St Therese Of Woodbury Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Woodbury, Minnesota.
- Location
- 7555 Bailey Road, Woodbury, Minnesota 55129
- CMS Provider Number
- 245632
- Inspections on file
- 22
- Latest survey
- March 20, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at St Therese Of Woodbury Llc during CMS and state inspections, most recent first.
The facility failed to maintain food safety standards, as cooks were observed plating food without beard covers, and expired nutritional supplements were found in a unit kitchen. Additionally, the dishwasher temperatures were often below the required 180°F for proper sanitization, with staff unaware of the correct temperature requirements. These deficiencies indicate lapses in adherence to food safety and sanitation protocols.
The facility failed to ensure accurate documentation of code status for two residents, leading to discrepancies between the POLST and EMR. One resident's POLST indicated DNR, while the EMR showed full code, and the other resident's POLST also indicated DNR, conflicting with the provider order. Interviews confirmed the residents' wishes for DNR, but the facility's records did not reflect this, violating policies on treatment and advance directives.
A resident with impaired cognition and multiple medical conditions did not receive proper bowel monitoring as per standing orders. The facility failed to document bowel movements and initiate the protocol for constipation management, which included medication administration and provider notification. Staff interviews revealed inconsistencies in following the protocol, leading to a deficiency in care.
A resident with cognitive impairment, Parkinson's, and dysphagia was not provided with adequate supervision to prevent aspiration, as the facility failed to follow speech therapy recommendations. The resident's care plan and orders did not include a restriction on straw use, leading to the resident using straws despite a sign indicating otherwise. Staff interviews revealed a lack of documentation on the resident's refusal to remove straws, and the care plan was not updated to reflect the necessary dietary modifications.
A resident with specific dietary needs due to IBS did not receive the ordered meal, missing fresh fruit, despite the facility's policy ensuring residents' rights to make choices about their care. The dietary aide acknowledged potential oversights in meal delivery, and the Dietary Director confirmed no shortage of fruit, highlighting a lapse in the meal service process.
A facility failed to monitor a resident's antibiotic use for a UTI. Despite receiving ceftriaxone injections, there was no documentation of symptom monitoring or treatment effectiveness. Staff interviews revealed a lack of monitoring and documentation, contrary to the facility's antibiotic stewardship policy.
Two residents in the facility experienced deterioration of pressure ulcers due to inadequate assessment and monitoring. One resident's stage 1 ulcer progressed to an unstageable ulcer, while another resident's heel ulcer became unstageable with significant eschar. The facility failed to follow its policies for skin assessments and wound management, contributing to the residents' conditions worsening.
A resident with dysphagia received a cold breakfast and requested an alternative meal, which was not provided, leaving the resident hungry. Staff interviews revealed a failure to adhere to facility expectations for meal service, and the dietary policy was not provided.
A resident with a PICC line and pressure ulcers did not receive care in compliance with enhanced barrier precautions (EBP) at a facility. Staff failed to wear gowns during high-contact activities and did not perform hand hygiene after glove removal, despite clear signage and care plan instructions. Interviews confirmed the expectation for EBP use to prevent infection spread, highlighting a deficiency in adherence to infection control protocols.
A facility failed to implement enhanced barrier precautions for a resident with a history of ESBL, and staff did not adhere to proper hand hygiene and glove use during personal care. The resident was not placed on EBP upon admission, and a nursing assistant did not perform hand hygiene or change gloves appropriately while assisting the resident. The infection preventionist and DON confirmed the lapses in following facility policies.
The facility failed to complete a self-administration of medications (SAM) assessment for two residents who were observed with medications at their bedside. One resident with Alzheimer's had a topical ointment left in their room despite being unable to self-administer, while another resident with Parkinson's had pills left at their bedside without a SAM assessment or doctor's order. Staff confirmed that medications should not have been left without proper assessments and orders.
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in care. One resident's care plan lacked instructions for a TLSO brace, resulting in improper application due to inadequate staff training. Another resident was not informed of their therapy schedule, as the process to update their whiteboard was not followed. A third resident's need for a back brace was not documented, leading to improper use. These issues highlight a breakdown in communication and documentation within the facility.
A facility failed to conduct weekly wound assessments for a resident with a diabetic foot wound, despite having a care plan and provider orders for dressing changes. The resident's medical record lacked evidence of wound assessments or measurements since admission, and staff relied on an outside provider for wound management without documenting the wound's status. Interviews revealed that the facility did not follow its policy requiring weekly wound assessments.
A resident with left-sided hemiparesis did not consistently receive prescribed ROM exercises and the application of a left hand splint as ordered. Despite being cooperative, the resident reported that staff often neglected these tasks, and documentation confirmed several instances where ROM was not performed. Staff interviews revealed that the care plan was sometimes overlooked, and the hand splint was not consistently applied, contributing to the deficiency.
A resident with COPD was observed receiving oxygen at 2.5 LPM instead of the prescribed 2.0 LPM due to a failure to document the physician's order in the MAR. The nursing staff was unaware of the correct oxygen level, as confirmed by interviews with the RN, nurse manager, and LPN. The facility's policy did not require checking the LPM each shift, contributing to the oversight.
Deficiencies in Food Safety and Dishwasher Sanitization
Penalty
Summary
The facility failed to adhere to professional standards in food handling and sanitation, as observed during a survey. Two cooks were seen plating food without beard covers, which they admitted to not wearing unless instructed by leadership. Additionally, the facility's second-floor unit kitchen contained expired nutritional supplements, which were verified and discarded by a registered nurse. These actions indicate a lack of consistent adherence to food safety protocols, potentially affecting all residents. Furthermore, the facility's dishwasher temperatures were not consistently maintained at the required levels for proper sanitization. Observations revealed that the final rinse temperatures were frequently below the necessary 180 degrees Fahrenheit, with 36 out of 58 recorded instances meeting the required temperature. The dietary aide was unaware of the correct temperature requirements and continued to use the dishwasher despite inadequate temperatures. The Dietary Director acknowledged the issue but was not informed of the temperature discrepancies, indicating a communication gap and lack of oversight in ensuring compliance with sanitation standards.
Inaccurate Code Status Documentation for Two Residents
Penalty
Summary
The facility failed to ensure that the Physician Orders for Life Sustaining Treatment (POLST) accurately reflected the code status wishes of two residents, R147 and R198. For R198, the medical record contained conflicting information regarding the resident's code status. The face sheet and physician orders indicated a full code status, while the POLST signed by the resident indicated a Do Not Resuscitate (DNR) status. Interviews with the resident and nursing staff confirmed that the resident did not wish to receive resuscitation efforts, highlighting a discrepancy between the POLST and the electronic medical record (EMR). Similarly, for R147, there was a mismatch between the POLST and the provider order in the EMR. The POLST indicated a DNR status, while the provider order stated full code. Interviews with the resident confirmed their preference for DNR, yet the care plan and provider order did not reflect this. Nursing staff acknowledged the inconsistency and the need to clarify the correct code status with the provider. The facility's policies on Residents' Rights Regarding Treatment and Advance Directives and Communication of Code Status were not adhered to, as they require accurate documentation and communication of a resident's code status. The failure to ensure that the POLST and EMR matched the residents' wishes could lead to unwanted resuscitation efforts, as noted by the nursing staff during interviews.
Failure in Bowel Monitoring for a Resident
Penalty
Summary
The facility failed to ensure proper bowel monitoring for a resident with moderately impaired cognition and several medical conditions, including chronic diastolic heart failure and benign prostatic hyperplasia. The resident required assistance with most activities of daily living and had a catheter. Despite standing orders for bowel monitoring, the facility did not document bowel movements from March 5 to March 7 and March 15 to March 17, 2025. The standing orders included steps such as rectal checks, fluid intake encouragement, dietary consultations, and administration of medications like Sennoside and Biscodyl if no bowel movement occurred by the third day. However, the resident's records lacked documentation of bowel assessments, administration of PRN medications, or notification of the provider or hospice. Interviews with staff revealed inconsistencies in the implementation of the standing orders. Nursing assistants were responsible for documenting bowel movements, but there was a lack of communication with nurses unless there was an abnormality. Licensed practical nurses acknowledged that the standing orders should have been initiated on the third day without a bowel movement, but this protocol was not followed. The clinical coordinator confirmed the absence of a PRN medication order for constipation and the lack of documentation regarding provider or hospice notification. The director of nursing emphasized the importance of following the standing orders to prevent complications such as bowel obstruction or impaction.
Failure to Follow Speech Therapy Recommendations for Aspiration Risk
Penalty
Summary
The facility failed to follow speech therapy recommendations to minimize the risk of aspiration for a resident with mild cognitive impairment, Parkinson's disease, and dysphagia. The resident required a soft diet with bite-sized food and thin liquids without the use of a straw, as per the speech therapy assessment. However, the resident's provider orders and care plan did not include the restriction on straw use. Observations revealed that the resident was using straws with their drinks, despite a sign in the room indicating no straw use. Interviews with staff and family members confirmed that the resident had been using straws and had refused to have them removed, although there was no documentation of this refusal. The speech therapist was informed of the resident's refusal to remove straws and re-educated the resident after observing coughing when using a straw. The Director of Nursing expected recommendations to be communicated in the care plan and for staff to follow them, with documentation of any resident refusals. The facility's policy required care plan revisions upon status changes, but the care plan was not updated to reflect the no straw recommendation, leading to a failure in ensuring the resident's safety and adherence to dietary modifications.
Failure to Provide Ordered Meal Choices for Resident
Penalty
Summary
The facility failed to ensure that meal choices were provided as ordered for a resident, identified as R147, who was recently admitted following back surgery and had specific dietary needs due to irritable bowel syndrome (IBS). R147's care plan required adherence to a regular diet with thin liquids and avoidance of certain foods due to intolerances. Despite these requirements, R147 reported that the meals provided did not always match what was ordered, leading to frustration and reliance on family-provided food. On one occasion, R147 ordered a plain hamburger with fresh fruit, but the fruit was not delivered, which was confirmed by a registered nurse. The dietary aide responsible for meal delivery stated that meals were checked for accuracy multiple times, but acknowledged that items might be missed due to the volume of trays. The Dietary Director confirmed that fresh fruit should always be available and there was no shortage on the day in question, but admitted that the process was not perfect. The facility's policy on Resident Rights emphasizes the importance of respecting residents' choices regarding their care, which was not upheld in this instance.
Failure to Monitor Antibiotic Use for UTI
Penalty
Summary
The facility failed to ensure proper monitoring of antibiotic use for a resident who was treated for a urinary tract infection (UTI). The resident, who was cognitively intact and had a diagnosis of lung failure, was occasionally incontinent of bowel and bladder. The resident's laboratory results confirmed a UTI, and the provider ordered a 1-gram ceftriaxone intramuscular injection. However, there was no indication in the resident's orders or nursing progress notes that the resident was monitored for symptoms or the effectiveness of the antibiotic treatment. The resident continued to experience symptoms of burning and urgency, and a second round of antibiotics was ordered without documentation of monitoring. Interviews with staff, including a nursing assistant, registered nurse, infection preventionist, and the Director of Nursing, revealed a lack of monitoring and documentation of the resident's symptoms and response to the antibiotic treatment. The facility's antibiotic tracking document also lacked information on whether the resident's symptoms had resolved. The facility's policy on antibiotic stewardship required nursing staff to assess residents suspected of having an infection, notify the provider, and monitor the response to antibiotics, but these actions were not documented in the case of this resident.
Failure to Assess and Monitor Pressure Ulcers
Penalty
Summary
The facility failed to comprehensively assess and monitor pressure ulcers for two residents, leading to the deterioration of their conditions. One resident was admitted with a stage 1 pressure ulcer that was not properly assessed or documented, resulting in it developing into an unstageable pressure ulcer. The resident's care plan lacked interventions for pressure ulcer prevention, and the facility did not perform comprehensive skin assessments as required. The resident was eventually sent to the hospital, where the unstageable pressure ulcer was identified, along with a stage 3 pressure ulcer on the coccyx. Another resident was admitted with a pressure ulcer on the left heel, which was not properly assessed or monitored. The resident reported that the pressure sore was not looked at for eight days, and the facility's documentation did not include comprehensive wound assessments. The resident experienced ongoing pain, and the pressure ulcer eventually developed into an unstageable ulcer with significant eschar and slough. The facility's failure to perform regular assessments and follow treatment orders contributed to the deterioration of the resident's condition. Interviews with facility staff, including nursing assistants and registered nurses, revealed that the facility's policies for skin assessments and wound treatment management were not followed. Comprehensive skin assessments were not conducted upon admission or weekly as required, and there was a lack of communication with physicians and family members regarding changes in the residents' conditions. The facility's director of nursing acknowledged the deficiencies in assessing and monitoring the residents' pressure ulcers, which led to their deterioration.
Failure to Serve Palatable Meals and Offer Alternatives
Penalty
Summary
The facility failed to ensure that meals were served in a warm and palatable manner, affecting the quality of life and nutritional intake for a resident on a short-term stay. The resident, who had intact cognition and a diagnosis of dysphagia, was on a mechanically altered diet and required setup assistance with eating. During an observation, the resident received a breakfast tray with cold eggs and turkey sausages and requested an alternative meal option, which was not provided. The resident expressed dissatisfaction with the cold food and requested a sweet roll, but no alternative was offered, and the resident remained hungry. Interviews with staff revealed a lack of adherence to the facility's expectations regarding meal service. The food server acknowledged that an alternative should be offered if food was cold, but failed to address the resident's request. The director of social services and the director of nursing both stated that staff should offer an alternative or reheat the food if it was cold. Despite these expectations, the dietary policy was requested but not received, indicating a possible gap in policy communication or implementation.
Failure to Implement Enhanced Barrier Precautions and Hand Hygiene
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for a resident with a pressure ulcer wound and a peripherally inserted central catheter (PICC), which are critical for reducing the transmission of multidrug-resistant organisms. The resident, identified as R2, had specific care instructions for PICC site maintenance and wound dressing changes. Despite these instructions, during an observation, it was noted that the nursing assistant (NA) and nurse practitioner (NP) did not wear gowns while providing incontinence care, which is a high-contact activity requiring EBP. Additionally, the NA failed to perform hand hygiene after removing gloves, further increasing the risk of infection transmission. The resident's care plan clearly indicated the need for EBP due to the presence of a PICC line and pressure ulcers, with instructions for staff to adhere to these precautions. However, during the observed care, the staff did not comply with the facility's policy, which mandates the use of gowns and gloves during high-contact activities such as toileting and wound care. The facility had signage posted in the resident's room to remind staff of the EBP requirements, yet these were not followed during the observed incident. Interviews with the nursing assistant, registered nurse, and director of nursing confirmed the expectation that EBP should be used for residents with PICC lines or wounds to prevent infection spread. The facility's policy on enhanced barrier precautions and hand hygiene was not adhered to, as evidenced by the staff's actions during the care of the resident. This non-compliance with established infection control protocols led to the deficiency noted in the report.
Failure to Implement Enhanced Barrier Precautions and Proper Hand Hygiene
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for a resident colonized with a multidrug-resistant organism (MDRO), specifically extended-spectrum-beta lactamase (ESBL). The resident, who had a history of recurrent urinary tract infections due to ESBL, was not placed on EBP upon admission, as indicated by the absence of signage or a cart outside their room. This oversight was confirmed by the infection preventionist, who acknowledged that the resident should have been placed on EBP due to their medical history. Additionally, the facility did not ensure proper hand hygiene and glove use during personal care for the resident. An observation revealed that a nursing assistant entered the resident's room without performing hand hygiene, assisted the resident with toileting without wearing gloves initially, and failed to change gloves or perform hand hygiene after handling soiled items. The nursing assistant admitted to not following proper procedures, citing the absence of appropriately sized gloves and a misunderstanding of when glove changes were necessary. Interviews with the infection preventionist and the Director of Nursing highlighted the expectation for staff to perform hand hygiene upon entering and exiting resident rooms and to use gloves and gowns during high-contact care activities. The facility's policies on enhanced barrier precautions and hand hygiene were not adhered to, contributing to the deficiency in infection prevention and control measures.
Failure to Complete SAM Assessment for Residents
Penalty
Summary
The facility failed to ensure that a self-administration of medications (SAM) assessment was completed for two residents who were observed with medications at their bedside. The first resident, identified as R15, had severely impaired cognition due to Alzheimer's disease and was dependent on staff for most activities of daily living. Despite a previous SAM assessment indicating that R15 did not wish to self-administer medications, a container of Menthol-Zinc Oxide ointment was found on R15's nightstand. The trained medication assistant confirmed that R15 was unable to self-administer medications and that the ointment should not have been left in the room. The clinical coordinator also stated that a SAM assessment and a doctor's order are required for residents to self-administer medications, which R15 did not have. The second resident, identified as R360, was recently admitted with a diagnosis of traumatic subdural hematoma and Parkinson's disease. R360's medical records lacked evidence of a SAM assessment, and there was no provider order for self-administration of medication. During an observation, a pill cup containing Parkinson's medication was found on R360's bedside table. R360 explained that the medication was left for her to take later, as it was too early to take it at the time it was brought in. The LPN confirmed that no SAM assessment was completed for R360 and that the medication should not have been left in the room. The nurse manager and the director of nursing reiterated that a SAM assessment and a doctor's order are necessary for residents to self-administer medications, and medications should not be left at the bedside without these requirements being met.
Deficiencies in Care Planning and Communication
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan for three residents, leading to deficiencies in their care. For one resident, identified as R103, the care plan did not include instructions for the use of a TLSO brace, which was necessary due to a lumbar vertebra fracture. Despite the resident's intact cognition and ability to communicate, staff were not adequately trained on how to apply the brace, resulting in it being applied incorrectly on multiple occasions. Interviews with staff revealed a lack of written instructions and inconsistent training, which contributed to the improper application of the brace. Another resident, R304, experienced a lack of communication regarding their therapy schedule. Although the resident received therapy five times a week, they were not informed of the specific times, which was supposed to be communicated via a whiteboard in their room. Observations confirmed that the whiteboard was not updated with therapy times, and interviews with staff indicated a breakdown in the process of informing residents about their therapy schedules. This lack of communication left the resident unaware of their therapy schedule, contrary to the facility's policy. The third resident, R355, had severe cognitive impairment and required a back brace, but the care plan and Kardex did not reflect this need. The staff were unaware of the specific instructions for the brace, leading to its improper use. Interviews with nursing staff confirmed that the necessary information was not included in the care plan or Kardex, which was crucial for ensuring all staff were informed about the resident's needs. This oversight in documentation and communication resulted in inadequate care for the resident.
Failure to Conduct Weekly Wound Assessments
Penalty
Summary
The facility failed to ensure weekly wound assessments were completed for a resident with a non-pressure related wound. The resident, who was cognitively intact, had a diabetic foot wound requiring dressing changes and was followed by an outside provider for wound management. Despite having a care plan and provider orders for dressing changes, the facility did not conduct or document any wound assessments or measurements since the resident's admission. The medical record lacked evidence of wound assessments, and there were no progress notes from the resident's appointments with a vascular provider. Interviews with facility staff revealed that the wound was changed three times a week, but no assessments or measurements were completed by the facility. The staff relied on the outside provider for wound management and did not document the wound's appearance, measurements, or signs of infection. The Director of Nursing expected staff to assess wounds during treatment and receive documentation from the outside provider, but this was not done. The facility's policy required wound assessments upon admission, weekly, and as needed, but this was not followed for the resident in question.
Failure to Provide Prescribed ROM Exercises and Splint Application
Penalty
Summary
The facility failed to ensure that a resident, identified as R16, received the prescribed range of motion (ROM) exercises and the application of a left hand splint as ordered. R16, who was admitted with left-sided hemiparesis due to a previous stroke, required assistance with activities of daily living and was at risk for complications such as contractures. Despite being cooperative with care, documentation revealed that ROM exercises were not consistently performed on several dates, and the left hand splint was not applied as required. Observations and interviews with R16 and staff indicated that the ROM exercises and the application of the hand splint were frequently neglected. R16 reported that staff did not perform the ROM exercises and that he had to remind them to apply the hand splint, which was often left out of reach. Staff interviews confirmed that R16's care plan was not always followed, and there were instances where staff did not have time to complete the ROM exercises. Additionally, the hand splint was not consistently applied, even when R16 expressed a desire for it to be used to prevent his fingers from curling. The facility's policy on the prevention of decline in range of motion emphasized the importance of consistent implementation of care plan interventions, including the use of braces or splints. However, interviews with nursing staff and the director of nursing revealed that the care plan was sometimes overlooked, and staff did not always offer the hand splint to R16, who was sometimes forgetful. The lack of consistent care and adherence to the care plan contributed to the deficiency in providing appropriate ROM exercises and splint application for R16.
Failure to Administer Oxygen as Prescribed
Penalty
Summary
The facility failed to administer oxygen to a resident, identified as R305, according to the physician's orders. R305, who has chronic obstructive pulmonary disease (COPD), was observed receiving oxygen at 2.5 liters per minute (LPM) instead of the prescribed 2.0 LPM. The physician's order for oxygen was not entered into the computer or medication administration record (MAR), which led to the nursing staff being unaware of the correct oxygen level to administer. This oversight was confirmed through interviews with the registered nurse (RN)-B, nurse manager RN-A, and licensed practical nurse (LPN)-C, who all verified the discrepancy in the oxygen administration. The director of nursing (DON) stated that it was the nurses' responsibility to ensure the oxygen LPM matched the physician's orders and to check it each shift. However, the facility's policy on oxygen administration did not include a requirement for checking the LPM each shift. The lack of documentation in the MAR and the absence of a clear policy contributed to the failure in providing the correct oxygen level, potentially leading to adverse effects such as shortness of breath or low oxygen saturations for the resident.
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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