Mount Olivet Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Minneapolis, Minnesota.
- Location
- 5517 Lyndale Avenue South, Minneapolis, Minnesota 55419
- CMS Provider Number
- 24E102
- Inspections on file
- 16
- Latest survey
- April 30, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Mount Olivet Home during CMS and state inspections, most recent first.
The facility failed to implement and document appropriate interventions and root cause analyses after falls for two residents, resulting in serious injuries including fractures. Additionally, the facility did not complete an elopement risk assessment for a resident who attempted to leave unsupervised, and did not provide required monitoring for a resident with reported swallowing difficulties during meals. Staff interviews and record reviews revealed lapses in care plan updates, supervision, and adherence to facility policies.
Surveyors found that food items in kitchenettes were not consistently labeled or dated, and beverage machines—including coffee, ice/water, and juice machines—were not properly cleaned, with visible residues and standing liquids present. Staff interviews confirmed that all items should be labeled and machines kept clean, but there was confusion about cleaning responsibilities. Facility policy assigned cleaning duties to culinary staff, but observations showed these tasks were not reliably completed.
Two residents with histories of trauma did not have comprehensive care plans that included their identified trauma-related triggers or individualized trauma-informed interventions. Despite assessments and clinical notes detailing specific triggers and care preferences, these were not documented in the care plans or Kardexes, and staff were not consistently aware of them. Facility policy required such documentation, but it was not followed, as confirmed by staff interviews and record reviews.
A resident with MASD to the buttocks did not receive wound care as ordered, including the use of a cloth pillow case over cushions to wick away moisture. Staff were unaware of this intervention due to its absence from the care plan and Kardex, and adhesive dressings were applied despite orders to avoid them. The facility failed to ensure wound care orders were followed and properly documented.
Two residents with histories of trauma did not have their trauma-related triggers or individualized trauma-informed interventions documented in their care plans or Kardexes. One resident with PTSD and other mental health diagnoses had identified triggers and coping strategies that were not included in her care documentation, and staff were unable to identify these triggers. Another resident with severe cognitive impairment and a history of childhood sexual abuse also lacked documentation of specific triggers and preferences, such as a preference for male caregivers, despite clinical recommendations. Staff interviews confirmed the absence of this information in care documentation, contrary to facility policy.
A resident with advanced dementia and other conditions was admitted to hospice care, but the facility did not arrange a required care conference with the hospice team, family, and staff after hospice admission. Documentation and interviews confirmed that no care conference occurred within the expected timeframe, despite facility policy and agreements mandating such collaboration.
The facility failed to properly sanitize dishware due to the high-temperature sanitizing dishwasher not reaching adequate wash and rinse temperatures. The Ecolab dishwasher required a wash temperature of 160 degrees F and a rinse temperature of 180 degrees F, but logs showed these were not consistently met. During an observation, the dishwasher's electronic thermostat showed low temperatures, with alarms that were not acknowledged by the dietary aide. The Culinary Director confirmed the low readings and noted regular servicing by Ecolab, but the issue persisted. Facility policies required monitoring and recording of temperatures to ensure proper sanitization.
The facility failed to ensure proper pharmaceutical services, leading to potential medication errors. An RN prepared insulin for a resident using a pen labeled for another resident, and the facility did not follow procedures for medication storage and disposal for a discharged resident. Staff interviews revealed a lack of routine auditing and misunderstanding of medication handling protocols.
The facility failed to properly label and securely store insulin pens, affecting two residents during insulin administration. Insulin pens were mislabeled, with one pen having a different resident's name and another pen's concentration information covered. Additionally, insulin pens were stored in an unlocked drawer, accessible without unlocking, posing a risk to all residents on the memory care unit.
Three cognitively intact residents expressed frustration over their inability to open windows in their rooms due to facility-imposed restrictions. The facility removed window cranks and installed stoppers to limit window openings, citing safety concerns. However, no individualized assessments were conducted to evaluate residents' ability to manage windows safely, leading to dissatisfaction among residents who valued fresh air.
A resident with cognitive impairment and mobility issues was using an electric lift chair without proper assessment or supervision. The facility's care plan and records did not reflect the use of the chair, and staff interviews revealed a lack of routine assessments for such devices, despite facility policy requiring them.
A resident with moderate cognitive impairment and arthritis experienced frequent pain but did not receive non-pharmacological interventions, despite being on scheduled pain medications. Staff interviews revealed a lack of implementation of non-pharmacological approaches, contrary to the facility's Pain Management Program policy.
A facility failed to use nonpharmacological interventions before administering PRN antipsychotic medication to a resident with anxiety and bipolar disorder, who showed no behaviors requiring intervention. The resident received Seroquel without documentation of attempted interventions, and the medication order lacked a required 14-day limit. Staff interviews revealed a lack of adherence to policy, which mandates nonpharmacological attempts and documentation before PRN medication use.
A facility failed to ensure proper hand hygiene and disinfection of a shared glucometer during blood sugar checks for three residents. An RN did not change gloves or perform hand hygiene between tasks, and the glucometer was not disinfected between uses. Interviews with staff confirmed the lack of adherence to infection control protocols, despite facility policies requiring hand hygiene and glucometer disinfection between residents.
Failure to Implement Fall Interventions, Complete Root Cause Analyses, and Assess Elopement and Swallowing Risks
Penalty
Summary
The facility failed to ensure that interventions were implemented and root cause analyses were completed following falls for two residents, resulting in actual harm. One resident with severe cognitive impairment, Alzheimer's disease, and osteoporosis experienced two unwitnessed falls. The first fall occurred when the resident slid out of bed, with improper footwear identified as a predisposing factor. Although a perimeter mattress was implemented, the intervention for gripper socks was not added to the care plan or consistently documented as refused. The resident later suffered a second fall, again slipping on socks, resulting in a right femur fracture that required surgical intervention. Observations revealed that staff did not consistently provide the required supervision or follow care plan interventions, such as using a walker, transfer belt, or wheelchair during ambulation, and did not ensure proper footwear. Another resident with multiple comorbidities, including COPD, CHF, and a history of falls, experienced two unwitnessed falls in the bathroom, resulting in a head laceration and a fractured clavicle. After the first fall, there was no documentation of a root cause analysis or new interventions added to the care plan, despite facility policy requiring such actions. The only intervention following the second fall was a referral to physical and occupational therapy. Interviews with staff confirmed that root cause analyses and care plan updates were not consistently completed after falls, and there was a lack of clarity on how to determine the resident's safety for independent transfers and toileting after such incidents. The facility also failed to complete an elopement risk assessment for a resident who attempted to leave the facility without supervision, despite policy requiring such assessments upon admission. Additionally, a resident with reported coughing during meals was not monitored while eating in their room, and the care plan and Kardex lacked information about swallowing difficulties or the need for supervision. Staff interviews revealed inconsistent understanding and documentation of monitoring requirements for residents with potential swallowing issues, and there was no evidence that the provider was updated or that a risk versus benefit assessment was completed for eating in the room.
Failure to Properly Label Food and Maintain Cleanliness of Kitchenettes and Beverage Machines
Penalty
Summary
Surveyors observed that the facility failed to ensure proper labeling, dating, and storage of food items, as well as adequate cleaning of kitchenettes and beverage machines on multiple floors. Unlabeled and uncovered food items were found in refrigerators and freezers, and various beverage machines—including coffee, ice/water, and juice machines—had visible residues such as white flaky substances, standing water, and dried or standing brown liquid. These issues were confirmed by staff interviews, who acknowledged that all food items should be labeled and dated, and that machines should be clean and free of stains or water drippings. Further review revealed that there was confusion among staff regarding responsibility for cleaning the machines, with some staff unsure whether culinary or housekeeping was responsible. The facility's policy and cleaning log indicated that culinary staff were responsible for cleaning beverage machines, refrigerators, freezers, and microwaves, and that a cleaning schedule and sign-off log were maintained. However, observations showed that cleaning was not consistently performed according to policy, as evidenced by repeated findings of residue and unclean conditions in all three kitchenettes inspected.
Failure to Develop and Implement Comprehensive Trauma-Informed Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed trauma-related triggers and individualized trauma-informed care approaches for two residents with a history of trauma. For one resident with diagnoses including anxiety, depression, bipolar disorder, and PTSD, assessments identified specific traumatic experiences, emotional responses, and potential triggers such as being touched, loud noises, lack of control, and certain anniversaries. The resident also identified activities that could help her cope. However, her care plan and Kardex did not document these triggers or resident-specific interventions to mitigate the risk of re-traumatization. Interviews with staff confirmed that trauma-related triggers were not included in her care plan, and staff were unable to identify or reference these triggers in her records. For another resident with severe cognitive impairment, Alzheimer's disease, aphasia, depression, PTSD, and a history of childhood sexual abuse, the trauma assessment indicated that his trauma could influence his resistance to bathing and other behaviors. While his care plan acknowledged his trauma history and included some general behavioral interventions, it did not specify his trauma-related triggers or preferences for male versus female caregivers, despite documentation in clinical notes that he responded better to male caregivers and benefited from paired care with female staff. The Kardex also lacked documentation of specific triggers and preferences, and staff interviews revealed inconsistent awareness of his trauma-related needs. Facility policy required individualized care plans to address past trauma and minimize exposure to triggers, but the care plans and Kardexes for both residents did not meet these requirements. Staff interviews confirmed that trauma-related triggers and interventions were not consistently documented or communicated, increasing the risk that staff would not be aware of or able to avoid re-traumatizing residents with PTSD. The deficiency was identified through interviews, document reviews, and direct observation of care planning practices.
Failure to Implement and Document Wound Care Orders for Skin Integrity
Penalty
Summary
The facility failed to follow and implement wound care orders for a resident with moisture associated skin damage (MASD) to the buttocks. The resident, who was cognitively intact, ambulatory, and independent with most activities of daily living, had a care plan indicating a potential for skin integrity issues due to urinary incontinence, but was not at risk for pressure ulcers according to the most recent assessments. Despite this, the resident developed MASD, and wound care orders were issued by the nurse practitioner, including specific instructions not to use adhesive dressings and to ensure that any cushions or pads used by the resident were covered with a cloth pillow case to wick away moisture. Observations and interviews revealed that these wound care interventions were not consistently implemented. The resident was repeatedly observed sitting on a cushion without a cloth or pillow case, contrary to the wound care plan. Staff interviews confirmed that the intervention to cover cushions with a pillow case was not included in the resident's care plan or Kardex, and nursing assistants were unaware of the requirement. Additionally, there were instances where staff applied dressings to the affected area despite explicit orders not to use adhesives, and the resident reported that staff did not consistently apply prescribed creams and did not communicate with him about the progress of his skin condition. Documentation review further showed that the care plan and Kardex lacked the necessary interventions for moisture management as directed by the nurse practitioner. The facility's policy required that interventions be care planned according to resident assessment and risk factors, but this was not done in this case. The director of nursing confirmed that orders should be followed and care planned, and staff should be aware of all interventions, but this expectation was not met, resulting in the deficiency.
Failure to Document Trauma-Related Triggers and Interventions in Care Plans
Penalty
Summary
The facility failed to ensure that trauma-related triggers and individualized trauma-informed interventions were documented in the comprehensive care plans for two residents with a history of trauma. One resident, who had diagnoses including PTSD, anxiety, depression, and bipolar disorder, had completed a trauma assessment identifying specific traumatic experiences, emotional responses, and potential triggers such as being touched, loud noises, lack of control, and certain anniversaries. The assessment also listed activities that could help her cope. However, her care plan and Kardex did not include these identified triggers or resident-specific interventions to mitigate the risk of re-traumatization. Staff interviewed were unable to identify her trauma-related triggers and confirmed that such information was not present in the care documentation they used. Another resident, who had severe cognitive impairment, aphasia, and a history of childhood sexual abuse, was also missing documentation of trauma-related triggers in his care plan and Kardex. Although his care plan acknowledged his trauma history and included some general behavioral interventions, it did not specify his preference for male versus female caregivers, despite clinical notes indicating he responded better to male caregivers and benefited from paired care with female caregivers. Staff interviews revealed a lack of awareness of his trauma-related triggers and preferences, and the recommended interventions from clinical notes were not consistently transcribed into the care plan or Kardex. Staff relied on word of mouth and daily huddles for information, but key details were not formally documented. Facility policy required individualized care plans to address past trauma and identify and decrease exposure to triggers that may re-traumatize residents. Despite this, the care plans and Kardexes for both residents lacked the necessary documentation of triggers and specific interventions. Multiple staff members, including nursing assistants, nurses, and social services, confirmed that trauma-related triggers and recommended interventions were not present in the care documentation, which could have impacted the care provided to these residents.
Failure to Coordinate Hospice Care Conference After Admission
Penalty
Summary
The facility failed to collaborate with hospice for the development, implementation, and revision of a coordinated plan of care for a resident who was receiving hospice services. The resident, who had diagnoses including Alzheimer's disease, non-Alzheimer's dementia, depression, and anxiety, was identified as having severely impaired cognition and was on hospice care. Documentation showed that the care plan directed staff to work cooperatively with the hospice team to meet the resident's needs, and the hospice plan of care emphasized coordination between the facility, hospice, the resident, and her family. However, there was no documentation of a care conference after the resident's admission to hospice, despite facility policy and hospice agreement requiring such collaboration. Interviews with the resident's family, hospice RN, social services, and the DON confirmed that a care conference had not been held within the expected timeframe after the resident's admission to hospice. The last documented care conference occurred prior to the resident's hospice admission, and both facility and hospice staff acknowledged that the required meeting had not taken place. The facility's policy and hospice agreement both specified the need for coordinated care and family involvement, but these were not followed in this instance.
Dishwasher Sanitization Failure
Penalty
Summary
The facility failed to ensure proper sanitization of dishware used for meal preparation and resident service due to the high-temperature sanitizing dishwasher not reaching adequate wash and rinse temperatures. The Ecolab EC-66HH dishwasher specifications required a wash temperature of 160 degrees F and a sanitizing rinse temperature of 180 degrees F. However, the facility's Culinary Services Dish Washer Temperature Log indicated that the final rinse temperatures only reached 180 degrees F once from June 1 to June 26, 2024. During an observation, the dishwasher's electronic thermostat showed wash temperatures as low as 140.1 degrees F and rinse temperatures as low as 175 degrees F, with alarms sounding for low temperatures that were not acknowledged by the dietary aide (DA). The DA was unaware of the alarm and did not monitor the temperatures, stating he was unsure of the required wash and rinse temperatures. The Culinary Director (CD) verified the low temperature readings and reset the alarm, confirming that the dishwasher used heat for sanitizing dishes and that the temperature gauges indicated a need for 150 degrees F for wash and 180 degrees F for rinse. Despite regular servicing by Ecolab, the facility logs showed rinse temperatures below the required 180 degrees F. The assistant administrator expected dishwasher temperatures to be monitored to ensure proper sanitization, and if not met, the CD should notify maintenance or Ecolab for assistance. Facility policies directed staff to monitor and record dish machine temperatures to ensure proper sanitization, with the dietary manager responsible for spot-checking logs and ensuring appropriate temperatures were maintained.
Medication Administration and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper pharmaceutical services, specifically in the administration of insulin to the correct resident and adherence to medication receiving procedures. During an observation, RN-D prepared an insulin pen labeled for a different resident and facility, intending to administer it to a resident with moderate cognitive impairment and multiple diagnoses, including diabetes. Despite recognizing the label discrepancy, RN-D proceeded to prepare for administration until stopped by another staff member. The insulin pen was not found in the designated storage, and the pharmacy was contacted for clarification. Further investigation revealed that the facility did not follow proper procedures for medication storage and labeling. A discharged resident's medications, including insulin, were found in the medication storage room and cart, contrary to the facility's policy. The medications were not disposed of or returned to the pharmacy, and there was no discharge drug disposition form in the resident's electronic health record. Interviews with staff indicated a lack of routine auditing of medication storage and a misunderstanding of procedures for handling medications of discharged residents. The facility's policies required staff to verify medications upon delivery and ensure correct labeling before administration. However, the staff failed to adhere to these protocols, leading to potential medication errors. The director of nursing and consulting pharmacist emphasized the importance of following the six rights of medication administration and the three-check process, which were not consistently practiced, as evidenced by the incidents involving insulin administration and medication storage.
Improper Labeling and Storage of Insulin Pens
Penalty
Summary
The facility failed to ensure that insulin pens were labeled in accordance with professional standards for two of the three residents observed during insulin administration. Specifically, insulin pens for residents R18 and R53 were not properly labeled. R18's insulin pen had a label with a different resident's name and a different facility's name, which was not the name of the resident for whom the insulin was prepared. R53's insulin pen had a label that covered the concentration information, and the facility's label did not include the order directions such as the prescribed dose. These labeling issues were identified during observations and interviews with nursing staff, who acknowledged the potential for medication errors due to incorrect labeling. Additionally, the facility failed to store insulin pen-injectors in a locked compartment, which had the potential to affect all 31 residents residing on the locked memory care unit. During observations, insulin pens were found in an unlocked drawer behind the nursing station, which was accessible without unlocking. The nursing staff, including RN-D and LPN-C, confirmed that the insulin pens were kept in an unlocked drawer and that the half-door to the nursing station was also unlocked. This lack of secure storage posed a risk of unauthorized access to the insulin pens. The facility's policy on medication storage indicated that medications and biologicals were to be stored safely, securely, and properly, accessible only to authorized personnel. However, the policy did not specify the information required on pharmacy labels. Interviews with the director of nursing and consulting pharmacist highlighted the expectation that medication labels should not cover important information and that insulin pens should be locked up to prevent unauthorized use. Despite these expectations, the facility's practices did not align with the policy, leading to the identified deficiencies.
Failure to Accommodate Resident Preferences for Window Operation
Penalty
Summary
The facility failed to accommodate the preferences of three residents who wished to open the windows in their rooms. Resident 16, who was cognitively intact and had several medical conditions including depression and heart failure, expressed frustration over the inability to open their windows due to the removal of window cranks. The facility had removed the cranks following a directive to prevent windows from being opened more than four inches, citing safety concerns. However, Resident 16, who was not at risk of jumping or falling out, was unable to open the windows independently, leading to dissatisfaction. Similarly, Resident 60, who was also cognitively intact and had a preference for fresh air, was unable to fully open their sliding window due to a black stopper that limited the opening to six inches. Despite understanding the safety rule for confused residents, Resident 60 expressed frustration over the restriction, as they valued having fresh air. Resident 61, another cognitively intact individual, faced the same issue with their sliding window, which was also restricted by a black stopper. This resident expressed frustration, questioning the necessity of the restriction given their cognitive status. Interviews with staff revealed that the facility had not conducted individualized assessments to determine if residents were capable of safely managing their windows. The assistant administrator and director of nursing acknowledged the restriction was based on a consultant's recommendation to mitigate safety risks. However, the facility's policy emphasized respecting residents' rights to self-determination, which was not upheld in this instance, as the residents' preferences for window operation were not accommodated.
Failure to Assess Electric Lift Chair Use for Resident
Penalty
Summary
The facility failed to ensure that an electric lift chair was assessed for safe use for a resident with cognitive impairment and multiple diagnoses, including osteoporosis, spinal stenosis, and dementia. The resident required partial to moderate assistance for transfers and used a walker for mobility. Despite these needs, the resident's care plan, Kardex, and medical records lacked any indication of the use of an electric lift chair or the need for assistance with it. Observations revealed the resident was using the lift chair independently, but was confused about its operation, indicating a lack of proper assessment and supervision. Interviews with staff, including a trained medication assistant, LPN, RN, and the Director of Nursing, revealed inconsistencies in the assessment process for electric lift chairs. The staff acknowledged that assessments for such devices were not routinely completed, and there was no provider order for the chair. The chair was brought in by the resident's family, and the facility's policy required assessments for physical devices upon admission, annually, and with significant changes. However, this policy was not followed, leading to the deficiency in ensuring the resident's safety while using the electric lift chair.
Failure to Implement Non-Pharmacological Pain Management
Penalty
Summary
The facility failed to implement resident-specific non-pharmacological interventions for pain management for a resident with moderate cognitive impairment and multiple diagnoses, including rheumatoid arthritis and osteoarthritis. The resident, who was independent with ambulation, reported frequent pain in the knees and right hip, rating it at a level four on a 1-10 scale. Despite receiving scheduled pain medications such as acetaminophen, methotrexate, prednisone, and Voltaren, the resident did not receive any PRN medications or non-pharmacological interventions. The care plan lacked resident-centric approaches to address the resident's pain, and the resident expressed a desire not to be on more medications. Interviews with staff, including a trained medication aide, nursing assistant, registered nurse, and the director of nursing, revealed that non-pharmacological interventions were not utilized or documented in the care plan. The staff acknowledged the importance of trying alternatives to limit medication use, but no such interventions were in place for the resident. The facility's Pain Management Program policy emphasized the need for both pharmacological and non-pharmacological interventions, but this was not reflected in the resident's care plan or practice.
Failure to Utilize Nonpharmacological Interventions and Adhere to PRN Antipsychotic Medication Policy
Penalty
Summary
The facility failed to ensure nonpharmacological interventions were utilized before administering a PRN antipsychotic medication to a resident, identified as R9, who was cognitively intact and diagnosed with anxiety disorder and bipolar disorder. Despite R9 exhibiting no behaviors that required intervention, the resident received Seroquel, an antipsychotic medication, on two occasions without documentation of attempted nonpharmacological interventions. The care plan for R9 included interventions such as calming activities and family interactions, but these were not documented as attempted prior to the administration of the medication. The facility also failed to ensure that the PRN antipsychotic medication order for R9 included a 14-day limit, as required by policy. The order for Seroquel did not have an end date, and staff interviews revealed a lack of awareness and adherence to the policy requiring a stop date for PRN antipsychotic medications. The consulting pharmacist and the Director of Nursing both confirmed the expectation for a 14-day limit and the need for provider documentation to extend the order. Interviews with nursing staff indicated that nonpharmacological interventions should be attempted and documented before administering PRN medications. However, there was no documentation of such interventions or behaviors in R9's medical record. The facility's policy on psychotropic drugs emphasized the importance of recognizing and responding to resident behaviors with interventions to eliminate the need for medication, and required PRN antipsychotic medications to be ordered for no longer than 14 days.
Infection Control Deficiency in Blood Glucose Monitoring
Penalty
Summary
The facility failed to ensure proper hand hygiene and disinfection of a shared glucometer during blood sugar checks for three residents. The observations revealed that a registered nurse (RN-D) did not change gloves or perform hand hygiene between dirty and clean tasks while checking blood glucose levels. The RN used the same gloves to handle clean items such as alcohol wipes, lancets, and test strips after touching potentially contaminated surfaces. This practice was observed during blood sugar checks for three residents, where the RN did not disinfect the glucometer between uses, increasing the risk of cross-contamination. Interviews with the RN and other staff members, including a licensed practical nurse (LPN-C) and infection preventionists (IP-E and IP-F), confirmed the lack of adherence to infection control protocols. The RN admitted to not disinfecting the glucometer between residents and acknowledged the risk of infection. The LPN and infection preventionists emphasized the importance of disinfecting the glucometer after each use and performing hand hygiene before and after procedures to prevent the spread of germs. The facility's policies on hand hygiene and blood glucose testing required staff to perform hand hygiene after potential contamination and to disinfect glucometers between each resident. However, these protocols were not followed, as evidenced by the RN's actions during the blood sugar checks. The director of nursing (DON) also confirmed the expectation for staff to change gloves and perform hand hygiene to prevent infection and cross-contamination.
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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