The Emeralds At Faribault Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Faribault, Minnesota.
- Location
- 500 Southeast First Street, Faribault, Minnesota 55021
- CMS Provider Number
- 245067
- Inspections on file
- 40
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at The Emeralds At Faribault Llc during CMS and state inspections, most recent first.
A resident with extensive cardiac history and long-term warfarin therapy had a care plan that lacked individualized cardiac management interventions and detailed monitoring for anticoagulant-related bleeding, despite physician orders specifying signs and symptoms to observe. The Kardex and NA care guides did not indicate that the resident was on blood thinners or list bleeding signs to monitor, and NAs reported they did not know which residents were on anticoagulants, were unfamiliar with terms like "tarry stool," and did not consistently report bruising or other potential bleeding indicators. Facility leadership confirmed that the care guides, which serve as the primary tool for directing daily care, omitted anticoagulant monitoring instructions and that the resident’s care plan did not include individualized interventions for recognizing and responding to cardiac symptoms such as chest pain and SOB.
A resident with extensive cardiac history experienced sudden severe left-sided chest pain radiating to the left arm, shortness of breath, nausea, and anxiety, reported that it felt like a heart attack, and repeatedly requested transfer to the ED. Staff checked basic vital signs but did not complete or document a comprehensive cardiac assessment, did not initially honor the resident’s repeated requests for EMS activation, and were unaware of a specific cardiac assessment policy. The resident continued to call a family member, who contacted the administrator about staff allegedly refusing to send the resident out, and only after this escalation were the NP notified and EMS called. Documentation showed that only vital signs and pain scores were recorded, with no detailed cardiac assessment, and the resident was ultimately transported by EMS and diagnosed in the ED with NSTEMI, severe anemia, and GI hemorrhage.
A resident with extensive cardiac history experienced sudden left-sided chest pain radiating down the left arm, with shortness of breath and nausea, and repeatedly told staff he believed he was having a heart attack and wanted to go to the ED. A NA reported the resident said he might be having a heart attack and appeared very worried, repeatedly using the call light to ask when an ambulance was coming. The assigned RN stated he attempted a cardiac assessment but was unaware of the resident’s cardiac history, could not describe the assessment performed, and admitted he did not document the cardiac assessment or the resident’s requests for ED transfer. Progress notes only reflected vital signs and hospital transfer for 10/10 chest pain later that evening, and record review confirmed there was no documentation of a comprehensive cardiac assessment or of the resident’s repeated requests for emergent evaluation. The DON confirmed the lack of required documentation, and the facility did not provide a policy outlining expectations for complete, accurate, and timely medical record documentation.
A newly hired NAIT was allowed to work full-time across all units without a completed pre-employment background screening, as required by facility policy and state regulations. The NAIT had not completed the fingerprinting process, resulting in no background clearance, and this oversight was not identified by facility leadership until the time of the survey. This failure had the potential to affect all residents in the facility.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
The facility did not protect a resident from the wrongful use of their belongings or money, resulting in a deficiency related to safeguarding personal property and financial resources.
The facility did not accurately post the actual hours worked by RNs, LPNs, and CNAs on the daily nurse staffing form, instead only listing the number of staff and total hours per role. The DON confirmed that actual hours worked were only available in staff schedules at nursing stations, not in the required public posting, affecting all residents and visitors seeking this information.
Surveyors found that staff did not follow proper sanitization procedures in the kitchen, using Dawn dish detergent instead of required chemical sanitizers in the three-compartment sink and failing to send all items through the dishwasher. Additionally, staff with beards were not wearing beard restraints as required by facility policy. These deficiencies had the potential to affect all residents receiving meals from the main kitchen.
Soiled personal laundry and linens were observed being transported loosely in bins without being bagged at the point-of-use, both in the main laundry washroom and in two units. The housekeeper and interim DON confirmed that items should have been bagged to prevent cross-contamination, but this was not consistently done. Facility audits did not include soiled utility rooms, and there was no policy addressing soiled linen handling or transportation.
A resident who receives all nutrition via a PEG tube was found to have tube feeding equipment and a pole coated with dried feeding solution and greasy smears, with multiple observations confirming the lack of cleaning. Nursing staff acknowledged responsibility for cleaning the equipment but admitted it was not being done, and both the resident and their spouse reported the equipment was always dirty. The DON confirmed staff were expected to clean the equipment and recognized the issue as a concern for infection control and dignity.
Two residents with indwelling urinary catheters were observed with uncovered urine drainage bags visible to others, both in their rooms and in common areas. Staff, including nursing personnel, acknowledged that catheter bags should be covered for dignity, but did not act to address the issue. One resident reported never being asked about covering the bag, and both staff and residents expressed discomfort with the lack of privacy.
A resident who was cognitively intact reported an incident involving a nursing assistant and filed a grievance, requesting the assistant not return to her unit. The facility did not document the grievance, failed to provide follow-up or resolution to the resident, and could not locate any records of the grievance, despite policy requiring documentation and retention of such records.
A resident with nicotine dependence, emphysema, and CHF was identified as a current smoker through multiple assessments and staff interviews, but her care plan did not reflect her smoking status or include safety interventions such as removal of oxygen during smoking. Staff confirmed the omission, and the care plan was not updated until after the survey process began.
A resident who completed OT for left wrist weakness and was discharged with a wrist brace and independent ambulation was not properly care planned for these changes. The care plan continued to require staff assist for walking and did not mention the brace, despite staff confirming the resident's independence and the need to monitor for skin integrity.
A resident with Parkinson's Disease and a history of constipation experienced prolonged periods without bowel movements despite being on scheduled laxatives. Staff failed to reassess the resident's bowel regimen or document interventions, and there was no clear tracking or consistent management of the resident's constipation, resulting in inadequate care.
A resident with sensorineural hearing loss experienced ongoing difficulty communicating needs due to the facility's failure to follow up on and document the use of hearing aids, despite physician notes and resident requests. Care plans and treatment records did not reflect hearing aid use, and staff were unaware or lacked updated information regarding the resident's adaptive equipment, resulting in the resident not receiving appropriate hearing support.
A resident with multiple medical conditions and an existing stage IV pressure ulcer developed a new stage III pressure injury, but the facility did not comprehensively reassess the resident or update interventions in the medical record. Staff interviews indicated the resident was resistant to care and the required skin evaluation was left incomplete, with care plan updates only occurring after the survey began. The facility's policy lacked clear guidance on documenting comprehensive reassessments after significant changes.
A resident with limited mobility and multiple medical conditions did not receive recommended physical therapy or restorative nursing services to maintain or improve range of motion, despite medical orders and ongoing mobility limitations. The care plan lacked evidence of restorative interventions, and staff confirmed that the resident was not reassessed for therapy after discharge, resulting in a failure to provide necessary contracture care.
A resident with moderate cognitive impairment and an indwelling catheter did not have documented ongoing medical justification for catheter use, and no attempts were made to remove the catheter or reassess the need for it. The medical record lacked evidence of assessment for urine retention or follow-up on a urology recommendation for a suprapubic catheter, and the facility's policy only addressed catheter care, not ongoing evaluation.
A resident with chronic pain was not comprehensively reassessed for pain following a hospitalization and changes to her pain medications. Despite ongoing reports of severe pain and frequent use of PRN pain medications, no updated pain assessment was documented, and staff confirmed that a reassessment should have occurred after the change in condition.
Staff left care sheets containing private resident information exposed and unattended on medication carts in hallways and near common areas. Multiple staff, including an LPN, RN, and TMA, acknowledged the care sheets should not have been left out, and the DON confirmed this was a HIPAA violation and against facility policy.
A resident with multiple health issues experienced a change in condition, but the facility delayed assessing her and contacting EMS. The LPN noticed the change at 8:00 a.m., but vital signs were not taken until 10:30 a.m., and EMS was called at 11:33 a.m. The resident had unstable vital signs and was unresponsive, yet there was a delay in providing necessary medical intervention.
A resident with chronic respiratory conditions and dependence on supplemental oxygen was admitted to the facility without a documented physician's order for continuous oxygen therapy. Despite the resident's medical history indicating the need for oxygen, the facility's MAR and TAR lacked the necessary order, leading to a deficiency in care. Interviews revealed that the oxygen orders were not included in the discharge orders but were found in the history and physical documentation, resulting in a failure to ensure proper management of the resident's oxygen therapy.
A resident with narcolepsy did not receive their prescribed methylphenidate, as indicated by a negative urine drug screen. Despite awareness of potential drug diversion, the LTC facility failed to report the incident to the state agency as required by policy. The administrator acknowledged the deficiency in reporting and investigation.
A facility failed to investigate an alleged drug diversion involving a resident with narcolepsy. Despite hospital findings indicating the absence of prescribed medication in the resident's system, the facility did not implement a protection plan or conduct a thorough investigation. The facility's policy required immediate reporting and investigation, but these actions were not taken, leaving the resident vulnerable to further incidents.
A facility failed to coordinate hospice services for a resident with cancer, malnutrition, and depression, resulting in missing documentation such as a medication list and care plan. The hospice nurse did not provide comprehensive assessments to the facility, and communication issues persisted despite attempts to obtain necessary documentation. The facility's policy and hospice contract required coordination and communication, which were not effectively followed.
A resident reported being sexually abused by a nurse, but the allegation was not reported to the State Agency immediately as required. The incident was later disclosed to law enforcement during a hospital transfer, prompting a report to the facility administrator. The administrator acknowledged the delay in reporting, which violated the facility's policy.
A resident with chronic kidney disease and a history of falls reported being sexually abused by a nurse, but the LTC facility failed to investigate the allegation. Despite the resident's intact cognition and communication of the incident to staff, the facility's records showed no evidence of an investigation, violating their abuse policy.
A resident with a history of heart disease, morbid obesity, and type 2 diabetes was found with multiple oral medications in their room without a self-administration order. The resident admitted to forgetting to take the medications despite reminders from a nurse. The facility's policy requires physician authorization and observation to ensure medication ingestion, which was not followed in this case.
A resident with a history of respiratory and circulatory issues was left unsupervised during nebulizer treatment, and necessary assessments were not conducted. Additionally, the facility failed to apply compression stockings as ordered, despite the resident's swollen legs and expressed concerns. The DON acknowledged the need for staff supervision during treatments and accurate documentation.
A resident with a history of intestinal issues did not receive scheduled acetaminophen via PEG tube, leading to uncontrolled pain and the need for narcotic medication. A trained medication assistant improperly set up medications for another staff member to administer, violating facility policy. The resident experienced severe pain and distress due to the delay in receiving pain relief.
A resident with a history of hemiplegia and chronic kidney disease experienced a delay in the collection of a urine analysis with urine culture (UA/UC) despite a provider order due to dysuria. The order was documented from 6/14 to 6/17, but the sample was not collected until 6/18. Interviews with staff revealed a lack of documentation and timely action, with the resident continuing to experience symptoms.
Failure to Individualize and Communicate Anticoagulant and Cardiac Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a complete, individualized care plan addressing anticoagulant therapy and cardiac management for a resident with extensive cardiac history and long-term anticoagulation. The resident had diagnoses including acute diastolic congestive heart failure, prior TIA, cerebral infarction, atrial fibrillation, coronary artery disease, ischemic cardiomyopathy, prior STEMI, and long-term anticoagulation. Physician orders included warfarin 2 mg nightly and specific monitoring for signs and symptoms of bleeding such as discolored urine, black tarry stools, sudden severe headache, nausea, vomiting, diarrhea, muscle/joint pain, lethargy, bruising, sudden changes in mental status or vital signs, shortness of breath, and nosebleeds. The comprehensive care plan, reviewed on 3/9/26, lacked individualized cardiac management interventions and goals, and only contained a generic problem for potential alteration in blood formation and coagulation related to anticoagulant use, without detailed, individualized cardiac monitoring interventions. The facility also failed to ensure that care plan interventions related to anticoagulant therapy were effectively communicated to direct care staff. The resident’s Kardex and nursing assistant care guide sheets did not include interventions or instructions for monitoring or reporting signs and symptoms of bleeding or indicate that the resident was on blood-thinning medication. Nursing assistants reported they were unaware which residents were on anticoagulants and did not know the specific signs and symptoms of bleeding they should observe and report. One nursing assistant stated she did not know what a tarry stool was and did not report every bruise, assuming nursing staff could see them, and another stated she might delay reporting bruising or weakness until the end of the shift because she did not recognize them as significant. Events preceding the deficiency included the resident’s hospitalization for gastrointestinal bleeding, with an ED note identifying a suspected GI source of anemia and reference to dark stools that the resident himself did not witness because he used a bedpan managed by staff. The resident reported that a male staff member had informed him of dark stools a couple of days before hospitalization and that he assumed staff were monitoring this condition. Facility leadership, including the nurse manager and DON, confirmed that the Kardex and care guides did not contain instructions for monitoring or reporting bleeding for residents on anticoagulants and that the resident’s care plan lacked individualized interventions for monitoring and responding to cardiac symptoms such as chest pain and shortness of breath. The facility’s own care planning policy required a person-centered, individualized comprehensive care plan used by staff to guide daily care and updated as the resident’s condition changed, which was not met in this case.
Failure to Perform Timely Cardiac Assessment and Honor Resident’s Requests for ED Transfer
Penalty
Summary
The deficiency involves the facility’s failure to provide timely, comprehensive cardiac assessment and response for a resident with extensive cardiac history who reported acute chest pain and requested emergency evaluation. The resident had multiple serious cardiac diagnoses, including acute diastolic CHF, prior TIAs and stroke, atrial fibrillation on warfarin, prior CABG, multiple stents, prior MIs, ischemic cardiomyopathy, and atherosclerotic heart disease. Despite this history, the resident’s care plan did not include a cardiac-focused problem or individualized interventions to guide staff in monitoring and responding to changes in cardiac status. On the day of the incident, the resident reported sudden, severe left-sided chest pain radiating down the left arm, shortness of breath, nausea, and anxiety, and stated that the pain felt like a heart attack. The resident activated the call light and initially spoke with a female staff member, telling her he was having chest pain that felt like a heart attack and wanted to go to the ED. A male nurse then came to the room; the resident reported telling him he was having chest pain radiating down his left arm, believed he was having a heart attack, and wanted to be sent to the ED. According to the resident, the nurse refused to call an ambulance, stating that the resident’s vital signs were fine and he did not need to go, and only checked blood pressure, pulse oximetry, and temperature without auscultating heart or lungs or performing a more detailed cardiac assessment. The resident stated he repeatedly requested transfer, attempted unsuccessfully to call 911 himself, and felt frantic and unsafe due to the delay. A nursing assistant later reported that the resident told her he might be having a heart attack, described severe left arm pain and prior heart attacks, and that she immediately notified the RN. She observed that it took a significant amount of time before the resident was transported, that this did not occur until after supper, and that during this period the resident was visibly distressed, repeatedly pressing the call light and asking when the ambulance was coming. The resident’s family member reported receiving four frantic calls from the resident over a period of time, during which the resident stated he was having chest pain radiating down his left arm, believed he was having a heart attack, and that staff would not send him to the ED despite his requests. The family member contacted the administrator by text and phone, reporting that staff were refusing to send the resident despite his extensive cardiac history. The administrator confirmed receiving these messages and that the family member relayed the resident’s complaints of chest and arm pain and his belief he was having a cardiac episode. The nurse assigned to the resident stated he was unaware of the resident’s extensive cardiac history, was not aware of a specific facility policy for assessing cardiac symptoms, and could not clearly describe or document a comprehensive cardiac assessment or the resident’s request to go to the ED. The nurse manager later assessed the resident after being alerted that staff were reportedly refusing to send him, found the resident upset with left-sided chest pain and a history of multiple cardiac events, and obtained vital signs that were within normal limits. He stated that vital signs can be normal during a heart attack and that the resident wanted to go to the hospital immediately. Facility documentation showed that the resident was ultimately transferred to the hospital for chest pain rated 10/10, with EMS called after 6:00 p.m. EMS records indicated they received an emergent call for chest pain, found the resident reporting crushing chest pain radiating down the left arm for approximately 30 minutes, and provided aspirin, nitroglycerin, and oxygen before transport. Facility progress notes documented vital signs and pain assessment but did not include a comprehensive cardiac assessment or detailed clinical evaluation of the reported chest pain. The ED record documented that the resident reported chest pain beginning around 5:00 p.m., similar to prior heart attacks, and that he stated it took staff a while to call EMS. The ED identified NSTEMI, severe anemia with hemoglobin 5.7, GI hemorrhage, hypoxia, and other conditions. The DON confirmed that no comprehensive cardiac assessment was documented, that staff had not received written education or competency testing on cardiac assessment and monitoring, and that the facility lacked a comprehensive cardiac assessment and monitoring policy, which was requested but not provided.
Failure to Document Cardiac Assessment and Resident Requests for ED Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure complete and accurate medical record documentation for a resident with extensive cardiac history who experienced acute chest pain. The resident’s diagnoses included acute diastolic congestive heart failure, prior TIA, cerebral infarction, atrial fibrillation, prior CABG, hypertension, ischemic cardiomyopathy, atherosclerotic heart disease, and prior STEMI. On the evening in question, the resident reported sudden left-sided chest pain radiating down the left arm, accompanied by shortness of breath and nausea, and believed he was having a heart attack. He activated his call light, informed staff of his symptoms, and requested to be sent to the ED. According to the resident and his family member, the resident repeatedly requested hospital evaluation and contacted his son multiple times, stating that staff were refusing to send him to the ED. A nursing assistant reported that the resident told her he might be having a heart attack and had severe left arm pain; she immediately notified the RN. The nursing assistant observed that the resident appeared very worried and repeatedly used the call light asking when the ambulance was coming, and estimated that the incident began around 5:00 p.m., with transport occurring after supper around 6:00 p.m. Progress notes later documented transfer to the hospital for chest pain rated 10/10, with vital signs recorded shortly after 6:00 p.m., and EMS activation and transport documented between approximately 6:03 p.m. and 6:34 p.m. The RN assigned to the resident stated he was informed by a nursing assistant that the resident wanted to see him and that the resident reported chest pain and appeared agitated. The RN stated he was unaware of the resident’s cardiac history and reported that he attempted to perform a cardiac assessment, but he could not describe what the assessment included and acknowledged that he did not document the cardiac assessment or the resident’s requests to go to the ED in the medical record. Review of the medical record confirmed there was no documentation of a comprehensive cardiac assessment or of the resident’s repeated requests for hospital evaluation at the onset of symptoms. The nurse manager and DON confirmed that the RN failed to document the cardiac assessment and the resident’s requests for emergent care, and that this information should have been documented. Requested facility policy on resident-identifiable records and documentation expectations was not provided.
Failure to Complete Pre-Employment Background Screening for Staff Member
Penalty
Summary
The facility failed to implement its policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents, as well as misappropriation of property, by not completing pre-employment background screening for a newly hired nursing assistant in training (NAIT). Documentation review revealed that the NAIT began working in the facility without a completed criminal background study, as required by both facility policy and state regulations. The NAIT worked full-time across all units in the facility for several months, and the required background clearance was not present in the employee file. The NAIT had completed the background study form online but did not complete the fingerprinting process, resulting in no background clearance being issued. Interviews with facility staff, including the DON and the administrator, confirmed that the background screening process was not completed prior to the NAIT starting work, contrary to facility policy. The administrator was unaware of the missing background clearance until the time of the survey. Facility policies reviewed specified that employees may not begin working until background study results are received and confirm the applicant is not disqualified. The failure to complete the required background screening had the potential to affect all 71 residents in the facility, as the NAIT worked on all units.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Protect Residents' Belongings and Money
Penalty
Summary
A deficiency was identified regarding the protection of residents from the wrongful use of their belongings or money. The report documents that the facility failed to ensure that each resident was safeguarded against unauthorized or improper use of their personal property or financial resources. Specific details about the actions or inactions that led to this deficiency, as well as information about the residents involved or their medical history, are not provided in the report.
Failure to Accurately Post Daily Nurse Staffing Hours
Penalty
Summary
The facility failed to post accurate daily nurse staffing information as required. On the date of observation, the nurse staff posting form was found at the front desk and included the daily resident census, total number of nursing staff hours, and breakdowns by unit and shift for various nursing roles. However, the posting did not specify the actual hours worked by each category of nursing staff. Instead, it only indicated the number of staff in each role and the total hours for those roles, without detailing the actual hours worked by individual staff members. During an interview, the DON confirmed that the actual hours worked were only reflected in staff schedules posted at the nursing stations, not in the daily nurse staff posting accessible to residents and visitors. The facility's own policy required the posting to include the total number and actual hours worked by RNs, LPNs, and CNAs per shift, in accordance with federal law. This deficiency had the potential to affect all 71 residents and their visitors who may wish to review the staffing information.
Improper Kitchen Sanitization and Lack of Beard Restraints
Penalty
Summary
The facility failed to ensure proper sanitization procedures were followed in the main kitchen, specifically regarding the use of the three-compartment sink. Surveyors observed that the bottles for quaternary sanitizer and pot/pan detergent above the sink were empty, and staff were using Dawn dish detergent instead of the required chemical sanitizing solutions. Staff confirmed that pots, pans, and kitchen utensils were hand washed with Dawn and water, and these items were not always sent through the dishwasher for proper sanitization, contrary to facility policy. Additionally, there was no thermometer available to check water temperature, and items were rinsed for less than 30 seconds before being set to dry, which does not meet the required sanitization standards outlined in facility policy. The facility also failed to ensure that employees wore appropriate beard restraints while preparing food. Observations revealed that a cook with a beard was not wearing a beard cover, and beard restraints were not available at the kitchen entrance or in the office. Interviews with dietary staff and directors confirmed that beard covers were required for beards longer than a specified length, but staff were not consistently following this policy. These failures had the potential to affect all 76 residents who received meals from the main kitchen.
Failure to Bag Soiled Laundry and Linens at Point-of-Use
Penalty
Summary
The facility failed to ensure that soiled personal laundry and linens were properly bagged at the point-of-use and transported in a manner that would reduce the risk of cross-contamination and infectious spread. During a tour of the main laundry washroom and two units, it was observed that soiled linens and personal clothing were placed loosely in mobile bins without being bagged, causing items to touch each other. The housekeeper confirmed that these items should have been bagged prior to transport and acknowledged that this issue had occurred before. In the soiled utility rooms of both units, similar practices were observed, with soiled laundry not being bagged and, in one instance, biohazard-marked bags were placed on top of uncovered soiled laundry. Review of facility documentation revealed that monthly audits of laundry and linen areas did not include the soiled utility rooms where soiled linens were kept before transport. The facility's infection prevention and control program policy did not address soiled linen handling or transportation, and the only related protocol provided was specific to isolation rooms. The interim DON, who also served as the infection preventionist, confirmed that staff had been educated on the need to bag soiled items at the point-of-use, but acknowledged the ongoing issue. No facility policy on soiled laundry handling and transportation was provided.
Failure to Maintain Clean and Sanitary Tube Feeding Equipment
Penalty
Summary
A deficiency was identified when a resident's tube feeding (TF) pole and equipment were observed to be coated with a dried white substance and greasy smears, indicating a lack of proper cleaning and maintenance. The resident, who has intact cognition and a history of depression, anxiety, chronic respiratory failure requiring oxygen, and head and neck cancer with all nutrition provided via a PEG tube, was found to have TF equipment that was visibly soiled on multiple occasions. Observations revealed the dried substance on the entire surface of the pole and all five legs of the base, as well as greasy smears on the front programming screen of the TF machine. Interviews with nursing staff, including an LPN and an RN, confirmed that it was the responsibility of nursing staff to clean the TF equipment if spills or visible soil were present. Both staff members acknowledged the equipment was not being cleaned as expected, with the RN describing the condition as 'horrible' and attributing the residue to TF solution not wiped up after use. The resident and their spouse also reported that the equipment was consistently dirty and that they had never seen staff clean it. The DON confirmed the expectation for staff to clean the equipment and recognized the issue as a concern for infection control and resident dignity. The facility's policy on environmental cleaning of patient care equipment was requested but not provided.
Failure to Maintain Dignity for Residents with Urinary Catheters
Penalty
Summary
The facility failed to maintain the dignity of two residents who utilized indwelling urinary catheters. Both residents were observed with uncovered urine drainage bags that were visible to others, either from the hallway or in common areas. Staff members, including nursing staff, walked past the rooms or observed the residents with uncovered bags but did not take action to cover them. One resident reported that staff had never asked if they wanted a cover on their urine bag and expressed discomfort at the idea of others seeing the contents. Another resident was seen moving around the hallway and dining area with an uncovered urine drainage bag attached to their wheelchair, visible to other residents and staff. Interviews with staff, including an RN, LPN, and the DON, confirmed that catheter bags should be covered for reasons of dignity and decency. The DON also noted concerns regarding infection control and dignity related to uncovered catheter bags. Despite requests, the facility's policy on dignity was not provided for review. The observations and interviews demonstrate that the facility did not ensure the residents' right to a dignified existence was upheld in relation to the management of urinary catheter drainage bags.
Failure to Document and Resolve Resident Grievance
Penalty
Summary
The facility failed to sufficiently act upon a grievance filed by a cognitively intact resident regarding an incident with a nursing assistant. The resident reported that a nursing assistant entered her room during an evening shift and attempted to change an incontinent brief, despite her not wearing them, and was unkind during the encounter. The resident reported the incident to staff the following morning and subsequently filed a grievance, requesting that the nursing assistant not return to her unit. However, there was no follow-up from the facility regarding the outcome of her grievance, and the nursing assistant continued to work on the unit. A review of the facility's grievance records and the resident's progress notes revealed no documentation of the incident or the grievance. Interviews with staff indicated that grievances should be documented, investigated, and resolved using both hard copy forms and an electronic system, but no record of the resident's grievance could be found. The administrator confirmed that the incident was known and addressed with the nursing assistant, but no written resolution or follow-up was provided to the resident, and the grievance form was missing. The facility's policy requires all grievances to be documented and retained for at least three years, which was not followed in this case.
Failure to Include Smoking Status and Safety Interventions in Care Plan
Penalty
Summary
A deficiency was identified when the facility failed to develop and maintain a comprehensive care plan for a resident who was a current smoker. The resident, who had diagnoses including nicotine dependence, emphysema, and congestive heart failure, was assessed multiple times as a smoker and reported to staff that she smoked cigarettes and used oxygen at night only, ensuring she did not wear oxygen while smoking. Despite these assessments and the resident's disclosure, her care plan did not reflect her smoking status or include necessary safety interventions related to smoking, such as ensuring oxygen was removed during smoking. Interviews with nursing staff and review of the electronic medical record confirmed that the resident's smoking status was known to staff and documented in smoking assessments, but this information was not incorporated into the care plan until after the survey process began. The facility's policy required that care plans be used to guide daily care routines, but the omission of the resident's smoking status and related safety measures from the care plan resulted in a lack of comprehensive planning for her care needs.
Failure to Update Care Plan for Resident's Mobility and Brace Use
Penalty
Summary
The facility failed to update and revise the care plan to reflect current interventions for a resident who had recently completed occupational therapy for left wrist weakness and joint pain. The resident was provided with a wrist brace and discharged from therapy with instructions to use the brace as tolerated and to walk independently with a walker. Despite these changes, the care plan continued to list a walking program requiring staff assistance and did not mention the use of the wrist brace. Interviews with therapy and nursing staff confirmed that the care plan was outdated and did not reflect the resident's current level of independence or the use of the brace. Additionally, the care plan lacked documentation regarding the monitoring of the wrist brace for potential skin integrity issues, as noted by a registered nurse who stated that all braces and splints should be care planned to ensure proper monitoring. The facility's policy required care plans to be updated as the resident's condition and care needs changed, but this was not done in this case. The deficiency was identified through observation, interviews, and document review, which showed a disconnect between the resident's current needs and the interventions documented in the care plan.
Failure to Reassess and Intervene for Resident with Chronic Constipation
Penalty
Summary
The facility failed to reassess and implement new interventions for a resident with a known history of constipation, despite clear evidence of ongoing issues. The resident, who was cognitively intact and had Parkinson's Disease—a condition commonly associated with constipation—was frequently incontinent of bowel and required significant assistance with toileting. Documentation showed the resident often went several days without a bowel movement, including a period of ten days without one, and had only minimal bowel movements over the course of the month. Although the resident was on scheduled medications for constipation, there was no recent bowel evaluation that assessed her typical patterns, what was normal or abnormal for her, or what interventions had been attempted or were in place to prevent constipation. Progress notes for the relevant period lacked documentation of the resident's constipation or any interventions used to promote bowel movements until after the resident reported constipation and discomfort. Interviews with staff revealed inconsistent practices and expectations regarding bowel movement tracking and intervention, with some staff unsure of what actions were being taken to manage the resident's constipation. The facility was unable to provide a policy on constipation management when requested. These actions and omissions resulted in a failure to provide appropriate treatment and care according to the resident's needs and medical condition.
Failure to Implement and Document Hearing Aid Use for Resident with Hearing Loss
Penalty
Summary
The facility failed to follow up and implement appropriate treatment for a resident with documented hearing loss. The resident was identified as having highly impaired hearing and a diagnosis of unspecified sensorineural hearing loss, with care plans indicating the use of a pocket talker but omitting any mention of hearing aids. Despite a physician's note stating the resident wore hearing aids, multiple assessments and care documents, including the treatment administration record and care sheets used by nursing assistants, did not reflect the use or management of hearing aids. The resident repeatedly expressed difficulty hearing and a desire for assistance with hearing aids, but was observed without them, and staff interviews confirmed that care documentation was not updated to include hearing aids or their management. Further review revealed inconsistencies and lack of communication among staff regarding the resident's use of hearing aids. Nursing assistants and the activities director noted the resident had hearing aids available but had not worn them regularly, and only after new batteries were provided did the resident begin to use them again. The registered nurse responsible for the resident's hearing assessment confirmed moderate hearing difficulty but did not find hearing aids in use at the time and noted a previous refusal for a referral for hearing aids. The facility's medication and treatment policy did not specifically address adaptive devices such as hearing aids, contributing to the lack of consistent follow-up and documentation.
Failure to Reassess and Update Interventions After New Pressure Injury
Penalty
Summary
The facility failed to comprehensively reassess and develop proactive interventions after a new pressure injury was identified in a resident with multiple medical conditions, including heart failure, hypertension, and multiple sclerosis. The resident was already at risk for pressure injuries and had an existing stage IV pressure ulcer that developed after admission. Despite the development of a new stage III pressure injury, there was no documented evidence of a comprehensive reassessment or updated interventions in the medical record. The care plan and interventions were not revised until after the survey began, and the required skin evaluation form was left incomplete. Interviews with staff revealed that the resident was largely independent in her care decisions, often refusing repositioning and other recommended interventions. Staff described the resident as dismissive and resistant to care, with a preference for remaining in bed and limited time spent in her wheelchair. Although the interdisciplinary team (IDT) discussed the resident's wounds and care plan, there was a lack of documentation regarding what interventions were considered, offered, or refused, especially after the new wound developed. The IDT notes provided were undated and lacked specific details about the reassessment process or any new interventions implemented. The facility's policy required a pressure ulcer risk assessment and completion of a skin evaluation form upon significant change, but the policy did not provide clear guidance on how a comprehensive reassessment should be conducted or documented. The director of nursing acknowledged that the medical record lacked evidence of a comprehensive reassessment and that proper documentation was important for continuity of care. The absence of a thorough reassessment and documentation following the development of a new pressure injury constituted the deficiency identified by surveyors.
Failure to Provide Range of Motion and Contracture Care
Penalty
Summary
A deficiency was identified when a resident with limited mobility and multiple diagnoses, including chronic pain, muscle weakness, and spinal cord disease, did not receive appropriate services to maintain or prevent loss of range of motion (ROM) and contracture care. The resident, who was dependent on staff for lower body dressing and transfers and used a wheelchair for mobility, reported not receiving physical therapy (PT) or occupational therapy (OT) for at least two weeks. The resident expressed frustration, stating that therapy was the primary reason for their stay and that nursing staff were not performing recommended leg exercises in bed. The resident also noted a decline in the ability to straighten her left leg, which she could do prior to admission, and was currently using a Hoyer lift for transfers. Review of the resident's medical record revealed external facility orders recommending daily PT participation while maintaining non-weight bearing status to the left heel, with toe-touch transfers allowed. Despite these recommendations, the resident's care plan lacked evidence of a restorative nursing program or recent PT assessments. Interviews with nursing and therapy staff confirmed that the resident had been discharged from OT and PT and was not receiving any restorative nursing services. Staff also verified that the resident had not been reassessed for PT services after discharge, despite the presence of new orders and ongoing mobility limitations. Further interviews with facility leadership, including the RN manager, director of therapy, and DON, confirmed that communication lapses occurred regarding therapy reassessment and implementation of restorative care. The director of therapy acknowledged that a PT assessment should have been completed, and the DON stated the importance of working with therapy and restorative nursing to prevent unnecessary decline. The facility's policy required timely transcription of treatment orders, but this was not followed, resulting in the resident not receiving necessary services to maintain or improve ROM.
Failure to Ensure Ongoing Medical Justification and Assessment for Indwelling Catheter Use
Penalty
Summary
The facility failed to ensure that a resident with an indwelling catheter had ongoing medical justification for its use and did not attempt a trial removal as recommended. The resident, who had moderate cognitive impairment and required assistance with toileting and bathing, was admitted with a catheter in place. Although the resident's diagnoses included several conditions that could potentially justify catheter use, the electronic medical record did not document the duration of urinary retention, any attempts to manage the condition without a catheter, or clear medical justification for continued catheterization. There was also no evidence of post void residual measurements to assess the extent of urine retention. Additionally, a urology note indicated a plan for a suprapubic catheter placement, but the record lacked follow-up on this order. Interviews with the resident and nursing staff revealed that the catheter had been in place since admission, primarily to prevent urine leakage during travel, and that no attempts had been made to remove it or reassess the need for ongoing catheterization. The facility's policy addressed catheter care procedures but did not address the need for ongoing assessment or justification for continued use.
Failure to Reassess Pain After Hospitalization and Medication Changes
Penalty
Summary
The facility failed to comprehensively reassess a resident for pain management following a hospitalization related to concerns with her pain medication regimen and subsequent medication changes. The resident, who was cognitively intact and independent with most ADLs, had a history of chronic pain and was receiving multiple pain medications, including Buprenorphine, Oxycodone, Pregabalin, and Acetaminophen. Despite these interventions, the resident continued to report almost constant, severe pain that affected her sleep and daily activities. Documentation showed frequent use of PRN pain medications, and the most recent comprehensive pain assessment was dated over two months prior to the hospitalization and medication changes. After the resident's hospitalization for over-sedation and subsequent adjustments to her pain medications, there was no evidence in the electronic medical record of a comprehensive pain reassessment to evaluate the effectiveness of the new regimen or to consider additional interventions. Observations and interviews confirmed the resident continued to experience significant pain, and staff interviews indicated that comprehensive pain assessments were expected after a change in condition, such as hospitalization. However, the required reassessment was not completed, and the facility was unable to provide a policy on pain management when requested.
Failure to Secure Resident Care Sheets and Maintain Confidentiality
Penalty
Summary
Facility staff failed to maintain the privacy and confidentiality of residents' personal and medical records by leaving care sheets containing private information exposed and unattended on medication carts in accessible areas. On multiple occasions, staff members, including an LPN, RN, and TMA, left care sheets with sensitive information for multiple residents visible on top of medication carts in hallways and near common areas. These unattended documents were observed by surveyors as staff and residents passed by, with the information remaining exposed for several minutes each time. Interviews with the involved staff confirmed that the care sheets contained private patient information and should not have been left unattended or exposed. The DON acknowledged that leaving such documents out in the open constituted a HIPAA violation and compromised resident dignity and privacy. Facility policy also explicitly prohibits leaving care sheets or other client-identifying papers unattended or visible.
Delayed Response to Change in Resident's Condition
Penalty
Summary
The facility failed to immediately assess a resident after a change in condition was noted. A Licensed Practical Nurse (LPN) observed a change in the resident's condition at 8:00 a.m., but vital signs were not taken until 10:30 a.m., and Emergency Medical Services (EMS) were not called until 11:33 a.m. The resident, who had a history of acute cystitis with hematuria, chronic obstructive pulmonary disease, acute kidney failure, and other significant health issues, was noted to have unstable vital signs and was unresponsive to stimuli. Despite these observations, there was a delay in contacting EMS and providing necessary medical intervention. The resident's care plan required daily monitoring of skin integrity and reporting any changes to the provider. On the day of the incident, the resident's vital signs were unstable, with low blood pressure and oxygen saturation levels, and she was not responding to verbal commands or sternal rubs. The nursing staff increased the resident's oxygen levels, but her condition did not improve significantly. The family member present at the facility initially instructed the staff not to send the resident to the emergency department, as they were planning to discharge her home with hospice services. However, the family member later approved the transfer to the emergency department after arriving at the facility. Interviews with facility staff revealed that there was a lack of immediate action following the observed change in the resident's condition. The LPN and other nursing staff did not promptly notify the provider or perform a thorough assessment. The Director of Nursing and other staff members acknowledged that the delay in assessing the resident's condition and notifying the provider was inappropriate. The facility's policy required immediate assessment and notification of changes in a resident's condition, which was not followed in this case.
Failure to Obtain Physician's Order for Supplemental Oxygen
Penalty
Summary
The facility failed to obtain a physician's order for supplemental oxygen for a resident who was on continuous oxygen therapy. The resident, who was admitted with a primary diagnosis of acute cystitis with hematuria and additional diagnoses including chronic obstructive pulmonary disease, COVID-19, and chronic respiratory failure, required supplemental oxygen as part of their home regimen. Despite the resident's medical records indicating the need for oxygen therapy, the facility did not have an order for supplemental oxygen documented in the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for February and March 2025. Interviews with the Director of Nursing (DON) and a registered nurse (RN) revealed that the oxygen orders were not included in the discharge orders but were instead found in the history and physical documentation from the provider. This oversight resulted in the orders not being translated into the resident's MAR and TAR. The RN stated that he would typically rely on the MAR and TAR to determine if a resident required supplemental oxygen and would apply it based on standing orders if necessary. However, in this case, the lack of a documented order led to a failure in ensuring the resident's continuous oxygen therapy was properly managed.
Failure to Report Potential Drug Diversion
Penalty
Summary
The facility failed to recognize and report a potential drug diversion involving a resident's medication to the state agency. The resident, who was diagnosed with narcolepsy, was prescribed methylphenidate to manage their condition. However, a series of events indicated that the resident might not have been receiving their medication as prescribed. The resident experienced episodes of unresponsiveness and was taken to the emergency department, where a urine drug screen showed no presence of amphetamines, which was unexpected given the medication regimen documented in the facility's records. Interviews and record reviews revealed that the facility staff, including nurses and the interim director of nursing, were aware of the negative drug screen results and the potential for drug diversion. Despite this, the incident was not reported to the state agency as required by the facility's policy. The facility's policy mandates that any suspected misappropriation of resident property, including medication, should be reported to the Minnesota Department of Health within 24 hours if it did not result in serious bodily injury. The failure to report the potential drug diversion was acknowledged by the facility's administrator, who stated that the incident should have been reported immediately to the director of nursing or themselves and subsequently to the state agency. The lack of timely reporting and investigation into the potential drug diversion represents a deficiency in the facility's adherence to its abuse prohibition and vulnerable adult policy.
Failure to Investigate Alleged Drug Diversion
Penalty
Summary
The facility failed to implement a protection plan and conduct a thorough investigation following an allegation of drug diversion involving a resident with narcolepsy. The resident, who was prescribed methylphenidate for narcolepsy, experienced episodes of unresponsiveness and was taken to the emergency department (ED) on multiple occasions. During one of these visits, a urine drug screen revealed no presence of amphetamines, raising concerns about potential drug diversion, as the medication was reportedly administered according to the facility's records. Despite the hospital's notification to the facility about the negative drug screen and the suspicion of drug diversion, the facility did not take immediate action to protect the resident or investigate the matter thoroughly. Interviews with staff revealed that the information was communicated to the facility's director of nursing (DON) and administrator, but no protection plan was put in place, and the investigation was not initiated promptly. The facility's policy required immediate reporting and investigation of such incidents, but this protocol was not followed. The facility's failure to respond appropriately to the alleged drug diversion and to protect the resident from potential harm constitutes a deficiency. The lack of a timely investigation and protection plan left the resident vulnerable to further incidents, and the facility did not comply with its own policies regarding the reporting and handling of such allegations.
Lack of Coordination in Hospice Services
Penalty
Summary
The facility failed to ensure proper coordination of hospice services for a resident receiving hospice care. The resident, who had intact cognition and was diagnosed with cancer, malnutrition, and depression, required assistance with daily activities and was at risk for pressure ulcers. Despite being on hospice, the resident's medical record lacked essential documentation, including a current medication list, hospice care plan, goals for care, hospice certification, and hospice orders. The hospice nurse admitted to not providing comprehensive assessments to the facility, as she was unaware of the requirement, and did not have access to the facility's electronic medical record. Interviews with the Director of Nursing (DON) and the Administrator revealed ongoing communication issues between the facility and the hospice agency. The facility had attempted to obtain the necessary hospice documentation through various means but faced challenges in receiving timely updates. The facility's policy and hospice contract outlined the responsibilities of both parties in coordinating care, including the development of an integrated care plan and regular communication. However, these protocols were not effectively followed, leading to a lack of coordination and communication regarding the resident's hospice care.
Failure to Timely Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse immediately to the State Agency as required. A resident, who had a history of falling and chronic kidney disease, reported being sexually abused by a female nurse on a specific date. The resident informed the nurse manager and later the social worker about the incident. However, the social worker did not report the allegation to the State Agency immediately, as required by the facility's policy. The incident was further brought to light when the resident mentioned the abuse to law enforcement and emergency medical services during a hospital transfer. The registered nurse who was informed by law enforcement reported the allegation to the facility administrator. The administrator acknowledged that the allegation was not reported within the required two-hour timeframe, which is a violation of the facility's Abuse Prohibition/Vulnerable Adult policy.
Failure to Investigate Alleged Sexual Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of sexual abuse and provide adequate resident protection for a resident who reported being inappropriately touched by a nurse. The resident, who had a history of falling, chronic kidney disease, and required extensive assistance with activities of daily living, reported the incident to the nurse manager and social worker. Despite the resident's intact cognition and clear communication of the incident, the facility's medical records lacked evidence of an investigation. The facility's administrator acknowledged that the allegation was not investigated, despite being informed of the incident by a registered nurse. The facility's policy on Abuse Prohibition/Vulnerable Adult Abuse required prompt reporting, documentation, and investigation of all alleged or suspected abuse incidents. However, the facility did not adhere to these procedures, resulting in a failure to ensure the safety and protection of the resident involved.
Failure to Assess Resident for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident, who was observed to have medications in their room, was appropriately assessed and deemed safe to self-administer medications. The resident, who had a history of heart disease, morbid obesity, and type 2 diabetes, was cognitively intact and dependent on staff for most activities of daily living. The resident's care plan indicated that medications should be administered as ordered, and there was a specific order allowing the resident to keep inhalers at the bedside. However, there was no documentation of assessments for safe self-administration of oral medications. During an observation, multiple oral medications were found in the resident's room, and the resident admitted to forgetting to take them despite being reminded by a nurse. The trained medication aide confirmed that the resident did not have a self-administration order for oral medications, and the director of nursing stated that visual observation of medication ingestion is expected unless a self-administration order is in place. The facility policy requires that residents can only self-administer medications when authorized by the attending physician and that they must be observed to ensure the dose is ingested.
Failure to Supervise Nebulizer Treatment and Apply Compression Stockings
Penalty
Summary
The facility failed to adhere to professional standards of practice in the administration of nebulizer treatment and the application of compression stockings for a resident. The resident, who had a history of acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, and pulmonary embolism, was observed receiving nebulizer treatment without proper supervision. The trained medication assistant left the resident unsupervised during the treatment and did not perform necessary assessments such as checking lung sounds, heart rate, oxygen saturation, or pulse after the treatment. Additionally, the facility did not follow the physician's order to apply compression stockings daily for the resident. The resident was observed with swollen lower extremities and no compression stockings or wraps were applied, despite the resident's care plan indicating the need for assistance with putting on compression stockings. The resident reported to staff multiple times about the inability to put on the stockings and expressed concerns about skin splitting open due to swelling, yet no action was taken. The Director of Nursing acknowledged the expectations for staff to remain with residents during nebulizer treatments and to document the application of compression stockings accurately. The facility's policy for oral inhalation administration included specific instructions for monitoring and documenting the resident's condition during and after nebulizer treatments, which were not followed in this case.
Failure to Administer Scheduled Pain Medication
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for a resident, resulting in the resident experiencing uncontrolled pain and requiring narcotic pain medication. The resident, who had a history of intestinal perforation and required medication via a PEG tube, did not receive her scheduled acetaminophen dose. The medication administration record indicated that the resident was supposed to receive acetaminophen every six hours for pain management. However, during an observation, a trained medication assistant was seen setting up medications for another staff member to administer, which is against facility policy. The facility's policy requires that the person who prepares the medication is the one who administers it, ensuring the five rights of medication administration are followed. Despite this, the trained medication assistant set up medications for a nurse who was on break, leading to a delay in the resident receiving her pain medication. The resident expressed severe pain and distress, having requested pain relief since noon without receiving it. The registered nurse on duty later administered PRN oxycodone for the resident's pain, as per the resident's request and physician orders. Interviews with staff, including the director of nursing, confirmed that the facility's policy was not followed, contributing to the resident's unmanaged pain.
Failure to Timely Collect Urine Sample for Resident
Penalty
Summary
The facility failed to ensure a timely collection of a urine analysis with urine culture (UA/UC) and sensitivity for a resident who was experiencing a change in condition. The resident, who had a history of hemiplegia, hemiparesis following cerebral infarction, and chronic kidney disease, was cognitively intact and able to communicate effectively. On 6/13/24, a provider ordered a UA/UC due to the resident's symptoms of dysuria and facial tingling. However, the urine sample was not collected until 6/18/24, despite the order being documented in the medication administration record (MAR) and treatment administration record (TAR) from 6/14/24 to 6/17/24, with no documentation for the day shift. Interviews with the resident, a licensed practical nurse (LPN), the nurse practitioner (NP), and the director of nursing (DON) revealed that the facility staff failed to collect the urine specimen in a timely manner. The resident expressed concern about not receiving the test results and continued to experience symptoms. The LPN acknowledged the lack of documentation indicating the completion of the order and the NP emphasized the importance of timely specimen collection to prevent further complications. The DON confirmed that the expectation was for the specimen to be collected as soon as possible. The facility did not provide a procedure or process for lab collection when requested.
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 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 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 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 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 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 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 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 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 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 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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