The Estates At Lynnhurst Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Paul, Minnesota.
- Location
- 471 Lynnhurst Avenue West, Saint Paul, Minnesota 55104
- CMS Provider Number
- 245394
- Inspections on file
- 35
- Latest survey
- August 13, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at The Estates At Lynnhurst Llc during CMS and state inspections, most recent first.
A resident with a history of bipolar disorder reported unwanted physical contact from another resident, but staff did not immediately update care plans, initiate safety checks, or begin an investigation as required by policy. The incident was documented, but no immediate protective actions or interviews with other potential witnesses occurred, and monitoring interventions were delayed.
A resident reported an allegation of sexual abuse to an LPN, who then informed the nurse manager. Due to a misunderstanding of the required reporting timeframe, the administrator was not notified until over five hours later, resulting in a failure to report the incident to authorities within the mandated two-hour window as required by facility policy.
A resident with a chronic heel wound and diabetic foot ulcer repeatedly refused to wear physician-ordered heel suspension boots, citing discomfort. The care plan was not updated to address these refusals or to provide alternative interventions, despite staff awareness of the issue and facility policy requiring care plan revisions as resident needs changed.
A resident did not receive appropriate care for existing pressure ulcers, and the facility failed to implement effective measures to prevent new ulcers from developing. Surveyors found that necessary interventions, assessments, and monitoring were not consistently provided, resulting in the occurrence and worsening of pressure ulcers.
The facility did not employ a full-time RD or a qualified DM to oversee food and nutrition services, with the RD only present eight hours per week and the Culinary Director not pursuing required certification, despite administrative expectations.
Dietary staff, including the Culinary Director, were observed preparing food without wearing beard guards, despite having facial hair. The Culinary Director acknowledged not wearing a beard guard and indicated uncertainty about facility requirements and lack of available beard guards. The administrator confirmed that beard guards were expected for infection control, but no related policy was provided.
A resident with heart failure, diabetes, and dementia, who was able to communicate and make daily decisions, was not consistently invited to participate in care conferences, nor was her legal guardian. Documentation for multiple care conferences lacked evidence of invitations or attendance, and staff confirmed the absence of records showing resident or guardian involvement in care planning.
A resident was not given required Medicare Part A coverage termination and appeal rights notices at least two days before the last covered day, as both the NOMNC and SNFABN forms were signed after coverage ended and the SNFABN lacked documentation of the resident's appeal option choice.
A resident who required staff assistance with personal hygiene was exposed to view from the hallway when a nursing assistant failed to fully close the privacy curtain and the room door remained open. The resident's genitals were visible in a wall mirror during incontinence care, contrary to staff expectations for maintaining privacy and dignity.
A resident with cataracts and aphasia did not have their care plan properly reviewed or revised to address vision needs, including follow-up on a cataract extraction referral and a consult for new eyeglasses. The care plan lacked documentation of the use of multiple non-prescription glasses, and there was no evidence that the resident's or representative's input was considered during care planning. Observations and interviews confirmed ongoing vision issues and missing documentation of necessary follow-up actions.
A resident who was dependent on staff for toileting and frequently incontinent was left waiting over an hour in a soiled brief while staff attended to a roommate's wound care and took breaks. Despite the resident's requests for assistance and the presence of a noticeable odor, timely incontinence care was not provided, resulting in the resident remaining wet and soiled until staff were available to assist.
A resident with paraplegia and neurogenic bladder, admitted with a Foley catheter, did not receive a scheduled urology appointment as ordered upon hospital discharge. The HUC failed to arrange the referral, and neither the DON nor nursing staff could find evidence of a completed or scheduled appointment, despite established processes for order verification.
Two residents experienced deficiencies in care when the facility did not follow up on vision consults and failed to ensure the use of assistive hearing devices. One resident with cataracts and impaired vision did not have referrals for cataract extraction or new eyeglasses scheduled or documented, despite multiple orders and requests. Another resident with moderate hearing loss was not consistently provided with a pocket talker as directed in the care plan, and staff were unclear about its use. Staff interviews and record reviews confirmed lapses in communication, documentation, and adherence to care plans.
A resident with diabetes and neuropathy did not receive timely podiatry services or diabetic shoes despite multiple provider orders and documented need. The resident experienced long toenails, dry skin, edema, and foot pain, while staff failed to schedule follow-up appointments or document refusals, and the facility lacked a clear referral policy.
A resident with severe cognitive impairment and right-sided hemiparesis, who was dependent on staff for transfers and had a history of falls, did not have a fall mattress in place next to the bed as required by the care plan. Multiple staff, including an LPN and a nursing assistant, entered and exited the room without ensuring the mattress was replaced after it was moved, leaving the resident without this key fall prevention intervention for an extended period. Staff interviews and facility policy confirmed the intervention should have been in place.
Staff failed to use required PPE while providing direct care to a resident on enhanced barrier precautions for a sacral wound. Despite clear signage and facility policy, staff entered the room, administered medications, and assisted with transfers without donning gowns or gloves, and were unaware of the resident's EBP status.
A resident with severe cognitive and physical impairments had a personal refrigerator in their shared room that was found to be unsanitary, containing multiple unlabeled and undated food items. Temperature logs were incomplete or missing, and staff interviews confirmed that required monitoring and cleaning procedures were not followed, despite facility policy mandating regular checks and cleaning.
A resident reported a loose grab bar in the second-floor shower room, which was not repaired promptly, posing a safety risk. The facility also faced a persistent fly infestation, confirmed by staff and observed in various areas, including a resident's room. Despite contracting a pest control company, the issue persisted due to maintenance scheduling problems and inadequate cleaning practices.
A resident with a history of agitation and behavioral issues was transferred to a locked behavioral unit, but the facility failed to update her care plan to address her specific needs and triggers. Despite being cognitively intact, the resident's care plan lacked interventions for managing her aggression, refusal of care, and known triggers. The Director of Nursing acknowledged the care plan was not comprehensive or specific to the resident's needs.
Failure to Immediately Investigate and Protect After Allegation of Inappropriate Physical Contact
Penalty
Summary
The facility failed to immediately provide protections and initiate an investigation after a resident reported unwanted and inappropriate physical contact from another resident. One resident, with diagnoses including alcohol dependence and bipolar disorder, reported to the social service designee (SSD) and the director of nursing (DON) that another resident sat on his lap and kissed him, despite his request for her to stop. The incident was documented in a progress note, but no immediate changes were made to the care plan, and safety interventions such as 15-minute checks were not implemented until several days later. The resident's care plan did not reflect any updates following the incident, and the resident continued to have direct proximity to the alleged perpetrator. The facility did not initiate an immediate investigation or interview other residents who may have witnessed the event. The SSD and DON did not further discuss the allegation or notify other staff to begin an investigation, contrary to facility policy requiring prompt reporting and investigation of abuse allegations. The alleged perpetrator, who had a history of impulsive and non-consensual touching, did not have her care plan updated until after the incident was reported to police. Documentation of safety checks for both residents was incomplete, and there was a lack of evidence that appropriate monitoring or protective interventions were put in place immediately following the report.
Failure to Timely Report Allegation of Sexual Abuse
Penalty
Summary
Facility staff failed to report an allegation of sexual abuse involving a resident within the required two-hour timeframe. The incident occurred when a resident, who did not have impaired cognition but had a history of stroke and metabolic encephalopathy, reported to an LPN that a man had put his fingers in her vagina and was also touching her daughter. The LPN immediately informed the nurse manager, but the nurse manager was unaware of the two-hour reporting requirement and believed the timeframe was 24 hours. As a result, the administrator was not informed of the allegation until approximately 5.5 hours after the initial report was made to staff. The facility's policy required immediate notification of the administrator and/or DON upon learning of an allegation of sexual abuse, as well as prompt reporting to the State Agency. However, the delay in communication among staff led to a failure to meet the mandated reporting timeframe. The administrator acknowledged that the facility did not comply with its own policy or regulatory requirements regarding timely reporting of abuse allegations.
Failure to Revise Care Plan for Pressure Ulcer Intervention Refusals
Penalty
Summary
The facility failed to revise the care plan for a resident with a chronic right heel wound and diabetic foot ulcer who was refusing physician-ordered pressure-relieving interventions. The resident, who had diagnoses including diabetes, heart failure, and a prosthetic heart valve, was cognitively intact and required maximal assistance for personal care and mobility. Despite having orders for the use of heel suspension boots while in bed to address a right heel ulcer, the care plan did not address the resident's refusals to wear the boots or provide alternative interventions. Observations confirmed that the resident was not wearing the boots as ordered and reported only being able to tolerate them for limited periods due to discomfort. Staff interviews revealed that the LPN was aware of the resident's refusals but did not know the reasons or have alternative approaches documented. The care plan and physician orders were reviewed and confirmed to lack documentation regarding the resident's refusals and did not outline specific interventions for such situations. The facility's policy required care plans to be updated as resident needs changed, but this was not done in response to the resident's ongoing refusal of a key pressure-relieving intervention.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that residents were not consistently receiving necessary interventions to manage existing pressure ulcers or to prevent new ones from forming. The lack of proper assessment, monitoring, and timely intervention contributed to the occurrence and worsening of pressure ulcers among residents.
Failure to Employ Qualified Food and Nutrition Service Staff
Penalty
Summary
The facility failed to employ either a full-time registered dietician (RD) or a qualified dietary manager (DM) to oversee the food and nutrition service since 3/26/24, potentially affecting all 65 residents. The RD reported working full-time across five buildings but only spent eight hours per week at this facility. The Culinary Director (CD), who had been employed for almost a year, had not started training for the Certified Dietary Manager's certificate, despite being asked about it and expressing reluctance to begin. The administrator confirmed that the expectation was for the CD to have the CDM upon hire or within the first three months, but this requirement had not been met.
Failure to Ensure Dietary Staff Wore Beard Guards During Food Preparation
Penalty
Summary
The facility failed to ensure that dietary staff wore beard guards while preparing food, as observed when the Culinary Director, who had a beard, was seen cutting fruit in the kitchen without a beard guard. During interviews, the Culinary Director confirmed he was not wearing a beard guard and stated uncertainty about the facility's requirements, also noting that beard guards were not available for staff use. The administrator later confirmed that dietary staff with beards were expected to wear beard guards for infection control purposes. A policy regarding infection control in the kitchen was requested but was not provided.
Failure to Involve Resident and Guardian in Care Plan Development
Penalty
Summary
The facility failed to ensure that a resident and her legal guardian were invited to participate in the development and review of her person-centered care plan. Multiple care conferences corresponding to the resident's Minimum Data Set (MDS) assessments, including annual, quarterly, significant change, and admission, lacked documentation showing that either the resident or her guardian were invited or attended. Progress notes and care conference forms did not consistently record invitations or attendance, and in some cases, there was no follow-up after initial outreach attempts. Interviews with staff confirmed the absence of documentation regarding invitations and participation of the resident and her guardian in care conferences. The resident, who had diagnoses of heart failure, diabetes, and dementia, was assessed as able to make herself understood and had modified independence in daily decision-making. She expressed a desire to participate in care conferences and voiced concerns about not being included since the appointment of her legal guardian. The resident also reported unmet personal needs and preferences, such as wanting access to personal belongings and assistive devices. Staff interviews and document reviews confirmed the lack of evidence that the resident or her guardian were involved in care planning as required.
Failure to Timely Provide Medicare Coverage Termination and Appeal Notices
Penalty
Summary
The facility failed to provide timely and complete notification of Medicare Part A coverage termination and associated appeal rights to a resident. Specifically, the resident's last day of covered Medicare Part A skilled services was identified, but both the Notice of Medicare Non-Coverage (NOMNC) and the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) were signed by the resident eight days after coverage ended, rather than at least two days prior as required. Additionally, the SNFABN did not indicate which appeal option the resident had chosen. The facility's policy requires that such notices be given at least two days before the last covered day, but this was not followed in this instance.
Failure to Maintain Resident Privacy During Personal Care
Penalty
Summary
A deficiency occurred when staff failed to maintain the privacy and confidentiality of a resident who required assistance with personal care. The resident, who had intact cognition and was dependent on staff for toileting hygiene and personal hygiene due to conditions such as hemiparesis, chronic lung disease, and COPD, was observed during care with the door to his shared room left open. The privacy curtain was not fully drawn, and a mirror on the wall reflected the resident's exposed genitals as a nursing assistant changed his incontinence brief. This allowed visibility from the hallway, compromising the resident's privacy. Interviews with staff confirmed that facility expectations were to close the door and fully pull the privacy curtain during personal care to protect resident dignity and privacy. The nursing assistant involved acknowledged that the curtain could have been closed further to prevent exposure, and this was demonstrated during the survey. The facility's policy on resident rights and privacy was requested but not provided during the survey.
Failure to Revise Care Plan and Follow Up on Vision Needs
Penalty
Summary
The facility failed to review and revise a resident's care plan with input from the resident to address vision needs, specifically for a resident with a history of cataracts and aphasia. The resident's quarterly MDS indicated moderately impaired cognition, adequate vision, and no use of corrective lenses, despite a diagnosis of bilateral age-related cataracts. The Care Area Assessment (CAA) triggered by the cataracts noted the need to maintain current visual function and referenced a consultation for cataract extraction, which the resident elected to pursue. However, the care plan, last revised several months later, did not document the use of multiple pairs of non-prescription glasses or follow-up on the cataract extraction referral and new eyeglasses order. Review of the resident's electronic health record (EHR) revealed a lack of documentation that the referral to a cataract extraction specialist was followed up, and there was no evidence that the order for a consult to optometry for new eyeglasses was addressed. Observations showed the resident using eyeglasses with a missing left temple, and the resident reported ongoing cataract issues, difficulty seeing without glasses, and a need for a new pair. Interviews with the optometrist confirmed that a referral for cataract extraction had been placed and that the facility was responsible for scheduling, but there was no record of the resident requesting eyeglasses or the facility communicating this need. Further, the care conference documentation did not indicate whether the resident or their representative's input was considered in the care planning process. The DON stated that staff were expected to follow up on appointment referrals and that resident preferences and interventions were discussed during care conferences, but also acknowledged that documentation of the use of over-the-counter non-prescription eyeglasses was lacking. Facility policy required person-centered care planning with resident participation and timely updates as needs changed, but these requirements were not met in this case.
Failure to Provide Timely Incontinence Care
Penalty
Summary
A deficiency occurred when a resident who was dependent on staff for toileting and frequently incontinent of bowel and bladder was not provided timely incontinence care. The resident, who had diagnoses including COPD, chronic atrial fibrillation, and pancreatitis, was observed waiting in his wheelchair for over an hour to have his soiled brief changed. Staff informed the resident that he needed to wait until his roommate's wound care was completed, which was expected to take 15 minutes but ultimately took longer. During this time, the resident remained in a soiled brief, and there was a noticeable odor of bowel movement. When care was finally provided, the resident was found to be wet with urine that had soaked through his pants, and he had also had a bowel movement. Interviews with staff confirmed that the resident waited an hour to be changed due to the ongoing wound care for his roommate and staff breaks. The nurse manager acknowledged that an hour was too long for a resident to remain in a soiled brief and that the resident should have been changed before wound care began. The DON stated that residents should be changed as soon as possible or within a set timeframe to prevent skin breakdown, and that other staff, such as the nurse manager, could assist if nursing assistants or nurses were busy. Facility policy required assistance with activities of daily living, including toileting and hygiene, for residents unable to perform these tasks independently.
Failure to Follow Up on Urology Referral for Resident with Neurogenic Bladder
Penalty
Summary
The facility failed to follow up on a urology referral for a resident with paraplegia and neurogenic bladder, who was admitted with a Foley catheter and required substantial assistance with mobility and toileting. The resident's care plan included interventions such as monitoring catheter output, changing the catheter monthly, and administering bowel medications as ordered. Hospital discharge orders specifically indicated the need for a urology appointment due to bladder spasms and urine bypassing the Foley catheter. Despite these orders, interviews and document review revealed that the Health Unit Coordinator (HUC) did not schedule the required urology appointment and was unable to provide a reason for this omission. The process for entering and verifying discharge orders involved both the HUC and nursing staff, with responsibilities for comparing and clarifying orders upon admission. However, the Director of Nursing (DON) confirmed that there was no record of a completed or scheduled urology appointment for the resident. A facility policy regarding coordination of care was requested but not provided.
Failure to Follow Up on Vision Consults and Provide Hearing Assistive Devices
Penalty
Summary
The facility failed to follow up on vision-related consults and provide necessary assistive devices for hearing for two residents. One resident with a history of cataracts, hemiplegia, and aphasia had multiple documented orders and recommendations for a cataract extraction consultation and new eyeglasses. Despite repeated documentation from optometry and provider notes indicating the need for a cataract extraction consult and new eyeglasses, there was no evidence in the electronic health record that these referrals were followed up on or scheduled. The resident continued to experience vision difficulties and used broken eyeglasses, with no documentation of timely action taken to address these needs. Interviews with facility staff, including the optometrist, health information management (HIM), LPN, and DON, confirmed that the process for handling referrals and consults was not consistently followed. Orders for vision care were not properly communicated or acted upon, and there was a lack of documentation regarding the status of referrals. The HIM and DON acknowledged that consults should have been forwarded and scheduled, and that there was an expectation for documentation of over-the-counter eyeglasses provided to the resident, which was not present in the record. For another resident with moderate hearing loss, the facility failed to ensure consistent use of an assistive hearing device (pocket talker) as directed in the care plan. Observations showed that staff did not offer or utilize the device during care interactions, and some staff were unaware of its intended use, mistaking it for a music device. Interviews with nursing staff and the DON confirmed that staff were expected to use assistive hearing devices for residents with communication deficits, but there was uncertainty about training and proper implementation. Requested policies related to communication devices and vision treatment were not provided.
Failure to Provide Timely Podiatry Services and Diabetic Footwear
Penalty
Summary
The facility failed to ensure that appropriate podiatry services were obtained for a resident with diabetes and neuropathy. The resident was identified as having a self-care deficit and required ongoing at-risk foot care, as documented in her care plan and podiatry notes. Despite a podiatry visit recommending continued care and a follow-up in nine to twelve weeks, no further podiatry appointments were scheduled for the resident over several months. The resident also reported being promised diabetic shoes, but no follow-up occurred, and her care plan lacked information regarding diabetic shoes or podiatry preferences. Multiple provider notes and orders indicated the need for podiatry referral and diabetic shoes, but these were not acted upon in a timely manner. Observations revealed the resident had long toenails, dry skin, edema, and reported foot pain, stating she could not wear her current shoes. Interviews with staff indicated confusion regarding the scheduling of podiatry appointments, with the health information manager unable to provide documentation of any refusal by the resident and the director of nursing noting a lapse in follow-up due to a change in guardianship. The facility was unable to provide a written policy for referrals, and the process described by the administrator was not followed in this case, resulting in the resident not receiving necessary podiatry care and diabetic shoes as ordered.
Failure to Consistently Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to consistently implement fall prevention interventions as outlined in the comprehensive care plan for a resident with significant fall risk factors. The resident had a history of falls, severe cognitive impairment, right-sided hemiparesis, and was dependent on staff for transfers. The care plan required a fall mattress to be placed next to the bed at all times when the resident was in bed, as he had previously fallen out of bed. Despite this, multiple staff members, including an LPN and a nursing assistant, entered and exited the resident's room without ensuring the fall mattress was in place after it had been moved. The mattress remained out of position for an extended period while the resident was in bed, contrary to the care plan directives. Observations confirmed that the fall mattress was not replaced after staff completed their tasks, and interviews with staff and the DON verified that the intervention should have been in place to prevent injury. The facility's policy required staff to implement and monitor resident-specific fall interventions, but this was not followed in this instance. The deficiency was identified through direct observation, staff interviews, and review of the resident's care plan and facility policy.
Failure to Use PPE for Resident on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure proper use of personal protective equipment (PPE) for a resident who was on enhanced barrier precautions (EBP) due to a wound on the sacrum. The resident, who was dependent on staff for all activities of daily living and had diagnoses including dementia, seizure disorder, and contractures, was identified as requiring EBP as per the care plan and signage outside the room. Despite this, staff members, including a trained medication assistant and a nursing assistant, entered the resident's room and provided direct care, such as medication administration and transferring the resident using a full body lift, without donning the required PPE. The staff had direct contact with the resident and her bedding during these activities. Interviews revealed that the staff were unaware that the resident was on EBP, even when shown signage and a poster indicating the precautions. There was also no PPE bin directly outside the resident's room, although one was available across the hallway. The facility's policy required the use of gown and gloves during high-contact care for residents with wounds or at increased risk of multidrug-resistant organism (MDRO) acquisition, but this protocol was not followed during the observed care activities.
Failure to Monitor and Maintain Sanitation of Resident's Personal Refrigerator
Penalty
Summary
A deficiency was identified when a personal refrigerator in a resident's shared room was found to be unsanitary and not properly monitored. The resident in question had severe cognitive impairment, required substantial to maximal staff assistance for mobility, and was dependent on staff for transfers. Diagnoses included hemiplegia, stroke, seizure disorder, and malnutrition. During observation, the refrigerator contained multiple unlabeled and undated food items, including plastic bags with unidentified contents, rolled aluminum foil, a cup with white liquid, and various containers. Temperature logs for the refrigerator were incomplete or missing for several dates, and a second refrigerator in the room was found unplugged and empty. A family member expressed concern about the cleanliness of the refrigerator, describing it as "very unsanitary." Interviews with staff revealed that nursing staff were responsible for checking and documenting refrigerator temperatures nightly, and that logs were to be turned in to management. However, the administrator was unable to provide complete temperature logs for the requested period, and the DON confirmed that the refrigerator should have been cleaned and logs updated prior to the survey. Facility policy required weekly temperature checks, removal of expired food, and monthly cleaning, but these procedures were not followed as observed and confirmed during the survey.
Safety and Sanitation Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain a safe environment when a resident, identified as R23, reported a loose safety grab bar in the second-floor shower room, which was not repaired in a timely manner. R23, who was cognitively intact and had a history of falls, pointed out the loose grab bar during an observation. The grab bar was missing screws, making it unstable and posing a risk to residents who used it for support during showers. Despite a work order being entered on 6/29/24, the issue was not addressed, and the grab bar remained a safety hazard. Additionally, the facility had an ongoing issue with flies throughout the building, including in the second-floor shower room and a resident's room. The presence of flies was confirmed by staff and observed during the survey. The facility had contracted with a pest control company, but the problem persisted due to maintenance scheduling issues and inadequate cleaning practices, particularly in the breakroom where flies were attracted to spilled trash and liquids. The facility's pest control policy, last revised in 2008, was not effectively implemented, as evidenced by the continued presence of flies. The administrator acknowledged the recurring fly problem and the need for targeted pest control measures, including drain cleaning and addressing resident behaviors contributing to the issue. Despite these efforts, the facility failed to maintain a clean and pest-free environment, impacting the quality of care provided to residents.
Failure to Update Care Plan for Resident in Locked Behavioral Unit
Penalty
Summary
The facility failed to revise and update a care plan to ensure it was individualized and comprehensive for a resident who was transferred to a locked behavioral unit. The resident, who was cognitively intact, had a history of agitation and behavioral issues, including involvement in resident-to-resident altercations and refusal of care. Despite these issues, the care plan was not updated to include specific interventions or address the resident's triggers and behaviors. The resident's care plan initially focused on mood and behavior alterations, with interventions such as monitoring mood changes and encouraging participation in therapy. However, after the resident was transferred to the locked unit due to increased agitation and feelings of unsafety, the care plan was not revised to include new interventions or address the resident's specific behaviors and triggers. Interviews with staff revealed that the care plan lacked details on managing the resident's aggression, refusal of care, and known triggers. The Director of Nursing acknowledged that the care plan was not comprehensive or specific to the resident's needs. The facility's policy required person-centered care plans to be developed and updated based on comprehensive assessments, but this was not done for the resident. The care plan did not include interventions for the resident's aggression towards staff, refusal of care, or the need to reapproach her multiple times, nor did it address her preferences regarding roommates and environment.
Latest citations in Minnesota
A resident with dry eye syndrome and degenerative eye disease had orders for cyclosporine ophthalmic emulsion and Refresh Tears, both scheduled at the same time. Medication records and direct observation showed a TMA instilled cyclosporine drops in both eyes and immediately followed with Refresh Tears in both eyes without waiting between medications. This practice conflicted with referenced professional guidance recommending several minutes between multiple eye drops and with the medical provider’s recommendation to wait fifteen minutes between the two ophthalmic medications. No facility policy on ophthalmic medication administration was provided when requested.
A resident with severe cognitive impairment, impaired mobility, and high fall risk was care planned to have wheelchair footrests in place at all times, with staff ensuring proper positioning and monitoring for leaning during transport. A NA transported the resident in a manual wheelchair from the shower without the footrests, and while going through the doorway the wheelchair struck the door frame, causing the resident, who was leaning forward, to fall out. The resident sustained a T12 fracture, head injury with concussion, abrasions and contusions, and multiple right-hand lacerations requiring sutures, and the DON confirmed the care plan had not been followed.
A high‑risk, immobile resident with MS and prior heel DTI developed an avoidable unstageable coccygeal pressure ulcer after staff failed to consistently assess and document skin status, did not transfer or timely provide ordered pressure‑relieving mattresses, and did not reliably perform q2h repositioning. The resident was repeatedly left on a bedpan for prolonged periods despite early reports of this issue, and the toileting care plan was not revised to a bedside commode until after the coccygeal wound had significantly worsened. Wound assessments lacked complete measurements and staging, changes in wound size and color were not promptly recognized as deterioration or reported to providers, and recommended interventions from a wound NP (including an air mattress and offloading) were not promptly implemented. As a result, the coccygeal ulcer rapidly progressed to a large, necrotic, malodorous wound requiring hospital transfer and surgical debridement.
A resident with spastic hemiplegia, muscle weakness, and moderate cognitive impairment was observed using bilateral bed grab bars for bed mobility and transfers, but the care plan did not address grab bar or side rail use. Review of the EMR showed no completed bed mobility device or side rail assessment to determine the necessity or safety of the grab bars, and no documentation that risks and benefits were discussed or that informed consent was obtained. An LPN and the ADON stated that a bed mobility device assessment is required before grab bars are installed and confirmed that no such assessment existed for this resident.
A resident with bilateral heel pressure ulcers and multiple comorbidities received wound care during which an RN removed dressings from both heels, cleansed both wounds, and wiped each heel without changing gloves or performing hand hygiene between wounds or after disposing of soiled dressings. This practice conflicted with the facility’s written wound care procedure, which requires glove removal and hand hygiene after dressing removal and after wound cleansing. In interviews, the RN, NP, and DON/IP acknowledged that hand hygiene and glove changes are expected between dirty and clean tasks and between separate wounds to prevent infection.
A resident with MS, neurogenic bladder, mobility limitations, and existing pressure injuries was identified as dependent for toileting hygiene and at risk for pressure ulcers, yet the care plan lacked an individualized toileting/incontinence plan and a defined repositioning schedule. Despite a new coccyx pressure ulcer and documentation that interventions such as increased repositioning and incontinent care were needed, the care plan was not revised for a period of time to reflect these changes. During this time, the resident sometimes fell asleep on a bedpan and remained on it until staff removed it, and staff were not initially informed that the bedpan should no longer be used. The DON later acknowledged that the care plan revisions for turning, repositioning, and toileting were delayed until after the resident’s coccyx ulcer had significantly worsened.
A resident with diabetes, Crohn’s disease, bowel incontinence, and a history of MASD on the right gluteus developed an open, painful lesion on the right gluteal area that was documented over time without complete wound characteristics, clear etiology, or timely provider notification. Wound care orders were written for a stage 3 pressure ulcer on the left buttocks, while staff reported the wound was only on the right side and applied the left‑sided orders to the right gluteal wound in the absence of specific right‑side treatment orders. The DON acknowledged discomfort with staging the wound, lack of early physician notification, and confusion over wound classification, despite a facility policy requiring comprehensive wound assessment, consistent measurement, and provider notification when treatment orders are absent.
A resident with diabetes, chronic leg ulcer, kidney transplant, and a documented gluteal wound was care-planned for Enhanced Barrier Precautions (EBP), with posted instructions requiring gown and gloves for high-contact care such as transfers and wound care. During a telehealth wound assessment, the DON donned a gown and initially performed hand hygiene but then applied gloves without hand hygiene, removed a soiled dressing from the resident’s gluteal area, discarded it, removed gloves, and applied new gloves again without performing hand hygiene between glove changes. On another occasion, during use of a sit-to-stand lift, an NA wore gown and gloves, but the DON handled the lift harness, the resident’s clothing, and assisted with the transfer and repositioning while wearing a gown but no gloves, despite EBP requirements for transfers. The DON stated EBP was only needed for catheter or wound care and not for transfers, contradicting the posted EBP instructions and facility policy.
A resident with severe dementia, psychiatric disorders, and high dependence for ADLs was verbally abused during evening care when a NA, frustrated with the resident’s crying and resistance, loudly ridiculed her as acting like a two-year-old, threatened to hit her back if struck, told her she would be sent to a locked unit, and questioned who would want to care for her when she cried like a baby. Multiple staff witnessed the loud, stern, and intimidating tone and reported it to an LPN, who recognized it as verbal abuse but did not immediately remove the NA from duty or promptly report the allegation per policy, allowing the NA to continue working on the unit. Following this incident, the resident demonstrated increased crying, combativeness, resistance to care, wandering, self-isolation, and refusal of food, fluids, and medications above baseline, with documentation of significant emotional distress and subsequent ED evaluation for aggressive behaviors and poor intake.
A resident with dementia, bilateral above‑knee amputations, vascular disease, and severe protein‑calorie malnutrition developed a wound on an amputation stump that had a dressing dated several days before any documentation or treatment orders appeared in the record. Although bath audits and nursing notes initially reported no skin issues, a later assessment described a full‑thickness stage 4 ulcer/diabetic ulcer on the stump with exposed bone, erythema/edema, slough, and moderate serosanguineous drainage. Nursing staff interviews showed no one could identify who first discovered the wound or applied the initial dressing, and there was no evidence that the wound was assessed, the provider notified, or standing orders implemented when it was first present, despite facility expectations that new wounds be promptly evaluated and reported.
Failure to Follow Professional Standards for Ophthalmic Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice for administering ophthalmic medications to a resident with dry eye syndrome and degenerative eye disease. The resident was cognitively intact, required assistance with ADLs, and had physician orders for cyclosporine ophthalmic emulsion 0.05% one drop in both eyes twice daily and Refresh Tears ophthalmic solution one drop in both eyes four times daily for dry eyes. The administration summary showed that both eye medications were scheduled for the same time and were documented as being given at the same time on multiple dates. During a medication pass observation, a trained medication aide administered the ordered oral medications, then applied gloves and instilled one drop of cyclosporine in each eye, immediately followed by one drop of Refresh Tears in each eye, without any waiting period between the two medications. The surveyors referenced guidance from the American Academy of Allergy, Asthma, and Immunology stating that when more than one eye drop is ordered, three to four minutes should be allowed between drops in the same eye, and five to fifteen minutes should be allowed between different eye medications to prevent dilution. Interviews with the DON, pharmacy consultant, and medical provider confirmed that best practice and the provider’s recommendation were to wait between administration of cyclosporine and Refresh Tears, with the medical provider specifying a fifteen-minute interval. The facility did not provide a policy on ophthalmic medications when requested. The observed practice and documented administration times demonstrated that staff did not follow these professional standards or the medical provider’s recommended interval between the two eye medications.
Failure to Follow Wheelchair Transport Care Plan Leads to Fall With Injuries
Penalty
Summary
The deficiency involves the facility’s failure to implement care-planned fall prevention interventions for a resident at high risk for falls, resulting in a fall with injury. The resident had diagnoses including aphasia, dysphagia, muscle weakness, traumatic brain injury, and impaired mobility, with severe cognitive impairment documented on the MDS and dependence on staff for transfers and wheelchair transport. A care plan addressing wheelchair transport safety and positioning directed staff to ensure the resident was fully positioned and supported in the wheelchair prior to transport, verify footrests were in place prior to transport, and monitor for leaning, sliding, or unsafe positioning. An additional care-planned approach required wheelchair pedals to be on at all times. On the date of the incident, a nursing assistant transported the resident in a manual wheelchair from the shower room to the resident’s room without the foot pedals in place, contrary to the care plan. While being wheeled through the doorway, the wheelchair struck the door frame, causing the chair to stop and the resident, who had begun leaning forward, to fall out of the wheelchair onto the floor. Progress notes and ED documentation identified that the resident sustained a T12 vertebral fracture, a head injury with concussion, an abrasion and contusion to the head, a bruise to the left knee, and multiple lacerations to the right hand requiring sutures. The nursing assistant later acknowledged awareness that the foot pedals should have been on but did not apply them because the transport was only from the shower to the room. The DON confirmed that the resident’s care plan had not been followed when the fall occurred.
Failure to Implement and Update Pressure Ulcer Prevention and Treatment Led to Avoidable Unstageable Coccygeal Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, monitor, and implement individualized pressure ulcer prevention and treatment interventions for multiple high‑risk residents, resulting in an avoidable, unstageable coccygeal pressure ulcer for one resident that required surgical debridement and hospitalization. The resident had primary progressive multiple sclerosis, hereditary spastic paraplegia, obesity, and pre‑existing pressure‑related deep tissue injury to the left heel, and was identified as high risk for pressure ulcers on the Braden Scale due to constant moisture, chairfast status, very limited mobility, inadequate nutrition, and friction/shear risk. Hospital records on readmission documented irritant contact dermatitis of the bilateral gluteal cleft with specific cleansing and barrier cream orders, and facility documentation showed the resident could not reposition in bed or chair and required assist of two and a full‑body mechanical lift for transfers. Despite this, the admission/readmission skin assessment and weekly skin checks lacked measurements and detailed wound characteristics for the heel ulcer and gluteal dermatitis, and the care plan did not include comprehensive, individualized interventions beyond generic repositioning and wound care orders. After a new coccyx pressure ulcer was identified and documented as a stage 2 lesion, the facility failed to promptly and accurately update the care plan and implement recommended pressure‑relieving interventions. The wound nurse practitioner on 3/5 ordered coccyx wound care, an air mattress, pressure offloading, and a dietician consult, but the care plan was not revised and there was no evidence that an air mattress was placed on the bed for nearly two weeks. The environmental services director later confirmed that when the resident was moved to a new room, the gel mattress was not transferred, and the air mattress requested on 3/17 was not actually placed until the following day, despite being marked as completed. During this period, TAR documentation showed gaps in the every‑2‑hour repositioning order, and staff interviews revealed that CNAs were unaware of which residents were on repositioning programs, were not consistently repositioning residents, and had not received recent education on pressure ulcer prevention. The DON and RN case manager acknowledged that the coccyx wound increased in size and changed color between assessments, that the bed lacked the ordered gel mattress, and that the physician was not notified of the wound’s deterioration at that time. The facility also failed to timely modify toileting and incontinence care practices despite knowledge that the resident was being left on a bedpan for extended periods. The DON reported hearing before an IDT meeting that the resident had fallen asleep on a bedpan for an undetermined amount of time, but the care plan was not revised to discontinue bedpan use and implement a bedside commode until after the coccyx wound had significantly worsened. CNAs confirmed that the resident sometimes fell asleep on the bedpan and that they were not informed she should no longer use it until after the sore had worsened. Subsequent wound assessments documented rapid progression of the coccyx wound from a small stage 2 ulcer to a large, malodorous, necrotic wound with eschar, slough, erythema, and purulent drainage, ultimately classified as an unstageable pressure ulcer. The DON, NP, PA, and medical director all indicated that the lack of a pressure‑relieving mattress, failure to adjust pressure‑reducing interventions, and prolonged time on a bedpan likely contributed to the development and deterioration of the resident’s pressure ulcer, which was determined to be avoidable and resulted in hospitalization and surgical debridement. Additional documentation and interviews showed systemic assessment and communication failures related to pressure ulcer management. Weekly skin checks and wound assessments often omitted complete measurements, staging, and wound characteristics, and changes in wound size and appearance were not consistently recognized as deterioration or communicated to providers. The DON acknowledged that a 3/12 assessment showing increased wound size and purple discoloration should have been identified as a deep tissue injury and reported to the physician, but this did not occur. When nursing later documented foul odor, increased pain, and expanding necrotic tissue, telemedicine and PA responses deferred in‑person evaluation and ED transfer despite earlier recommendations that the resident be sent to the ED if an in‑person provider could not assess the wound. The NP ultimately found a large, malodorous, purulent wound with expanding eschar and ordered transfer to the hospital, where imaging and surgical findings confirmed a large necrotic sacral wound requiring extensive debridement. Throughout this sequence, the facility did not consistently follow its own pressure ulcer protocols, did not ensure ordered pressure‑relieving equipment was in place, and did not promptly revise care plans or interventions in response to known risk factors and documented wound changes. The report also notes that other residents reviewed for pressure ulcers were affected by similar failures in monitoring and individualized intervention, though detailed narratives focus primarily on this resident. Staff interviews revealed that CNAs relied on paper care guides that did not clearly identify residents on repositioning programs or at risk for skin breakdown, and that they were unaware of some residents’ special mattress orders or toileting restrictions. The DON and medical director stated that residents at risk for pressure ulcers should have immediate pressure‑relieving interventions and that existing ulcers require ongoing evaluation to prevent deterioration, but the documented practices for this resident did not align with those expectations. These combined actions and inactions—insufficient assessment detail, delayed or missing care plan revisions, failure to implement ordered support surfaces and repositioning, and delayed response to wound deterioration—constituted the deficiency in providing appropriate pressure ulcer care and preventing new ulcers from developing.
Failure to Assess, Care Plan, and Obtain Consent for Bed Grab Bar Use
Penalty
Summary
The deficiency involves the facility’s failure to follow required procedures before installing and using bed grab bars for a resident. The resident had diagnoses including spastic hemiplegia affecting the left side and muscle weakness, and an admission MDS indicating moderate cognitive impairment. During observation, the resident was seen in a power chair with bilateral grab bars on the bed and reported using them to roll in bed and for transfers. The resident’s care plan, dated 1/23/26, documented a need for assistance with bed mobility and independence with transfers but did not mention or address the use of grab bars or side rails. Review of the electronic medical record showed no completed grab bar/side rail or bed mobility device assessment to determine the necessity of the grab bars or whether the resident could safely use them. There was also no evidence that the resident or the resident’s representative had been educated on the risks of having a grab bar on the bed or that informed consent had been obtained. In interviews, an LPN and the ADON both stated that a bed mobility device assessment was required to determine need and safety prior to installing grab bars, and both confirmed that no such assessment was present in the resident’s record.
Failure to Perform Hand Hygiene and Change Gloves During Wound Care
Penalty
Summary
Surveyors observed that a registered nurse (RN) and a nurse practitioner (NP) did not follow the facility’s established infection control practices during wound care for one resident. During a wound treatment, the RN wore gloves while removing the dressing from the resident’s left heel, then removed the dressing from the right heel, sprayed both wounds with wound cleanser, wiped the left heel with gauze, and then used a clean gauze pad to wipe the right heel. The RN did not remove her gloves or perform hand hygiene after disposing of the soiled dressings or between cleaning the left and right heel wounds, contrary to the facility’s written wound care procedure, which requires glove removal and hand hygiene after removing the previous dressing and again after cleaning the wound. The resident’s admission MDS documented diagnoses including multiple rib fractures, heart failure, dementia, anxiety, and the presence of a pressure ulcer, and indicated the resident was cognitively intact and required staff assistance with care and transfers. The resident’s care plan identified pressure ulcers on both heels requiring wound care. In interviews, the RN, NP, and the DON/infection prevention nurse each stated that gloves should be changed when moving from dirty to clean areas and that hand hygiene is expected after glove removal and between wounds to prevent infection, confirming that the observed practice did not align with facility policy or expected infection control standards.
Failure to Timely Revise Care Plan for Toileting and Skin Integrity
Penalty
Summary
The deficiency involves the facility’s failure to timely revise and individualize a resident’s care plan to address toileting and incontinence needs in relation to impaired skin integrity. The resident had diagnoses including primary progressive multiple sclerosis, hereditary spastic paraplegia, obesity, and a pressure-induced deep tissue injury to the left heel. A Significant Change MDS identified the resident as dependent for toileting hygiene, with lower extremity range-of-motion limitations, wheelchair use, dependence for transfers, occasional urinary incontinence, intact cognition, and at risk for pressure ulcers with existing unhealed pressure injuries and MASD. The resident’s skin-focused care plan, revised on various dates, included skin inspections, wound care orders, weekly skin checks, pressure ulcer care to the left heel, nutritional supplements, and a gel mattress, but did not include an individualized toileting or incontinence plan. On a weekly skin check dated 3/3/26, nursing staff identified a new Stage 2 pressure ulcer on the coccyx and contact dermatitis on both gluteal folds. An IDT Final Post Review Follow Up dated 3/10/26 (signed 3/23/26) documented that a new skin issue had occurred and that interventions after the incident included wound care treatment orders, increased repositioning, and increased incontinent care. However, the resident’s care plan from 3/3/26 through 3/16/26 did not show revisions reflecting increased incontinence care or a repositioning schedule, and the care plan was not updated to include these elements until 3/17/26. During this period, the care plan still lacked an individualized toileting plan despite the resident’s identified incontinence and new coccyx pressure ulcer. Progress notes on 3/17/26 documented that the resident’s coccyx wound had declined, with an evaluation describing a deteriorating wound characterized as a Kennedy terminal ulcer/End of Life, staged as a Stage 4 pressure ulcer, in-house acquired, with increased size, exudate, odor, pain, and surrounding erythema. On that same date, the skin focus care plan was revised to include prompt incontinence care and keeping the skin clean and dry, and the elimination focus care plan was revised to address incontinence due to neurogenic bladder with use of a bedside commode offered every 2–3 hours. A nursing assistant reported that when working with the resident, the resident would sometimes fall asleep on the bedpan and forget to ask staff to remove it, and that she was not aware the resident was not supposed to use the bedpan until after the sore had worsened. The DON stated that the resident’s care plan had not been revised earlier to include a turning and repositioning schedule or toileting changes, and that it should have been revised as soon as staff learned the resident was falling asleep on the bedpan, rather than waiting until after the pressure ulcer worsened.
Failure to Assess and Notify Provider for Right Gluteal Wound
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess and appropriately manage a non‑pressure skin issue on a resident’s right gluteal area, and to notify the physician in a timely manner. The resident had diagnoses including diabetes, Crohn’s disease, and a kidney transplant, and the MDS indicated occasional bowel incontinence, no pressure ulcers, and no moisture‑associated skin damage at that time. Earlier documentation identified a resolved MASD to the right gluteus, and a progress note later described a sacral wound with creams applied, noting that sores were still open and painful during application, but without any measurements, wound characteristics, or evidence of physician notification. Subsequent wound assessments documented an open lesion on the right gluteus with specific measurements on multiple dates, but did not identify the wound type or other characteristics, and the record did not show physician notification or treatment orders for the right gluteal lesion. Provider orders in place initially addressed cleansing the buttocks and applying barrier cream, and later included a detailed wound care order for a stage 3 pressure ulcer documented on the left buttocks. However, the resident’s record did not contain a specific treatment order for the right gluteal wound, despite the ongoing documentation of an open lesion in that area. Interviews revealed confusion and inconsistency in wound identification and classification. The DON stated that the right gluteal wound was documented as an open lesion because she did not feel comfortable determining the wound type, and acknowledged that the physician should have been notified when the wound was first identified. The DON was unaware that the NP had documented the wound as being on the left buttocks and as a stage 3 pressure ulcer, while the RN reported that the wound had never been on the left buttocks and that she had been applying the left‑sided wound orders to the right gluteal area because there was no open area on the left. The resident reported a recurring painful area on the right buttocks and chronic stool leakage since prior anal fistula surgery. The facility’s own wound treatment policy required comprehensive assessment of wound etiology and characteristics, consistent measurement and documentation, and provider notification in the absence of treatment orders, which were not followed for this resident’s right gluteal wound. The deficiency centers on the lack of a comprehensive wound assessment for the right gluteal lesion, incomplete documentation of wound characteristics, failure to clearly determine and document the wound etiology, and failure to notify the physician and obtain appropriate treatment orders when the wound was identified and remained open. These actions and inactions resulted in a discrepancy between the documented wound location and type and the actual clinical presentation, as well as a period during which the right gluteal wound had no specific, clearly ordered treatment despite being open and painful.
Failure to Perform Hand Hygiene and Implement Enhanced Barrier Precautions During Wound Care and Transfers
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper hand hygiene during wound care and to consistently implement Enhanced Barrier Precautions (EBP) for a resident requiring such measures. The resident had diagnoses including diabetes, a non-pressure chronic ulcer of the right lower leg, and a kidney transplant, and a wound assessment documented an open lesion on the right gluteal area. The resident’s care plan and a sign posted outside the room specified that EBP, including gown and gloves, were required for high-contact care activities such as dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, catheter care, and wound care. During one observation, the DON performed hand hygiene and donned a gown before entering the resident’s room for a telehealth wound assessment. Inside the room, the DON went into the bathroom, applied gloves without performing hand hygiene, removed the resident’s brief, and removed a foam dressing from the right gluteal area that had stool on one corner. After discarding the soiled dressing, the DON removed gloves and then applied new gloves without performing hand hygiene between glove changes. When questioned, the DON stated that hand hygiene should be done when hands or gloves are visibly soiled and before and after removing or applying gloves, and acknowledged that hand hygiene had not been performed each time gloves were removed and reapplied. In a separate observation, the resident was transferred using a sit-to-stand mechanical lift while EBP requirements were not fully followed. An NA entered the room wearing a gown and gloves with the lift, and the DON applied the lift harness under the resident’s arms and cinched the waist strap, encountering the resident’s clothing, while not wearing gloves. After the transfer to bed, the DON pulled down the resident’s pants and removed the harness while touching the resident’s clothes. Following wound care by a CNP-WOC, the DON again assisted the resident by sitting the resident on the edge of the bed, applying the lift harness, and adjusting the resident’s pants and shirt while wearing a gown but no gloves. The DON stated that EBP was only needed for catheter or wound care and not for transfers, and only upon reading the posted EBP sign acknowledged that EBP was required for all high-contact resident care activities, including transfers.
Failure to Protect Resident From Verbal Abuse and Delay in Removing Alleged Perpetrator
Penalty
Summary
The deficiency involves the facility’s failure to protect a vulnerable resident from mental abuse and to respond appropriately to an allegation of abuse. The resident had severe cognitive impairment, Alzheimer’s disease, dementia, anxiety, depression, psychotic disorder, and significant functional dependence, including frequent incontinence and the need for extensive assistance with ADLs and transfers. Her care plan identified behavioral and mood issues such as wandering, yelling, combative behavior, and calling staff names, with interventions including calm approaches, emotional support, redirection, and monitoring for emotional distress and mood/behavior changes. She was identified as a vulnerable adult, with instructions to monitor for signs of emotional distress and to follow the facility’s abuse reporting policy. On the evening in question, while the resident was crying on the phone with her son and expressing a desire to leave, NA-A and NA-B entered to provide evening care using an EZ stand lift. After the resident ended the phone call, multiple staff reported that NA-A spoke to the resident in a loud, stern, and frustrated tone, telling her to stop crying and that she was acting like a two-year-old. When the resident swatted at NA-A, NA-A stated, “If you hit me, I’m going to hit you back,” and later told the resident she was “in trouble now.” Staff reported that NA-A told the resident she would be sent to a locked unit so she could not get out, and questioned who would want to care for her when she cried like a baby, and that nobody would want to keep working with her. NA-C described NA-A yelling commands such as “HOLD ON!” and “Stop crying! Where would you be if you were not here? Probably lying on the floor,” and felt NA-A was obviously upset and overwhelmed. These statements were made in the presence of the resident while she was already distressed and crying. Following this interaction, the resident exhibited crying, yelling, combativeness, resistance to care, wandering into other residents’ rooms, self-isolation, and refusal of food, fluids, and medications above her prior baseline, as documented in behavior charts, target behavior monitoring, and nursing progress notes. Staff documented that she cried most of the morning, was very restless, difficult to redirect, hit and pinched staff, called staff names, and refused care and meals. She required repeated redirection, 1:1 attention, and non-pharmacological interventions, and was ultimately sent to the ED for evaluation of combativeness and emotional distress, where she was treated for dementia with aggressive behavior and hypoglycemia related to poor intake. The report identifies that the resident’s actual response and the reasonable person concept showed serious psychosocial harm, including increased crying and combative behavior above baseline, fear/anxiety manifested as combativeness, resistance to care and social interaction, and self-isolation. The facility also failed to immediately remove the alleged perpetrator from resident care and to promptly report and investigate the allegation in accordance with its abuse policy. After NA-B and NA-C reported to LPN-A that NA-A had yelled at and threatened the resident, LPN-A acknowledged it as verbal abuse but did not initiate immediate protective measures or timely reporting. LPN-A stated she believed she had 24 hours to report because there was no injury, despite facility policy requiring reporting within two hours. NA-A remained on the unit and continued working until the end of her shift, including after staff had clearly communicated their concerns to LPN-A. TMA and NA staff described uncertainty about their authority to remove NA-A and reliance on the nurse to act, while the DON later informed LPN-A that NA-A should have been removed from the floor to prevent further danger to residents. The Immediate Jeopardy was determined to have begun when NA-A’s derogatory, intimidating, and threatening statements were made and continued while she remained on duty with access to the resident and other vulnerable residents.
Failure to Timely Assess and Treat Newly Discovered Stump Wound
Penalty
Summary
The deficiency involves the facility’s failure to provide timely treatment and care for a newly discovered wound on a resident’s above‑knee amputation stump. The resident was admitted with diagnoses including unspecified dementia with behavioral disturbances, vascular dementia, bilateral above‑knee amputations, vascular disease, reduced mobility, and severe protein‑calorie malnutrition, and had no documented ulcers or skin problems on admission or on the most recent MDS. A weekly bath audit on 3/17/26 documented only non‑tender lymph nodes on the right upper hip and did not identify any open areas. However, when the wound was later assessed, the dressing on the stump was dated 3/16/26, indicating that a wound and dressing existed at that time, even though no corresponding assessment, provider notification, or treatment orders were documented. On 3/23/26, nursing staff documented a new skin issue above the resident’s knee at the amputation site, describing a stage 4 pressure ulcer/injury with full‑thickness skin and tissue loss, exposed bone, erythema/edema, and moderate serosanguineous exudate. The wound measured 1.56 cm by 1.64 cm, with 20–29% granulation tissue and 80% slough. A progress note and skin issues assessment on that date confirmed the wound characteristics and staging, and the NP, after reviewing a picture, determined the wound to be a diabetic ulcer with peripheral vascular disease and severe protein‑calorie malnutrition as contributing factors. On that same date, the NP was notified, antibiotic therapy (doxycycline) was ordered for possible cellulitis, and specific wound care orders were initiated, with documentation on the MAR that these treatments were carried out beginning 3/23/26. Multiple interviews with nursing staff revealed that no one could identify who discovered the wound or who applied the initial dressing dated 3/16/26, and there was no documentation of a wound assessment, provider notification, or interim treatment between 3/16/26 and 3/22/26. Several RNs and LPNs who worked shifts from 3/16/26 through 3/20/26 stated they did not notice a wound on the stump and that, per their usual practice, they would have contacted the provider and initiated treatment if they had found one. One LPN recalled seeing a band‑aid with a date on the stump but could not recall the date, and another LPN stated she did not see the wound because she was not looking for one. The facility’s standing orders required staff to assess all wounds daily, change dressings every three days and as needed, treat with normal saline or non‑cytotoxic cleanser and appropriate dressings, and notify the provider the next business day when a new wound or injury was found. Despite these expectations, the wound identified by the dated dressing on 3/16/26 was not assessed, reported, or treated according to orders and facility policy until 3/23/26.
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