scheduled ambulation and toileting. Additionally, recommendations from the pharmacist regarding medication review and orthostatic blood pressure monitoring were not acted upon, and there was no indication that root cause analyses were performed after each fall event. The facility's quality assurance and performance improvement (QAPI) records showed ongoing concerns with falls and falls with injury, but there was no evidence of systematic analysis or targeted interventions for the resident in question. The facility's fall policy did not specify the need for immediate intervention following a fall, and event reports often lacked root cause analysis. As a result, the resident continued to experience falls with significant injuries, and the facility did not demonstrate adequate supervision or hazard mitigation to prevent accidents.
Inadequate Transmission-Based Precautions for RSV
Penalty
Summary
The facility failed to ensure appropriate transmission-based precautions for a resident diagnosed with Respiratory Syncytial Virus (RSV). The resident, who had severe impaired cognition and dementia, was noted to have symptoms such as a runny nose and wet cough. On the morning of March 14, 2025, a physician confirmed the RSV diagnosis, and the resident was placed on droplet precautions. However, observations on March 18, 2025, revealed that the resident's room door was open, and the resident was seen wheeling himself into the hallway without a mask, indicating a lapse in maintaining droplet precautions. Further observations and interviews on the same day showed that staff members were not fully adhering to the required precautions. Nursing assistants entered the resident's room wearing gloves, masks, and goggles but did not wear gowns, which are part of the necessary protective equipment for RSV. The infection control preventionist confirmed that the precautions sign outside the resident's room was incorrect, and gowns were missing from the isolation cart. The interim director of nursing stated that staff were expected to follow CDC guidelines for infection control, but the facility's policy on isolation precautions was not fully implemented, leading to the deficiency.
Failure to Assess and Prevent Resident Elopement
Penalty
Summary
The facility failed to complete a timely comprehensive elopement risk assessment for a resident with a history of exit-seeking behavior. The resident, who had diagnoses of encephalopathy, hallucinations, tremors, and insomnia, was admitted to the facility with moderate cognitive impairment and a history of wandering. Despite these risk factors, the facility did not identify the resident as an elopement risk upon admission, nor did they complete a comprehensive risk assessment for elopement or wandering. On the night of the incident, the resident was restless and exhibited exit-seeking behavior, which included wandering into other residents' rooms and attempting to open exit doors. The resident had previously removed a wander guard bracelet, and no replacement was available, leading to the implementation of hourly checks. However, the resident managed to elope through a window in her room, which was found open with the screen removed. The resident was located by police and family approximately an hour later, having been exposed to the elements and showing signs of confusion and agitation. Interviews with staff revealed that the facility was aware of the resident's elopement risk but failed to implement adequate interventions to prevent the elopement. The social worker responsible for elopement risk assessments did not complete the assessment on the day of admission, and the facility's elopement policy did not address prevention measures. Additionally, the facility had not considered the risk of elopement through windows, despite previous incidents involving other residents. This oversight contributed to the resident's successful elopement and the subsequent immediate jeopardy situation.
Removal Plan
- Updated the Elopement Risk Assessment tool to include assessment of physical ability to elope from the windows.
- Updated the Facility Elopement policy to include to complete the elopement assessment on admission, readmission, change of condition, or as needed.
- Removed all window cranks in common areas.
- Reassessed all residents at risk for elopement for their physical ability to elope out the windows.
- Reviewed elopement policy and educated staff on recognizing elopement hazards, opportunities, window cranks all interventions.
Failure to Follow Care Plans for Mechanical Lift Transfers
Penalty
Summary
The facility failed to appropriately assess and follow care plans for three residents using sit-to-stand mechanical lifts, resulting in immediate jeopardy for two residents. Resident 11, who had diagnoses including dementia and diabetes, fell from the EZ-Stand when a nurse aide attempted a transfer alone, contrary to the care plan requiring two staff. This resulted in a head laceration and hospital evaluation. The nurse aide was unaware of the care plan requirements due to inadequate orientation and training. Resident 16, with diagnoses including diabetes and hypertension, experienced a fall when a nurse aide attempted a transfer alone using the EZ-Stand, despite the care plan requiring two staff. The resident held her breath during the transfer, passed out, and was lowered to the floor, later requiring hospitalization for a leg fracture. The nurse aide was aware of the two-staff requirement but did not follow it due to the resident's preference for certain staff. Resident 37, with a history of heart failure and falls, was observed being transferred using a sit-to-stand lift by a nurse aide who was unable to identify when a full mechanical lift should be used. The care sheet did not provide clear parameters for when to use a full lift, leading to potential safety risks during transfers. The facility's lack of proper training and adherence to care plans contributed to these deficiencies.
Removal Plan
- Reviewed and updated policies related to care sheets, care plans, and using the EZ Lift/Stand.
- Educated all licensed staff and nursing assistants including agency staff and performed competencies on how to appropriately use the EZ Stand and Care sheets.
- Updated the orientation checklist for agency staff.
- Re-assessed all residents currently using an EZ Stand to determine if they were able to be partial weight bearing per manufacturer's guidelines in order to use the EZ Stand.
- Educated staff on incident reporting to the SA.
Improper Storage of Staff Personal Items in Kitchen
Penalty
Summary
The facility failed to ensure that staff did not co-mingle personal food and effects with resident food, which had the potential to affect all 54 residents who consumed food prepared in the kitchen. During an observation, a reach-in refrigerator in the baking area of the kitchen was found to have two compartments. The top compartment contained staff personal items, including five tumbler-style drink cups with straws and two Tupperware containers with personal food. This compartment also stored resident food items such as butter, frosting, liquid eggs, ice cream topping, and glucerna supplements. The bottom compartment, which was not cooling, contained staff effects like shoes, pretzels, clothing, and bags with unknown items. The dietary manager acknowledged the findings and expressed that staff should have used the staff break room fridge and lockers for their personal items, as per the facility's 2017 Personal Hygiene Training Policy.
Deficiency in QAPI Data Analysis and Action Planning
Penalty
Summary
The facility failed to ensure that data submitted to the Quality Assurance and Performance Improvement (QAPI) committee was properly analyzed and documented. This deficiency was observed in the QAPI meetings from March to July 2024, where various concerns were raised by facility departments, including issues related to urinary tract infections (UTIs), infection control, grievances, and falls. Despite these concerns being brought to the committee's attention, there was no evidence of data analysis, root cause identification, measurable goals, or action plans being developed to address these issues. Specific instances included the lack of analysis and action plans for reducing UTIs, addressing infection control with multiple cases of norovirus and COVID-19, and handling grievances related to rough care and falls. Additionally, the facility's ongoing performance improvement project for pressure ulcers lacked data analysis and a clear action plan, despite having a goal to reduce the rate of pressure ulcers. The administrator acknowledged that the facility had not been working on anything other than the performance improvement project for skin integrity, which had not been analyzed since its inception.
Grievance Policy Implementation Failure
Penalty
Summary
The facility failed to ensure that its grievance policy and procedures were properly implemented, affecting all 54 residents. The grievance policy was not prominently posted throughout the facility, and there were no forms available for residents to submit grievances anonymously. Additionally, the facility did not document all grievances, the actions taken to resolve them, or the summary of their resolutions. This lack of documentation and accessibility to grievance forms was confirmed through interviews with residents, family members, and staff. Several residents and family members reported issues with long call light wait times, which were documented in a word document listing dates and concerns. However, follow-up documentation was only available for one instance, and no actions or resolutions were identified for the other grievances. Interviews with residents revealed that many were unsure of how to report complaints or were hesitant to do so due to fear of reprisal. The social worker and director of nursing acknowledged the lack of formal grievance documentation and the need for improvement in this area. The facility's grievance policy encouraged residents and representatives to communicate grievances verbally or in writing, but it did not specify that grievances should be documented, nor did it mention the availability of anonymous grievance submissions. The policy also lacked instructions for posting it throughout the facility. The administrator and director of nursing were unaware that the grievance forms had not been utilized, and the facility's grievance process was not effectively communicated to residents and their families.
Lack of Staff Competency in Mechanical Lifts and Care Plans
Penalty
Summary
The facility failed to ensure that all nursing assistants, registered nurses, the infection preventionist, and a licensed practical nurse were competent in the operation of mechanical lifts and in following care plans and care sheets. This deficiency was identified through interviews and record reviews, revealing that none of the staff had undergone competency evaluations upon hire, annually, or as needed when concerns about competence were noted. This lack of competency assessment had the potential to affect all 54 residents who required or might require the use of mechanical lifts and adherence to care plans and care sheets. Interviews with staff members, including a nursing assistant who had been working independently for a few weeks, indicated that they had not received training or competency evaluations related to mechanical lifts, care plans, or care sheets. The Director of Nursing confirmed that there were no competency evaluations conducted for these critical areas and acknowledged that the orientation process for all staff, including agency staff, could be improved. The facility's staff development policy required all personnel to participate in initial orientation and regularly scheduled in-service training classes, but this was not adhered to, as evidenced by the lack of training records in employee files.
Failure to Implement Facility-Wide Assessment Protocol
Penalty
Summary
The facility failed to implement its facility-wide assessment protocol, which is crucial for ensuring staff competencies align with their duties. During an interview, the administrator acknowledged that the competency requirements listed in the facility assessment did not match the actual staff training practices on the floor. This discrepancy arose after recent changes were made to the facility assessment, following new regulations mandated for nursing homes in July 2024. However, these changes were not communicated to all staff, leaving them uninformed and unupdated about the new requirements. The Quality Assessment and Assurance (QAA) committee was responsible for approving the assessment revisions and communicating the facility's operational goals related to person-centered care, staffing services, and resources to all staff. The facility's assessment tool identified the need for staff education, training, certifications, testing, and policies to support resident care, as well as processes and oversight to meet residents' needs through regulatory, operational, maintenance, and staff training requirements. Additionally, the facility planned to review resources annually and evaluate daily operations, including emergencies, to ensure residents' care maintained their highest practicable physical, mental, and psychosocial well-being.
Failure to Timely Remove and Destroy Discontinued Medications
Penalty
Summary
The facility failed to adhere to its policy regarding the timely removal and destruction of discontinued medications, resulting in the co-mingling of these medications with active ones in the medication carts. During an observation and interview, it was found that several residents, including those who had passed away or been discharged, still had their medications stored in the facility's medication carts. Specifically, the narcotic count revealed that a deceased resident had four bottles of morphine, another discharged resident had two bottles of morphine, and another deceased resident had two bottles of morphine. Additionally, another resident had discontinued Fentanyl patches and hydrocodone tablets still present in the cart. The staff, including registered nurses and licensed practical nurses, confirmed that the discontinued medications should have been removed and destroyed promptly. However, due to staffing challenges, the destruction of controlled medications, which requires two licensed staff members, had been delayed. The Director of Nursing acknowledged not having reviewed the medication destruction policy but confirmed that discontinued medications should not remain co-mingled with active medications for long. The facility's Medication Destruction/Disposal policy mandates timely destruction and disposal of medications in compliance with federal, state, and Board of Pharmacy guidelines.
Delayed Call Light Response in LTC Facility
Penalty
Summary
The facility failed to ensure timely response to call lights for four residents, leading to delays in assistance with activities of daily living (ADLs). Interviews and document reviews revealed that residents experienced significant wait times for assistance, with one resident reporting a wait of up to 86 minutes. The facility's call light logs confirmed these delays, showing multiple instances where call lights were not answered promptly, ranging from 41 to 189 minutes. Residents involved in the deficiency had intact cognition and required varying levels of assistance with ADLs. One resident, who was a fall risk, reported having to wait until 9:00 a.m. for assistance despite wanting to get up at 7:30 a.m. Another resident, who experienced frequent pain, reported waiting two hours for help. A third resident expressed concerns about having to get off the toilet by themselves due to delayed assistance, highlighting the potential risk of falls. Staff interviews indicated that the facility was aware of the issue but struggled to address it effectively. The interim administrator had previously managed to reduce call light response times, but this improvement was not sustained. Staff cited challenges such as being occupied with other residents and insufficient documentation of workload, which affected staffing levels. Despite the facility's policy requiring prompt response to call lights, grievances related to long wait times were not consistently resolved or addressed.
Failure to Report Fall and Potential Neglect
Penalty
Summary
The facility failed to report a fall with injury and potential neglect to the State Agency for a resident with dementia, diabetes mellitus, and acute kidney failure. The resident fell in her room while being transferred by a nursing assistant using the EZ-Stand. The resident let go of the bars, fell out of the sling, and was believed to have hit her head, resulting in a laceration. The incident was not reported to the State Agency, and there was no evidence of a thorough investigation or comprehensive fall analysis to determine the root cause. The nursing assistant involved in the incident was from a staffing agency and was new to the facility. She was unaware that the resident required assistance from two staff members during transfers with the EZ-Stand, as she had not received proper orientation or training on the care plan or care sheets. The clinical nurse manager confirmed that the nursing assistant had transferred the resident alone, contrary to the care plan, and was unsure of the orientation provided to the nursing assistant before she worked independently. The physical therapist noted that the resident had a history of being unpredictable in the EZ-Stand and required two staff members for transfers. The facility's policy on abuse, neglect, and exploitation required immediate reporting of such incidents, but the fall was not reported. The administrator expected all staff, including agency staff, to be trained to follow care sheets and care plans, and to report incidents as per facility policy.
Failure to Conduct Thorough Investigation of Resident Fall
Penalty
Summary
The facility failed to conduct a thorough investigation into a fall incident involving a resident, identified as R11, who had dementia, diabetes mellitus, and acute kidney failure. On the date of the incident, R11 fell in her room while being transferred by a nursing assistant using an EZ-Stand. The resident let go of the bars, fell out of the sling, and sustained a head laceration, which required evaluation at the ER. The facility's records lacked evidence of a comprehensive fall analysis to determine the root cause and whether the care plan was followed. The investigation revealed that the nursing assistant, who was new to the facility and worked for a staffing agency, was unaware that R11 required assistance from two staff members during transfers with the EZ-Stand. This lack of awareness was due to insufficient orientation and training on the care plan and mechanical lifts. The clinical nurse manager confirmed that the nursing assistant had transferred R11 alone, contrary to the care plan, and had only verbally reminded the assistant to follow care sheets after the incident. Interviews with the physical therapist and the director of nursing further confirmed that the care plan was not followed, as the resident required two staff members for transfers due to a history of unpredictability with the EZ-Stand. The director of nursing acknowledged that a thorough investigation, including a root cause analysis, had not been conducted, which was against the facility's policy on neglect and investigation procedures. The administrator also admitted that the investigation was insufficient to determine if neglect occurred.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
