Mother Of Mercy Senior Living
Inspection history, citations, penalties and survey trends for this long-term care facility in Albany, Minnesota.
- Location
- 230 Church Avenue, Box 676, Albany, Minnesota 56307
- CMS Provider Number
- 245339
- Inspections on file
- 30
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Mother Of Mercy Senior Living during CMS and state inspections, most recent first.
Two residents with heart failure were inadequately monitored, leading to one being re-hospitalized. The facility failed to follow physician orders for weight monitoring and PRN Lasix administration, resulting in significant weight gain and edema. Despite recommendations to clarify medication orders, the facility discontinued the PRN Lasix without proper authorization, contributing to the deficiency in care.
The facility failed to post accurate daily staffing information, affecting all 57 residents and their visitors. From 11/17/24 to 12/20/24, postings lacked details on the number of licensed staff and hours worked. The DON admitted to incorrect postings due to miscommunication, and the information was not updated on weekends. No policy was provided.
The facility failed to conduct a comprehensive facility-wide assessment, missing critical components such as facility information, quality assurance input, and contingency staffing plans. The administrator acknowledged the importance of the assessment for guiding staffing and resident care needs, but the document provided was incomplete, potentially affecting all 57 residents.
The facility's QAPI program was ineffective, failing to identify and address quality deficiencies, including communication of medication changes, bed-hold notices, and heart failure interventions. A resident was re-hospitalized due to exacerbation of heart failure. The facility lacked comprehensive assessments and proper hand hygiene practices. Meeting documentation was insufficient, and there was a delay in addressing known issues.
A facility failed to ensure a resident's advanced directives were accurately reflected in their medical records. The resident's POLST indicated a DNR status, but the EMR banner showed FULL CODE. This discrepancy was discovered by a nurse manager and confirmed by the DON, highlighting a failure to ensure the resident's wishes were documented correctly for emergency situations.
A facility failed to provide a written bed-hold notice during two hospital transfers for a resident with multiple health conditions, including dementia and CHF. Verbal consent was obtained from the family, but no written notice was given, contrary to the facility's policy requiring written information at the time of transfer or within 24 hours for emergencies.
The facility failed to complete and transmit a discharge MDS for two residents, one with osteoarthritis and another with hyponatremia, due to communication lapses. The MDS nurse, working offsite, did not receive necessary updates on resident discharges, and the DON noted a lack of involvement in MDS processes. The policy for MDS submissions was not provided, highlighting procedural gaps.
The facility failed to ensure proper hand hygiene during medication administration and handling of soiled clothing. An RN and an LPN did not perform hand hygiene between tasks and residents, while a nursing assistant carried soiled clothing without bagging it or wearing gloves. These actions were contrary to infection control standards and acknowledged by the staff involved.
A facility failed to provide a pneumococcal vaccine in a timely manner to a resident. The resident's MDS indicated they were not up to date with vaccinations, and a consent form was signed and uploaded to the EMR. The DON was unsure of the immunization process, and the IP, who reviewed immunization status using MIIC and an app, confirmed the vaccine was not administered by the expected date.
A facility failed to notify a resident's representative about the discontinuation of a PRN Lasix prescription for CHF-related edema. Despite the resident's significant medical conditions, including dementia and CHF, the family was not informed of the medication change, which was confirmed by the DON. This oversight violated the facility's policy on promptly notifying changes in medical care.
The facility failed to notify and consult the provider for two residents with heart failure monitoring needs. One resident did not receive prescribed Lasix for weight gain, and another had multiple missed weigh-ins without provider notification. The DON confirmed the nursing staff's responsibility to document and communicate concerns, which was not adhered to, leading to the deficiency.
The facility failed to update care plans for two residents with heart failure. One resident's care plan lacked updates for monitoring lung congestion and weight gain, while another's care plan did not reflect the required frequency of weight monitoring. Interviews with the DON confirmed the care plans were not updated as expected, which is essential for preventing acute exacerbations of heart failure.
A resident experienced a critical low potassium level due to missed medication doses, as the facility failed to notify the physician about the unavailability of potassium supplements. Despite knowing the medication was not available, staff did not contact the physician for guidance, leading to a critical drop in potassium levels and the need for emergency medical services.
A resident missed 10 doses of potassium due to the facility's failure to ensure timely administration, resulting in a critically low potassium level and an emergency room visit. The resident, recently discharged from the hospital, experienced a drop in potassium levels after starting a diuretic. Despite multiple faxes to the pharmacy, the medication was not delivered, and staff failed to notify the provider or follow up adequately.
The facility failed to implement effective infection control measures during a renovation project, leading to the spread of dust and potential mold exposure. The project was not overseen by a licensed contractor, and CDC guidelines were not followed. Immunocompromised residents were not relocated or monitored, and communication among staff was inadequate.
A resident with severe environmental allergies experienced significant health issues due to inadequate precautions during facility renovations. The care plan lacked necessary information on her allergies, and staff were not properly informed, leading to repeated exposure to allergens. Despite being offered measures like an N95 mask and supplemental oxygen, the resident declined a room change, believing odors were pervasive. The facility's failure to update the care plan and ensure staff awareness resulted in ongoing distress for the resident.
Failure to Monitor and Implement Heart Failure Interventions
Penalty
Summary
The facility failed to adequately monitor and implement interventions for heart failure in two residents, resulting in actual harm to one resident who was re-hospitalized due to exacerbation of heart failure. The resident, who had a history of dementia, chronic diastolic congestive heart failure (CHF), diabetes, and other conditions, was prescribed furosemide (Lasix) 20mg daily as needed for lung congestion and lower extremity edema. However, the facility did not contact the cardiologist for specific parameters for administering the PRN diuretic, nor did they monitor the resident for signs of lung congestion and edema as required. The resident's records showed multiple instances where weight gain and edema were not properly assessed or reported to the provider, and the PRN Lasix was not administered according to the prescribed parameters. Despite recommendations from the pharmacist to clarify the PRN Lasix order, the facility discontinued the medication without proper authorization or clarification from the provider. This lack of monitoring and communication led to the resident experiencing significant weight gain and edema, ultimately resulting in hospitalization for acute exacerbation of CHF. Another resident with a history of acute on chronic congestive heart failure and other cardiac conditions also experienced inadequate monitoring. The facility failed to consistently obtain and document weights as ordered, missing numerous opportunities to monitor the resident's condition. Despite the resident's reports of weight gain and tighter legs, the facility did not notify the provider of missed weights or changes in the resident's condition. This lack of adherence to physician orders and failure to communicate critical information contributed to the deficiency in care for both residents.
Failure to Post Daily Staffing Information
Penalty
Summary
The facility failed to ensure the required staffing information was posted daily, which had the potential to affect all 57 residents and their visitors. Upon entrance on 12/16/24 and 12/17/24, the staff postings were observed to include licensed staff and total hours worked. However, from 11/17/24 through 12/20/24, the postings lacked accurate information regarding the number of licensed staff working each day, the hours worked, and the total hours of all licensed staff. On 12/20/24, the Director of Nursing (DON) acknowledged that the information on the staff postings was incorrect due to miscommunication and that the information had been lost. The DON and the HR manager confirmed that the daily staffing sheets were incorrect or missing and were not updated in person on weekends. Additionally, the facility was unable to provide a policy regarding the posting of staffing information.
Incomplete Facility-Wide Assessment
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment necessary for providing adequate care and services to its residents. During the entrance conference, the survey team requested the facility assessment, which was not provided within the stipulated time. Subsequent requests were made, and eventually, the administrator sent an incomplete Facility Assessment Tool. The document, dated September 5, 2024, lacked critical components such as the facility's information, input from the quality assurance team, and a list of personnel involved in the assessment. Additionally, it did not include a contingency staffing plan, staff competencies, and health information technology resources. The administrator confirmed their responsibility for creating the facility assessment and acknowledged the importance of its completion in guiding staffing, equipment, and resident care needs. However, the assessment was incomplete, and no facility assessment policy was provided upon request. This deficiency had the potential to affect all 57 residents in the facility, as it indicated a lack of preparedness in both day-to-day operations and emergency situations.
Ineffective QAPI Program Leads to Multiple Deficiencies
Penalty
Summary
The facility failed to maintain an effective Quality Assurance Assessment/Quality Assurance and Performance Improvement (QAA/QAPI) program, which resulted in several deficiencies. The facility did not conduct ongoing quality assessment and assurance activities, nor did it develop and implement appropriate plans of action to correct repeated quality deficiencies. These deficiencies included failing to communicate medication changes to residents or their representatives, not providing written notice of a bed-hold during hospital transfers, and failing to monitor and implement interventions for heart failure, which led to the re-hospitalization of a resident. Additionally, the facility did not conduct a comprehensive facility-wide assessment and failed to ensure appropriate hand hygiene during medication pass and while handling soiled clothing. The facility's QAPI meeting minutes for the past 12 months were not adequately documented, with only one meeting agenda provided, which did not address previous survey results or current performance improvement projects. Interviews with the Director of Nursing (DON) and the administrator revealed awareness of ongoing quality of care issues, such as staff obtaining and documenting resident weights, but there was a delay in providing staff education or training. The administrator mentioned that the facility held monthly QAA meetings and quarterly QAPI meetings, but no monthly meeting minutes were provided, and the QAPI agenda lacked evidence of the reported performance improvement projects.
Failure to Accurately Reflect Advanced Directives in Medical Records
Penalty
Summary
The facility failed to ensure that a resident's advanced directives for emergency care and treatment were accurately reflected in all areas of the medical chart. This deficiency was identified for a resident who was moderately cognitively impaired and had multiple diagnoses, including hypertension, arthritis, osteoporosis, and asthma. The resident's Provider Orders for Life-Sustaining Treatment (POLST) indicated a Do Not Attempt Resuscitation (DNR) status, signed by the healthcare agent and a physician's assistant. However, the electronic medical record (EMR) banner incorrectly displayed the resident's resuscitation status as FULL CODE. The discrepancy was discovered when the registered nurse manager (RN-D) reviewed the resident's code status and found that the EMR banner did not match the POLST. The director of nursing (DON) confirmed that the EMR banner and POLST form did not match prior to the survey start. The facility's policy required that resuscitation orders be reviewed upon admission and verified with the POLST. The inconsistency in the resident's resuscitation status was noted to have been corrected after the survey entrance, indicating a failure to ensure the resident's wishes were accurately documented and could be implemented correctly in an emergent situation.
Failure to Provide Written Bed-Hold Notice During Hospital Transfers
Penalty
Summary
The facility failed to provide a written notice of a bed-hold at the time of transfer for a resident who was hospitalized on two separate occasions. The resident, who had a significant change in their Minimum Data Set (MDS) indicating diagnoses of dementia, chronic diastolic congestive heart failure (CHF), atrial fibrillation, peripheral neuropathy, and diabetes, was transferred to the hospital for increased redness and swelling in the left foot and later for increased pain and a change in transfers. In both instances, verbal consent for a bed-hold was obtained from the resident's family member, but there was no evidence that a written bed-hold notice was provided to the resident or their representative at the time of transfer. The facility's Bed-Holds and Returns Policy, revised in October 2022, required that residents or their representatives be provided with written information regarding bed-hold policies at the time of transfer or within 24 hours for emergency transfers. Despite this policy, the facility did not provide the necessary written documentation during the resident's transfers on both occasions. The Director of Nursing (DON) confirmed that the written bed-hold information was not provided as required, emphasizing the importance of such documentation to ensure residents and their representatives understand their rights and the implications of a bed-hold.
Failure to Complete and Transmit Discharge MDS for Two Residents
Penalty
Summary
The facility failed to complete and transmit a discharge return not anticipated Minimum Data Set (MDS) for two residents, leading to a deficiency in the transmission of resident assessments. Resident 25, who was cognitively intact and had a primary diagnosis of osteoarthritis with a joint replacement, was discharged without a completed discharge MDS. Similarly, Resident 48, who was also cognitively intact and had a primary diagnosis of hyponatremia, left the facility without a completed discharge MDS. The medical records for both residents lacked evidence of the required discharge MDS completion. The MDS registered nurse, who worked offsite, confirmed that she relied on the facility to update her on admissions, discharges, or significant changes in residents' conditions. She acknowledged that the discharge MDS was not completed for both residents, possibly due to a lack of updates from the facility. The Director of Nursing, who had limited involvement with MDS completion and submission, mentioned that there was a leadership email group intended to provide updates on resident status changes, which the MDS nurse should have been part of. However, the policy for MDS submissions was requested but not provided, indicating a potential gap in communication and procedural adherence within the facility.
Inadequate Hand Hygiene and Infection Control Practices
Penalty
Summary
The facility failed to ensure proper hand hygiene during medication administration and handling of soiled clothing, which could potentially affect all 57 residents, staff, and visitors. During a medication pass, an RN did not wash hands or use alcohol-based hand sanitizer after administering medication to a resident and before preparing medication for another resident. Similarly, an LPN did not perform hand hygiene after removing gloves following a blood sugar check and insulin administration, and before handling medication for another resident. Both staff members acknowledged the oversight during interviews, with the RN stating she intended to use hand sanitizer and the LPN admitting she forgot to do so. Additionally, a nursing assistant was observed carrying soiled clothing without placing it in a bag and without wearing gloves, as required by infection control standards. The nursing assistant confirmed the clothing should have been bagged before being removed from the resident's room. The infection preventionist stated that staff were expected to bag soiled items and wear gloves to prevent the spread of infection. The facility's policy on handling soiled clothing was requested but not provided.
Failure to Timely Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to provide a pneumococcal vaccine in a timely manner to one resident reviewed for immunizations. The resident's admission Minimum Data Set (MDS) indicated that they were not up to date with pneumococcal vaccinations. A consent form for the vaccination was signed by the resident and uploaded to the electronic medical record within the same week as admission. However, the Director of Nursing was unsure of the process for reviewing and administering immunizations, deferring to the infection preventionist. The infection preventionist stated that she reviewed immunization status upon admission using the Minnesota Immunization Information Connection and used an app recommended by the facility pharmacy to determine vaccine eligibility. Despite these steps, the immunization was not received and administered by the expected date.
Failure to Notify Resident's Representative of Medication Change
Penalty
Summary
The facility failed to ensure that changes in medication were communicated to a resident's representative, leading to a deficiency in the notification of change in medications. The resident, who had a significant change in their Minimum Data Set (MDS), was diagnosed with dementia, chronic diastolic congestive heart failure (CHF), atrial fibrillation, peripheral neuropathy, and diabetes. A cardiology clinic note indicated that the resident was prescribed furosemide (Lasix) 20mg daily as needed for lung congestion and lower extremity edema related to CHF. However, the medication was discontinued without notifying the resident's representative. The resident's family member, who accompanied them to the cardiologist, was not informed of the discontinuation of the PRN Lasix. This lack of communication was confirmed by the Director of Nursing (DON), who acknowledged that the progress notes failed to indicate that the family had been notified of the medication change. The facility's policy required prompt notification of any changes in medical care or nursing treatments, which was not adhered to in this case, resulting in a deficiency.
Failure to Monitor and Notify Provider for Heart Failure Management
Penalty
Summary
The facility failed to notify and consult the provider for two residents with heart failure monitoring needs. Resident R33 had a significant change in condition, with diagnoses including dementia, chronic diastolic congestive heart failure, atrial fibrillation, peripheral neuropathy, and diabetes. Despite having a physician's order for Lasix 20mg to be administered as needed for specific weight gains, the medication was not given on two occasions when the resident experienced weight gains that met the criteria. The registered nurse confirmed the failure to administer the medication as ordered. Resident R43, who was cognitively intact and had a history of acute on chronic congestive heart failure, hypertensive heart disease, and other related conditions, had an order for weights to be taken three times a week. However, the facility missed several opportunities to record weights over multiple months, and there was no evidence of provider notification regarding these missed weights. The resident reported feeling like she was gaining water weight, and her weight had increased over time, but the scheduled weigh-ins were not consistently performed. The Director of Nursing confirmed the orders for both residents and acknowledged the nursing staff's responsibility to obtain, document, and communicate any concerns regarding scheduled weights. The facility's policy required prompt notification of the resident's attending physician for changes in the resident's condition, but this was not adhered to in these cases, leading to the deficiency.
Failure to Update Care Plans for Residents with Heart Failure
Penalty
Summary
The facility failed to revise the comprehensive care plans for two residents, R33 and R43, who were reviewed for heart failure. R33 was admitted with diagnoses including chronic diastolic congestive heart failure (CHF), atrial fibrillation, chronic obstructive pulmonary disease (COPD), and diabetes. Despite a cardiology clinic note indicating the need for a PRN diuretic for lung congestion and lower extremity edema, R33's care plan was not updated to include interventions for monitoring these conditions. Additionally, hospital discharge orders for weight monitoring were not transcribed or implemented, and the care plan lacked updates for monitoring weight gain or signs of CHF exacerbation. R43, admitted with acute on chronic congestive heart failure and other cardiac conditions, had a care plan that included monitoring for signs of CHF exacerbation. However, despite an order for weights to be taken three times weekly, the care plan was not updated to reflect this, and weights were only recorded once weekly. This discrepancy was noted in physician notes, which highlighted ongoing concerns about the resident's weight gain due to fluid retention. Interviews with the Director of Nursing (DON) confirmed the expectations for nursing staff to implement interventions and update care plans based on assessments, provider notes, and hospital discharge orders. The DON acknowledged that the care plans for both residents were not updated as required, which is crucial for maintaining resident health and providing clear directives to prevent acute exacerbations of heart failure. A policy was requested during the interview but was not provided.
Failure to Notify Physician of Missed Medication Leads to Critical Low Potassium
Penalty
Summary
The facility failed to notify a resident's physician about a missed administration of medication, which led to a critical low potassium level in the resident. The resident, who had been admitted from the hospital with increased edema and pain, was prescribed Bumex for edema and potassium supplements due to low potassium levels. However, the potassium medication was not available from the pharmacy, resulting in the resident missing ten doses over several days. Despite the critical nature of the resident's low potassium levels, the facility staff did not inform the resident's physician about the missed doses until several days later. Interviews with staff revealed that they were aware of the medication's unavailability and the resident's low potassium levels but failed to contact the physician for further guidance. The facility's policy required prompt notification of the provider in the event of significant medication-related errors, which was not adhered to in this case. The resident's potassium level continued to drop, reaching a critically low level, which necessitated emergency medical services. The facility's failure to communicate the medication error and the resident's declining condition to the physician in a timely manner was a significant oversight, as per the facility's policies on medication errors and changes in resident condition.
Failure to Administer Potassium Timely Leads to Critical Deficiency
Penalty
Summary
The facility failed to ensure that potassium was available and administered timely as prescribed by the physician for a resident, resulting in the resident missing 10 doses of potassium. This led to a critically low potassium level of 2.4 mmol/L, requiring intravenous potassium administration. The resident, who was asymptomatic and stable, had been admitted from the hospital with a history of E. coli pneumonia and septic shock, and was experiencing pain and edema in the lower extremities. The resident's potassium level was initially recorded at 3.8 mmol/L upon admission, but dropped to 2.8 mmol/L, prompting an order for potassium chloride to be administered twice daily. However, the medication was not available from the pharmacy, and despite multiple faxes sent by the facility to the pharmacy, the potassium was not delivered until several days later. During this period, the resident's potassium level further decreased to 2.4 mmol/L, necessitating an emergency room visit for treatment. Interviews with facility staff revealed that there was a breakdown in communication and follow-up procedures, as staff did not adequately follow up with the pharmacy or notify the provider about the unavailability of the medication. The pharmacy also failed to process the order correctly, leading to a delay in medication delivery. The facility's policies on medication administration and error reporting were not adhered to, contributing to the deficiency.
Inadequate Infection Control During Renovation
Penalty
Summary
The facility failed to implement effective infection control measures during a demolition and renovation project, which had the potential to impact all 51 residents. The project was not overseen by a licensed contractor, and the facility did not adhere to CDC guidelines for infection control in long-term care construction. As a result, construction odors and dust traveled into resident areas, and a potential black mold discovery was not properly remediated. The facility did not establish a multidisciplinary team to coordinate the project, nor did it perform an Infection Control Risk Assessment (ICRA) before the project began. The construction area lacked proper barriers to prevent dust and mold spores from spreading, and there was no negative air pressure or air filtration system in place. The facility also failed to relocate immunocompromised residents or monitor their respiratory health during the project. Communication among staff was inadequate, with the Director of Nursing (DON) and Infection Control Preventionist (ICP) not being involved in decision-making or risk mitigation. Volunteers, rather than qualified contractors, managed the project, and there was no evidence of proper mold remediation. The facility's policies on construction and infection control were not followed, and there was a lack of documentation and monitoring of resident health during the construction.
Failure to Address Severe Allergies During Construction
Penalty
Summary
The facility failed to provide necessary care and services to a resident with severe environmental allergies, particularly during a period of construction. The resident, who was cognitively intact and had a history of chronic systolic congestive heart failure and allergic rhinitis, experienced significant discomfort and health issues due to exposure to construction-related odors and dust. Despite being offered a room change and other measures like an N95 mask and supplemental oxygen, the resident declined the room change, believing the odors permeated the entire facility through the ventilation system. The facility's care plan for the resident lacked critical information regarding her severe allergies and the necessary interventions to mitigate risks. The care plan did not include details about the resident's perfume and medication allergies, nor did it provide guidance on how to manage her reactions to allergens. Staff were not adequately informed or trained on the resident's specific needs, leading to repeated exposure to allergens and subsequent health issues for the resident. The resident expressed frustration and fear for her safety, feeling that staff did not take her allergies seriously or understand the severity of her condition. Observations during the survey revealed inadequate barriers to contain construction debris and odors, contributing to the resident's distress. Interviews with staff indicated a lack of consistent communication and documentation regarding the resident's allergies and the necessary precautions. The facility's failure to update the care plan and ensure all staff were aware of the resident's needs resulted in ongoing exposure to allergens, causing the resident to experience respiratory issues and consider relocating due to the facility's inability to provide a safe environment.
Latest citations in Minnesota
A resident with dry eye syndrome and degenerative eye disease had orders for cyclosporine ophthalmic emulsion and Refresh Tears, both scheduled at the same time. Medication records and direct observation showed a TMA instilled cyclosporine drops in both eyes and immediately followed with Refresh Tears in both eyes without waiting between medications. This practice conflicted with referenced professional guidance recommending several minutes between multiple eye drops and with the medical provider’s recommendation to wait fifteen minutes between the two ophthalmic medications. No facility policy on ophthalmic medication administration was provided when requested.
A resident with severe cognitive impairment, impaired mobility, and high fall risk was care planned to have wheelchair footrests in place at all times, with staff ensuring proper positioning and monitoring for leaning during transport. A NA transported the resident in a manual wheelchair from the shower without the footrests, and while going through the doorway the wheelchair struck the door frame, causing the resident, who was leaning forward, to fall out. The resident sustained a T12 fracture, head injury with concussion, abrasions and contusions, and multiple right-hand lacerations requiring sutures, and the DON confirmed the care plan had not been followed.
A high‑risk, immobile resident with MS and prior heel DTI developed an avoidable unstageable coccygeal pressure ulcer after staff failed to consistently assess and document skin status, did not transfer or timely provide ordered pressure‑relieving mattresses, and did not reliably perform q2h repositioning. The resident was repeatedly left on a bedpan for prolonged periods despite early reports of this issue, and the toileting care plan was not revised to a bedside commode until after the coccygeal wound had significantly worsened. Wound assessments lacked complete measurements and staging, changes in wound size and color were not promptly recognized as deterioration or reported to providers, and recommended interventions from a wound NP (including an air mattress and offloading) were not promptly implemented. As a result, the coccygeal ulcer rapidly progressed to a large, necrotic, malodorous wound requiring hospital transfer and surgical debridement.
A resident with spastic hemiplegia, muscle weakness, and moderate cognitive impairment was observed using bilateral bed grab bars for bed mobility and transfers, but the care plan did not address grab bar or side rail use. Review of the EMR showed no completed bed mobility device or side rail assessment to determine the necessity or safety of the grab bars, and no documentation that risks and benefits were discussed or that informed consent was obtained. An LPN and the ADON stated that a bed mobility device assessment is required before grab bars are installed and confirmed that no such assessment existed for this resident.
A resident with bilateral heel pressure ulcers and multiple comorbidities received wound care during which an RN removed dressings from both heels, cleansed both wounds, and wiped each heel without changing gloves or performing hand hygiene between wounds or after disposing of soiled dressings. This practice conflicted with the facility’s written wound care procedure, which requires glove removal and hand hygiene after dressing removal and after wound cleansing. In interviews, the RN, NP, and DON/IP acknowledged that hand hygiene and glove changes are expected between dirty and clean tasks and between separate wounds to prevent infection.
A resident with MS, neurogenic bladder, mobility limitations, and existing pressure injuries was identified as dependent for toileting hygiene and at risk for pressure ulcers, yet the care plan lacked an individualized toileting/incontinence plan and a defined repositioning schedule. Despite a new coccyx pressure ulcer and documentation that interventions such as increased repositioning and incontinent care were needed, the care plan was not revised for a period of time to reflect these changes. During this time, the resident sometimes fell asleep on a bedpan and remained on it until staff removed it, and staff were not initially informed that the bedpan should no longer be used. The DON later acknowledged that the care plan revisions for turning, repositioning, and toileting were delayed until after the resident’s coccyx ulcer had significantly worsened.
A resident with diabetes, Crohn’s disease, bowel incontinence, and a history of MASD on the right gluteus developed an open, painful lesion on the right gluteal area that was documented over time without complete wound characteristics, clear etiology, or timely provider notification. Wound care orders were written for a stage 3 pressure ulcer on the left buttocks, while staff reported the wound was only on the right side and applied the left‑sided orders to the right gluteal wound in the absence of specific right‑side treatment orders. The DON acknowledged discomfort with staging the wound, lack of early physician notification, and confusion over wound classification, despite a facility policy requiring comprehensive wound assessment, consistent measurement, and provider notification when treatment orders are absent.
A resident with diabetes, chronic leg ulcer, kidney transplant, and a documented gluteal wound was care-planned for Enhanced Barrier Precautions (EBP), with posted instructions requiring gown and gloves for high-contact care such as transfers and wound care. During a telehealth wound assessment, the DON donned a gown and initially performed hand hygiene but then applied gloves without hand hygiene, removed a soiled dressing from the resident’s gluteal area, discarded it, removed gloves, and applied new gloves again without performing hand hygiene between glove changes. On another occasion, during use of a sit-to-stand lift, an NA wore gown and gloves, but the DON handled the lift harness, the resident’s clothing, and assisted with the transfer and repositioning while wearing a gown but no gloves, despite EBP requirements for transfers. The DON stated EBP was only needed for catheter or wound care and not for transfers, contradicting the posted EBP instructions and facility policy.
A resident with severe dementia, psychiatric disorders, and high dependence for ADLs was verbally abused during evening care when a NA, frustrated with the resident’s crying and resistance, loudly ridiculed her as acting like a two-year-old, threatened to hit her back if struck, told her she would be sent to a locked unit, and questioned who would want to care for her when she cried like a baby. Multiple staff witnessed the loud, stern, and intimidating tone and reported it to an LPN, who recognized it as verbal abuse but did not immediately remove the NA from duty or promptly report the allegation per policy, allowing the NA to continue working on the unit. Following this incident, the resident demonstrated increased crying, combativeness, resistance to care, wandering, self-isolation, and refusal of food, fluids, and medications above baseline, with documentation of significant emotional distress and subsequent ED evaluation for aggressive behaviors and poor intake.
A resident with dementia, bilateral above‑knee amputations, vascular disease, and severe protein‑calorie malnutrition developed a wound on an amputation stump that had a dressing dated several days before any documentation or treatment orders appeared in the record. Although bath audits and nursing notes initially reported no skin issues, a later assessment described a full‑thickness stage 4 ulcer/diabetic ulcer on the stump with exposed bone, erythema/edema, slough, and moderate serosanguineous drainage. Nursing staff interviews showed no one could identify who first discovered the wound or applied the initial dressing, and there was no evidence that the wound was assessed, the provider notified, or standing orders implemented when it was first present, despite facility expectations that new wounds be promptly evaluated and reported.
Failure to Follow Professional Standards for Ophthalmic Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice for administering ophthalmic medications to a resident with dry eye syndrome and degenerative eye disease. The resident was cognitively intact, required assistance with ADLs, and had physician orders for cyclosporine ophthalmic emulsion 0.05% one drop in both eyes twice daily and Refresh Tears ophthalmic solution one drop in both eyes four times daily for dry eyes. The administration summary showed that both eye medications were scheduled for the same time and were documented as being given at the same time on multiple dates. During a medication pass observation, a trained medication aide administered the ordered oral medications, then applied gloves and instilled one drop of cyclosporine in each eye, immediately followed by one drop of Refresh Tears in each eye, without any waiting period between the two medications. The surveyors referenced guidance from the American Academy of Allergy, Asthma, and Immunology stating that when more than one eye drop is ordered, three to four minutes should be allowed between drops in the same eye, and five to fifteen minutes should be allowed between different eye medications to prevent dilution. Interviews with the DON, pharmacy consultant, and medical provider confirmed that best practice and the provider’s recommendation were to wait between administration of cyclosporine and Refresh Tears, with the medical provider specifying a fifteen-minute interval. The facility did not provide a policy on ophthalmic medications when requested. The observed practice and documented administration times demonstrated that staff did not follow these professional standards or the medical provider’s recommended interval between the two eye medications.
Failure to Follow Wheelchair Transport Care Plan Leads to Fall With Injuries
Penalty
Summary
The deficiency involves the facility’s failure to implement care-planned fall prevention interventions for a resident at high risk for falls, resulting in a fall with injury. The resident had diagnoses including aphasia, dysphagia, muscle weakness, traumatic brain injury, and impaired mobility, with severe cognitive impairment documented on the MDS and dependence on staff for transfers and wheelchair transport. A care plan addressing wheelchair transport safety and positioning directed staff to ensure the resident was fully positioned and supported in the wheelchair prior to transport, verify footrests were in place prior to transport, and monitor for leaning, sliding, or unsafe positioning. An additional care-planned approach required wheelchair pedals to be on at all times. On the date of the incident, a nursing assistant transported the resident in a manual wheelchair from the shower room to the resident’s room without the foot pedals in place, contrary to the care plan. While being wheeled through the doorway, the wheelchair struck the door frame, causing the chair to stop and the resident, who had begun leaning forward, to fall out of the wheelchair onto the floor. Progress notes and ED documentation identified that the resident sustained a T12 vertebral fracture, a head injury with concussion, an abrasion and contusion to the head, a bruise to the left knee, and multiple lacerations to the right hand requiring sutures. The nursing assistant later acknowledged awareness that the foot pedals should have been on but did not apply them because the transport was only from the shower to the room. The DON confirmed that the resident’s care plan had not been followed when the fall occurred.
Failure to Implement and Update Pressure Ulcer Prevention and Treatment Led to Avoidable Unstageable Coccygeal Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, monitor, and implement individualized pressure ulcer prevention and treatment interventions for multiple high‑risk residents, resulting in an avoidable, unstageable coccygeal pressure ulcer for one resident that required surgical debridement and hospitalization. The resident had primary progressive multiple sclerosis, hereditary spastic paraplegia, obesity, and pre‑existing pressure‑related deep tissue injury to the left heel, and was identified as high risk for pressure ulcers on the Braden Scale due to constant moisture, chairfast status, very limited mobility, inadequate nutrition, and friction/shear risk. Hospital records on readmission documented irritant contact dermatitis of the bilateral gluteal cleft with specific cleansing and barrier cream orders, and facility documentation showed the resident could not reposition in bed or chair and required assist of two and a full‑body mechanical lift for transfers. Despite this, the admission/readmission skin assessment and weekly skin checks lacked measurements and detailed wound characteristics for the heel ulcer and gluteal dermatitis, and the care plan did not include comprehensive, individualized interventions beyond generic repositioning and wound care orders. After a new coccyx pressure ulcer was identified and documented as a stage 2 lesion, the facility failed to promptly and accurately update the care plan and implement recommended pressure‑relieving interventions. The wound nurse practitioner on 3/5 ordered coccyx wound care, an air mattress, pressure offloading, and a dietician consult, but the care plan was not revised and there was no evidence that an air mattress was placed on the bed for nearly two weeks. The environmental services director later confirmed that when the resident was moved to a new room, the gel mattress was not transferred, and the air mattress requested on 3/17 was not actually placed until the following day, despite being marked as completed. During this period, TAR documentation showed gaps in the every‑2‑hour repositioning order, and staff interviews revealed that CNAs were unaware of which residents were on repositioning programs, were not consistently repositioning residents, and had not received recent education on pressure ulcer prevention. The DON and RN case manager acknowledged that the coccyx wound increased in size and changed color between assessments, that the bed lacked the ordered gel mattress, and that the physician was not notified of the wound’s deterioration at that time. The facility also failed to timely modify toileting and incontinence care practices despite knowledge that the resident was being left on a bedpan for extended periods. The DON reported hearing before an IDT meeting that the resident had fallen asleep on a bedpan for an undetermined amount of time, but the care plan was not revised to discontinue bedpan use and implement a bedside commode until after the coccyx wound had significantly worsened. CNAs confirmed that the resident sometimes fell asleep on the bedpan and that they were not informed she should no longer use it until after the sore had worsened. Subsequent wound assessments documented rapid progression of the coccyx wound from a small stage 2 ulcer to a large, malodorous, necrotic wound with eschar, slough, erythema, and purulent drainage, ultimately classified as an unstageable pressure ulcer. The DON, NP, PA, and medical director all indicated that the lack of a pressure‑relieving mattress, failure to adjust pressure‑reducing interventions, and prolonged time on a bedpan likely contributed to the development and deterioration of the resident’s pressure ulcer, which was determined to be avoidable and resulted in hospitalization and surgical debridement. Additional documentation and interviews showed systemic assessment and communication failures related to pressure ulcer management. Weekly skin checks and wound assessments often omitted complete measurements, staging, and wound characteristics, and changes in wound size and appearance were not consistently recognized as deterioration or communicated to providers. The DON acknowledged that a 3/12 assessment showing increased wound size and purple discoloration should have been identified as a deep tissue injury and reported to the physician, but this did not occur. When nursing later documented foul odor, increased pain, and expanding necrotic tissue, telemedicine and PA responses deferred in‑person evaluation and ED transfer despite earlier recommendations that the resident be sent to the ED if an in‑person provider could not assess the wound. The NP ultimately found a large, malodorous, purulent wound with expanding eschar and ordered transfer to the hospital, where imaging and surgical findings confirmed a large necrotic sacral wound requiring extensive debridement. Throughout this sequence, the facility did not consistently follow its own pressure ulcer protocols, did not ensure ordered pressure‑relieving equipment was in place, and did not promptly revise care plans or interventions in response to known risk factors and documented wound changes. The report also notes that other residents reviewed for pressure ulcers were affected by similar failures in monitoring and individualized intervention, though detailed narratives focus primarily on this resident. Staff interviews revealed that CNAs relied on paper care guides that did not clearly identify residents on repositioning programs or at risk for skin breakdown, and that they were unaware of some residents’ special mattress orders or toileting restrictions. The DON and medical director stated that residents at risk for pressure ulcers should have immediate pressure‑relieving interventions and that existing ulcers require ongoing evaluation to prevent deterioration, but the documented practices for this resident did not align with those expectations. These combined actions and inactions—insufficient assessment detail, delayed or missing care plan revisions, failure to implement ordered support surfaces and repositioning, and delayed response to wound deterioration—constituted the deficiency in providing appropriate pressure ulcer care and preventing new ulcers from developing.
Failure to Assess, Care Plan, and Obtain Consent for Bed Grab Bar Use
Penalty
Summary
The deficiency involves the facility’s failure to follow required procedures before installing and using bed grab bars for a resident. The resident had diagnoses including spastic hemiplegia affecting the left side and muscle weakness, and an admission MDS indicating moderate cognitive impairment. During observation, the resident was seen in a power chair with bilateral grab bars on the bed and reported using them to roll in bed and for transfers. The resident’s care plan, dated 1/23/26, documented a need for assistance with bed mobility and independence with transfers but did not mention or address the use of grab bars or side rails. Review of the electronic medical record showed no completed grab bar/side rail or bed mobility device assessment to determine the necessity of the grab bars or whether the resident could safely use them. There was also no evidence that the resident or the resident’s representative had been educated on the risks of having a grab bar on the bed or that informed consent had been obtained. In interviews, an LPN and the ADON both stated that a bed mobility device assessment was required to determine need and safety prior to installing grab bars, and both confirmed that no such assessment was present in the resident’s record.
Failure to Perform Hand Hygiene and Change Gloves During Wound Care
Penalty
Summary
Surveyors observed that a registered nurse (RN) and a nurse practitioner (NP) did not follow the facility’s established infection control practices during wound care for one resident. During a wound treatment, the RN wore gloves while removing the dressing from the resident’s left heel, then removed the dressing from the right heel, sprayed both wounds with wound cleanser, wiped the left heel with gauze, and then used a clean gauze pad to wipe the right heel. The RN did not remove her gloves or perform hand hygiene after disposing of the soiled dressings or between cleaning the left and right heel wounds, contrary to the facility’s written wound care procedure, which requires glove removal and hand hygiene after removing the previous dressing and again after cleaning the wound. The resident’s admission MDS documented diagnoses including multiple rib fractures, heart failure, dementia, anxiety, and the presence of a pressure ulcer, and indicated the resident was cognitively intact and required staff assistance with care and transfers. The resident’s care plan identified pressure ulcers on both heels requiring wound care. In interviews, the RN, NP, and the DON/infection prevention nurse each stated that gloves should be changed when moving from dirty to clean areas and that hand hygiene is expected after glove removal and between wounds to prevent infection, confirming that the observed practice did not align with facility policy or expected infection control standards.
Failure to Timely Revise Care Plan for Toileting and Skin Integrity
Penalty
Summary
The deficiency involves the facility’s failure to timely revise and individualize a resident’s care plan to address toileting and incontinence needs in relation to impaired skin integrity. The resident had diagnoses including primary progressive multiple sclerosis, hereditary spastic paraplegia, obesity, and a pressure-induced deep tissue injury to the left heel. A Significant Change MDS identified the resident as dependent for toileting hygiene, with lower extremity range-of-motion limitations, wheelchair use, dependence for transfers, occasional urinary incontinence, intact cognition, and at risk for pressure ulcers with existing unhealed pressure injuries and MASD. The resident’s skin-focused care plan, revised on various dates, included skin inspections, wound care orders, weekly skin checks, pressure ulcer care to the left heel, nutritional supplements, and a gel mattress, but did not include an individualized toileting or incontinence plan. On a weekly skin check dated 3/3/26, nursing staff identified a new Stage 2 pressure ulcer on the coccyx and contact dermatitis on both gluteal folds. An IDT Final Post Review Follow Up dated 3/10/26 (signed 3/23/26) documented that a new skin issue had occurred and that interventions after the incident included wound care treatment orders, increased repositioning, and increased incontinent care. However, the resident’s care plan from 3/3/26 through 3/16/26 did not show revisions reflecting increased incontinence care or a repositioning schedule, and the care plan was not updated to include these elements until 3/17/26. During this period, the care plan still lacked an individualized toileting plan despite the resident’s identified incontinence and new coccyx pressure ulcer. Progress notes on 3/17/26 documented that the resident’s coccyx wound had declined, with an evaluation describing a deteriorating wound characterized as a Kennedy terminal ulcer/End of Life, staged as a Stage 4 pressure ulcer, in-house acquired, with increased size, exudate, odor, pain, and surrounding erythema. On that same date, the skin focus care plan was revised to include prompt incontinence care and keeping the skin clean and dry, and the elimination focus care plan was revised to address incontinence due to neurogenic bladder with use of a bedside commode offered every 2–3 hours. A nursing assistant reported that when working with the resident, the resident would sometimes fall asleep on the bedpan and forget to ask staff to remove it, and that she was not aware the resident was not supposed to use the bedpan until after the sore had worsened. The DON stated that the resident’s care plan had not been revised earlier to include a turning and repositioning schedule or toileting changes, and that it should have been revised as soon as staff learned the resident was falling asleep on the bedpan, rather than waiting until after the pressure ulcer worsened.
Failure to Assess and Notify Provider for Right Gluteal Wound
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess and appropriately manage a non‑pressure skin issue on a resident’s right gluteal area, and to notify the physician in a timely manner. The resident had diagnoses including diabetes, Crohn’s disease, and a kidney transplant, and the MDS indicated occasional bowel incontinence, no pressure ulcers, and no moisture‑associated skin damage at that time. Earlier documentation identified a resolved MASD to the right gluteus, and a progress note later described a sacral wound with creams applied, noting that sores were still open and painful during application, but without any measurements, wound characteristics, or evidence of physician notification. Subsequent wound assessments documented an open lesion on the right gluteus with specific measurements on multiple dates, but did not identify the wound type or other characteristics, and the record did not show physician notification or treatment orders for the right gluteal lesion. Provider orders in place initially addressed cleansing the buttocks and applying barrier cream, and later included a detailed wound care order for a stage 3 pressure ulcer documented on the left buttocks. However, the resident’s record did not contain a specific treatment order for the right gluteal wound, despite the ongoing documentation of an open lesion in that area. Interviews revealed confusion and inconsistency in wound identification and classification. The DON stated that the right gluteal wound was documented as an open lesion because she did not feel comfortable determining the wound type, and acknowledged that the physician should have been notified when the wound was first identified. The DON was unaware that the NP had documented the wound as being on the left buttocks and as a stage 3 pressure ulcer, while the RN reported that the wound had never been on the left buttocks and that she had been applying the left‑sided wound orders to the right gluteal area because there was no open area on the left. The resident reported a recurring painful area on the right buttocks and chronic stool leakage since prior anal fistula surgery. The facility’s own wound treatment policy required comprehensive assessment of wound etiology and characteristics, consistent measurement and documentation, and provider notification in the absence of treatment orders, which were not followed for this resident’s right gluteal wound. The deficiency centers on the lack of a comprehensive wound assessment for the right gluteal lesion, incomplete documentation of wound characteristics, failure to clearly determine and document the wound etiology, and failure to notify the physician and obtain appropriate treatment orders when the wound was identified and remained open. These actions and inactions resulted in a discrepancy between the documented wound location and type and the actual clinical presentation, as well as a period during which the right gluteal wound had no specific, clearly ordered treatment despite being open and painful.
Failure to Perform Hand Hygiene and Implement Enhanced Barrier Precautions During Wound Care and Transfers
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper hand hygiene during wound care and to consistently implement Enhanced Barrier Precautions (EBP) for a resident requiring such measures. The resident had diagnoses including diabetes, a non-pressure chronic ulcer of the right lower leg, and a kidney transplant, and a wound assessment documented an open lesion on the right gluteal area. The resident’s care plan and a sign posted outside the room specified that EBP, including gown and gloves, were required for high-contact care activities such as dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, catheter care, and wound care. During one observation, the DON performed hand hygiene and donned a gown before entering the resident’s room for a telehealth wound assessment. Inside the room, the DON went into the bathroom, applied gloves without performing hand hygiene, removed the resident’s brief, and removed a foam dressing from the right gluteal area that had stool on one corner. After discarding the soiled dressing, the DON removed gloves and then applied new gloves without performing hand hygiene between glove changes. When questioned, the DON stated that hand hygiene should be done when hands or gloves are visibly soiled and before and after removing or applying gloves, and acknowledged that hand hygiene had not been performed each time gloves were removed and reapplied. In a separate observation, the resident was transferred using a sit-to-stand mechanical lift while EBP requirements were not fully followed. An NA entered the room wearing a gown and gloves with the lift, and the DON applied the lift harness under the resident’s arms and cinched the waist strap, encountering the resident’s clothing, while not wearing gloves. After the transfer to bed, the DON pulled down the resident’s pants and removed the harness while touching the resident’s clothes. Following wound care by a CNP-WOC, the DON again assisted the resident by sitting the resident on the edge of the bed, applying the lift harness, and adjusting the resident’s pants and shirt while wearing a gown but no gloves. The DON stated that EBP was only needed for catheter or wound care and not for transfers, and only upon reading the posted EBP sign acknowledged that EBP was required for all high-contact resident care activities, including transfers.
Failure to Protect Resident From Verbal Abuse and Delay in Removing Alleged Perpetrator
Penalty
Summary
The deficiency involves the facility’s failure to protect a vulnerable resident from mental abuse and to respond appropriately to an allegation of abuse. The resident had severe cognitive impairment, Alzheimer’s disease, dementia, anxiety, depression, psychotic disorder, and significant functional dependence, including frequent incontinence and the need for extensive assistance with ADLs and transfers. Her care plan identified behavioral and mood issues such as wandering, yelling, combative behavior, and calling staff names, with interventions including calm approaches, emotional support, redirection, and monitoring for emotional distress and mood/behavior changes. She was identified as a vulnerable adult, with instructions to monitor for signs of emotional distress and to follow the facility’s abuse reporting policy. On the evening in question, while the resident was crying on the phone with her son and expressing a desire to leave, NA-A and NA-B entered to provide evening care using an EZ stand lift. After the resident ended the phone call, multiple staff reported that NA-A spoke to the resident in a loud, stern, and frustrated tone, telling her to stop crying and that she was acting like a two-year-old. When the resident swatted at NA-A, NA-A stated, “If you hit me, I’m going to hit you back,” and later told the resident she was “in trouble now.” Staff reported that NA-A told the resident she would be sent to a locked unit so she could not get out, and questioned who would want to care for her when she cried like a baby, and that nobody would want to keep working with her. NA-C described NA-A yelling commands such as “HOLD ON!” and “Stop crying! Where would you be if you were not here? Probably lying on the floor,” and felt NA-A was obviously upset and overwhelmed. These statements were made in the presence of the resident while she was already distressed and crying. Following this interaction, the resident exhibited crying, yelling, combativeness, resistance to care, wandering into other residents’ rooms, self-isolation, and refusal of food, fluids, and medications above her prior baseline, as documented in behavior charts, target behavior monitoring, and nursing progress notes. Staff documented that she cried most of the morning, was very restless, difficult to redirect, hit and pinched staff, called staff names, and refused care and meals. She required repeated redirection, 1:1 attention, and non-pharmacological interventions, and was ultimately sent to the ED for evaluation of combativeness and emotional distress, where she was treated for dementia with aggressive behavior and hypoglycemia related to poor intake. The report identifies that the resident’s actual response and the reasonable person concept showed serious psychosocial harm, including increased crying and combative behavior above baseline, fear/anxiety manifested as combativeness, resistance to care and social interaction, and self-isolation. The facility also failed to immediately remove the alleged perpetrator from resident care and to promptly report and investigate the allegation in accordance with its abuse policy. After NA-B and NA-C reported to LPN-A that NA-A had yelled at and threatened the resident, LPN-A acknowledged it as verbal abuse but did not initiate immediate protective measures or timely reporting. LPN-A stated she believed she had 24 hours to report because there was no injury, despite facility policy requiring reporting within two hours. NA-A remained on the unit and continued working until the end of her shift, including after staff had clearly communicated their concerns to LPN-A. TMA and NA staff described uncertainty about their authority to remove NA-A and reliance on the nurse to act, while the DON later informed LPN-A that NA-A should have been removed from the floor to prevent further danger to residents. The Immediate Jeopardy was determined to have begun when NA-A’s derogatory, intimidating, and threatening statements were made and continued while she remained on duty with access to the resident and other vulnerable residents.
Failure to Timely Assess and Treat Newly Discovered Stump Wound
Penalty
Summary
The deficiency involves the facility’s failure to provide timely treatment and care for a newly discovered wound on a resident’s above‑knee amputation stump. The resident was admitted with diagnoses including unspecified dementia with behavioral disturbances, vascular dementia, bilateral above‑knee amputations, vascular disease, reduced mobility, and severe protein‑calorie malnutrition, and had no documented ulcers or skin problems on admission or on the most recent MDS. A weekly bath audit on 3/17/26 documented only non‑tender lymph nodes on the right upper hip and did not identify any open areas. However, when the wound was later assessed, the dressing on the stump was dated 3/16/26, indicating that a wound and dressing existed at that time, even though no corresponding assessment, provider notification, or treatment orders were documented. On 3/23/26, nursing staff documented a new skin issue above the resident’s knee at the amputation site, describing a stage 4 pressure ulcer/injury with full‑thickness skin and tissue loss, exposed bone, erythema/edema, and moderate serosanguineous exudate. The wound measured 1.56 cm by 1.64 cm, with 20–29% granulation tissue and 80% slough. A progress note and skin issues assessment on that date confirmed the wound characteristics and staging, and the NP, after reviewing a picture, determined the wound to be a diabetic ulcer with peripheral vascular disease and severe protein‑calorie malnutrition as contributing factors. On that same date, the NP was notified, antibiotic therapy (doxycycline) was ordered for possible cellulitis, and specific wound care orders were initiated, with documentation on the MAR that these treatments were carried out beginning 3/23/26. Multiple interviews with nursing staff revealed that no one could identify who discovered the wound or who applied the initial dressing dated 3/16/26, and there was no documentation of a wound assessment, provider notification, or interim treatment between 3/16/26 and 3/22/26. Several RNs and LPNs who worked shifts from 3/16/26 through 3/20/26 stated they did not notice a wound on the stump and that, per their usual practice, they would have contacted the provider and initiated treatment if they had found one. One LPN recalled seeing a band‑aid with a date on the stump but could not recall the date, and another LPN stated she did not see the wound because she was not looking for one. The facility’s standing orders required staff to assess all wounds daily, change dressings every three days and as needed, treat with normal saline or non‑cytotoxic cleanser and appropriate dressings, and notify the provider the next business day when a new wound or injury was found. Despite these expectations, the wound identified by the dated dressing on 3/16/26 was not assessed, reported, or treated according to orders and facility policy until 3/23/26.
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