Maplewood Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Maplewood, Minnesota.
- Location
- 1900 Sherren Avenue East, Maplewood, Minnesota 55109
- CMS Provider Number
- 245276
- Inspections on file
- 41
- Latest survey
- January 27, 2026
- Citations (last 12 mo.)
- 28
Citation history
Health deficiencies cited at Maplewood Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to include individualized care plan problems, goals, and interventions for three residents receiving antiplatelet or anticoagulant medications, despite physician orders and TAR entries documenting blood‑thinner use and monitoring. Residents on clopidogrel with aspirin, apixaban, and enoxaparin had admission MDS assessments indicating antiplatelet or anticoagulant therapy, but their comprehensive care plans, Kardexes, and care guides did not identify bleeding risk or blood‑thinner use. One resident reported daily abdominal injections and bruising at the injection site. An NA stated she relies on care guides and the Kardex, which did not show blood‑thinner use, and needed to ask a nurse for this information. An LPN indicated such risks should be care planned, while the clinical care coordinator and DON either were unaware of or could not explain the need to address high‑risk medications in care plans. The facility’s care planning policy lacked specific guidance on identifying and care planning for high‑risk medications and administration routes.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents. The environment presented risks that were not properly mitigated, and supervision was insufficient to ensure resident safety.
A facility failed to clean the ceiling exhaust fan in a third-floor shower room, affecting residents using the room. Observations showed the vent was covered in gray debris, and interviews with staff revealed confusion over cleaning responsibilities. Maintenance and housekeeping staff had differing accounts of cleaning routines, and the facility lacked a clear policy or checklist for daily cleaning.
The facility failed to implement Enhanced Barrier Precautions (EBP) and proper use of PPE during high-contact resident care activities, such as IV antibiotic administration and wound care. Additionally, hand hygiene practices were not followed, and shared equipment was not disinfected between uses. Reusable ice packs were improperly stored with resident food, violating infection control protocols.
Two residents at the facility were not offered or provided updated pneumococcal vaccinations as per CDC guidelines. One resident, with a history of chronic conditions, had consented to additional vaccines, but there was no documentation of shared clinical decision-making. Another resident's vaccine history was unclear, and there was no follow-up on her vaccination status. The DON admitted to not reviewing vaccines per updated CDC recommendations and failing to verify the second resident's vaccine history.
A resident with intact cognition was not included in healthcare decisions, as the facility continued to involve a family member as power of attorney without the resident's consent. Despite the resident's expressed desire to change the power of attorney, the facility did not facilitate this change or include the resident in care conferences.
A resident with diabetes, hypertension, and congestive heart failure experienced new vision loss, but the facility failed to notify the physician or schedule an urgent appointment with a retinal specialist as recommended. Despite the resident's complaints and visible eye irritation, staff did not assess or document the condition properly. The facility's policy on change in condition notification was not followed, leading to a delay in addressing the resident's vision issues.
A facility failed to include a swallow study referral in a resident's discharge plan, despite recommendations from the SLP due to dysphagia. The resident, with multiple medical conditions, was discharged without arrangements for the study, and staff interviews revealed a lack of communication and coordination. The facility's discharge planning policy was not effectively executed, leading to a deficiency in meeting the resident's post-discharge needs.
A resident with diabetes and hypertension experienced vision loss due to the facility's failure to schedule a timely appointment with a retinal specialist, despite urgent recommendations. The resident reported symptoms for weeks, but the nursing staff did not assess or document the condition, and the Health Information Manager missed the urgency in the follow-up instructions.
A resident with intact cognition was not invited to participate in care conferences, despite being capable of making her own healthcare decisions. The facility failed to document any refusal or impracticability of her participation, leading to a deficiency in care planning. Interviews revealed a lack of communication and adherence to policies regarding resident involvement in care planning.
A facility failed to adequately assess and supervise a resident for safe smoking practices, leading to safety hazards. The resident, who used intermittent oxygen therapy, had a history of smoking incidents, but the facility did not conduct timely assessments. Additionally, the facility did not address a safety hazard involving resident-to-resident abuse, where a resident with cognitive impairment and substance use history was involved in an altercation. The facility's failure to follow policies for smoking assessments and managing resident behavior contributed to the deficiencies.
A resident with pulmonary embolism and dyspnea did not have their oxygen tubing changed weekly as required, despite documentation indicating otherwise. Observations showed the tubing was dated 9/3, and staff interviews confirmed the lapse in maintenance and documentation accuracy. The facility lacked a specific policy on oxygen tubing but expected adherence to batch orders.
A resident with moderate cognitive impairment reported being raped at the facility to a family member over the phone, which was overheard by an NA and an LPN. Despite hearing the allegation, the LPN did not report it immediately, as required by facility policy and state regulations. The incident occurred on a Saturday evening, but the facility did not report it to the State Agency until the following Monday morning, exceeding the two-hour reporting requirement.
The facility failed to monitor edema and comprehensively assess non-pressure related wounds for a resident with multiple health conditions, including brain cancer, hypertension, and chronic ischemic heart disease, who was receiving hospice care. The documentation of edema and weight monitoring was inconsistent and lacked comprehensive details, and the resident's skin evaluations and wound assessments were found to be lacking. Interviews with staff revealed that the required monitoring and documentation were not adequately performed.
Failure to Care Plan for Residents on Blood-Thinning Medications
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive care plans addressing the use of blood‑thinning medications for three residents receiving antiplatelet or anticoagulant therapy. For one resident with a history of stroke and dysphagia who received clopidogrel via G‑tube and aspirin via J‑tube, the admission MDS documented antiplatelet use and the Treatment Administration Record (TAR) contained physician‑ordered monitoring related to blood‑thinning medications. However, the comprehensive care plan in effect at the time of survey did not identify any problem, goal, or interventions related to blood‑thinner use, did not identify the resident as being at risk for bleeding, and did not include interventions to manage or mitigate bleeding risk. The Kardex and requested care guide also did not identify the resident’s use of blood‑thinning medications. A second resident with atrial fibrillation had an admission MDS documenting anticoagulant use and a physician’s order for apixaban twice daily. The FDA‑approved labeling for apixaban notes increased risk of serious, potentially fatal bleeding and lists signs and symptoms of blood loss. The January TAR showed physician‑ordered monitoring interventions associated with blood‑thinning medications, but the comprehensive care plan did not include any problem, goal, or interventions related to anticoagulant therapy. This resident was not identified in the care plan as being at risk for bleeding, and there were no individualized interventions addressing management or mitigation of bleeding risk. The Kardex did not identify the resident’s use of blood‑thinning medications, and the requested care guide was not provided. A third resident with an infection and inflammatory reaction due to an internal joint prosthesis of the left knee had an admission MDS documenting anticoagulant use and a physician’s order for daily enoxaparin injections. The FDA‑approved labeling for enoxaparin states it should be used with extreme caution in conditions with increased risk of hemorrhage. The January TAR again showed physician‑ordered monitoring interventions related to blood‑thinning medications, but the comprehensive care plan did not identify any problem, goal, or interventions related to anticoagulant therapy or bleeding risk. The Kardex and an undated care guide did not identify the resident’s use of blood‑thinning medications. During interview, this resident reported receiving a daily blood‑thinner injection in the abdomen and experiencing bruising at the injection site. Staff interviews revealed that NAs rely on care guides and Kardexes, which did not list blood‑thinner use, and that the nurse manager and DON were unaware or unable to explain the need to address blood‑thinning medications and associated bleeding risk in the care plans. The facility’s care planning policy lacked specific guidance requiring identification and care planning of high‑risk medications and routes, and therefore did not ensure foreseeable risks such as bleeding from blood‑thinning medications were addressed through individualized care plan interventions.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment posed risks that were not properly addressed, and supervision measures were insufficient to prevent potential incidents. No further details about the specific hazards, the nature of the supervision, or the residents involved are provided in the report.
Uncleaned Shower Room Vent in LTC Facility
Penalty
Summary
The facility failed to ensure that the ceiling exhaust fan in a multi-resident shower room on the third floor was cleaned, potentially affecting all residents using the shower room. Observations revealed that the vent was coated with gray debris, with some particles hanging off, indicating a lack of regular cleaning. Interviews with a resident, who had previously worked as a janitor, confirmed that the vent in the common shower room was in worse condition than the one in his room, which also contained dark debris. Interviews with staff, including a social worker, maintenance personnel, and housekeeping staff, highlighted a lack of clarity and responsibility regarding the cleaning of the vents. Maintenance staff indicated that vents were supposed to be cleaned monthly, while housekeeping staff claimed daily cleaning routines included dusting and cleaning vents. However, the presence of significant debris on the vent suggested these procedures were not followed. The facility was unable to provide a policy or checklist for daily cleaning, further indicating a gap in the implementation of cleaning protocols.
Infection Control and EBP Failures in LTC Facility
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) and proper use of Personal Protective Equipment (PPE) during high-contact resident care activities. For instance, a resident with a central line did not have EBP signage or PPE available, and staff did not wear gowns during IV antibiotic administration. Another resident with a foley catheter and a history of antibiotic-resistant infections had a wound doctor who did not don a gown during wound care, despite EBP signage being present. Additionally, the facility did not ensure appropriate hand hygiene practices. A trained medication assistant changed gloves without performing hand hygiene after washing a resident's rectal area. Shared equipment, such as a Hoyer lift, was not disinfected between uses, as observed when a lift was moved from a resident's room to a spa room without being cleaned immediately. The facility also failed to store reusable ice packs separately from food in kitchen refrigerators, which is against infection control protocols. Ice packs were found touching residents' labeled food items in multiple kitchenettes, despite signage indicating the refrigerators were for resident food only. Staff interviews confirmed that ice packs should be stored in a separate medication freezer to prevent contamination.
Failure to Provide Updated Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that two residents, identified as R5 and R20, were offered and/or provided updated vaccinations for pneumococcal disease in accordance with CDC recommendations. R5, who was at increased risk due to chronic obstructive pulmonary disease, heart failure, and a history of acute respiratory failure, had received PCV-13 and PPSV23 vaccines in 2015. Although R5 consented to receive additional pneumococcal vaccines per CDC guidelines, her medical record lacked documentation of shared clinical decision-making regarding further vaccination. The Director of Nursing (DON) stated that shared clinical decision-making was not completed because R5's vaccines were considered complete according to the Minnesota Immunization Information Connection (MIIC), and the DON had not reviewed the vaccines in accordance with updated CDC recommendations. R20, who was also at increased risk due to conditions such as pulmonary embolism, dyspnea, chronic heart failure, and obstructive sleep apnea, had a vaccine consent form indicating previous receipt of PPSV23 and PCV-13, but the dates were unclear. Her immunization form showed no history of pneumococcal vaccinations, and her medical record lacked follow-up regarding the declination or administration of the vaccines. The DON acknowledged that no one had followed up to verify R20's vaccine history. The facility's policy required offering vaccines within 30 days of admission unless already vaccinated or contraindicated, and to verify immunization status if unknown, but these steps were not adequately followed for R20.
Failure to Respect Resident's Healthcare Decision Rights
Penalty
Summary
The facility failed to ensure a resident's right to determine their own healthcare decisions and to revoke a power of attorney. The resident, identified as R30, had intact cognition according to multiple assessments, yet the facility continued to involve a family member, FM-A, as the power of attorney for healthcare decisions without R30's consent. Despite R30's clear cognitive status and expressed desire to change the power of attorney, the facility did not facilitate this change or include R30 in care conferences. R30's medical records indicated a history of fluctuating cognitive status due to various medical conditions, including dementia, anxiety, depression, and acute illnesses like encephalopathy and diverticulitis. However, during periods of intact cognition, R30 expressed dissatisfaction with FM-A's involvement in healthcare decisions and sought to revoke FM-A's power of attorney. The facility's records lacked evidence of R30's participation in care planning or any re-evaluation of R30's decision-making capacity following acute illnesses. Interviews with R30 and facility staff revealed that R30 was not informed or invited to care conferences, and the facility continued to rely on FM-A for consent and decision-making. The social worker and director of nursing acknowledged that R30 should have been included in care conferences and decision-making processes, given her intact cognition. The facility's failure to recognize and act upon R30's expressed wishes and cognitive status led to a deficiency in respecting the resident's rights.
Failure to Notify Physician of Resident's Vision Loss
Penalty
Summary
The facility failed to notify the physician of a change in condition for a resident experiencing new vision loss. The resident, who had intact cognition and diagnoses of type II diabetes mellitus, hypertension, and congestive heart failure, was noted to have adequate vision and did not wear corrective lenses according to their care plan. However, the resident reported experiencing vision loss and irritation in the right eye, which had been occurring for three weeks. Despite this, there was no documentation that the physician had been notified or that an appointment had been made until much later. The resident had a visit summary note from an eye exam indicating the need for an urgent appointment with a retinal specialist, but the appointment was scheduled weeks later. The assistant director of nursing (ADON) and other nursing staff failed to assess the resident's eye condition or document the incident properly. The ADON admitted to not documenting the incident or notifying the provider, and the licensed practical nurse (LPN) only applied more tape to the bandage without assessing the eye. The Health Information Manager (HIM) was unaware of the urgency of the follow-up appointment and scheduled it for a later date, missing the 'ASAP' instruction from the eye doctor. Interviews with various staff members revealed a lack of communication and documentation regarding the resident's condition. The director of nursing (DON) stated that nurses were responsible for assessing new injuries or changes in condition, but this protocol was not followed. The facility's policy on notification of a change in condition was not adhered to, resulting in a delay in addressing the resident's vision issues. The resident expressed frustration over the lack of action taken by the facility, highlighting a significant deficiency in the care provided.
Failure to Include Swallow Study in Discharge Plan
Penalty
Summary
The facility failed to ensure that a swallow study referral was included in the post-discharge plan for a resident with dysphagia, among other medical conditions. The resident, identified as having intact cognition and several diagnoses including type one diabetes mellitus, dysphagia, and end-stage renal disease, was on a therapeutic diet and had active discharge planning in place. Despite the speech language pathologist's (SLP) recommendation for a swallow study due to esophageal dysphagia, the care plan did not include an intervention for the resident to make her own post-discharge appointments for the study. The SLP had evaluated and treated the resident, recommending a swallow study on 9/19/24, but the facility's records lacked documentation of whether the study was scheduled or discussed with the resident. The discharge instructions and summary form did not include arrangements for the swallow study, and the resident reported not being made aware of any such arrangements before discharge. Interviews with facility staff revealed a lack of communication and coordination regarding the scheduling of the swallow study, with various staff members assuming others were responsible for the task. The facility's discharge planning policy required coordination by the interdisciplinary team to ensure continuity of care, but this was not effectively executed in this case. The resident expressed a desire for the facility to assist in scheduling the swallow study, as she was unsure how to do it herself. The failure to include the swallow study referral in the discharge plan highlights a breakdown in communication and responsibility among the facility's staff, leading to a deficiency in meeting the resident's post-discharge needs.
Failure to Provide Timely Vision Care
Penalty
Summary
The facility failed to ensure that a resident received proper treatment to maintain vision, as evidenced by the case of a resident with intact cognition and diagnoses of type II diabetes mellitus, hypertension, and congestive heart failure. The resident's care plan indicated adequate vision and no need for corrective lenses, with an intervention to observe for changes in visual status. However, the resident's last eye exam recommended an urgent appointment with a retinal specialist, which was not promptly scheduled. The resident experienced vision loss and reported symptoms such as looking through a red fog, which had been occurring for three weeks without appropriate intervention from the facility. The assistant director of nursing (ADON) acknowledged that the resident returned from dialysis with a patch over his eye and new orders but did not consider it a cause for concern. The ADON failed to document the incident or notify the provider, and no assessment of the resident's eye was conducted by the nursing staff. Interviews with various nursing staff revealed a lack of documentation and assessment of the resident's eye condition, despite the presence of a new bandage and the resident's complaints of irritation and vision issues. The Health Information Manager (HIM) was unaware of the need for an urgent follow-up appointment and only learned of the resident's eye issues when the resident personally reported them. The HIM admitted to missing the urgency indicated in the visit summary and scheduled the specialist appointment weeks later. The facility's policy on ancillary appointments was requested but not provided, indicating a possible lack of protocol in managing such situations. The director of nursing (DON) outlined the expected procedure for handling changes in condition, which was not followed in this case.
Resident Excluded from Care Conferences Despite Intact Cognition
Penalty
Summary
The facility failed to ensure that a resident, identified as R30, was invited to participate in care conferences, which is a requirement for care planning. R30, who had intact cognition and was capable of making her own decisions, was not included in care conferences, and there was no documentation indicating that she refused to attend or that her participation was not practicable. Despite having a health care directive that appointed a family member as her health care agent, R30 expressed dissatisfaction with not being included in healthcare decisions and care conferences. R30's medical records and interviews revealed that she was alert and oriented, with adequate long-term recall and fair short-term recall. She had a history of anemia, hypertension, dementia, anxiety, depression, and borderline personality disorder. Despite these conditions, R30 was capable of participating in her care planning, as evidenced by her ability to express her preferences and dissatisfaction with the current arrangement where her family member was contacted instead of her. Interviews with facility staff, including the social worker and director of nursing, indicated a lack of clarity and communication regarding R30's participation in care conferences. The social worker acknowledged that R30 should have been asked if she wanted to attend care conferences, given her intact cognition. The facility's policy stated that residents have the right to participate in their healthcare planning, but this was not adhered to in R30's case, leading to the deficiency.
Inadequate Smoking and Behavioral Assessments Lead to Safety Hazards
Penalty
Summary
The facility failed to adequately assess and supervise a resident, R15, for safe smoking practices. R15, who was cognitively intact and used intermittent oxygen therapy, had a history of smoking incidents, including lighting a cigarette in her room and dropping ash on her clothing. Despite these incidents, the facility did not conduct timely smoking assessments as required by their policy. R15's care plan indicated she was initially assessed as safe to smoke independently, but subsequent assessments revealed safety concerns, such as burn holes in her clothing and the need for a smoking apron. The facility's failure to conduct quarterly assessments and address these safety hazards contributed to the deficiency. Additionally, the facility did not adequately address a safety hazard involving resident-to-resident abuse. R50, who had moderate cognitive impairment and a history of depression and substance use, was involved in an altercation with another resident, R71, who was intoxicated and made inappropriate comments. R50, feeling threatened, used his wheelchair to confront R71, leading to a physical altercation. The facility's care plan for R50 included interventions to manage his behavior and ensure his safety, but these measures were not effectively implemented, as evidenced by the altercation and R50's continued agitation and use of a flashlight for self-defense. The facility's policies and procedures for smoking assessments and managing resident behavior were not consistently followed, leading to safety hazards for both R15 and R50. The lack of timely assessments and interventions for R15's smoking safety and R50's behavioral issues contributed to the deficiencies identified in the report. The facility's failure to act upon identified safety hazards and ensure adequate supervision and assessment of residents' needs resulted in potential risks to resident safety.
Deficiency in Oxygen Tubing Maintenance and Documentation
Penalty
Summary
The facility failed to ensure that supplemental oxygen was properly maintained and accurately documented for a resident with intact cognition and diagnoses including pulmonary embolism and unspecified dyspnea. The resident had physician orders to monitor for skin breakdown due to oxygen tubing, follow enteric contact precautions due to C. Difficile, and maintain oxygen saturations at 88% or above with 2 liters of oxygen. The resident's medication administration record (MAR) and treatment administration record (TAR) indicated that oxygen tubing was to be changed weekly, but observations revealed that the tubing had not been changed as required, with a sticker on the tubing dated 9/3, despite documentation indicating otherwise. Interviews with staff, including a registered nurse (RN) and the assistant director of nursing (ADON), confirmed that the oxygen tubing was not changed weekly as per the orders, and the documentation in the TAR was inaccurate. The assistant director of nursing acknowledged that the staff should not have signed off on the task if it was not completed, highlighting the importance of changing the tubing for infection control. The director of nursing (DON) confirmed the lack of a specific policy on oxygen tubing but expected staff to follow batch orders and document accurately. The deficiency was identified through observations and staff interviews, revealing a lapse in following professional standards for respiratory care and documentation accuracy.
Failure to Timely Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident to the State Agency (SA) within the required timeframe. The resident, who had moderate cognitive impairment and was dependent on staff for all hygiene care, mobility, and transfers, reported being raped at the facility to a family member over the phone. This report was overheard by a nursing assistant (NA) and a licensed practical nurse (LPN) who were present in the room. Despite hearing the allegation, the LPN did not report it immediately, as required by facility policy and state regulations. The incident occurred on the evening of 9/14/24, but the facility did not report it to the SA until the morning of 9/16/24, well beyond the two-hour reporting requirement. The NA assumed the LPN would report the incident, while the LPN, despite acknowledging hearing the allegation, did not take action to report it, citing being preoccupied with other duties. The Director of Nursing (DON) confirmed that both the NA and LPN were aware of the allegation on the day it occurred but failed to report it as mandated. The facility's policy clearly states that any suspected abuse must be reported immediately, not later than two hours after the suspicion arises. The administrator confirmed that the expectation and policy were not followed, as the report to the SA was delayed. This failure to report in a timely manner constitutes a deficiency in the facility's adherence to abuse reporting protocols.
Failure to Monitor Edema and Assess Non-Pressure Related Wounds
Penalty
Summary
The facility failed to monitor edema and comprehensively assess non-pressure related wounds for a resident with multiple health conditions, including brain cancer, hypertension, and chronic ischemic heart disease, who was receiving hospice care. The resident's physician orders required nurses to chart the resident's condition every shift for edema and lung checks, but the documentation was inconsistent and lacked comprehensive details. The treatment administration records indicated the presence or absence of edema and lung sounds but did not include the extent of the edema. Additionally, the resident's weight gain of 16.2 pounds over a period was not comprehensively assessed to determine if it was nutritional or fluid-related, and there was no evidence that the weight gains were evaluated for changes in the resident's overall health status and possible disease progression. The resident's skin evaluations and wound assessments were also found to be lacking. Multiple skin inspections and wound evaluations noted various bruises, skin tears, and wounds, but the documentation often did not include specific details such as wound measurements, wound beds, drainage, odor, periwound area, wound edges, risk factors, and pain. The resident's care plan identified a risk for alteration in skin integrity but did not include interventions related to edema. The facility's policies on skin assessment and wound management were not fully adhered to, as comprehensive assessments and follow-up interventions were not consistently documented. Interviews with the facility's staff, including the Director of Nursing (DON), revealed that edema was not being specifically monitored every shift as required by the physician's order. The DON acknowledged that the documentation of edema and weight monitoring was inadequate and that the resident's care plan did not include edema management. The facility's policies on resident weight evaluation and skin assessment were not fully implemented, leading to deficiencies in the monitoring and assessment of the resident's condition.
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 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 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 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 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 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 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 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 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 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 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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