North Ridge Health And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in New Hope, Minnesota.
- Location
- 5430 Boone Avenue North, New Hope, Minnesota 55428
- CMS Provider Number
- 245183
- Inspections on file
- 50
- Latest survey
- December 8, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at North Ridge Health And Rehab during CMS and state inspections, most recent first.
A resident with complex medical needs did not receive medications according to physician orders, with staff failing to separate doses of Oxycodone and Suboxone as required and administering medications outside the prescribed time window on numerous occasions. These actions resulted in multiple medication errors and noncompliance with care plan directives.
A resident with multiple complex medical conditions required repositioning every two hours per their care plan, but staff did not document when repositioning occurred. Interviews with nursing assistants and an RN confirmed that documentation of turning and repositioning was not performed, and no ADL documentation policy was provided when requested.
Two residents who required assistance with toileting experienced significant delays in staff response to call lights, resulting in prolonged periods of incontinence and discomfort. Despite care plans and facility policy requiring prompt assistance, call light logs and interviews confirmed that staff often took much longer than the expected 10-15 minutes to respond, especially for those needing two staff members for care. These delays led to residents remaining in soiled briefs, causing distress and a loss of dignity.
A resident with impaired cognition and respiratory diagnoses did not have oxygen saturation monitored every shift as ordered by the provider. Staff and leadership confirmed that checks were not consistently performed or documented, and there was no task on the treatment administration record to prompt this monitoring, contrary to facility policy and provider orders.
A resident with chronic kidney disease and heart failure received supplemental oxygen therapy on multiple occasions without a provider order or care plan documentation. Staff and provider notes referenced ongoing oxygen use, but no official order was present, and the facility's policy requiring a physician's order for oxygen administration was not followed.
A facility failed to accurately document a resident's advance directives, leading to a discrepancy in their code status. The resident, who wished to be full code, had their EMR banner and physician orders indicating DNR, contradicting their POLST form. Staff relied on the EMR banner, risking non-compliance with the resident's wishes. Additionally, the facility did not update the POA for another resident, leading to potential miscommunication in care decisions.
The facility's call system was deficient, lacking audible alerts and functioning pagers for staff, affecting all 250 residents. Observations showed no call light indicators above rooms, and staff relied on visual cues from kiosks without carrying communication devices. Only nurse managers and supervisors had pagers for alerts, and the facility's call light policy was not provided.
A LTC facility experienced a medication error rate of 22.58%, involving four residents. Errors included administering expired medication, incorrect mixing of potassium chloride, late administration of ondansetron, and missing medications due to unavailability. Staff failed to adhere to medication administration guidelines, leading to these deficiencies.
The facility failed to properly track and secure emergency kits containing controlled substances, such as lorazepam, which were not included in narcotic counts at shift changes and were not secured in the refrigerator. The DON acknowledged the oversight, noting that staff should have visually confirmed the kit's presence during narcotic counts, as per facility policy.
The facility failed to properly label and store insulin pens and other medications, affecting multiple residents. Insulin pens lacked expiration dates, and expired medications were found in medication carts and rooms. Additionally, medications and supplies for discharged residents were not disposed of properly. Temperature control issues in medication storage areas were also identified, with refrigerator temperatures frequently outside the safe range.
The facility failed to follow infection control practices during tracheal care for two residents and tube feeding for another. A respiratory therapist did not use proper PPE during tracheal suctioning, and a nurse did not maintain sterility of gloves. Additionally, staff did not sanitize hands between glove changes during care for a cognitively impaired resident. Tube feeding procedures were compromised by using undated nutritional supplements and not cleaning shared surfaces, leading to potential infection risks.
A resident with significant physical limitations and a tracheostomy was not provided with an appropriate call light in a LTC facility. Despite the care plan indicating the need for a reachable call light, the resident was unable to use the provided call light due to left-sided weakness and a restraint mitt on the right hand. A nurse acknowledged the oversight, noting the resident should have had a soft-touch call light, which was not provided upon readmission.
A resident's request for nausea medication before meals was not honored due to a transcription error, leading to improper scheduling of ondansetron. The medication was given at times that did not align with meal times, resulting in episodes of nausea and vomiting. The facility's policy did not adequately address order transcription, contributing to the oversight.
A facility failed to monitor and assess a resident's restraint use effectively, leading to the resident self-decannulating his tracheostomy tube multiple times. The resident used a restraint mitt to prevent pulling on medical devices, but the facility did not consistently follow the required schedule for releasing and repositioning the restraint. Staff interviews revealed a lack of clarity and documentation regarding the restraint's effectiveness and alternative interventions.
A resident experienced significant physical and cognitive decline after a stroke, including severe cognitive impairment and weight loss. Despite these changes, the facility failed to complete a Significant Change in Status Assessment (SCSA). Staff interviews confirmed the resident's increased need for assistance, and the Director of Nursing acknowledged the oversight.
A resident with severe cognitive impairment and multiple medical conditions was found to have a deficient care plan, lacking documentation of a pressure ulcer and personal preferences. The resident was often seen in hospital gowns, contrary to his preference, and the facility failed to use communication aids for his language barrier. Family members provided showers and laundry, which were not reflected in the care plan, highlighting a lack of communication and awareness among staff.
Two residents in a facility, both dependent on staff for ADLs, did not receive proper nail care. One resident with COPD, diabetes, and CKD had long, dirty nails despite a weekly care order. Another resident with multiple sclerosis and respiratory failure also had untrimmed nails and expressed dissatisfaction with staff assistance. Observations and interviews revealed lapses in care and documentation, contrary to the facility's nail care policy.
A resident with severe cognitive impairment and physical limitations was not comprehensively reassessed for activity interests and socialization needs after a stroke. Despite significant changes in her condition, the facility did not update her care plan or conduct a new activities assessment. Observations showed the resident spent time in a dark, quiet room, unable to engage in activities. Staff interviews confirmed the resident's previous activity level and the lack of reassessment post-hospitalization.
The facility failed to maintain accurate orders and ensure proper site care for two residents. One resident had outdated orders for fluid restriction and antibiotic monitoring, while staff were unaware of the current status. Another resident, with multiple diagnoses, had issues with tube feeding and catheter sites that were not properly documented or addressed. These deficiencies highlight a lack of adherence to policies and procedures for resident care and documentation.
A resident at risk for pressure ulcers was not provided with appropriate care, leading to the development and worsening of a stage 3 pressure ulcer. The facility failed to implement pressure-relieving devices and did not adhere to repositioning protocols, resulting in inadequate treatment and documentation of the wound. Despite hospital notes indicating a stage 3 ulcer, the facility continued to classify it as MASD, delaying necessary interventions.
A facility failed to implement a functional maintenance program for a resident with limited range of motion (ROM), leading to a deficiency. The resident's care plan required daily ROM exercises for the lower extremities, but these were not documented or performed. Nursing staff were unaware of the specific ROM tasks due to an oversight in task assignment, and the resident was not receiving physical therapy at the time.
A resident with multiple health conditions was observed using an electric heating pad without a provider order or documented approval. Facility staff were unaware of the resident's use of the heating pad, and there was no clear policy communicated regarding personal electrical devices. The Director of Nursing confirmed that heating pads should not be used without a provider order and regular skin checks, which were not conducted.
Two residents receiving tube feeding were observed lying flat in bed, increasing the risk of aspiration. The facility failed to maintain correct feeding rates and did not follow infection prevention practices, such as dating and changing supplies. The facility's policies lacked guidance on aspiration prevention and proper labeling, contributing to these deficiencies.
The facility failed to follow oxygen administration orders for two residents. One resident with COPD had their oxygen set higher than prescribed, risking over-oxygenation. Another resident had no active orders for oxygen use despite having equipment in their room. Staff confirmed these discrepancies, which violated the facility's policy requiring physician orders for oxygen administration.
A resident with severe cognitive impairment and recent stroke was not assessed for trauma after undergoing a SANE exam for vulvar lesions. Despite family concerns and facility policies requiring trauma assessments, the facility failed to update the care plan or conduct a comprehensive assessment, leading to poor communication and inadequate care planning.
The facility failed to follow up on pharmacy consultant recommendations for two residents regarding medication management. One resident's issues included the need for an AIMS assessment and aspirin administration adjustment, which were not addressed until months later. Another resident's medication regimen required monitoring for specific behaviors and potential adverse events, but there was no provider response. The facility's Drug Regimen Review policy was not provided.
A resident with severely impaired cognition continued to receive nystatin powder for a resolved rash due to the facility's failure to evaluate the medication's necessity. Despite weekly skin evaluations showing no rash, the medication was applied twice daily. Staff interviews confirmed the rash was gone, but the facility's policy lacked guidance on antimicrobial monitoring.
The facility failed to conduct timely and quarterly care conferences for three residents, leading to deficiencies in care planning. One resident with cancer and PTSD did not have a care conference as requested, another with diabetes and respiratory failure lacked discharge planning documentation, and a third with cognitive impairment had not been invited to a care conference since August. Staff interviews revealed inconsistencies in scheduling and conducting care conferences, contrary to facility policy.
The facility failed to record actual working hours for nursing staff on the daily staffing sheet, as observed during inspections. The lead staffing person was unaware of the requirement to include actual hours, and the director of nursing highlighted the importance of this information to show adequate staffing.
The facility failed to ensure call lights were within reach for three residents, compromising their ability to request assistance. One resident with dementia and muscle weakness had a call light cord on the floor behind her wheelchair, while another with diabetes and muscle weakness had a call light stuck between the bed and wall. A third resident with encephalopathy had a call light cord on the floor near the bed. Staff confirmed the call lights were out of reach, contrary to facility policy.
A resident with severe cognitive impairment and dependency on staff was admitted with various skin issues, but the facility failed to document an inflammatory skin condition on the resident's hands and elbow. Despite staff observations of callouses and scaly build-up, these were not recorded in assessments. The condition was only identified as psoriasis during a hospital visit, highlighting a deficiency in the facility's care and documentation practices.
A resident with chronic kidney disease and an indwelling urinary catheter had lab results indicating E.coli and pseudomonas infections, but the facility failed to notify the physician. Despite changes in urine color and the presence of blood clots, the registered nurse did not document or inform the physician. The physician's assistant confirmed that the lab results were not communicated, which would have led to an antibiotic prescription. The director of nursing was unaware of the issue until later, despite policies requiring prompt notification.
A resident with an indwelling catheter did not receive appropriate care to minimize the risk of urinary tract infections. Observations showed that a nursing assistant placed the collection bag on the floor and allowed the drain tube to touch the inside of the collection container without proper sanitization. Additionally, a registered nurse administered twice the amount of normal saline than ordered for catheter flushing and did not use an alcohol swab to clean the catheter tubing, contrary to facility policies and physician orders.
The facility failed to provide a dignified dining experience for residents in the memory care unit, with some eating in the hallway on tray tables or low side tables due to limited space at dining room tables. Interviews revealed residents' discomfort and staff uncertainty about seating arrangements.
The facility failed to develop comprehensive care plans for residents, lacking individualized interventions for mood and behavior management, dementia care, and accurate treatment orders. One resident's care plan did not address severe depression and recent life changes, while another's lacked dementia care interventions and documentation for PRN medication use. Additionally, a resident with Dupuytren's contracture did not have timely care plan updates for brace and glove application, leading to self-management without staff assistance.
A resident reported rough wound care by an LPN, perceived as abuse. The facility identified the LPN as the alleged perpetrator but allowed her to continue working unsupervised during the investigation, contrary to policy requiring suspension or supervision. This oversight potentially affected all residents' safety.
The facility's memory care unit was found to be unsanitary and uncomfortable, with persistent odors, unclean carpets, and missing wallpaper. Observations revealed unaddressed brown spots and sticky areas on floors and handrails. Staff confirmed these issues, and the administrator acknowledged the need for carpet and wallpaper replacement, as well as exhaust fan repairs.
A facility failed to ensure a resident had the appropriate physician's orders and care plan for self-administration of medication (SAM). The resident, who was independent and preferred to self-administer Belbuca buccal film, did not have a SAM order, and staff did not adhere to procedures for narcotic medications. Interviews revealed a lack of awareness and adherence to SAM policies, leading to the deficiency in managing the resident's medication administration.
A resident with dementia and a desire to smoke was not provided smoking opportunities at the facility. Despite being marked safe to smoke with limitations, the resident's care plan did not address her wish to smoke. Staff interviews revealed that no residents on the unit smoked, and the facility did not provide escorts for memory care residents who wished to smoke, leading to the deficiency.
The facility failed to notify the OOLTC of facility-initiated transfers for two residents who were hospitalized with sepsis. The medical records lacked evidence of notification, and the residents were omitted from the June Ombudsman Report. The DON confirmed the omission, and the facility's policy did not include instructions to notify the OOLTC of such transfers.
A resident was transferred to the hospital with possible sepsis, but the facility failed to notify them or their representative of the bed hold policy within the required timeframe. The resident's record lacked documentation of the notification, as confirmed by both a registered nurse and the DON, despite the facility's policy requiring such notification at discharge or within 24 hours.
A facility failed to update a resident's care plan after hospitalization and removal of a dialysis access device. Despite the resident no longer receiving dialysis, the care plan still included dialysis-related interventions. Staff interviews confirmed that the care plan was not updated upon readmission, contrary to facility protocols.
A resident with dementia, chronic obstructive disease, and major depressive disorder did not have a comprehensive care plan addressing their dementia and mental health needs. The care plan lacked individualized interventions, as confirmed by a registered nurse and the DON, highlighting a deficiency in the facility's care planning process.
The facility failed to provide individualized non-pharmacological interventions for two residents on psychotropic medications. One resident, with Alzheimer's and depression, lacked specific care plan interventions despite behavioral issues. Another resident, with cognitive impairment and depression, received PRN antipsychotic medication without documented non-pharmacological attempts or reasons for use. Staff interviews confirmed the absence of personalized strategies in care plans, contrary to facility policy.
The facility failed to ensure that three residents were offered or received pneumococcal vaccinations according to CDC guidelines. The infection preventionist did not engage in shared clinical decision-making discussions about the PCV-20 dose, leaving it to providers. The director of nursing indicated that the responsibility for immunization largely fell to the infection preventionist, who was expected to determine eligibility and obtain consent. Documentation of shared clinical decision-making was not provided.
A resident requiring partial assistance with personal hygiene did not receive adequate bathing care, despite documentation indicating otherwise. Interviews revealed that the resident had not received a full shower since admission, and nursing assistants signed off on tasks without completing them. Miscommunication between nursing and therapy staff contributed to the deficiency, as therapy staff did not provide full bathing assistance after an initial attempt.
The facility failed to provide timely follow-up care and proper medication administration for residents, leading to deficiencies in care. One resident did not receive necessary follow-up appointments with an infectious disease specialist, while another was given blood pressure medication outside prescribed parameters. Additionally, vital signs and weights were not consistently monitored for residents with heart failure, and a documentation error led to incorrect colostomy care being recorded for a resident without a colostomy.
A resident with dementia, hemiplegia, and malnutrition, who was dependent on staff for toileting, was not provided timely assistance in repositioning and toileting, despite having a care plan requiring assistance every 2-3 hours to prevent skin breakdown. The resident was left in a wheelchair for several hours without staff intervention, and the facility's pressure ulcer prevention policy was not provided.
A LTC facility failed to update care plans and accurately document dialysis care for residents. One resident's dialysis access was removed, yet staff continued outdated documentation. Additionally, post-dialysis assessments were inconsistently completed for three residents, missing vital information. The facility's practices did not align with its policies for end-stage renal disease care.
A facility failed to review a critical clinic note for a resident with a history of depression and cognitive impairment, which documented suicidal ideation and abuse allegations. The note was uploaded to the EHR but not reviewed by staff, leading to a lack of necessary interventions. Interviews revealed a breakdown in communication and responsibility among staff, leaving the resident at risk.
Failure to Prevent Significant Medication Errors and Adhere to Medication Administration Times
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the administration of medications not in accordance with physician orders and prescribed timing requirements. Specifically, a resident with multiple complex diagnoses, including acute and subacute infective endocarditis, pneumonitis, a tibia fracture, cognitive communication deficit, and fibromyalgia, had physician orders for Oxycodone and Suboxone that required specific intervals between doses. The staff did not consistently separate Oxycodone doses by the required four hours or separate Oxycodone and Suboxone doses by the required two hours, resulting in at least 12 documented instances where these instructions were not followed. Additionally, the facility did not ensure that medications were administered within the required window of one hour before or after the scheduled administration time. Over the course of a month, there were 360 documented instances where medications were given outside of this window. These included a wide range of medications such as antibiotics, pain medications, and other routine prescriptions, with administration times often delayed by more than an hour from the scheduled time. The resident's care plan included directives for staff to administer medications as ordered and to promptly address pain management needs, including evaluating the effectiveness of interventions and compliance with dosing schedules. Despite these care plan interventions, the facility's staff failed to adhere to the prescribed medication administration protocols, leading to multiple medication errors and deviations from physician orders.
Failure to Document Resident Repositioning as Required by Care Plan
Penalty
Summary
The facility failed to accurately document the turning and repositioning of a resident whose care plan required repositioning every two hours. The resident, who had multiple complex medical diagnoses including acute and subacute infective endocarditis, pneumonitis, a displaced bicondylar fracture, COPD, dysphagia, and peripheral vascular disease, was care planned to be repositioned at least every two hours to facilitate lung secretion movement and drainage. Despite this, interviews with multiple nursing assistants revealed that while they reported repositioning residents every two hours, they did not document these actions. The registered nurse also confirmed that the facility staff did not document when residents were rounded on or repositioned. Additionally, when the facility's policy for activities of daily living (ADL) documentation was requested, none was provided. The lack of documentation was consistent across all interviewed staff, and there was no evidence in the resident's records to confirm that the required repositioning was performed as per the care plan. This failure to maintain accurate and complete medical records is not in accordance with accepted professional standards.
Failure to Promote Dignity Due to Delayed Response to Toileting Assistance
Penalty
Summary
The facility failed to promote dignity for two residents who required assistance with toileting, as staff did not respond in a timely manner to their requests for help with toileting and hygiene. One resident, who had intact cognition, a history of urinary catheter use, bowel incontinence, and was fully dependent on staff for transfers, experienced significant delays in call light response, with logs showing response times ranging from 15 to 77 minutes. The resident's care plan required prompt response to all requests for assistance, but interviews and documentation revealed that the resident often waited extended periods, resulting in sitting in urine and feces, which caused distress and feelings of lost dignity. Family members and the resident reported long waits and expressed concerns about safety and emotional well-being due to these delays. Another resident, with severe cognitive impairment and incontinence, also experienced delayed responses to call lights, with logs indicating response times between 15 and 63 minutes. This resident required substantial assistance for activities of daily living and care in pairs. The resident reported discomfort and embarrassment from waiting to be changed after incontinence episodes. Staff interviews confirmed that delays occurred, particularly for residents needing two staff members for care, and acknowledged that these delays could result in residents remaining in soiled briefs for extended periods. Staff, including nursing assistants and the RN, acknowledged that while the facility had enough staff to answer call lights, the need for two staff members to assist certain residents contributed to longer wait times. The facility's policy required call lights to be answered as soon as possible, and the expectation was a response within 10-15 minutes. However, documentation and interviews confirmed that this standard was not consistently met, leading to residents experiencing incontinence and loss of dignity while waiting for assistance.
Failure to Monitor Oxygen Saturation per Provider Orders
Penalty
Summary
The facility failed to implement resident-directed care and treatment consistent with provider orders and professional standards for a resident with moderately impaired cognition and diagnoses including acute respiratory failure with hypoxia and COPD. The resident had a provider order for continuous oxygen at 2 liters per minute by nasal cannula, with instructions to maintain oxygen saturations above 90% and to check oxygen saturation every shift. The care plan also directed staff to administer oxygen according to the provider order. However, review of the electronic health record showed that oxygen saturation was not checked every shift as required, with documentation indicating checks occurred only sporadically over a two-month period. Interviews with the resident, LPN, NP, and DON confirmed that staff were not consistently monitoring oxygen saturation as ordered, and there was no task on the treatment administration record to prompt staff to perform these checks. The facility's policy on oxygen administration required assessment of oxygen saturation when a resident was receiving oxygen therapy, but this was not followed. The lack of consistent monitoring and documentation was acknowledged by staff and leadership during interviews.
Failure to Obtain Provider Order for Supplemental Oxygen Administration
Penalty
Summary
A resident with diagnoses including chronic kidney disease and heart failure was found to have received supplemental oxygen therapy on multiple occasions over a period of several months without a corresponding provider order or care plan documentation. The resident's medical records, including the provider order list and care plan, lacked any information regarding the use or monitoring of supplemental oxygen, despite documentation showing the resident used oxygen via nasal cannula on numerous days in May, June, and July. Nursing notes and provider visit notes repeatedly referenced the resident's use of oxygen at varying flow rates, but none of these notes included an official order for oxygen therapy. Interviews with facility staff, including an LPN, RN, nurse practitioner, and the DON, confirmed that the resident had been receiving supplemental oxygen without a provider order prior to a specific date in July. The facility's own policy required a physician's order for oxygen administration, which was not followed in this case. Observations on the day of the survey confirmed the resident was using oxygen, and staff acknowledged the absence of a provider order for this therapy.
Failure to Accurately Document Advance Directives and POA
Penalty
Summary
The facility failed to ensure a resident's advance directives were accurately and consistently documented across various records, leading to a discrepancy in the resident's code status. The resident, who was cognitively intact and had multiple diagnoses including end-stage renal disease and congestive heart failure, had expressed a desire to change their code status to full code, indicating they wanted cardiopulmonary resuscitation (CPR) in the event of a cardiac arrest. However, the electronic medical record (EMR) banner and physician orders still indicated a do-not-resuscitate (DNR) status, which contradicted the resident's wishes as documented in the Provider Order for Life-Sustaining Treatment (POLST) form. The inconsistency arose because the POLST form, which directed CPR, was not signed by the provider and was not dated, leading to confusion among staff about the resident's true code status. Interviews with various staff members revealed that they relied on the EMR banner to determine code status, which at the time indicated DNR. This reliance on the EMR banner, coupled with the lack of a signed and dated POLST, meant that the resident's wishes for CPR might not have been honored in an emergency situation. Additionally, the facility failed to ensure that the power of attorney (POA) for another resident was correctly identified in the electronic health record. This oversight meant that staff would have contacted the wrong individual for care decisions, as the emergency contact list was not updated to reflect the correct POA. This failure to update the contact information could have led to inappropriate decision-making regarding the resident's care, as the staff were not aware of the correct person to contact for decisions.
Removal Plan
- Corrected R43's code status on the EMR banner/provider order to CPR
- Completed a facility-wide audit to ensure there were no other code status discrepancies
- Reviewed related policies and procedures
- Provided education for all staff involved in ensuring advance directives were honored
- Provided education on CPR and POLST policies/procedures and their respective roles in the process
Deficient Call System in Facility
Penalty
Summary
The facility failed to ensure a complete wireless call system, affecting all 250 residents. Observations revealed that there were no call light indicators above resident rooms on the East side in hallways 500, 600, or 700. Instead, scrolling kiosks displayed the room and bed number of the resident who activated their call light. However, these kiosks did not provide an audible tone, and staff did not carry pagers or communication devices to alert them to call light activations. Nursing assistants and registered nurses confirmed that they relied on visual cues from the kiosks, and if they were in a resident's room, they had to either yell for help or turn on the call light themselves. Interviews with staff, including nursing assistants, registered nurses, the acting administrator, and the director of campus plant operations, confirmed the lack of an audible alert system and the absence of pagers for most staff. Only nurse managers and supervisors carried pagers, which alerted them if a call light was on for more than ten minutes. The facility's call light policy and procedure were requested but not provided, indicating a potential gap in documentation and protocol adherence. The deficiency was further compounded by the fact that the maintenance person who knew how to reprogram the pagers was no longer employed at the facility.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 22.58% with seven errors out of 31 opportunities. This involved four residents who were observed during medication passes. One resident received expired calcium carbonate, as the LPN administering the medication did not check the expiration date. Another resident was given potassium chloride mixed with pudding instead of being dissolved in water or juice as per the medication's instructions, leading to inconsistent administration practices among staff. A third resident, who required ondansetron 30 minutes before dialysis, received the medication late due to a delay in administration by the RN. This resident was already at the dialysis unit when the medication was administered, contrary to the prescribed timing. Additionally, a fourth resident did not receive several medications, including gabapentin and ezetimibe, due to them being unavailable, and the LPN did not administer other medications due to a low blood pressure reading without documented parameters to hold the medications. The Director of Nursing and the consultant pharmacist both indicated that medications should be administered as ordered, with missing medications promptly addressed by contacting the pharmacy. The facility's medication administration guidelines emphasize verifying the correct medication, dose, route, rate, time, and resident, as well as checking expiration dates and following manufacturer guidelines, which were not adhered to in these instances.
Failure to Secure and Track Emergency Kits with Controlled Substances
Penalty
Summary
The facility failed to ensure proper tracking and security of emergency kits containing controlled substances, which could potentially lead to theft and diversion of medications. During a tour of the medication room, it was observed that an insulin kit containing lorazepam, a controlled substance, was not included in the narcotic count at shift changes and was not secured in the refrigerator. The Director of Nursing (DON) acknowledged that the emergency kit did not need to be counted at shift changes due to a security tab that only the pharmacy could replace. However, the DON admitted that staff should have visually confirmed the presence of the kit during narcotic counts, as it was not secured. The facility's policy requires controlled substances to be stored in a locked container and counted at the end of each shift, with any discrepancies reported to the DON. This policy was not followed, leading to the deficiency.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper labeling and storage of insulin pens and other medications, affecting multiple residents. During various tours, it was observed that insulin pens for several residents were not dated with an expiration date after being opened. Staff members, including registered nurses and licensed practical nurses, incorrectly believed that the manufacturer's expiration date was sufficient for determining the usability of the insulin pens. Additionally, there was a lack of reference materials on medication carts to guide staff on the appropriate duration for which insulin pens could be used after opening. The facility also failed to remove and dispose of outdated medications properly. During inspections of medication carts and rooms, expired medications were found, including famotidine and Geri-Dryl, as well as insulin pens without open or expiration dates. Furthermore, medications and supplies belonging to discharged residents were not disposed of appropriately, with some items remaining in the medication room long after the residents had left the facility. Temperature control issues were identified in the medication storage areas, with refrigerator temperatures frequently falling outside the safe range. This was confirmed by temperature logs and staff verification. The director of nursing and consultant pharmacist acknowledged the importance of maintaining proper storage conditions to ensure medication viability. However, the facility's policies did not adequately address the labeling of insulin pens or the management of medication refrigerator temperatures, contributing to the deficiencies observed.
Infection Control Deficiencies in Tracheal and Tube Feeding Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during tracheal care for two residents. One resident, with a tracheostomy, was observed being suctioned by a respiratory therapist who did not wear a gown or eye protection, despite the resident being on enhanced barrier precautions (EBP) due to an indwelling medical device. The therapist admitted to not applying additional personal protective equipment (PPE) due to moving quickly. Another resident with a tracheostomy was also on EBP, and during suctioning, the respiratory therapist used sterile gloves but contaminated them by touching non-sterile items in the room before completing the suctioning procedure. The director of respiratory therapy and the infection preventionist confirmed that tracheal suctioning should be a sterile procedure, and the therapist should have maintained sterility of the gloves. The facility also failed to ensure proper hand hygiene during care for a resident who was severely cognitively impaired and on hospice care. During a brief change, a nursing assistant and a registered nurse were observed changing gloves multiple times without sanitizing their hands in between. They acknowledged the importance of hand sanitization between glove changes to prevent infection but did not have hand sanitizer readily available in the room and chose to continue with the care without sanitizing their hands. Additionally, the facility did not follow clean procedures when administering tube feedings for a resident with a gastrostomy tube. An open bottle of nutritional supplement was found without a date or time, and a used tube feeding bag was undated. A registered nurse used the undated supplement and did not clean the overbed table used for tube feeding supplies, which belonged to the resident's roommate. The resident's tube site was red and painful, but the nurse did not document or report this condition promptly. The facility's policy did not address the need for dating and timing tube feeding bottles, contributing to the oversight.
Inadequate Call Light Accommodation for Resident with Physical Limitations
Penalty
Summary
The facility failed to provide a call light that accommodated the needs of a resident with significant physical limitations. The resident, who had a functional limitation in the range of motion of both upper extremities and was dependent on staff for most activities of daily living, was observed with a call light that was not suitable for his condition. The resident had a tracheostomy and communication problems, and his care plan indicated the call light should be within reach. However, the care plan did not specify the type of call light needed, and the resident was unable to use the provided call light due to his physical limitations, including left-sided weakness and the use of a restraint mitt on his right hand. During multiple observations, the resident was seen with a call light that had a small red button, which he confirmed he could not use. A registered nurse acknowledged the oversight and stated that the resident should have been provided with a soft-touch call light, which he previously used before being readmitted to the facility. The facility's policy on reasonable accommodation of needs required assessing and accommodating individual resident needs, but this was not adequately implemented for the resident in question.
Failure to Administer Nausea Medication as Requested
Penalty
Summary
The facility failed to ensure that a resident's family request for pretreatment of nausea before meals was honored, impacting the resident's self-determination. The resident, who was severely cognitively impaired and under hospice care, had a care plan that included managing symptoms such as nausea and vomiting. Despite an order for ondansetron to be administered before meals and at bedtime, the medication was scheduled and given at 4:00 p.m. and 8:00 p.m., which did not align with the intended therapeutic schedule. This discrepancy was noted by the resident's family, who observed that the resident experienced nausea and vomiting when the medication was not administered as requested. The issue was further compounded by a transcription error in the medication order, which was supposed to be administered four times a day but was only ordered for two times a day. The registered nurse and the director of nursing acknowledged the error, noting that the medication schedule did not provide the desired therapeutic effects. The consulting pharmacist confirmed that the current order was insufficient to cover all meals, as the half-life of the medication would not last until the next meal. The facility's policy on medication orders did not address the transcription of orders, contributing to the oversight.
Failure to Monitor and Assess Restraint Use Effectively
Penalty
Summary
The facility failed to ensure ongoing monitoring and assessments of a resident's condition during restraint use, which led to adverse outcomes. The resident, identified as R190, had a tracheostomy and was using a restraint mitt to prevent pulling on his tracheostomy tube and catheter. Despite the restraint, R190 was able to self-decannulate his tracheostomy tube on multiple occasions, indicating that the restraint was ineffective. The facility did not complete comprehensive assessments or reassessments to determine if the least restrictive device was used or if the restraint was effective. R190's care plan and informed consent for restraint use indicated that the restraint mitt was to be used with a release and reposition schedule of every two hours. However, documentation and interviews revealed that staff did not consistently follow this schedule, and there was a lack of documentation on how often the restraint was removed or when skin assessments were conducted. The facility's failure to document and monitor the restraint use properly contributed to the resident's ability to remove his tracheostomy tube, which posed a significant risk to his health. Interviews with staff, including RN-L and RN-J, highlighted a lack of clarity and consistency in the application and monitoring of the restraint mitt. Staff were unsure of the interventions attempted to address the medical symptoms leading to the need for restraint use, and there was no evidence of reassessment for less restrictive alternatives. The director of nursing acknowledged that the facility's policy required reassessment of restraint necessity every month, but this was not documented or followed, leading to the continued use of an ineffective restraint.
Failure to Complete SCSA After Resident's Stroke
Penalty
Summary
The facility failed to initiate and complete a Significant Change in Status Assessment (SCSA) for a resident, identified as R42, following a significant physical and cognitive decline after a stroke. According to the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, an SCSA is required when a resident experiences a major decline that affects multiple areas of health status and necessitates an interdisciplinary review and care plan revision. R42's quarterly Minimum Data Set (MDS) indicated severe cognitive impairment, significant weight loss, a mechanically altered diet, and impairments in extremities, contrasting with a previous MDS that showed no such impairments. Despite these changes, the facility did not complete an SCSA. Interviews with staff and family members revealed that R42 had become mostly non-verbal and required assistance with daily activities such as eating and transferring, which she previously managed independently. The MDS nurse acknowledged that an SCSA should have been completed due to changes in R42's mobility, transfer status, and eating assistance needs. The Director of Nursing confirmed that an SCSA should have been initiated upon R42's return from the hospital, which would have triggered other comprehensive assessments. The facility's policy on MDS was requested but not provided, indicating a lack of documentation to support the assessment process.
Failure to Maintain Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and maintain a comprehensive care plan for a resident, identified as R86, which led to inadequate care provision. R86, who has severely impaired cognition due to vascular dementia, type 1 diabetes, chronic kidney disease, and hypertension, was found to have a stage 2 pressure ulcer. The care plan did not include this pressure ulcer or additional interventions to prevent its worsening. Furthermore, the care plan lacked documentation of R86's preference for laundry to be done by his daughter, preference for male caregivers, and the use of a walker or wheelchair when ambulating. Observations and interviews revealed that R86 was often seen wearing hospital gowns instead of street clothes, which was not his preference. The family member expressed concerns about the language barrier, as R86 primarily speaks Somali, and the facility's failure to use communication aids or interpreters. The family member also noted that the facility had not communicated the need for clothes for R86, despite previous notifications. Additionally, the family member stated that they provide showers and laundry services for R86, which were not reflected in the care plan. Staff interviews indicated a lack of awareness and communication regarding R86's needs and preferences. The registered nurse and nursing assistant acknowledged the absence of clothes for R86 and the lack of communication aids. The director of nursing emphasized the importance of having up-to-date care plans, but the facility's policy on comprehensive care plans was not adhered to, resulting in the deficiency.
Failure to Provide Adequate Nail Care for Residents
Penalty
Summary
The facility failed to ensure proper nail care for two residents who were dependent on staff for activities of daily living (ADLs). Resident R21, with intact cognition and diagnoses including COPD, diabetes, and CKD, required moderate assistance with bathing, dressing, and toileting. Despite having a provider order for weekly nail care, observations revealed R21's fingernails were long and dirty. Nursing staff confirmed the nails were not properly maintained, and there was no documentation of care refusal, indicating a lapse in following care plans and documentation protocols. Similarly, Resident R28, diagnosed with multiple sclerosis and respiratory failure, was dependent on staff for personal hygiene and required extensive assistance with bathing. Observations showed R28's fingernails were excessively long and dirty, and the resident expressed dissatisfaction with the lack of assistance in trimming them. Despite claims from a nursing assistant that R28 refused nail care, the resident denied such refusals, and there was no documentation to support the claim. This indicates a failure in communication and documentation, as well as a lack of adherence to the facility's nail care policy.
Failure to Reassess Resident's Activity Needs Post-Stroke
Penalty
Summary
The facility failed to comprehensively reassess a resident, identified as R42, for activity interests and socialization needs following a hospitalization for a stroke. R42, who had severe cognitive impairment and required substantial assistance with daily activities, was hospitalized for a stroke that resulted in right-sided weakness. Despite these significant changes in condition, the facility did not update R42's care plan or conduct a comprehensive activities assessment post-hospitalization to address her new limitations and socialization needs. Observations revealed that R42 spent most of her time in a dark, quiet room, appearing restless and unable to use the television remote. Staff interviews indicated that R42 was previously active and enjoyed going outside but was no longer able to do so independently after her stroke. The activities aide confirmed that R42 had not been comprehensively reassessed for activities since November, prior to her hospitalization, and no one-to-one visits had been initiated to engage her in activities suitable for her current condition. The facility's policy required staff to evaluate residents' physical and mental capacity to participate in activities, noting any limitations or needs. However, this was not done for R42 after her stroke, as confirmed by the director of nursing, who acknowledged that a comprehensive activities assessment should have been completed. The lack of reassessment and updated interventions left R42 without adequate socialization opportunities, as she was no longer able to participate in her preferred activities.
Deficiencies in Order Accuracy and Site Care
Penalty
Summary
The facility failed to ensure that orders were current and accurate for a resident, R90, who was reviewed for orders. R90 had multiple diagnoses, including intestinal malabsorption, gastrostomy tube status, malnutrition, diabetes mellitus, heart failure, anxiety, and depression. Despite being cognitively intact and independent with activities of daily living, R90's care plan did not address a fluid restriction or antibiotic monitoring, even though the Order Summary Report indicated active orders for both. Interviews with staff revealed confusion and lack of awareness regarding R90's current orders, with some staff members unsure about the fluid restriction and antibiotic monitoring status. The director of nursing confirmed that staff should understand what they are documenting when signing off on tasks in the medication and treatment records. The facility also failed to ensure proper site care for R4, who was reviewed for tube feeding. R4 was moderately cognitively impaired with diagnoses including epilepsy, traumatic brain injury, quadriplegia, diabetes, and sepsis. R4's care plan included goals for tube feeding and catheter care, but interventions did not include dressing changes or assessment of the catheter insertion site. Observations and interviews revealed that R4 had noticeable issues with the tube feeding and suprapubic catheter sites, including redness, moisture, and crusting, which were not properly documented or addressed in the skin assessments. The facility's policies for suprapubic catheter care and enteral nutrition did not adequately address the necessary skin assessments and documentation. The deficiencies in the facility's care for R90 and R4 highlight a lack of adherence to established policies and procedures for maintaining accurate and current orders, as well as ensuring proper site care and documentation. The failure to document and address changes in skin condition and site care for R4, along with the confusion surrounding R90's orders, indicate a need for improved communication and understanding among staff regarding resident care and documentation requirements.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for a resident identified as R4. R4 was moderately cognitively impaired and at risk of developing pressure ulcers upon re-admission, with no unhealed pressure ulcers noted at that time. However, hospital notes later identified a stage 3 pressure ulcer on R4's coccyx, which the facility failed to document and address in a timely manner. The facility did not implement the recommended pressure-relieving devices for R4's chair and bed, and there was a lack of documentation regarding the identification and treatment of the pressure ulcer. Observations revealed that R4 was consistently positioned on their back with the head of the bed elevated, contrary to the care plan's instructions for repositioning every two hours to relieve pressure. Interviews with staff indicated a lack of adherence to repositioning protocols, with R4 often being returned to the same position after care. The facility's care plan and wound documentation were not updated to reflect the presence of a pressure ulcer, and the necessary interventions, such as a pressure-relieving mattress and wound nurse consultation, were not implemented promptly. The facility's failure to identify and document R4's pressure ulcer led to inadequate treatment and worsening of the wound. Despite hospital documentation of a stage 3 pressure ulcer, the facility continued to classify the wound as moisture-associated skin damage (MASD) and did not update the care plan or involve a wound nurse. The facility's policy required daily monitoring and provider contact if a pressure ulcer showed no progression, but these protocols were not followed, contributing to the deficiency.
Failure to Implement Functional Maintenance Program for ROM
Penalty
Summary
The facility failed to implement a nursing functional maintenance program to prevent a decline in range of motion (ROM) for a resident identified as R190. R190's admission Minimum Data Set indicated functional limitations in the range of motion of both upper extremities, and the resident was dependent on staff for most activities of daily living. The care plan and Functional Maintenance Program (FMP) required nursing staff to perform bilateral lower extremity ankle and knee ROM exercises daily. However, the medical record did not show evidence that these exercises were completed since the FMP's initiation. Interviews with nursing assistants and registered nurses revealed a lack of awareness and execution of the ROM exercises for R190. Nursing assistants relied on electronic health records to determine tasks, but no ROM tasks were listed for R190. Additionally, the registered nurse responsible for R190 was unsure of the specific ROM exercises required and deferred to therapy for guidance. The director of rehabilitation confirmed that R190 was not currently receiving physical therapy, and the nurse manager admitted to an oversight in not adding the ROM exercises as a task for nursing assistants to document, which was the standard procedure.
Resident's Use of Heating Pad Without Proper Oversight
Penalty
Summary
The facility failed to ensure that a resident, identified as R90, was free from potential injury due to the use of an electric heating pad. R90, who had multiple diagnoses including intestinal malabsorption, diabetes mellitus, and heart failure, was observed using an electric heating pad on several occasions without a provider order or documented approval for heat therapy. The resident's care plan did not include the use of a heating pad, and there were no changes in the resident's skin condition noted in weekly assessments. Despite this, R90 was repeatedly observed lying on a heating pad that was plugged into the wall. Interviews with facility staff revealed a lack of awareness and understanding regarding the policy for personal electrical devices brought in by residents. Nursing assistants and registered nurses were unaware of any residents using heating pads, and there was no clear policy communicated to them. The Director of Nursing confirmed that electrical heating pads should not be brought in from home without a provider order and that staff should conduct regular skin checks. The facility's policy on electrical safety discouraged the use of heating pads and required inspection of such devices, which was not adhered to in this case.
Failure to Prevent Aspiration and Ensure Infection Control in Tube Feeding
Penalty
Summary
The facility failed to ensure appropriate interventions were taken to reduce the risk of aspiration for two residents who were using tube feeding. Both residents were observed to be positioned flat in bed while their feeding was running, which is against the recommended practice of keeping the head of the bed elevated to prevent aspiration. Additionally, the facility did not follow infection prevention practices, as evidenced by undated syringes, tubing, and feeding solution containers, which were not changed or documented as required. One resident, who was moderately cognitively impaired and received a significant portion of their nutrition via tube feeding, was observed multiple times with their feeding running at an incorrect rate of 50 ml/hour instead of the ordered 60 ml/hour. The registered nurse confirmed the discrepancy and adjusted the rate accordingly. However, the failure to maintain the correct feeding rate and to date and change supplies daily posed a risk of infection and inadequate nutrition. Another resident, who was severely cognitively impaired and dependent on staff for activities of daily living, was also observed lying flat in bed with the tube feeding running. The nursing assistant did not pause the feeding before lowering the bed, as the nurse was busy, which could lead to aspiration. The facility's policies did not adequately address aspiration prevention or the labeling and dating of supplies, contributing to these deficiencies.
Deficiencies in Oxygen Administration for Residents
Penalty
Summary
The facility failed to ensure proper oxygen administration for two residents, leading to deficiencies in respiratory care. For one resident with chronic obstructive pulmonary disease (COPD) and respiratory failure, the facility did not adhere to the prescribed oxygen flow rate. The resident's medical records indicated an order for oxygen at 3.5 liters per minute to maintain oxygen saturation levels above 90%. However, observations revealed that the oxygen was set to five liters per minute on multiple occasions, which was confirmed by a registered nurse. This discrepancy posed a risk of over-oxygenation, particularly given the resident's COPD condition. Another resident, who had a history of acute respiratory failure and other respiratory conditions, had access to oxygen equipment in their room but lacked a current provider order for oxygen administration. Despite the presence of an oxygen concentrator and portable oxygen, the resident's medical records did not contain active orders for oxygen use. Interviews with nursing staff confirmed the absence of such orders, even though the resident used oxygen as needed. The facility's policy required verification of a physician's order before administering oxygen, which was not followed in this case.
Failure to Conduct Trauma Assessment for Resident
Penalty
Summary
The facility failed to assess a resident, identified as R42, for potential trauma after she was found to have vulvar lesions and underwent a Sexual Assault Nurse Examiner (SANE) exam. R42, who had severe cognitive impairment and required substantial assistance with daily activities, was admitted to the hospital following a stroke. During her hospital stay, she was found to have vulvar lacerations, prompting a SANE exam. Despite the potential trauma from the exam and the stroke, the facility did not conduct a trauma assessment or update R42's care plan to address these issues. Interviews with facility staff revealed a lack of communication and documentation regarding R42's situation. The family member, FM-E, expressed frustration over the facility's poor communication and lack of awareness about the potential sexual assault and subsequent exam. The licensed practical nurse (LPN) and nurse manager (RN) acknowledged the absence of a trauma assessment in R42's care plan, and the social worker admitted to not conducting a trauma assessment, believing R42 was not affected by the incident. The facility's director of nursing (DON) and clinical director of business (CDB) were aware of the situation but did not ensure a comprehensive assessment was completed. The facility's policy on trauma-informed care required assessments upon admission, quarterly, and with any change in condition, but this was not followed in R42's case. The facility's internal investigation suggested the lesions might be self-inflicted, but the potential trauma from the SANE exam and stroke was acknowledged as significant.
Failure to Address Pharmacy Consultant Recommendations in a Timely Manner
Penalty
Summary
The facility failed to ensure timely follow-up on pharmacy consultant recommendations for two residents, R183 and R204, regarding their medication management. For R183, the consultant pharmacist's medication review reports (CPMR) identified several issues, including the need for an Abnormal Involuntary Movement Scale (AIMS) assessment due to the use of Aripiprazole and Reglan, and a recommendation to adjust the administration time of aspirin due to dialysis. These recommendations were not addressed until months later, only after the surveyor brought attention to the lack of an AIMS assessment. The director of nursing (DON) confirmed that the CPMRs for R183 had not been completed until March 6, 2025, despite the expectation that they should be addressed within a week or on the provider's next rounding day. For R204, the CPMR dated January 23, 2025, identified irregularities with the order for Aripiprazole, including the need for monitoring specific target behaviors, documentation of behavior frequency and impact, non-pharmacological interventions, and potential adverse events. There was no response from the provider regarding these recommendations. The consulting pharmacist explained that recommendations are emailed to the facility monthly, and if no provider response is received within 60 days, the recommendations are resent. The DON and assistant administrator acknowledged the importance of pharmacy reviews in ensuring correct medication administration and provider awareness of potential medication problems. However, the facility's Drug Regimen Review policy was not provided.
Failure to Discontinue Unnecessary Antifungal Medication
Penalty
Summary
The facility failed to ensure that a scheduled antifungal medication, nystatin powder, prescribed for a rash, was evaluated for its continued appropriateness for a resident with severely impaired cognition. The medication order, which began on April 2, 2024, did not have an end date, and the resident continued to receive the medication twice daily despite the absence of a rash. Weekly skin evaluations conducted in February and March 2025 consistently indicated that the resident's skin was intact, with no rash present, except for one instance of unspecified redness. Interviews with nursing staff confirmed that the rash had resolved, yet the medication was still being applied. The registered nurse responsible for applying the medication acknowledged that the rash was no longer present, and the nurse manager stated that staff should notify her or the provider if the rash had resolved. The infection preventionist and consulting pharmacist both indicated that the medication should be discontinued if the condition it was prescribed for had resolved, to avoid unnecessary medication use. The facility's Infection Prevention and Control Program policy did not include a process for antimicrobial monitoring, contributing to the oversight in medication management.
Failure to Conduct Timely Care Conferences
Penalty
Summary
The facility failed to provide timely and quarterly care conferences for three residents, leading to deficiencies in care planning. Resident R184, who was cognitively intact and diagnosed with cancer, gastroesophageal reflux disease, and post-traumatic stress disorder, did not have a care conference documented around the requested date of November 2024. Despite a request from Anoka County, there was no evidence of a care conference being held, and the resident was not aware of the last care conference. Interviews with staff revealed that care conferences were supposed to be scheduled by the social worker 14-21 days after admission and then quarterly and annually, but this was not adhered to in R184's case. Resident R224, also cognitively intact and diagnosed with diabetes mellitus and respiratory failure, lacked documentation of care conferences prior to January 2025. The resident's care plan was missing information related to discharge planning and goals. Interviews indicated that the social services department was responsible for setting up care conferences, which should occur within 21 days of admission and then quarterly. However, the initial care conference was not conducted, and the social worker responsible for the resident's care during the first two months confirmed that no care conference was held. Resident R146, who was mildly cognitively impaired and diagnosed with hemiplegia, hemiparesis, cognitive communication deficit, and type 2 diabetes, had not attended or been invited to a care conference since August 2024. The resident expressed that they were not informed about their care plan or invited to care conferences. The facility's policy encouraged resident and family participation in care planning but did not specify the frequency of care conferences. Interviews with staff confirmed that care conferences should occur quarterly, but this was not consistently implemented for R146.
Failure to Record Actual Working Hours on Daily Staffing Sheet
Penalty
Summary
The facility failed to ensure that the actual working hours for nursing staff were recorded on the daily staffing sheet posted each day. This deficiency was observed during inspections on March 4, 5, and 6, 2025, where the facility's daily staffing reports included staff positions, the number of staff, facility census, and scheduled hours, but omitted the actual working hours of the staff scheduled for those days. A review of the facility's posted staffing from February 20 to March 3, 2025, also revealed the absence of actual working hours for nursing staff. During an interview, the lead staffing person (LSP) admitted responsibility for posting the daily staffing but was unaware that actual hours needed to be included. The LSP mentioned that the actual schedule contained these hours, but this information was not transferred to the daily staffing posting due to a change in the staffing program about a year ago. The director of nursing (DON) emphasized the importance of posting actual hours worked daily to demonstrate adequate staffing.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to accommodate the needs of residents by ensuring that call lights were within reach for three residents. One resident, with intact cognition and diagnoses including dementia and muscle weakness, was observed in a wheelchair with the call light cord on the floor behind her, making it inaccessible. She expressed that attempting to retrieve it could result in a fall. A registered nurse confirmed the call light was out of reach, and it was noted that staff should ensure call lights are accessible before leaving the room. Another resident, also with intact cognition and diagnosed with type 2 diabetes and muscle weakness, was found without a call light while seated in a wheelchair. The resident was unaware of the call light's location, which was later found stuck between the bed and the wall. A licensed practical nurse confirmed the call light was out of reach. A third resident, diagnosed with encephalopathy, was observed in bed with the call light cord on the floor, out of reach. The resident did not know the call light's location and would resort to yelling for help. A nursing assistant confirmed the call light was inaccessible. The facility's policy requires call lights to be within easy reach when residents are in bed or confined to a chair.
Failure to Accurately Assess and Document Resident's Skin Condition
Penalty
Summary
The facility failed to accurately assess a resident's skin condition, leading to a deficiency in care. The resident, who was severely cognitively impaired and dependent on staff for daily activities, was admitted with various skin issues, including necrotic toes and a wound on the left foot. However, the facility's assessments did not document an inflammatory skin condition on the resident's hands and elbow, which was later identified as psoriasis during a hospital visit. The resident's Minimum Data Set (MDS) and care plan also failed to mention these skin conditions, focusing instead on other areas of potential skin impairment. Throughout the resident's stay, weekly skin evaluations consistently reported the skin as intact, with no dryness, rash, redness, or other issues noted. Despite observations from staff members about callouses and scaly build-up on the resident's hands, these were not documented or addressed in the assessments. Interviews with staff revealed a lack of communication and documentation regarding the resident's skin condition, with some staff assuming that the providers were aware of the issues. The deficiency was further highlighted when the resident was admitted to the hospital with dirty hands, long fingernails, and a diagnosis of psoriasis affecting multiple areas of the body. The hospital's dermatology consultation provided a treatment plan for the psoriasis, which had not been identified or treated by the facility. The facility's failure to document and address the resident's skin condition resulted in a lack of appropriate care and treatment for the resident's psoriasis.
Failure to Notify Physician of Critical Lab Results
Penalty
Summary
The facility failed to provide timely notification of critical lab results to the physician for a resident who was cognitively intact and had diagnoses of chronic kidney disease and benign prostatic hyperplasia. The resident required an indwelling urinary catheter and was on anticoagulants. Lab results dated 10/18/24 indicated the presence of E.coli and pseudomonas in the resident's urine, but there was no documentation that the physician was informed of these results. The resident's care plan required monitoring for blood-tinged urine, and the physician's orders directed staff to observe for symptoms of bleeding and document unusual findings. On 11/4/24, the resident and a family member noted changes in the urine color, indicating potential internal bleeding. A registered nurse observed the resident's urine was dark red and acknowledged the presence of blood clots on 10/31/24 but had not documented these findings or notified the physician. The physician's assistant confirmed that the providers were not notified of the lab results, which would have prompted an antibiotic prescription. The health unit coordinator stated that lab results should be faxed to the provider, but the document was not properly stamped, indicating it was not sent. The director of nursing was unaware of the failure to notify the provider until 11/4/24, despite facility policies requiring prompt notification of abnormal lab results.
Inadequate Catheter Care and Non-Compliance with Physician Orders
Penalty
Summary
The facility failed to provide appropriate catheter care and services to minimize the risk of urinary tract infections for a resident with an indwelling catheter. The resident, who had a history of urinary tract infections and several medical conditions including neurogenic bladder, diabetes mellitus, and multiple sclerosis, required specific catheter care as per physician orders. However, during observations, it was noted that the nursing assistant did not follow proper procedures for handling the catheter and collection bag, leading to potential contamination. The nursing assistant placed the collection bag on the floor and allowed the drain tube to touch the inside of the collection container multiple times without proper sanitization. Further observations revealed that the nursing assistant and registered nurse did not adhere to the physician's orders regarding the flushing of the catheter. The registered nurse administered twice the amount of normal saline than was ordered, without verifying the current physician orders. Additionally, the registered nurse did not use an alcohol swab to clean the catheter tubing before and after flushing, which is a critical step to prevent the spread of bacteria and infection. The resident expressed concerns about the catheter care, indicating that staff often forgot to sanitize the tubing and that she had to remind them to use alcohol wipes. Interviews with the facility staff, including the floor manager, infection control nurse, and director of nursing, confirmed that the expected procedures were not followed. The staff acknowledged the importance of wiping the catheter tubing with an alcohol swab to prevent infection and the necessity of adhering to physician orders for catheter flushing. The facility's policies and skills checklists also emphasized the need for proper catheter care to prevent contamination and infection, but these were not consistently followed by the staff.
Lack of Dignified Dining Experience in Memory Care Unit
Penalty
Summary
The facility failed to provide a dignified dining experience for residents in the locked memory care unit dining room. Observations revealed that some residents were eating in the hallway on tray tables next to the nurse's station, while others were eating off low side tables or their walkers. This arrangement was due to all spots at the dining room tables being occupied by other residents. During meal service, food was brought to the unit on a cart, which remained in the dining room, and residents at the same table were not served simultaneously, causing delays in eating. Interviews with residents and staff highlighted the discomfort and lack of dignity in the dining arrangements. One resident expressed a preference for eating at a normal table, which was not offered. A family member confirmed the resident's discomfort and previous dining arrangements at a traditional table. Staff, including a registered nurse and the director of nursing, acknowledged the situation but were unsure why residents were not eating at traditional tables or if there was enough room to accommodate all residents who wished to do so.
Deficiencies in Care Plan Development and Implementation
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that included individualized approaches for managing mood and behavior for residents. For one resident, identified as R67, the care plan lacked specific interventions to address mood and behaviors despite the resident's history of severe major depressive disorder with psychotic features and recent significant life changes, such as the loss of a spouse and inability to return to their previous home. Interviews with staff revealed a lack of awareness of specific interventions for R67, indicating a gap in communication and documentation within the care plan. Another resident, R184, who had moderate cognitive impairment and a history of major depressive disorder and dementia, also had a care plan that lacked individualized interventions for dementia care and mental health needs. The care plan did not document non-pharmacological interventions prior to administering PRN antipsychotic medication, nor did it specify the target behaviors for which the medication was intended. This oversight was confirmed by the nursing staff, who acknowledged the absence of necessary interventions in the care plan to address the resident's dementia and behavioral health needs. Additionally, the facility failed to ensure accurate orders for a resident, R190, who required a brace and glove for Dupuytren's contracture. The care plan did not include directives for staff to apply these at night, and there was a delay in entering the order into the electronic medical record. This resulted in the resident having to manage the application of the brace and glove independently, without assistance from the nursing staff. The director of nursing confirmed the delay and acknowledged the need for timely updates to the care plan to reflect necessary treatments.
Failure to Implement Safety Plan During Abuse Investigation
Penalty
Summary
The facility failed to implement an appropriate safety plan during an ongoing investigation of an abuse allegation. A resident, identified as R145, reported that a nurse performed wound care in an excessively rough manner, causing unnecessary pain, which the resident perceived as intentional abuse. The facility identified the nurse, LPN-E, as the alleged perpetrator. Despite this, LPN-E continued to work unsupervised and provided direct care to residents, including R145, during the investigation period. The facility's policy required that an alleged perpetrator be suspended or work under supervision until the investigation concluded. However, LPN-E was neither suspended nor required to work alongside another staff member. The Director of Nursing confirmed that the investigation was still active and acknowledged that LPN-E had been identified as the alleged perpetrator but had not been removed from duty or paired with another staff member. This oversight potentially affected the safety of all residents in the facility.
Environmental Deficiencies in Memory Care Unit
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment for residents, staff, and visitors in the locked memory care unit. Observations and interviews revealed that the facility was consistently dirty, with a persistent odor of urine in the hallways. A family member reported having to clean a resident's room to maintain cleanliness. The dining room carpet was observed to have crumbs, debris, and numerous spots, while a section of wallpaper was missing, exposing a wall with multiple dried stains. Further observations noted that the handrails and floors in the unit were not adequately cleaned, with brown spots and sticky areas remaining unaddressed over several days. Housekeeping staff were seen vacuuming the dining room while residents were present, but tables were not wiped down after meals. Interviews with staff confirmed the presence of unclean areas, with some spots described as being like glue and difficult to clean. The director of housekeeping acknowledged the issues and stated that the wallpaper was old and needed replacement. The facility administrator confirmed the need for carpet replacement and acknowledged the unsatisfactory condition of the wallpaper and handrails. The administrator also noted that non-functioning exhaust fans contributed to the odor issue and that the facility was in the process of obtaining quotes for replacements. Despite recognizing these deficiencies, there was no solid timeline for addressing the issues, and some handrails were missing endcaps, posing a potential injury risk.
Failure to Ensure Proper Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident, identified as R173, had the appropriate physician's orders for self-administration of medication (SAM) and that the SAM occurred at the scheduled times. R173, who had intact cognition and was independent with activities of daily living, was observed with an unopened packet of Belbuca buccal film on their bedside table. The resident preferred to self-administer the medication without staff assistance, but there was no physician's order for SAM, and the care plan lacked information about it. Interviews with nursing staff revealed a lack of awareness and adherence to the facility's procedures regarding SAM, particularly for narcotic medications like Belbuca. RN-I and RN-J stated that there were no residents with physician orders for SAM, and RN-J emphasized that narcotics should not be left in a resident's room. Despite this, RN-K admitted to leaving the Belbuca at the resident's bedside without checking if it was taken, and RN-L confirmed that R173 did not have an order or care plan for SAM. The facility's policy required an assessment and a physician's order for SAM, which was not followed in this case. The consulting pharmacist and the director of nursing (DON) highlighted the importance of ensuring medications are taken at the scheduled times and checking back to confirm administration, especially for narcotics. The facility's policy on self-administration of drugs required staff to assess residents' abilities to self-administer medications safely, which was not adequately implemented for R173. The lack of proper documentation, assessment, and adherence to procedures led to the deficiency in managing the resident's medication administration.
Failure to Provide Smoking Opportunities for Resident
Penalty
Summary
The facility failed to provide smoking opportunities for a resident, identified as R581, who was reviewed for choices. R581's admission records indicated a diagnosis of weakness and dementia without behavioral disturbance, and the nursing admission evaluation confirmed the resident's use of flame-lit tobacco. A smoking evaluation conducted on 7/1/24 revealed that R581 wished to smoke during her stay and was marked safe to smoke with limitations. However, the resident's care plan did not address her wish to smoke, and progress notes indicated that she frequently asked to smoke and spent time looking for cigarettes. Interviews with staff, including an LPN, RN, and the DON, revealed that no residents on the unit smoked, and residents wishing to smoke would be assessed for safety. The DON confirmed that R581 wished to smoke based on assessments and progress notes, but the facility did not provide escorts for memory care residents who wished to smoke. The facility's smoking policy required a safety risk assessment for residents wishing to smoke, but it appears that R581's desire to smoke was not adequately addressed in her care plan, leading to the deficiency.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the Office of Ombudsman for Long-Term Care (OOLTC) of facility-initiated transfers for two residents who had been hospitalized. Resident R45 was sent to the emergency room due to confusion and was admitted with possible sepsis, remaining hospitalized from June 24 to July 1, 2024. The medical record for R45 lacked evidence that notice of the transfer was provided to the OOLTC. Similarly, Resident R143 was hospitalized with sepsis from June 17 to June 26, 2024, and the medical record also lacked evidence of written notification of the transfer to the OOLTC. The June 2024 Ombudsman Report, dated July 1, 2024, identified four residents who had been transferred to the hospital in June 2024, but did not include R45 or R143. During an interview, the Director of Nursing (DON) stated that nursing staff updated the OOLTC monthly and electronically, and all residents who are discharged or transferred from the facility were to be included in the electronic communication to the OOLTC. The DON confirmed that R45 and R143 were omitted from the list. The facility's Documentation of Transfers/Discharges policy, dated September 2023, directed staff to notify residents' representatives and primary providers at the time of transfer/discharge, but lacked instructions to notify the OOLTC of facility-initiated or emergency transfers within 30 days.
Failure to Notify Resident of Bed Hold Policy
Penalty
Summary
The facility failed to provide timely notification to a resident and/or their representative regarding the bed hold policy following an emergency transfer to the hospital. Resident R45 was sent to the emergency room due to confusion and was admitted with possible sepsis. The resident was hospitalized with sepsis from June 24 to July 1, 2024. During interviews, R45 stated they did not recall being notified of the bed hold policy, and RN-H confirmed that R45's record lacked documentation of such notification. The Director of Nursing also confirmed the absence of bed hold notification in R45's clinical record, which was required by the facility's policy to be provided at the time of discharge or within 24 hours of the transfer.
Failure to Update Care Plan After Resident's Hospitalization
Penalty
Summary
The facility failed to revise and update a comprehensive care plan for a resident who was reviewed for hospitalizations and dialysis services. The resident, identified as R45, was admitted to the facility with diagnoses including anemia, heart failure, high blood pressure, and end-stage renal failure. After being hospitalized with sepsis and having a dialysis access device surgically removed, the resident's care plan was not updated to reflect these significant changes. The care plan still included interventions related to dialysis, despite the resident no longer receiving dialysis treatment. Interviews with facility staff revealed that the resident's discharge paperwork indicated the removal of the dialysis access device, yet the care plan and orders were not updated upon the resident's readmission. The Director of Nursing stated that it was expected for nursing staff to conduct a full assessment and update care plans within 24 hours of a resident's readmission. However, this protocol was not followed, leading to the deficiency in the resident's care plan management.
Deficiency in Dementia Care Planning
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident diagnosed with dementia, chronic obstructive disease, and major depressive disorder. The resident's quarterly Minimum Data Set indicated moderate cognitive impairment, yet their care plan, last reviewed on April 17, 2024, lacked individualized interventions to address the dementia diagnosis and mental health needs. During interviews, a registered nurse confirmed the absence of dementia care and mental health interventions in the resident's care plan. The Director of Nursing acknowledged that the care plan should have included specific interventions to support the resident's dementia and mental health needs, confirming the deficiency in the care plan.
Failure to Implement Individualized Non-Pharmacological Interventions
Penalty
Summary
The facility failed to implement individualized non-pharmacological interventions for two residents, R67 and R184, who were reviewed for unnecessary medications. R67, who was cognitively intact and diagnosed with Alzheimer's disease and depression, was on antipsychotic and antidepressant medications. Despite the absence of exhibited behaviors in the MDS, R67's care plan lacked specific interventions to address mood and behaviors, such as the behavior of sitting with a blanket over their head. Interviews with staff revealed a lack of awareness of specific interventions for R67, and the care plan was confirmed to be lacking in resident-specific strategies. R184, with moderate cognitive impairment and diagnoses including major depressive disorder and dementia, was receiving antipsychotic, antidepressant, and hypnotic medications. A gradual dose reduction was deemed contraindicated. The facility's records showed that R184 received a PRN dose of olanzapine without documentation of non-pharmacological interventions or the reason for administration. Interviews confirmed the absence of alternative interventions in R184's care plan and the lack of specified target symptoms for the PRN medication. The facility's policy on psychotropic drug use required evaluations and non-pharmacological interventions to be documented in care plans, which was not adhered to in these cases. The director of nursing acknowledged the importance of personalized interventions and the need for care plans to reflect these strategies, which were missing for both residents. The failure to provide individualized care and document necessary interventions led to the identified deficiencies.
Failure to Administer Pneumococcal Vaccinations per CDC Guidelines
Penalty
Summary
The facility failed to ensure that three out of five residents were offered or received pneumococcal vaccinations in accordance with CDC recommendations. The residents involved were identified as having incomplete or unverified vaccination records. Specifically, one resident had received the PPSV-23 and PCV-13 vaccines but lacked documentation of a shared clinical decision-making process regarding the administration of the PCV-20 vaccine. Another resident had a similar vaccination history, with no evidence of a discussion or decision about the PCV-20 dose. The third resident's immunization records were incomplete, with an unspecified pneumococcal vaccine noted, and the resident was incorrectly listed as ineligible for further vaccination. The infection preventionist (IP) explained the facility's process for determining vaccination status, which included reviewing immunization reports prior to admission and providing vaccine information sheets to residents. However, the IP admitted to not engaging in shared clinical decision-making discussions about the PCV-20 dose, leaving it to the providers. The IP also struggled to locate two residents in the vaccination tracking log and confirmed that there were no progress notes indicating provider discussions about the PCV-20 dose. The director of nursing (DON) indicated that the responsibility for immunization largely fell to the IP, who was expected to determine eligibility and obtain consent. The DON was not familiar with the process but believed that providers were responsible for the shared clinical decision-making. The facility's policy required staff to assess eligibility and offer vaccinations according to CDC guidelines, but documentation of shared clinical decision-making was not provided.
Failure to Provide Adequate Bathing Assistance
Penalty
Summary
The facility failed to provide adequate bathing assistance to a resident, identified as R166, who was cognitively intact and required partial assistance with activities of daily living, including personal hygiene. Despite documentation indicating that R166 received weekly baths, interviews and observations revealed that the resident had not received a full shower since admission. The resident expressed that only one bed bath was provided, and therapy staff attempted but did not complete a full shower due to the resident's anxiety. Nursing assistants signed off on bathing tasks without completing them, and there was no record of the resident refusing care. The deficiency was further compounded by a lack of communication between the nursing and therapy departments. Nursing staff believed that therapy staff were responsible for R166's bathing, while therapy staff had not provided full bathing assistance after an initial attempt. The Director of Nursing was unaware of the issue, as the documentation inaccurately reflected that care was provided. The facility's policy required staff to document and communicate any uncompleted care, which was not adhered to in this case, leading to the resident not receiving necessary personal hygiene care.
Deficiencies in Resident Care and Documentation
Penalty
Summary
The facility failed to ensure timely follow-up treatment and care for residents, as evidenced by several deficiencies. One resident did not receive appropriate follow-up appointments with an infectious disease specialist after being discharged from the hospital with a severe infection. The resident's electronic health record lacked documentation of future appointments, and there was a significant delay in scheduling a follow-up appointment. The facility's infection preventionist and medical records staff were unable to provide evidence of scheduled appointments or progress notes from the infectious disease specialist, indicating a lapse in communication and documentation. Another resident received blood pressure medication, Midodrine, outside of the prescribed parameters. The medication was administered despite the resident's blood pressure readings being above the threshold for administration. The facility's documentation policy did not include specific instructions for taking blood pressure readings before administering medication with parameters, leading to the inappropriate administration of the medication. The director of nursing acknowledged that the medication should not have been given under these circumstances. Additionally, the facility failed to monitor vital signs and weights as ordered for residents with heart failure and other conditions. One resident's weight was not recorded on multiple occasions, despite orders to monitor weight changes due to heart failure. Another resident's vital signs were not consistently documented, and there was a significant weight gain that went unnoticed. Furthermore, a resident was documented as receiving colostomy care, despite not having a colostomy, indicating a documentation error that persisted for several months.
Failure to Provide Timely Repositioning and Toileting for Resident
Penalty
Summary
The facility failed to provide timely assistance in repositioning and toileting for a resident with a history of pressure ulcers. The resident, who had diagnoses of dementia, hemiplegia, and malnutrition, was dependent on staff for toileting hygiene and transfers. The care plan indicated the resident required assistance every 2-3 hours to prevent skin breakdown. However, during an observation period, the resident was left in a wheelchair in the dining room for several hours without being approached by staff for toileting or repositioning. Interviews with staff revealed that the nursing assistant could not recall if the resident had been taken to the bathroom, and the resident refused toileting when approached. The registered nurse confirmed the resident's incontinence and history of pressure ulcers, emphasizing the need for regular toileting every 2-3 hours. The director of nursing acknowledged the importance of repositioning and toileting to maintain skin integrity, especially for residents with memory impairments, who should be encouraged and reapproached if they refuse care. The facility's pressure ulcer prevention policy was requested but not provided.
Inadequate Dialysis Care and Documentation in LTC Facility
Penalty
Summary
The facility failed to complete a post-hospitalization assessment for a resident who had their dialysis access site removed and no longer required dialysis. Despite the removal of the dialysis access device, the resident's care plan was not updated to reflect the change in treatment needs. Additionally, staff continued to document the completion of dialysis-related tasks for this resident, even though these tasks were no longer applicable. This oversight was confirmed by the Director of Nursing (DON) and the kidney unit manager, who acknowledged the lack of a readmission assessment and the continuation of outdated orders. Furthermore, the facility did not consistently complete and accurately document post-dialysis monitoring assessments for three residents receiving dialysis care. The medical records for these residents showed missing post-dialysis assessments on multiple occasions, and some assessments lacked vital information such as current weight and vital signs. Interviews with nursing staff revealed that the responsibility for documenting pre- and post-dialysis assessments was not consistently fulfilled, leading to gaps in the residents' medical records. The facility's policies directed that residents with end-stage renal disease should be cared for according to recognized standards, including comprehensive care plans that reflect their dialysis needs. However, the failure to update care plans and accurately document dialysis care tasks and assessments indicates a significant lapse in adherence to these policies. The DON confirmed the importance of accurate documentation for patient safety and continuity of care, yet the facility's practices did not align with these expectations.
Failure to Review Critical Clinic Note Leads to Unaddressed Suicidal Ideation
Penalty
Summary
The facility failed to review a critical progress note from a physician's appointment for a resident, identified as R1, which documented suicidal ideation and allegations of physical abuse. R1 had a complex medical history, including diagnoses of adult failure to thrive, cirrhosis of the liver, breast neoplasm, depression, cognitive function issues, and dementia. The resident's PHQ-9 assessment indicated significant depressive symptoms, including thoughts of self-harm. Despite these indicators, the endocrinology clinic note, which was uploaded to the facility's EHR, was not reviewed by the responsible staff. This note highlighted R1's suicidal ideation and allegations of abuse by facility staff, which were not addressed due to the oversight. Interviews with facility staff revealed a breakdown in communication and responsibility regarding the review of external clinic notes. The registered nurse, social worker, administrator, director of nursing, and health information manager were all unaware of the critical information contained in the endocrinology clinic note. The facility's policy on suicide threats required immediate reporting and evaluation, which did not occur in this case. The lack of awareness and action regarding the clinic note left R1 at risk, as the staff did not implement necessary interventions or update the care plan based on the new information.
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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