Sterling Park Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Waite Park, Minnesota.
- Location
- 142 North First Street, Waite Park, Minnesota 56387
- CMS Provider Number
- 245375
- Inspections on file
- 24
- Latest survey
- August 1, 2025
- Citations (last 12 mo.)
- 10 (1 serious)
Citation history
Health deficiencies cited at Sterling Park Health Care Center during CMS and state inspections, most recent first.
Two residents with clear wishes for resuscitation, as documented in their signed POLST forms, had conflicting code status information in the EHR and physician orders, which incorrectly indicated DNR/DNI. Staff interviews confirmed they would have followed the incorrect EHR information in an emergency, resulting in actions contrary to the residents' wishes. The facility's inconsistent process for updating and verifying code status led to these discrepancies.
The facility did not maintain required RN coverage for at least 8 consecutive hours daily, as staffing records showed an RN shift was filled by an LPN on one occasion, resulting in no RN on-site for that day. Staff interviews revealed reliance on scheduling apps, on-call rotations, and contingency plans, but a scheduling oversight led to the deficiency.
A resident with significant cognitive and physical impairments was found to have a parameter mattress in place for an extended period to prevent falls, despite being non-ambulatory and unable to get out of bed independently. Staff interviews revealed the mattress was not assessed or documented as a restraint in the required physical device assessment, and its continued use was not clearly justified. Facility policy prohibits the use of physical restraints for staff convenience or fall prevention without proper assessment and documentation.
A resident with multiple chronic conditions left the facility against medical advice without a comprehensive discharge plan or proper documentation of education regarding the risks of leaving AMA. The facility did not provide a discharge summary or recapitulation of stay at the time of discharge, and key information such as medication instructions and follow-up care was not given to the resident.
A resident with multiple complex diagnoses and moderate ADL assistance needs did not have a person-centered care plan with specific goals and interventions. The care plan contained only problem statements without measurable objectives or individualized actions, and facility staff confirmed the plan was incomplete and not tailored to the resident.
Staff did not consistently follow physician orders or honor a resident’s preferences and goals, resulting in care that was not individualized or aligned with the resident’s needs.
A resident with moderate cognitive impairment and multiple health conditions was not assessed for safe use of an electric recliner, despite being identified as a fall risk and requiring assistance for mobility. The electric recliner was not included in the physical device assessment, and staff had to intervene when the resident nearly slid from the recliner. Nursing leadership confirmed the assessment should have included the recliner, but it was omitted.
A resident was repeatedly observed handling the tops and rims of other residents' coffee cups during meal service without staff intervention, despite this being a regular occurrence. Staff did not redirect or stop the resident, and the Infection Preventionist confirmed this was not in line with infection control protocols.
A resident with a history of peripheral vascular disease and cerebrovascular accident experienced worsening pain and swelling in the right lower leg, which was not promptly communicated to a physician by the facility staff. Despite documentation of significant changes in the resident's condition, including a large swelling and pain, the delay in notifying the medical provider led to a hospitalization for cellulitis and a hematoma.
A facility failed to implement a resident's physician's orders for tube feeding and did not coordinate care for incontinence needs during cancer center appointments. The resident, requiring tube feeding due to tongue cancer, missed scheduled feedings during appointments, and the facility did not send necessary incontinence supplies or clothing. The care plan lacked interventions for these appointments, and staff did not consult the physician or revise the care plan, leading to a deficiency.
The facility failed to store and label food properly, dispose of undated and expired food items, and maintain cleanliness in the kitchen, affecting 34 residents. Observations included uncovered and undated food, outdated buns without signage, improperly thawed fish, and significant ice buildup in the walk-in freezer. Interviews revealed that contracted kitchen staff were not consistently following proper food storage procedures.
The facility failed to assess a resident for the ability to self-administer medications and did not obtain an order for medication self-administration. The resident was observed taking high-risk medications without staff supervision, and staff confirmed that medications were sometimes left in the room for the resident to take independently, despite the lack of a self-administration order or assessment.
A facility failed to document and communicate required information when a resident with multiple diagnoses was emergently transferred to a hospital. The medical record lacked essential details, and staff interviews confirmed that the transfer process was not followed correctly.
A facility failed to inform a resident or their legal representative of bed hold rights during hospitalization. The resident was sent to the emergency room, but no bed hold notification was documented. Interviews confirmed the oversight, and a review of the medical records showed non-compliance with the facility's transfer and bed hold notification procedures.
The facility failed to ensure proper coordination of care and communication between the facility and the dialysis center for a resident receiving hemodialysis. Despite having pre and post-dialysis assessments documented, the resident's record lacked a dialysis care plan and did not include the dialysis center's contact information. Interviews revealed no paperwork was exchanged between the facility and the dialysis center, and no clinical communication was documented.
A facility failed to ensure that a resident's prescribed medication, Vascepa, was available and administered, resulting in 19 missed doses over ten days. The issue was attributed to a change in the resident's payer source and a lack of communication between the facility staff and the pharmacy. The nurse practitioner was not informed of the missed doses despite being in frequent contact with the facility.
A resident with diagnoses including congestive heart failure, diabetes, and hypertension was eligible for the PCV20 vaccine beginning December 2023, but the facility's EMR incorrectly indicated eligibility for December 2024. The resident was not provided education, offered, or received the PCV20 vaccination. The DON stated that the facility followed CDC recommendations and used a CDC-based tool to track eligible residents, but the error in the EMR led to the deficiency.
Failure to Accurately Document and Update Advance Directives and Code Status
Penalty
Summary
The facility failed to ensure that advance directives, specifically code status and resuscitation wishes, were accurately documented and updated in the electronic health record (EHR) banner, physician orders, and the Physician's Orders for Life Sustaining Treatment (POLST) for two residents. For one resident with diagnoses including congestive heart failure, hypertension, renal failure, diabetes, and chronic respiratory failure, the POLST signed by both the resident and the medical provider indicated a full code status, meaning the resident wished to receive cardiopulmonary resuscitation (CPR). However, the EHR banner and physician orders incorrectly reflected a do not resuscitate/do not intubate (DNR/DNI) status. Multiple staff interviews confirmed that in the event of an emergency, staff would have followed the incorrect DNR/DNI status in the EHR and not performed CPR, contrary to the resident's expressed wishes. A similar issue was identified for another resident with diagnoses including diabetes with polyneuropathy, hypothyroidism, hypertension, and chronic kidney disease. This resident's POLST and Directives to Define Scope of Medical Care form, both signed by the resident and provider, indicated a wish to be resuscitated (full code). However, the EHR banner and order summary incorrectly listed the resident as DNR. Staff interviews revealed that in an emergency, staff would have referred to the EHR and not initiated CPR, again contrary to the resident's wishes. The process for updating and verifying code status orders was inconsistent, with reliance on both the EHR and physical binders, leading to discrepancies and confusion among staff. The facility's policy required that advance directives and code status be discussed at admission and reviewed at care conferences, but the process for ensuring that changes were accurately reflected in all relevant documentation was not followed. The case manager was responsible for entering provider-signed orders into the EHR, but this step was missed, resulting in outdated or incorrect information being available to staff. Staff training and understanding of where to find the most current code status information varied, contributing to the risk of not honoring residents' wishes regarding life-sustaining treatment.
Removal Plan
- Completed an audit of all residents' code status.
- Reviewed the process to ensure the entered POLST information into the EMR was accurate and updated.
- Educated licensed staff regarding the updated POLST procedure and where to find a residents' code status.
- Continued education for staff.
Failure to Ensure Daily RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on-site for at least 8 consecutive hours on a daily basis, as required. Payroll Based Journal (PBJ) staffing data for a specific quarter revealed that there was no RN coverage on at least one weekend day. Specifically, on one Sunday, an open RN shift was posted but was ultimately filled by an LPN instead of an RN, resulting in a lack of required RN presence. The facility's assessment indicated the need for one RN for 40 residents, and staffing schedules showed RNs were typically scheduled for 12-hour shifts. However, the absence of an RN on the identified day was not recognized as an error at the time. Interviews with facility staff, including the Director of Operations (DOO), Staffing Coordinator (SC), and Human Resources (HR), confirmed the processes in place for managing RN coverage, such as using the OnShift app to post open shifts, maintaining an on-call rotation, and having contingency plans for emergency staffing. Despite these measures, the facility's scheduling and oversight failed to prevent a lapse in RN coverage, as the open shift was inadvertently assigned to an LPN. Staff interviews also revealed a misunderstanding regarding the allowable number of days without RN coverage per quarter, with the SC believing a maximum of three days was permitted, though the goal was zero.
Failure to Properly Assess and Document Use of Parameter Mattress as Restraint
Penalty
Summary
The facility failed to ensure that a parameter mattress, which is a type of mattress cover designed to create a gentle barrier around the edge of the bed, was not used in a manner that restrained a resident while in bed. The resident in question had moderate cognitive impairment, required assistance with all activities of daily living, and had multiple diagnoses including dementia, anxiety, and limited mobility. The resident's care plan indicated the use of a lipped mattress to decrease fall risk, but did not document the use of the parameter mattress as a restraint. The Minimum Data Set (MDS) and physical device assessment did not indicate the use of restraints or the parameter mattress for this resident. During observations and interviews, staff confirmed that the resident had a parameter mattress in place for several years to prevent falls, despite the resident being non-ambulatory and unable to get out of bed independently for approximately a year. The parameter mattress was not assessed or documented in the physical device assessment as required, and staff were unsure why it remained in use. The facility's policy defined physical restraints as any device that restricts freedom of movement and specified that such restraints should only be used for medical symptoms and not for staff convenience or fall prevention. The use of the parameter mattress in this case was not supported by assessment or documentation, leading to the deficiency.
Failure to Ensure Safe and Orderly AMA Discharge
Penalty
Summary
The facility failed to ensure a safe and orderly discharge for a resident who left against medical advice (AMA). The resident, who had intact cognition and required minimal to limited assistance with activities of daily living, had multiple diagnoses including type II diabetes mellitus, major depressive disorder, hypertension, osteoarthritis, hypothyroidism, and hyperlipidemia. Although the resident had previously planned to discharge to an assisted living facility, she ultimately left the facility with her daughter, refusing to re-enter the building. The facility provided an AMA form for the resident to sign in a vehicle, but did not complete a comprehensive discharge plan or adequately document efforts to educate the resident about the risks of leaving AMA. There was no documentation of a recapitulation of stay or a discharge summary in the resident's electronic health record at the time of discharge. The discharge summary was only entered as a late entry after being requested by a surveyor. Interviews with facility staff confirmed that the usual process of providing a discharge summary, including information on medications, recent labs, and follow-up appointments, was not followed in this case. The facility also did not provide documentation of efforts to educate the resident about appeal rights or bed-hold policies at the time of the AMA discharge.
Failure to Develop Person-Centered Care Plan with Measurable Goals
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident who was reviewed for care planning. The resident had intact cognition and required moderate assistance with activities of daily living (ADLs). Diagnoses included acute respiratory failure with hypoxia, atrial fibrillation, hypertension, benign prostatic hyperplasia, diabetes mellitus, hyperkalemia, depression, obstructive sleep apnea, and mild cognitive impairment. The care plan for this resident included several problem statements such as ADL self-care performance deficit, diabetes management, altered cardiovascular and hematological status, use of antidepressant medication, pain management, vulnerability, altered respiratory status, and a wish to return to the community. However, each of these care plan entries lacked specific goals and interventions. During interviews, the DON and RN clinical coordinators confirmed that the MDS coordinator, who was responsible for entering and revising care plans, had left the facility several months prior, and the resident's care plan was neither completed nor individualized. The facility's policy required the development and implementation of a comprehensive, person-centered care plan with measurable objectives and timeframes for each resident, but this was not done for the resident in question.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. This deficiency was identified through surveyor observation and review of care practices, which revealed that staff did not consistently follow prescribed care plans or honor the expressed wishes and goals of the resident. The lack of adherence to orders and resident preferences resulted in care that was not aligned with the individualized needs of the resident.
Failure to Assess Resident for Safe Use of Electric Recliner
Penalty
Summary
The facility failed to comprehensively assess a resident with moderate cognitive impairment and multiple medical diagnoses, including dementia, anxiety, and limited mobility, for safe use of an electric recliner. The resident's care plan indicated the use of a recliner to elevate her legs and identified her as a fall risk requiring assistance for bed mobility and transfers. However, the physical device assessment did not include the electric recliner, and there was no documentation that the resident's ability to safely use the recliner had been evaluated. Observations showed the resident using the electric recliner independently, with the remote consistently within reach. During one incident, staff had to intervene when the resident elevated the recliner to a point where she nearly slid to the floor. Interviews with staff revealed inconsistent understanding of the resident's ability to operate the recliner remote, with some stating she could use it and others noting confusion and fidgeting. Nursing leadership confirmed the recliner should have been assessed as part of the physical device assessment and acknowledged this was not done. The facility was unable to provide policies related to assistive device and physical device assessments.
Failure to Prevent Cross-Contamination During Meal Service
Penalty
Summary
During multiple dining observations, a resident was seen walking around the dining room and handling the coffee cups of other residents by touching the tops and rims while distributing them. This occurred during both lunch and breakfast meal services, with the resident picking up and handing out coffee cups to others, often gripping the cups around the top or rim. Staff members present in the dining area did not intervene or redirect the resident to prevent this contact, despite being aware that the resident regularly engaged in this behavior at every meal. Interviews with staff confirmed that the resident frequently assisted with coffee distribution and that staff did not take action to stop the resident from touching other residents' drinkware. The facility's Infection Preventionist acknowledged that such behavior was not in accordance with the facility's infection control protocols and that staff should have intervened to prevent possible transmission of infectious agents. The facility's infection prevention and control policy related to dining services was requested but not provided during the survey.
Failure to Notify Physician of Resident's Worsening Condition
Penalty
Summary
The facility failed to promptly notify a physician of a change in condition for a resident when a right lower leg abscess worsened and required hospitalization. The resident, who had a history of peripheral vascular disease, cerebrovascular accident, and was at risk for pressure ulcers, experienced significant pain and swelling in the right lower extremity. Despite the presence of a large, painful swelling on the resident's leg, the facility staff did not notify the physician in a timely manner, leading to a delay in appropriate medical intervention. The resident's condition was documented by various staff members, including physical therapy and nursing staff, who noted the presence of a softball-sized swelling, pain, and changes in skin integrity. However, there was a lack of communication and follow-up with the medical provider regarding these observations. The resident was eventually sent to the emergency room after the condition worsened, where he was diagnosed with cellulitis and a hematoma, requiring further medical treatment. Interviews with facility staff revealed inconsistencies in documentation and a failure to adhere to the facility's policy on notifying medical providers of changes in a resident's condition. Several staff members acknowledged that the provider should have been contacted earlier, and the resident's condition warranted immediate medical attention. The delay in notification and treatment highlights a deficiency in the facility's response to changes in resident health status.
Failure to Implement Physician's Orders and Coordinate Care
Penalty
Summary
The facility failed to implement treatment consistent with the resident's physician's orders and professional standards of practice for a resident who was not sent with sustenance to his appointment. The resident, who had diagnoses including acute respiratory failure, pneumonia, and adult failure to thrive, required tube feeding due to tongue cancer. The resident's Medication Administration Record indicated an order for Osmolite to be administered via gastrostomy tube four times a day. However, on two occasions, the resident did not receive the scheduled tube feeding while at the cancer center for appointments, and there was no evidence of staff notifying the resident's physician or adjusting the feeding schedule. Additionally, the facility did not adequately prepare for the resident's incontinence needs during appointments. The resident was reported to be incontinent multiple times during a cancer center visit, and the facility failed to send incontinence supplies or extra clothing, despite requests from the cancer center staff. The resident's care plan did not include interventions for these appointments, and staff did not revise the care plan or communicate the necessary adjustments to other staff members. The Director of Nursing confirmed that the resident did not receive the ordered tube feeding on specific dates and acknowledged the lack of documentation or consultation with the resident's physician. The facility's failure to coordinate care with the cancer center and to revise the resident's care plan to address these issues contributed to the deficiency. The facility also did not provide a requested policy for comprehensive care plans, indicating a lack of adherence to expected procedures.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The facility failed to store and label food properly, dispose of undated and expired food items, and maintain cleanliness in the kitchen, which had the potential to affect 34 residents who were provided meals from the kitchen. During an initial tour of the kitchen, surveyors observed multiple instances of improper food storage, including uncovered and undated jello and fruit cocktail in a cooler, outdated hamburger and hotdog buns stacked on the floor without signage, and improperly thawed fish in a sink with running water. Additionally, the dry storage area contained an open bag of breadcrumbs and loosely sealed bags of chocolate chips without labels. The walk-in cooler had several unlabeled and uncovered food items, including grated parmesan cheese, strawberries, cheese, apple pies, and hamburger logs. The walk-in freezer had significant ice buildup and improperly stored food items directly on the floor. In the food preparation area, a bin labeled as sugar was loosely covered with plastic wrap, leaving an open area exposed to potential contamination. During a second tour of the kitchen, surveyors observed similar issues, including unlabeled fruit cocktail cups in the three-door cooler and ice/frost buildup in the walk-in cooler. Several food items, including broccoli, shrimp, pumpkin pies, breaded chicken pieces, and beef sirloin, were stored directly on the floor of the walk-in freezer. Interviews with the dietary manager (DM) and the administrator revealed that the kitchen staff, who were contracted employees, had been trained on proper food storage procedures but were not consistently following them. The facility failed to provide a policy regarding food storage when requested by the surveyors.
Failure to Assess and Obtain Order for Self-Administration of Medications
Penalty
Summary
The facility failed to assess a resident for the ability to self-administer medications after staff set them up, and did not obtain an order for medication self-administration. The resident, identified as R27, was observed self-administering medications without staff supervision. R27, who had a BIMS score of 15 indicating cognitive intactness, was taking high-risk medications including opioids and anti-platelet medications. Despite this, there was no order for R27 to self-administer medications, nor was there a completed self-administration assessment. During an observation, R27 was seen taking pills from a medication cup left on the bedside table without knowing what the pills were or how long they had been there. Interviews with staff confirmed that medications were sometimes left in the room for R27 to take independently, despite the lack of a self-administration order or assessment. Facility guidelines require a self-administration assessment and a physician's order for residents to self-administer medications, but these procedures were not followed for R27.
Failure to Document and Communicate Transfer Information
Penalty
Summary
The facility failed to ensure adequate and required information was documented and communicated to a receiving healthcare facility when a resident was transferred emergently to a hospital. The resident, who had multiple diagnoses including essential hypertension, chronic kidney disease, and type 1 diabetes mellitus, was admitted to the facility after a brief hospitalization. The resident required significant assistance with daily activities and had intact cognition. On the night of the incident, the resident reported feeling nauseous, did not eat supper, and had one episode of vomiting. Later, the resident developed a moist non-productive cough and was placed on supplemental oxygen before being sent to the emergency room. However, the medical record lacked sufficient documentation that a notice of transfer had been provided or that communication with the receiving hospital had occurred, including essential information such as the reason for transfer, physician contact, and relevant medical details. Interviews with facility staff revealed that the process for transferring the resident was not followed correctly. A trained medication aide stated that the process should include getting an order from the provider, updating the family, and documenting the reason for the transfer in the electronic medical record (EMR). However, the registered nurse case manager and the registered nurse clinical reimbursement specialist both confirmed that there was no documentation in the EMR explaining why the resident was transferred to the emergency room or any communication with the provider and receiving hospital. The facility's documented process for notice of transfer/discharge, which includes providing a written notice and relevant medical information, was not adhered to in this case, leaving many questions unanswered.
Failure to Inform Resident of Bed Hold Rights During Hospitalization
Penalty
Summary
The facility failed to ensure that a resident or their legal representative was informed of bed hold rights at the time of hospitalization. The resident, who had intact cognition, was sent to the emergency room, but there was no documentation in the medical record indicating that a bed hold notification was provided to either the resident or her son, who was her emergency contact. The progress note indicated that the son was notified of the hospitalization, but there was no mention of a bed hold. Interviews with the registered nurse case manager and the registered nurse clinical reimbursement specialist confirmed that the bed hold form was not completed or documented in the resident's medical record. The facility's policy, updated in October 2021, required that residents and their representatives be given a Notice of Transfer for any transfer to acute care or an emergency department, including a bed hold notification. This notice should be provided prior to or within 48 hours of the transfer and documented in the resident's medical record. However, the review of the resident's electronic and paper medical records showed no evidence that this process was followed, resulting in a deficiency in the facility's compliance with its own transfer and bed hold notification procedures.
Failure to Ensure Coordination of Care for Dialysis Resident
Penalty
Summary
The facility failed to ensure proper coordination of care and communication between the facility and the dialysis center for a resident receiving hemodialysis. The resident, who had diagnoses including atrial fibrillation, hypertension, peripheral vascular disease, and end-stage renal disease, attended dialysis three times per week. Despite having pre and post-dialysis assessments documented in the electronic medical record, the resident's record lacked a dialysis care plan and did not include the name, address, and phone number of the dialysis center. Interviews with facility staff and the dialysis center's registered nurse revealed that no paperwork was exchanged between the facility and the dialysis center, and no clinical communication was documented in the resident's records. The dialysis center's registered nurse confirmed that the resident never arrived with paperwork from the facility, and the facility's registered nurse case manager and trained medication aide corroborated that no documents were sent or received. The facility's policy indicated that dialysis patients should have a care plan including the dialysis location and schedule, but this was not followed. Additionally, a request for a copy of the contract with the dialysis center was not fulfilled, further indicating a lack of formalized communication and coordination between the two entities.
Failure to Ensure Medication Availability and Administration
Penalty
Summary
The facility failed to ensure that medications were available and administered as prescribed by the physician for a resident diagnosed with atherosclerotic heart disease, diabetes mellitus type II, chronic A-fib, and end-stage renal failure. The resident had orders to take Vascepa, a medication used to reduce the risk of heart attack or stroke, but missed 19 doses over a period of ten days. The pharmacy technician reported no documentation of communication from the facility regarding the missing medication, and the trained medication aide and registered nurse charge nurse were unaware of why the medication had not been delivered. The registered nurse case manager stated that the provider should have been notified early in the process when the resident was missing medication doses. The administrator was unaware of the missed medication doses until informed by the surveyor and indicated that a change in the resident's payer source was a primary reason for the medication not being sent. The nurse practitioner, who had been in frequent contact with the facility, was not notified of the missed doses and stated that her expectation was to be informed after the first missed dose. The facility's medication ordering and receiving policy indicated that medications should be reordered several days in advance to ensure an adequate supply, but this procedure was not followed in this case.
Failure to Offer Pneumococcal Vaccine
Penalty
Summary
The facility failed to offer or provide the pneumococcal vaccine to a resident who was eligible for it. The resident, who had diagnoses including congestive heart failure, diabetes, and hypertension, had received previous pneumococcal vaccinations (Prevnar 13 and Pneumo-PPSV23) and was eligible to receive the PCV20 vaccine beginning December 2023. However, the facility's electronic medical record (EMR) incorrectly indicated that the resident was not eligible until December 2024, which was outside the CDC recommendation of five years after the last dose of Pneumo-PPSV23. Additionally, there was no evidence in the EMR that the resident was provided education, offered, or received the PCV20 vaccination. During an interview, the Director of Nursing (DON) stated that the facility followed CDC recommendations for pneumococcal vaccinations and used a CDC-based tool to track eligible residents. The DON mentioned that newly admitted residents who were eligible for vaccines would see the provider on the next rounding date, and the facility would request orders to administer the vaccine at that visit. Monthly audits were also performed to catch eligible residents. Despite these procedures, the resident's EMR and facility policy, which reportedly followed CDC guidance, incorrectly indicated the resident's eligibility date, leading to the failure to offer the PCV20 vaccine in a timely manner.
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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