The Waterview Shores Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Two Harbors, Minnesota.
- Location
- 402 - 13th Avenue, Two Harbors, Minnesota 55616
- CMS Provider Number
- 245471
- Inspections on file
- 25
- Latest survey
- September 11, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at The Waterview Shores Llc during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple fall risk factors experienced several falls, including one resulting in a rib fracture, due to the facility's failure to promptly update and implement person-centered fall prevention interventions in the care plan. Delays in care plan updates and inconsistent communication led to staff not being aware of or implementing required interventions at the time of the incidents.
Six residents with severe cognitive impairments and significant medical needs were not provided a dignified dining experience, as staff assisted them with eating while standing over them and served their meals earlier in a separate area, without offering them the choice to eat in the main dining room. Staff interviews indicated these practices were implemented for staff convenience rather than resident preference, contrary to facility policy requiring dignity and resident choice during meals.
Staff did not monitor or record food temperatures during breakfast service, with items such as eggs, sausage, and gravy kept in crock pots on the warm setting and served to residents without temperature checks. Dietary and nursing staff confirmed that no one was responsible for checking breakfast food temperatures, and the facility could not provide temperature logs for these meals, despite policy requiring such monitoring.
The facility did not accurately submit direct care staffing data to CMS for one quarter, as the PBJ report indicated a lack of 24-hour licensed nursing coverage on multiple dates despite timecards showing full coverage. Facility leadership was unaware of the submission issue and could not explain the discrepancy, and no PBJ policy was provided.
Surveyors found that hand sanitizer dispensers throughout the facility contained a non-alcohol-based product, contrary to CDC guidelines and facility policy. Staff failed to properly disinfect shared equipment, such as a mechanical lift, and did not consistently follow hand hygiene and glove use protocols during resident care. Additionally, an overnight urine collection bag was not cleaned before storage as required. These deficiencies were observed in the care of multiple residents with significant medical needs.
A resident with diabetes was incorrectly coded in the MDS as receiving insulin injections, when in fact the resident was prescribed dulaglutide, a GLP-1 receptor agonist, and did not receive insulin during the assessment period. This error was confirmed by both an LPN and the MDS coordinator after reviewing the medication records.
A deficiency was found when an oxygen tank was observed free standing in a resident's room instead of being secured in a holder. The resident, who had COPD and required oxygen therapy, was present in the room at the time. Staff, including the maintenance director, associate administrator, LPN, and DON, all confirmed that oxygen tanks should always be secured for safety, and the facility could not provide a policy on oxygen storage.
A resident with multiple respiratory diagnoses did not have their bipap machine water chamber emptied and dried daily as ordered. Observations showed water remaining in the chamber over several days, and the care plan did not address respiratory equipment care. Staff interviews confirmed the required daily maintenance was not performed.
The facility failed to provide dignified assistance with ADLs for two residents. One resident, with a history of stroke and anxiety, was not offered shaving assistance despite expressing a preference for it, and the care plan lacked documentation of this preference. Another resident, with traumatic brain injury and vision impairment, was fed by a standing nursing assistant, contrary to the facility's policy of sitting at the resident's level. Staff interviews revealed inconsistencies in policy implementation, contributing to the deficiency.
A resident with a history of stroke and anxiety disorder required assistance with transfers using a gait belt, as per their care plan. However, staff failed to use the gait belt during observed transfers, and there was confusion among staff about the resident's care needs. The interim DON and director of therapy confirmed the necessity of the gait belt, indicating a lapse in following the care plan.
The facility failed to maintain safe hot water temperatures, placing 24 residents at risk for burns. During a resident screening, excessively hot water was found in a resident's bathroom and the east kitchenette. The maintenance director confirmed weekly checks but acknowledged temperatures as high as 125 and 130 degrees Fahrenheit, which were too hot. The administrator and MD recognized the danger and confirmed the facility's hot water was running too hot, contrary to policies and state regulations requiring temperatures between 105 and 115 degrees Fahrenheit.
A resident with mild cognitive impairment was found with medications left at bedside without a completed SAM form or provider orders. Staff admitted to leaving the medications for the resident to take later, contrary to facility policy requiring a SAM assessment and provider orders.
A facility failed to provide privacy during personal care for a resident with Alzheimer's and other conditions. The NA did not fully close the privacy curtain or the curtain to the outside window, exposing the resident's genital area. Interviews confirmed that staff did not follow proper procedures to ensure privacy.
The facility failed to complete ordered laboratory tests and orthostatic blood pressure measurements for a resident with multiple diagnoses, including Alzheimer's and anemia. Despite orders for a CBC every three months and monthly orthostatic blood pressure measurements, these were not carried out, as confirmed by the DON and CP.
The facility failed to administer medications as per physician orders for two residents. One resident received only 20 mg of omeprazole instead of the prescribed 40 mg, and another resident received only 0.5 mg of ropinirole instead of the prescribed 1 mg in the morning. Both errors were confirmed by the DON.
A facility failed to ensure proper hand hygiene and glove use during personal care for a resident with Alzheimer's and other conditions. A nursing assistant performed peri-care and other tasks without changing gloves or washing hands, potentially spreading infection. The deficiency was confirmed by interviews and a review of the facility's hand washing policy.
A resident's bathroom was found to be missing a call light, which was confirmed by both a nursing assistant and the maintenance director. The resident had multiple diagnoses and was dependent on staff for assistance with activities of daily living.
Failure to Timely Update and Implement Fall Prevention Interventions
Penalty
Summary
A deficiency occurred when the facility failed to ensure that person-centered fall interventions were care planned and implemented for a resident at risk for falls, resulting in actual harm. The resident had multiple diagnoses, including metabolic encephalopathy, neurocognitive disorder with Lewy bodies, anxiety disorder, and severe cognitive impairment, and required assistance with all activities of daily living. The care plan identified the resident as a fall risk due to a history of falls, impaired gait and mobility, and other medical conditions. Despite this, there were lapses in updating and implementing fall prevention interventions following incidents. The resident experienced several falls, including one that resulted in a rib fracture. After a fall on one occasion, a floor mat was identified as a new intervention, but it was not added to the care plan until a later date. Similarly, after another fall, a soft touch call light was determined to be an appropriate intervention, but this was also not promptly updated in the care plan. Staff interviews revealed that not all staff were aware of the required interventions at the time of the incidents, as these were not reflected in the care plan or care guide sheets used by staff. Observations confirmed that some interventions, such as the floor mat, were not present in the resident's room at the time of a fall. Documentation and staff statements indicated that the process for updating care plans and communicating new interventions to staff was inconsistent. The interdisciplinary team (IDT) would determine interventions after reviewing incidents, but there were delays in updating the care plan and care sheets, leading to gaps in staff awareness and implementation of fall prevention measures. As a result, the resident did not consistently receive the interventions identified as necessary to prevent further falls and injury.
Failure to Promote Dignified Dining Experience for Residents Requiring Assistance
Penalty
Summary
The facility failed to promote a dignified dining experience for six residents with severe cognitive impairments who required assistance with eating. Observations revealed that staff, including nursing assistants and an LPN, assisted these residents with meals while standing over them, rather than sitting at their level, and sometimes while performing other tasks. Residents who required feeding assistance were served their meals earlier than other residents and in a separate dinette area, rather than being given the option to eat in the main dining room with others. Staff interviews confirmed that this practice was implemented to make it easier for staff to manage meal service, rather than based on resident preference or choice. The affected residents had significant medical histories, including dementia, Alzheimer's disease, traumatic brain injury, and other cognitive or physical impairments, and their care plans directed staff to provide meal set-up and assistance as needed. Despite these directives, the facility's approach did not encourage resident choice or dignity, as most of the residents receiving early trays were unable to choose whether they would have preferred to eat in the main dining room. Facility policy required that residents be encouraged to eat in the dining room and be fed with attention to safety, comfort, and dignity, including not standing over residents while assisting with meals and avoiding the use of labels such as "feeders."
Failure to Monitor Food Temperatures During Meal Service
Penalty
Summary
The facility failed to ensure that food temperatures were monitored prior to and during meal service, as required to prevent the risk of food-borne illness. Observations revealed that breakfast items such as scrambled eggs, sausage, and gravy were kept in crock pots set to the warm setting on both units, and staff served food directly from these crock pots without checking or recording food temperatures. This practice was observed over multiple days, with crock pots remaining on the warm setting for extended periods, and no evidence that temperatures were checked at any point during or after meal service. Interviews with dietary and nursing staff confirmed that food temperatures were not being monitored for breakfast, and staff were unsure who was responsible for this task. The facility was unable to provide breakfast temperature logs when requested, and the administrator acknowledged that breakfast was not included in their food temperature monitoring logs. The facility's own policy required that proper hot and cold food temperatures be maintained and monitored throughout meal service, but this was not followed for breakfast meals.
Failure to Accurately Submit Staffing Data to CMS
Penalty
Summary
The facility failed to ensure that complete and accurate direct care staffing information was electronically submitted to CMS for one of four quarters reviewed. Specifically, the Payroll Based Journal (PBJ) report for quarter 3 of 2024 indicated that the facility did not have licensed nursing coverage for 24 hours on several dates, and also triggered a low weekend staffing metric. However, a review of timecards for the listed dates showed that licensed nursing staff were present and provided 24-hour coverage on each date. During an interview, the administrator, associate administrator, and corporate nurse were unaware of any issues with the staffing data submission and could not explain the discrepancy, though the associate administrator speculated it might be related to agency staff usage. No policy on PBJ submission was provided.
Infection Control Deficiencies: Hand Hygiene, Equipment Disinfection, and Catheter Care
Penalty
Summary
The facility failed to ensure the use of alcohol-based hand sanitizer in hand hygiene dispensers throughout the building. During an observation, a hand sanitizer dispenser was found to contain a product labeled as benzalkonium chloride, not an alcohol-based sanitizer. Both the associate administrator and the DON were unaware that the product in use was not alcohol-based, and it was confirmed that all resident rooms had the same product. The nurse consultant verified that the product did not meet the CDC's recommendation of at least 60% alcohol content for hand sanitizers. Facility policy also required the use of alcohol-based hand sanitizer when soap and water were unavailable, but this was not followed. The facility also failed to ensure proper disinfection of shared equipment and adherence to hand hygiene and glove use protocols. A mechanical lift used for a resident on enhanced barrier precautions was not disinfected with appropriate cleaning wipes after use; instead, personal care wipes were used, which was not acceptable according to the DON. Additionally, staff did not change gloves or perform hand hygiene after providing incontinence care to two residents. In one instance, staff applied protective ointment and handled clean items with soiled gloves, and in another, a staff member wore the same gloves while assisting with multiple tasks and did not perform hand hygiene until much later. The DON stated that staff were expected to change gloves and clean their hands after such care, but this was not observed. Furthermore, the facility did not ensure that an overnight urine collection bag was cleaned prior to storage for a resident with a condom catheter. The bag and tubing were placed back into a privacy bag without being rinsed out, contrary to the expectations stated by the LPN and DON. Requested policies on equipment disinfection and care plans for some residents were not provided during the survey.
Inaccurate MDS Coding for Diabetes Medication
Penalty
Summary
The facility failed to ensure the accurate coding of Section N of the Minimum Data Set (MDS) for one resident reviewed for unnecessary medications. The resident, who had a diagnosis of diabetes mellitus, was documented in the MDS as having received insulin injections twice during the assessment period. However, a review of the provider's orders and the resident's medication administration record revealed that the resident was prescribed dulaglutide, a GLP-1 receptor agonist, administered once weekly, and was not receiving insulin during the look-back period. This discrepancy was confirmed by both an LPN and the MDS coordinator, who acknowledged the inaccuracy in the MDS coding. A policy regarding MDS completion and accuracy was requested but not provided.
Unsecured Oxygen Tank Found in Resident Room
Penalty
Summary
A deficiency was identified when an oxygen tank was found free standing in a resident's room rather than being secured in a designated holder. The resident involved had chronic obstructive pulmonary disease (COPD), depression, and anxiety, and required substantial to maximum assistance with activities of daily living. The resident was observed using oxygen via nasal cannula as ordered. During an observation, one oxygen tank was noted to be free standing near a stationary holder that contained five other secured tanks. Multiple staff members, including the maintenance director, associate administrator, LPN, and DON, confirmed that oxygen tanks should always be secured for safety reasons. The maintenance director and DON both stated that an unsecured tank could become a hazard if knocked over. Staff also verified that they receive training on oxygen safety as part of hazard training. When requested, the facility was unable to provide a policy on oxygen storage.
Failure to Maintain Bipap Machine Water Chamber as Ordered
Penalty
Summary
A deficiency was identified when the facility failed to ensure proper maintenance of a bipap machine for a resident with acute and chronic respiratory failure, COPD, acute bronchospasms, and sleep apnea. The resident's provider orders specified that the bipap water chamber should be emptied, dried, and refilled with distilled water daily at bedtime. However, multiple observations over several days revealed that the water chamber remained partly full and was not emptied or dried between uses. The resident confirmed that staff were responsible for filling the chamber, but stated that no one had come to empty and rinse it out as required. Interviews with staff, including an LPN and the DON, confirmed that the expected practice was to empty and dry the bipap water chamber daily to help prevent possible infections. The resident's care plan did not address the care of oxygen and bipap equipment, and the facility was unable to provide a policy regarding respiratory equipment care when requested. These actions and omissions led to the failure to provide safe and appropriate respiratory care for the resident.
Failure to Provide Dignified ADL Assistance
Penalty
Summary
The facility failed to ensure that residents were assisted with activities of daily living (ADLs) in a dignified manner, specifically for two residents. One resident, who had a history of cerebral infarction and anxiety disorder, expressed a preference for being shaved every two to three days. However, the resident's care plan lacked documentation of this preference, and staff did not offer assistance with shaving on the day of observation, despite the resident's visible whiskers and stated preference for being shaved. The staff's failure to document and respect the resident's grooming preferences led to a deficiency in providing dignified care. Another resident, diagnosed with traumatic brain injury, mood disorder, and dysphagia, required assistance with eating due to vision impairment. During an observation, a nursing assistant was seen standing over the resident while feeding her, rather than sitting at the resident's level, which is considered more respectful and less intimidating. The nursing assistant admitted to multitasking and not sitting while assisting the resident with her meal, which did not align with the facility's expectations for providing dignified care during meals. Interviews with staff, including nursing assistants and the interim director of nursing, revealed inconsistencies in the understanding and implementation of the facility's policies regarding resident care. Staff were expected to offer assistance with shaving and to sit at the resident's level during meals, but these practices were not consistently followed. The lack of documentation and adherence to the facility's policies contributed to the deficiency in providing dignified care to the residents.
Failure to Implement Care Plan During Resident Transfers
Penalty
Summary
The facility failed to implement a resident's care plan appropriately during transfers, as observed in the case of a resident with a history of cerebral infarction and anxiety disorder. The care plan, dated 10/4/24, specified that the resident required assistance from one staff member with a front-wheeled walker and a gait belt for transfers due to mobility issues related to an ischemic stroke. However, during an observation, a nursing assistant assisted the resident with transfers without using a gait belt, contrary to the care plan's instructions. The nursing assistant acknowledged the oversight but noted the absence of a gait belt in the resident's room or on the wheelchair. Interviews with various staff members revealed inconsistencies in their understanding of the resident's care needs and the use of gait belts. While some staff members were unaware of the requirement for a gait belt, others incorrectly believed it was not necessary. The interim director of nursing and the director of therapy confirmed that the care plan required the use of a gait belt for the resident's safety during transfers. The facility's policy on care planning emphasized the importance of using the care plan to guide daily care routines, highlighting a failure in communication and adherence to established protocols.
Failure to Maintain Safe Hot Water Temperatures
Penalty
Summary
The facility failed to ensure that hot water temperatures were maintained at safe levels, placing 24 residents who were independent with their mobility at risk for potential burns. During a resident screening, the water temperature in a resident's bathroom was found to be very hot to the touch. An LPN verified the temperature felt too hot and planned to report it to maintenance. Further checks revealed that the water temperature in the east kitchenette was also excessively hot. The maintenance director (MD) confirmed that he was checking water temperatures weekly and aimed to keep them between 114 - 116 degrees Fahrenheit. However, measurements taken during the survey showed temperatures as high as 125 and 130 degrees Fahrenheit in different locations within the facility, which the MD acknowledged were too hot. The facility's water temperature logs indicated a previous instance of high water temperature (121 degrees Fahrenheit) but did not show any corrective actions taken. The administrator confirmed that the facility aimed to keep water temperatures at 120 degrees Fahrenheit or below, based on maintenance guidance, but later acknowledged that safe temperatures should be between 105 and 115 degrees Fahrenheit. The administrator and MD both verified that the facility's hot water was running too hot and recognized the potential danger of burns to residents. Facility policies and state regulations also specified that hot water should be maintained within the 105 to 115 degrees Fahrenheit range to prevent scalding, and staff were directed to report any excessive water temperatures.
Failure to Perform SAM Assessment and Obtain Provider Orders
Penalty
Summary
The facility failed to perform a self-administration of medication assessment and obtain provider orders for a resident with mild cognitive impairment. During an observation, a medication cup with four pills was found on the resident's bedside table without any staff present. A trained medication aide admitted to leaving the medications for the resident to take later, without confirming if a self-administration of medication (SAM) form was filled out. Interviews with staff, including a licensed practical nurse and the director of nursing, confirmed that the resident did not have a SAM form completed or provider orders to self-administer medications. The facility's policy required a SAM assessment and provider orders before allowing residents to self-administer medications, which was not followed in this case.
Failure to Provide Privacy During Personal Care
Penalty
Summary
The facility failed to provide privacy during personal care for a resident diagnosed with Alzheimer's disease, dementia, depression, muscle weakness, and benign prostatic hyperplasia. The resident was moderately cognitively intact, always incontinent of bladder, frequently incontinent of bowel, and dependent on staff for assistance with activities of daily living. During an observation, a nursing assistant (NA) entered the resident's room without fully closing the privacy curtain or the curtain to the outside window facing the parking lot. The NA proceeded with personal care, exposing the resident's genital area while the curtains remained open, allowing visibility from the parking lot and the hallway. The NA continued to perform tasks such as emptying the catheter bag without changing gloves and left the resident's gown up and covers down, further compromising the resident's privacy. Interviews with the NA, a licensed practical nurse (LPN), and the director of nursing (DON) confirmed that the privacy curtains were not properly closed before care was performed. The DON verified that staff are expected to ensure privacy by closing both the privacy curtain and the curtain to the outside before starting personal care to maintain the resident's dignity and privacy.
Failure to Complete Ordered Laboratory Tests and Orthostatic Blood Pressure Measurements
Penalty
Summary
The facility failed to ensure that ordered laboratory tests and orthostatic blood pressure measurements were completed for a resident (R13) who was reviewed for unnecessary medications. R13 had multiple diagnoses including Alzheimer's disease, dementia, depression, muscle weakness, anemia, hypertension, and normal pressure hydrocephalus. The resident was moderately cognitively intact and dependent on staff for activities of daily living. Despite having orders for a complete blood count (CBC) every three months and monthly orthostatic blood pressure measurements, these were not carried out as required. The director of nursing (DON) confirmed that the CBC order was not followed and that orthostatic blood pressures were not measured as ordered, which could lead to unmonitored low hemoglobin levels and untreated conditions. The resident's care plan included monitoring for side effects and effectiveness of medications, as well as documenting and reporting signs and symptoms of anemia. However, a review of the resident's laboratory results and vital signs summary showed that the required tests were not performed. The consultant pharmacist (CP) also stated that staff should follow provider orders and contact the provider if they were unable to carry out the orders. The facility's medication and treatment orders did not address what staff should do when they were unable to complete an order, contributing to the deficiency in care for the resident.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure medications were administered in accordance with physician orders for two residents. For Resident 11, who has diagnoses including gastro-esophageal reflux disease, abnormal weight loss, anxiety, and Crohn's disease, the physician ordered 40 mg of omeprazole to be administered in the morning. However, during observation, an LPN prepared and administered only 20 mg of omeprazole, mistakenly believing the order had changed. The error was confirmed by the Director of Nursing (DON) after consultation with the LPN. For Resident 187, who has diagnoses including Parkinson's disease, major depression, and hypertension, the physician ordered 1 mg of ropinirole to be administered in the morning. However, a trained medication aid (TMA) prepared and administered only 0.5 mg of ropinirole, incorrectly stating that the resident should receive 0.5 mg in the morning and another 0.5 mg at noon. This error was also confirmed by the DON upon review of the MAR and medication label. The facility did not provide a policy specifically addressing how to administer medications when requested.
Failure to Maintain Proper Hand Hygiene and Glove Use
Penalty
Summary
The facility failed to ensure proper hand hygiene and glove use practices during personal care for a resident diagnosed with Alzheimer's disease, dementia, depression, muscle weakness, and benign prostatic hyperplasia. The resident was moderately cognitively intact, always incontinent of bladder, frequently incontinent of bowel, and dependent on staff for assistance with activities of daily living. During an observation, a nursing assistant (NA) was seen performing peri-care and other tasks without changing gloves or performing hand hygiene, despite handling various items in the resident's room, including the resident's beverage cup and call light. The NA only washed his hands after leaving the resident's room, which was confirmed during an interview with the NA and the licensed practical nurse (LPN). The facility's hand washing policy required staff to perform hand hygiene before donning gloves and after removing them, especially after changing incontinent products or cleaning up after someone who has used the toilet. The director of nursing (DON) confirmed that staff were expected to change gloves and perform hand hygiene during peri-care to prevent contamination and infection. The NA's failure to change gloves and perform hand hygiene as required by the facility's policy had the potential to spread infection. The deficiency was identified through observation, interview, and document review, highlighting a lapse in adherence to infection prevention and control protocols within the facility.
Missing Bathroom Call Light for Resident
Penalty
Summary
The facility failed to provide a bathroom call light for a resident (R13) who was reviewed for call lights. R13's quarterly Minimum Data Set (MDS) indicated that he had diagnoses including Alzheimer's disease, dementia, depression, muscle weakness, and benign prostatic hyperplasia with lower urinary tract symptoms. R13 was moderately cognitively intact, always incontinent of bladder, frequently incontinent of bowel, and dependent on staff for assistance with activities of daily living. During a resident screening, it was observed that R13's bathroom had no call light. This was verified by a nursing assistant (NA-B) and the maintenance director (MD-A), who both confirmed that any resident using R13's bathroom would have no means to call for help. The administrator also verified that each resident bathroom should have a call light to ensure residents can call for help if needed.
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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