The Waterview Pines Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Virginia, Minnesota.
- Location
- 1201 8th Street South, Virginia, Minnesota 55792
- CMS Provider Number
- 245283
- Inspections on file
- 32
- Latest survey
- January 15, 2026
- Citations (last 12 mo.)
- 19 (1 serious)
Citation history
Health deficiencies cited at The Waterview Pines Llc during CMS and state inspections, most recent first.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
A resident with dementia and mobility issues was transferred using a toileting sling instead of the care-planned full body sling, resulting in a fall from the lift and head injury. The staff did not report the incident to the state agency as required by facility policy, despite evidence that the transfer method was inappropriate for the resident's condition.
The facility did not honor a resident's right to voice grievances without discrimination or reprisal and failed to establish a grievance policy or make prompt efforts to resolve grievances.
A resident with chronic respiratory conditions was found with an oxygen humidifier bottle that had not been changed for over a month, contrary to facility policy. The facility's order summary lacked a schedule for changing the oxygen bubbler, and there was no documentation in the resident's electronic medical record. Both a registered nurse and the DON confirmed the expectation for regular changes, but the facility could not provide the relevant policies.
The facility failed to maintain adequate staffing levels, resulting in delayed care and unmet needs for residents. Interviews revealed long call light wait times, insufficient personal care, and reliance on undertrained agency staff. Specific incidents included residents left soiled, delayed morning care, and untimely pain medication administration. The facility's staffing assessment was not met, impacting care during emergencies. The resident council expressed ongoing concerns about staffing, with no satisfactory response from administration.
The facility failed to ensure timely repositioning and coordination of care for a hospice patient, did not follow weight monitoring orders for a resident with CHF, and did not complete dressing changes as ordered for a resident with an amputation. Additionally, the facility failed to ensure the placement of an AFO for a resident and did not deliver medications timely for a resident experiencing significant pain. These deficiencies highlight a pattern of inadequate care coordination and documentation.
A facility failed to provide adequate supervision for a resident with dementia, multiple sclerosis, depression, and dysphagia during dining. The resident, who required assistance with eating, was left alone in the dining room while a dietary staff member cleared tables. The resident remained unsupervised until a nursing assistant arrived to escort her to her room. Interviews with the RN and DON confirmed the need for nursing staff presence during meals for safety, as per facility policy.
The facility failed to dispose of an expired bottle of half and half, which was still accessible to residents. The culinary aide and director confirmed the product should have been discarded five days after opening or by the expiration date. The infection preventionist highlighted the increased risk of bacteria and foodborne illness from using expired dairy products. The facility's policy lacked guidance on monitoring expiration dates.
A facility failed to secure a resident's hospice medical records. The resident, with dementia and congestive heart failure, had hospice care orders not integrated into the EHR. Hospice staff recorded notes on paper stored in a binder, which went missing. Efforts to locate the chart were unsuccessful, and the facility's record retention policy did not address security.
A facility failed to ensure PRN lorazepam orders were time-limited to 14 days and lacked a documented diagnosis for a resident with severe cognitive impairment. The resident's care plan included psychotropic drug monitoring, but the order for lorazepam was set for six months without a rationale for extending beyond 14 days, contrary to facility policy. After discharge from hospice, a new order with an indication and rationale should have been documented.
The facility failed to provide adequate pressure ulcer care for two residents, leading to deficiencies. One resident did not receive documented education or proper heel elevation, while another experienced gaps in weekly skin inspections and delayed notification to the RD about wound care needs. The DON acknowledged the importance of following care plans and conducting regular inspections, but the facility's failure to adhere to protocols resulted in these deficiencies.
A resident with traumatic brain injury and hemiplegia was not provided with a palm protector as outlined in their care plan, leading to a deficiency in care. The resident's left hand was found in a fist, and staff were unable to locate the palm protector. The director of nursing confirmed that the care plan was not followed, which could prevent further contractures.
A resident with cognitive intactness and multiple diagnoses, including anxiety, was not provided adequate personal hygiene care, leading to greasy hair and discomfort. Despite the resident's care plan indicating a need for assistance and proactive care, the facility only scheduled weekly showers, failing to maintain the resident's dignity. Staff acknowledged the oversight, emphasizing the importance of offering hair washing without the resident having to request it.
A resident with cognitive impairment and multiple diagnoses was not assisted in getting dressed and going to the dining room for breakfast due to staffing shortages. The resident's care plan indicated a preference for dining in the main dining room and being ready by 8:00 a.m., but staff were unable to meet these preferences consistently. The facility's policy emphasized person-centered care, yet the resident's rights and dignity were compromised.
A resident's concern about a broken toilet went unaddressed due to a lack of communication and reporting among staff. The cracked toilet bowl was not reported by housekeeping or nursing staff, and no maintenance request was submitted. The regional director of maintenance confirmed the need for replacement, highlighting a failure in the facility's process for reporting and repairing broken equipment.
The facility failed to complete all sections on the MDS for two residents, leading to deficiencies in their assessments. One resident's cognitive and mood assessments were not conducted, while another resident's use of a wanderguard was not documented. These oversights were confirmed by facility staff, highlighting the need for accurate assessments to ensure proper care and billing.
The facility failed to address ADLs for two residents. One resident with a self-care deficit had neglected nail care, while another resident, dependent on staff for transfers, was left in bed undressed and unable to attend meals as preferred. Staff shortages and lack of documentation contributed to these deficiencies.
The facility failed to post daily nurse staffing information over the weekend, impacting all 53 residents and visitors. An observation found the staffing sheet dated from the previous Friday, and the administrator confirmed that the charge nurse was responsible for updating and posting the sheets daily, including weekends.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Report Suspected Neglect After Resident Fall from Mechanical Lift
Penalty
Summary
The facility failed to report an allegation of neglect to the state agency after a resident experienced a fall from a mechanical lift. The resident, who had diagnoses including dementia with behavioral disturbance, back pain, chronic pain, and spinal stenosis, was care planned to be transferred using a ceiling lift with a toileting sling for toileting and a full body split leg sling for all other transfers. On the date of the incident, staff transferred the resident from the wheelchair to the bed using a toileting sling, contrary to the care plan, and the resident fell out of the sling and hit her head. The nursing assistant involved stated the resident, who was confused and tired, placed her arms inside the sling during the transfer, despite being instructed to keep them outside. The ceiling lift representative confirmed that the toileting sling required the resident to keep their arms outside and that the sling may not have been appropriate for someone with cognitive or physical limitations. Despite the incident, the administrator and DON did not report the event to the state agency, stating that the care plan had been followed, even though documentation and interviews indicated otherwise. Facility policy required all suspected abuse or neglect, defined as failure to provide necessary goods and services to avoid harm, to be reported to the state agency within two hours of suspicion. The failure to report the incident as required constituted a deficiency in timely reporting of suspected neglect.
Failure to Honor Resident Grievance Rights
Penalty
Summary
The facility failed to honor the resident's right to voice grievances without discrimination or reprisal. Additionally, the facility did not establish a grievance policy or make prompt efforts to resolve grievances as required. This deficiency was identified based on the facility's lack of appropriate procedures and actions to address and resolve resident grievances in a timely and non-discriminatory manner.
Failure to Implement Respiratory Care Orders
Penalty
Summary
The facility failed to implement orders for respiratory care for a resident with multiple chronic respiratory conditions. The resident was observed lying in bed with oxygen administered via nasal cannula at 2 liters per minute, with the oxygen being humidified. The humidifier bottle was dated over a month prior, indicating it had not been changed as expected. The resident's medical history included centrilobular emphysema, chronic obstructive pulmonary disease, pulmonary fibrosis, atherosclerosis of the aorta, morbid obesity with alveolar hypoventilation, and chronic respiratory failure with hypoxia. The facility's order summary for the resident included instructions to fill the concentrator bubbler every evening shift, but did not specify a schedule for changing it. A review of the resident's electronic medical record revealed no documentation of the oxygen bubbler being changed. A registered nurse confirmed the lack of documentation and stated that the oxygen bubbler should be changed monthly according to policy for infection control purposes. The director of nursing also confirmed the expectation for regular changes of oxygen bubblers per policy, but the facility was unable to provide the relevant respiratory care policies upon request.
Inadequate Staffing Leads to Delayed Care and Resident Neglect
Penalty
Summary
The facility failed to ensure adequate staffing levels, resulting in delayed and insufficient care for residents. Multiple interviews with staff, residents, and family members highlighted significant concerns about the lack of staff, particularly during weekends and night shifts. Residents experienced long wait times for call lights, leading to incidents of incontinence and unmet personal care needs. Family members reported having to assist with care themselves due to the lack of available staff. The use of agency staff without proper training further exacerbated the issue, as regular staff had to spend time guiding them, detracting from their own duties. Specific incidents included a resident being left soiled for extended periods, another resident not receiving morning care until the afternoon, and a resident not receiving timely pain medication. The facility's staffing assessment indicated a need for a certain nurse-to-resident and NA-to-resident ratio, but actual staffing levels fell short, with hours of care per resident per day ranging from 1.6 to 2.2, below the required 2.8 to 3.2. The facility's administration acknowledged the staffing issues but believed their ratios supported the care being provided, despite evidence to the contrary. The deficiency was further highlighted by the facility's inability to manage care during emergencies or unexpected events, such as a resident's death, which impacted the care of other residents. The facility's policy on Activities of Daily Living emphasized person-centered care, but the lack of staff prevented the fulfillment of residents' preferences and needs. The resident council and ombudsman also expressed concerns about staffing, indicating that the issue was a recurring topic in their meetings, with no satisfactory response from the administration.
Deficiencies in Care Coordination and Documentation
Penalty
Summary
The facility failed to ensure timely repositioning and coordination of care for a hospice patient, identified as R8, who experienced a change in condition. R8, who had moderately intact cognition and diagnoses of dementia and congestive heart failure, was dependent on staff for various activities of daily living. Despite orders for repositioning every three hours and communication with hospice for changes in condition, R8 was not repositioned for over four hours, and hospice was not notified of her unresponsiveness and lack of intake. Observations revealed that staff were unaware of the last repositioning time, and there was a lack of coordination in administering medications appropriately. The facility also failed to follow provider orders for weight monitoring for a resident, identified as R26, with congestive heart failure and chronic kidney disease. The resident's care plan did not address weight monitoring, and there were multiple lapses in weekly weight checks, which could lead to fluid overload. The Director of Nursing acknowledged these lapses and the associated risks. Additionally, the facility did not complete dressing changes as ordered for a resident, identified as R40, with an above-the-knee amputation and surgical wounds. The dressing change was not documented, and the resident reported that the dressing had not been changed as scheduled. The facility also failed to ensure the placement of an ankle-foot orthosis for a resident, identified as R32, and did not deliver medications timely for a resident, identified as R1, who experienced significant pain due to delayed medication administration. These deficiencies highlight a pattern of inadequate care coordination and documentation within the facility.
Lack of Supervision During Dining for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure adequate supervision for a resident during dining, leading to a deficiency. The resident, who was diagnosed with dementia, multiple sclerosis, depression, and dysphagia, was identified as severely cognitively impaired and required partial to moderate assistance with eating. On the evening of November 18, 2024, the resident was observed alone in the dining room, eating and drinking without supervision from nursing staff or trained feeding staff. A dietary staff member was present but was engaged in clearing tables rather than supervising the resident. The resident remained unsupervised until a nursing assistant arrived to escort her to her room. Interviews with the RN and DON confirmed that nursing staff should be present in the dining room during meals to ensure safety, particularly in the event of choking. The facility's policy, dated August 26, 2020, stated that a nursing assistant or other designated, trained personnel should be assigned to the dining room at all meals to assist residents with food preparation and feeding.
Expired Dairy Product Not Disposed of in Facility
Penalty
Summary
The facility failed to dispose of an expired bottle of half and half dairy product, which was still available for residents to use. An opened bottle of half and half was found in the refrigerator of the dining hall dinette room with a handwritten open date and a manufacturer's expiration date. The culinary aide confirmed the dates and acknowledged that the dairy product should have been discarded five days after opening or by the manufacturer's expiration date. The culinary director reiterated that dairy products should be disposed of after five days of being opened or by the expiration date. The infection preventionist noted that using dairy products past their expiration date increases the risk of bacteria and foodborne illness. The facility's policy on food receiving and storage, last revised in 2017, did not include information on monitoring foods and liquids for expiration dates.
Failure to Secure Hospice Medical Records
Penalty
Summary
The facility failed to ensure the security of medical records for a resident receiving hospice care. The resident, who had moderately intact cognition and diagnoses of dementia and congestive heart failure, was dependent on staff for daily activities. The resident's care plan included hospice care through Essentia East Range Hospice, with specific orders to maintain communication with hospice staff. However, the hospice care plan was not integrated into the resident's electronic health record (EHR). During the survey, it was discovered that the facility could not locate the resident's hospice chart. Hospice staff recorded their notes on paper, which were stored in a binder at the nurse's station, rather than in the EHR. Despite efforts by the corporate nurse consultant and the director of nursing to locate the hospice chart, it remained missing. The facility's document on the retention of medical records did not address the security of these records, contributing to the deficiency.
Failure to Time-Limit PRN Lorazepam Orders
Penalty
Summary
The facility failed to ensure that PRN orders for lorazepam, a psychotropic medication, were time-limited to 14 days and accompanied by a documented associated diagnosis for a resident with severe cognitive impairment. The resident's care plan included psychotropic drug monitoring and interventions for cognitive and mood alterations, but the order summary for lorazepam lacked a medical diagnosis. The order was set for a duration of six months without a documented rationale for extending the PRN use beyond 14 days, contrary to the facility's policy. The resident was previously on hospice care, during which lorazepam was used for comfort and symptom management. However, after discharge from hospice, the hospice order should have been discontinued, and a new order with an indication and rationale for PRN lorazepam use should have been documented. The facility's policy required that PRN psychotropic medications be prescribed for the shortest period necessary and that any extension beyond 14 days be justified by the healthcare practitioner, which was not done in this case.
Deficiencies in Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for two residents, leading to deficiencies in their care. For one resident, identified as R35, the facility did not document education or refusals related to pressure ulcer relief. R35, who had multiple diagnoses including hemiplegia, dementia, and morbid obesity, was observed multiple times without proper heel elevation or the use of prescribed heel boots, despite care plan interventions requiring these measures. Staff interviews revealed that attempts to encourage heel elevation were not consistently documented, and there was no record of education provided to R35 about the importance of these interventions. Another resident, R39, experienced gaps in weekly skin inspections as ordered, and there was a lack of timely notification to the registered dietician (RD) regarding new and worsening wounds. R39, who had diabetes and chronic kidney disease, was dependent on staff for mobility and had developed pressure ulcers while at the facility. The care plan required weekly skin inspections, but records showed significant gaps in these inspections over several months. Additionally, the RD was not promptly informed of the resident's nutritional needs related to wound care, despite changes in the resident's condition and dietary orders. The Director of Nursing (DON) acknowledged the importance of following care plans and conducting regular skin inspections to monitor and address skin integrity issues. However, the facility's failure to adhere to these protocols resulted in deficiencies in the care provided to residents R35 and R39, as evidenced by the lack of documentation and communication regarding their pressure ulcer care and nutritional needs.
Failure to Use Palm Protector for Resident with Limited ROM
Penalty
Summary
The facility failed to ensure the use of a palm protector for a resident with limited range of motion, leading to a deficiency in care. The resident, who had a history of traumatic brain dysfunction, hemiplegia, and traumatic brain injury, was severely cognitively impaired and dependent on staff for activities of daily living. The care plan specified the use of a foam built-up palm protector to reduce contraction in the resident's left hand, which was to be worn overnight and removed in the morning. During observations and interviews, it was noted that the resident's left hand was in a fist and the palm protector was not in use. Staff, including a nursing assistant and an LPN, were unable to locate the palm protector in the resident's room, and the nursing assistant admitted not having seen it for a long time. An occupational therapist confirmed the absence of the palm protector and noted debris on the resident's hand, indicating a lack of proper care. The director of nursing acknowledged that the care plan was not followed, which could prevent further contractures.
Failure to Maintain Resident Dignity Through Adequate Hygiene Care
Penalty
Summary
The facility failed to ensure the dignity of a resident, identified as R52, by not providing adequate personal hygiene care. R52, who was cognitively intact and had diagnoses including diabetes, depression, hemiplegia, and hemiparesis, required moderate assistance for personal hygiene and maximal assistance for showering. The resident's care plan indicated that R52 was shy, had anxiety, and often did not ask for help, leading to incontinence issues. Despite these needs, R52 was only scheduled for a shower once a week, which was insufficient as their hair became greasy quickly, causing discomfort and a feeling of uncleanliness. Interviews and observations revealed that R52's hair appeared greasy on multiple occasions, and the resident expressed a desire for more frequent hair washing. Staff, including a nursing assistant and a registered nurse, acknowledged that residents should not have to request hair washing if it was visibly needed, and it should be offered proactively to maintain dignity. The Director of Nursing also stated that staff should recognize and address such needs without the resident having to ask. The facility's policy on Activities of Daily Living emphasized the importance of person-centered care and maintaining residents' dignity, which was not upheld in this case.
Failure to Honor Resident's Preference for Dining Room Breakfast
Penalty
Summary
The facility failed to honor a resident's preference to be dressed and have breakfast in the dining room, as observed in the case of a resident with significant cognitive impairment and multiple diagnoses, including neurological disorders and dementia. The resident's care plan indicated a preference to dine in the main dining room and to be ready by 8:00 a.m. However, the resident was found shirtless in bed during an interview, expressing frustration about not being able to get dressed and go to the dining room due to insufficient staffing. The resident required maximal assistance for activities of daily living and was dependent on staff for transfers. Interviews with nursing staff revealed that the resident was not consistently assisted in getting up and dressed in the morning due to staffing shortages, particularly because the resident required a two-person transfer. The nursing assistant confirmed that they were unable to meet the resident's preferences on days when only one nursing assistant was scheduled until later in the morning. The director of nursing acknowledged that the resident's preferences should be honored, and the facility's policy emphasized the importance of person-centered care and honoring resident preferences. Despite this, the resident's preferences were not consistently met, leading to a deficiency in resident rights and dignity.
Failure to Report and Repair Broken Toilet
Penalty
Summary
The facility failed to ensure a safe and homelike environment for a resident due to a broken toilet that was not reported or repaired. The resident expressed concern about the cracked toilet bowl, which was observed to be damaged near where the seat attached. Despite the resident's concern, there was no maintenance request submitted to address the issue. Staff members, including LPNs and housekeeping personnel, were unaware of the broken toilet or did not report it. The regional director of maintenance confirmed the need for the toilet bowl to be replaced and noted that no maintenance slip had been filled out. The housekeeping staff assumed the issue had been reported by others, and the housekeeping director was not informed of the problem. The associate administrator and regional director of operations emphasized the importance of reporting and addressing broken equipment to prevent injuries.
Incomplete MDS Assessments for Two Residents
Penalty
Summary
The facility failed to complete all sections on the Minimum Data Set (MDS) for two residents, leading to deficiencies in their assessments. For one resident, identified as R23, the quarterly MDS did not assess cognitive patterns and mood, despite indications that these assessments should have been conducted. This oversight was confirmed by both a registered nurse and the director of nursing, who acknowledged that these assessments were necessary to ensure the resident received appropriate medication and care planning. Another resident, identified as R14, had an annual MDS that failed to document the use of a wanderguard, a device intended to prevent elopement. The director of nursing verified this omission and emphasized the importance of accurate assessments for billing, payment, and identifying elopement concerns. The facility did not provide a policy on filling out resident assessments, which may have contributed to these deficiencies.
Failure to Address ADLs for Residents
Penalty
Summary
The facility failed to ensure activities of daily living (ADL) were adequately addressed for two residents. One resident, identified as R4, had a care plan indicating a self-care deficit related to traumatic brain injury and hemiplegia, requiring assistance with dressing, grooming, and bathing. Despite this, weekly skin care assessments documented that R4's fingernails and toenails were not addressed on multiple occasions. Observations revealed that R4's fingernails were approximately 1/2 inch in length with a brown substance underneath, indicating neglect in nail care. The Director of Nursing stated that nail care should be completed by nursing assistants on shower days, or by a licensed nurse if the resident is diabetic, but documentation of this care was not provided. Another resident, R32, required maximal assistance for ADLs and was dependent on staff for transfers. R32 expressed frustration about not being dressed and out of bed in time for breakfast, as was their preference. On multiple occasions, R32 was observed shirtless in bed, stating that staff shortages were the reason for the delay in assistance. Interviews with staff confirmed that R32's preferences should have been honored, but they were not consistently met, resulting in the resident remaining in bed for extended periods without being dressed or able to attend meals in the dining room.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the required nurse staffing information was posted daily over the weekend, which had the potential to impact all 53 residents and visitors who may wish to review this information. During an observation on a Sunday, the posted staffing sheet was found to be dated from the previous Friday, indicating that the staffing information had not been updated for the weekend. For the remainder of the survey period, the daily staffing information sheets were updated and posted each day. In an interview, the administrator acknowledged that staffing hours should be updated and posted daily, including on weekends. The responsibility for updating and posting the staffing sheets on Saturdays and Sundays was assigned to the charge nurse, who failed to post a new staffing sheet each day over the past weekend.
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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