Villa St Vincent
Inspection history, citations, penalties and survey trends for this long-term care facility in Crookston, Minnesota.
- Location
- 516 Walsh Street, Crookston, Minnesota 56716
- CMS Provider Number
- 245484
- Inspections on file
- 30
- Latest survey
- July 10, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Villa St Vincent during CMS and state inspections, most recent first.
A resident experienced a significant medication error due to a failure in the medication administration process. The report does not provide further details about the circumstances or the resident's condition.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual. The report identifies a lapse in ensuring resident safety but does not provide further details about the specific events or individuals involved.
The facility did not promptly report a significant medication error involving a resident who received both oxycodone and morphine, leading to hospitalization for opioid overdose, nor did it report a resident-to-resident abuse incident within the required timeframe. In both cases, the DON delayed notification to the state agency, contrary to facility policy requiring immediate reporting of such events.
Two residents at high risk for falls did not receive care planned interventions, including use of transfer belts, slip grips, and appropriate staff assistance during transfers and ambulation. As a result, one resident suffered a vertebral fracture after a fall, and another experienced multiple falls, some unwitnessed, due to staff not following or being aware of the required interventions.
The facility failed to maintain complete infection surveillance data and did not ensure proper use of enhanced barrier and contact precautions for residents with infections and wounds. Staff did not consistently use required PPE or perform hand hygiene during wound care, and housekeeping staff did not follow contact precaution protocols while cleaning a room of a resident with norovirus. Care plans did not always reflect the need for specific precautions, and staff demonstrated inconsistent understanding of infection control requirements.
A resident with severe cognitive impairment and dementia had a significant amount of clothing and slippers go missing after being brought to the nurses' desk, as reported by a family member. Although staff made some attempts to locate the items, there was no formal documentation of the grievance or follow-up, and the family was not reimbursed. The facility did not follow its grievance policy or ensure proper reporting and resolution of the issue.
A facility failed to protect two residents from abuse, resulting in one resident being harmed. Despite R2's history of aggression and R1's tendency to wander, staff lacked specific supervision plans. R2 pushed a chair R1 was holding, causing her to fall and sustain a head injury. The facility's interventions were insufficient to prevent the incident.
A resident with moderate cognitive impairment and at risk for falls was not assisted with a gait belt during a transfer, contrary to their care plan. The resident fell in the bathroom, resulting in a lumbar compression fracture. The incident led to significant pain and deterioration in the resident's condition, eventually resulting in hospice care and the resident's passing. Staff interviews confirmed the expectation of gait belt use during transfers, which was not followed in this case.
The facility failed to offer updated pneumococcal vaccinations (PCV15 or PCV20) to four residents, despite CDC recommendations. The residents, who had various medical conditions, had received previous pneumococcal vaccines, but their records lacked evidence of the newer vaccines being offered. The RN responsible for infection prevention was aware of the need but had not yet offered the vaccines, and the DON was unaware of the oversight. The facility's policy had not been updated to reflect new CDC guidelines.
A facility failed to ensure a provider documented a rationale for continued use of antidepressants for a resident. Despite a pharmacist's recommendation for a trial reduction, the primary physician continued the medication without proper documentation. The DON acknowledged issues with providers not addressing pharmacy recommendations, and the Medical Director planned to address the problem.
A facility failed to ensure a process for gradual dose reduction (GDR) or adequate medical justification for a resident's continued use of psychotropic medications. Despite a consultant pharmacist's recommendation for a trial reduction, the primary physician did not provide further documentation or justification. Interviews revealed a lack of awareness and follow-up on the pharmacist's recommendations, and no clear nursing process was identified to address GDRs.
A resident with moderate cognition and multiple health issues had medications left unsecured in their room. The facility's records showed an order for a wound cleanser but not for Nystatin powder, which was also found in the room. Nursing staff acknowledged the medications should not be left unsecured, and the facility's policy requires secure storage.
A resident on warfarin sodium did not receive timely INR results, leading to potential health risks. The facility failed to promptly communicate INR results to the medical provider, with delays in documentation and response. Staff interviews revealed inconsistencies in handling INR results, and the facility's policy lacked clear guidelines for timely reporting and follow-up actions.
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents with indwelling catheters, leading to a deficiency in infection prevention and control. Observations showed no PPE carts or gowns used during care, and staff interviews revealed a lack of clarity on EBP implementation. The facility's policy required EBP for residents with indwelling devices, but it was not applied to these residents.
The facility failed to complete significant change MDS assessments for two residents who experienced declines in mobility and care needs. One resident became dependent on staff for transfers and unable to ambulate, while another was admitted to hospice care following a fall. The responsible RN and LPN did not recognize or schedule the necessary assessments, leading to deficiencies in care planning.
The facility failed to adequately supervise a resident with schizo-affective disorder and dementia who had multiple incidents of unsafe behavior related to marijuana use. Despite having a care plan and a marijuana use contract, the resident was frequently observed using marijuana unsupervised, leading to multiple falls and unsafe behaviors. Staff interviews revealed a lack of clear communication and understanding of the resident's fall interventions and marijuana use contract, contributing to the resident's repeated falls and unsafe behaviors.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident received a significant medication error, indicating a failure in the medication administration process. Specific details about the actions or inactions leading to the error, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. Specific details about the actions or inactions leading to the deficiency, as well as information about the residents involved or their medical conditions at the time, are not provided in the report.
Failure to Timely Report Medication Error and Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure timely reporting to the state agency (SA) regarding two separate incidents: a significant medication error and a resident-to-resident abuse event. In the first case, a resident with a care plan for high-risk pain medications received both oxycodone and morphine, resulting in altered mental status, hypoxia, and hospital admission for opioid overdose and aspiration pneumonia. The medication error was not reported to the SA until the day after the incident, as the DON delayed reporting while further investigating the significance of the error, despite facility policy requiring immediate reporting of significant medication errors. In the second case, two residents with dementia were involved in a physical altercation resulting in injuries, including a bump on the head and facial bruising. The incident occurred in the morning, but was not reported to the SA within the required two-hour timeframe. The DON acknowledged the delay, stating she reported the incident as soon as she was able after being notified by staff. Facility policy mandates immediate reporting of suspected abuse or incidents resulting in serious bodily injury, but this protocol was not followed in either event.
Failure to Implement Care Planned Fall Interventions Resulting in Resident Harm
Penalty
Summary
The facility failed to ensure that care planned interventions to reduce the risk for falls were followed for two residents, resulting in actual harm to one resident who sustained a vertebral fracture. One resident, who had a history of dementia, thoracic vertebrae fractures, muscle weakness, and osteoporosis, was assessed as high risk for falls and required assistance with mobility and transfers. Her care plan specified the use of a wheelchair for transport and the need for extensive assistance from one to two staff members during transfers. Despite these interventions, a nursing assistant attempted to ambulate the resident without a transfer belt, contrary to the care plan and family wishes, resulting in a fall and subsequent T12 compression fracture. The nursing assistant admitted to not reviewing the care plan and not being trained on it prior to the incident. Another resident with diagnoses including traumatic subdural hemorrhage, Alzheimer's disease, multiple fractures, and repeated falls was also identified as high risk for falls. His care plan required two caregivers for all transfers and ambulation, use of slip grip in his wheelchair and recliner, and other specific interventions. Despite these directives, the resident experienced multiple falls, some unwitnessed, including incidents where the slip grip was not in place and the resident was found on the floor. Staff interviews revealed a lack of awareness of the care plan interventions, with some staff unsure where to find the information or not realizing interventions were listed on the care guide. Observations and interviews confirmed that care planned fall interventions were not consistently implemented for both residents. Staff failed to use required safety equipment, such as transfer belts and slip grips, and did not always follow the specified level of assistance for transfers and ambulation. Documentation and staff statements indicated that care plans and care guides were not adequately reviewed or followed, contributing to repeated falls and injury.
Infection Control Deficiencies in Surveillance and Precaution Implementation
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by incomplete infection surveillance data and improper implementation of precautions for residents with infections and wounds. The infection prevention line listing and infection spreadsheet lacked critical information such as symptoms, treatments, and other relevant data for multiple residents, including those with norovirus and other infections. Surveillance was limited to residents who were prescribed antibiotics or antivirals, excluding those with symptoms but without a confirmed diagnosis or prescribed treatment. The infection prevention nurse was unaware of some residents' symptoms, and the surveillance process did not capture all necessary information to track, trend, and analyze infections as required by facility policy. During wound care for a resident with osteomyelitis and a stage 4 pressure ulcer, staff did not follow enhanced barrier precautions or standard precautions. Staff entered the resident's room and performed wound care without donning gowns, failed to perform hand hygiene between glove changes, and did not clean equipment after use. The care plan did not specify the need for enhanced barrier precautions, and staff demonstrated a lack of understanding regarding when to use personal protective equipment (PPE) during high-contact care activities. Observations showed that staff did not consistently use gowns or perform hand hygiene as required, and equipment used during wound care was not sanitized before being removed from the room. For another resident on contact precautions due to norovirus, the care plan did not reflect the need for these precautions. Housekeeping staff entered the resident's room, donned only gloves, and cleaned the room without wearing a gown or mask, contrary to facility policy and CDC guidelines. Staff interviews revealed inconsistent understanding and application of contact precautions, with some staff believing PPE was only necessary when providing direct care. Facility policies required the use of gowns and gloves for contact precautions and specified cleaning procedures for isolation rooms, but these were not followed during the observed events.
Failure to Address and Document Grievance Regarding Missing Resident Clothing
Penalty
Summary
The facility failed to follow its grievance policy and adequately address a grievance regarding missing clothing for a resident with severe cognitive impairment and diagnoses of Alzheimer's disease and dementia. The resident's family member reported that approximately half of the resident's clothing and slippers went missing after being brought to the nurses' desk, as instructed. The family member was not aware of the need to label the clothing and was not reimbursed for the missing items, ultimately deciding to handle the resident's laundry personally. Interviews with staff revealed that while some efforts were made to search for the missing items, such as contacting laundry and searching the lost and found, there was no formal documentation of the grievance or follow-up actions taken. Staff interviews indicated inconsistent practices regarding the reporting and documentation of missing items. The LPN recalled notifying laundry but was unaware of any formal report being made. The social services staff member stated that a grievance form was not filled out and that the family was simply asked if they wanted to file a grievance, which they declined. The DON acknowledged that there was no documentation to show that the missing items were addressed according to facility policy, which requires reporting, searching, and working with the resident or representative to determine next steps if items are not found. The lack of documentation and follow-through on the grievance process resulted in the facility's failure to honor the resident's right to voice grievances and ensure prompt resolution.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to implement effective interventions to protect two residents from resident-to-resident abuse, resulting in harm to one of the residents. Resident R2, who had a history of aggressive behavior and cognitive impairments, was involved in an altercation with Resident R1, leading to R1's transport to the Emergency Department for a scalp laceration. R2's care plan acknowledged his potential for aggression and included measures such as using a stop sign on his door and redirecting him when agitated. However, these interventions were insufficient to prevent the incident. R2's behavior had been documented as physically aggressive toward others, with incidents occurring in the days leading up to the altercation. Despite this, staff were not given specific directions for supervising R2 or R1, who was known to wander into other residents' rooms and had previously been a victim of aggression. On the day of the incident, R1 was found on the floor with a head wound after an unwitnessed fall, and video surveillance later revealed that R2 had pushed a chair R1 was holding, causing her to fall. Interviews with staff indicated a lack of clear supervision plans or new interventions following previous incidents involving R2. Staff members reported trying to keep an eye on R2 but acknowledged that redirection efforts were not always successful. The facility's abuse prevention policy required immediate safety measures to protect residents from further harm, but these measures were not effectively implemented in this case, leading to the deficiency.
Failure to Use Gait Belt Results in Resident Fall and Injury
Penalty
Summary
The facility failed to ensure the use of a gait belt when transferring or walking a resident, identified as R296, who was at risk for falls. R296 had moderate cognitive impairment and required maximum assistance with transfers and ambulation. The care plan for R296 included the use of a gait belt during ambulation and transfers, but this was not adhered to during the incident. R296 experienced a fall while being assisted in the bathroom, resulting in a lumbar compression fracture. The incident occurred when a nursing assistant was assisting R296 in the bathroom. R296 stood up from the toilet without issues, but subsequently fell forward, hitting her head on a safety bar. The nursing assistant did not use a gait belt during this transfer, which was against the facility's policy and R296's care plan. The fall was witnessed, and R296 was unresponsive for approximately ten minutes before being sent to the emergency room for evaluation. Following the fall, R296 experienced significant pain and was diagnosed with a lumbar compression fracture. The resident's condition deteriorated, leading to increased pain and discomfort, refusal to eat, and eventually admission to hospice care. R296 passed away shortly after the incident. Interviews with staff revealed that the use of a gait belt was expected during transfers and ambulation, but it was not utilized in this case, contributing to the resident's fall and subsequent injury.
Failure to Offer Updated Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that recommended pneumococcal vaccinations, as outlined by the CDC, were offered and/or provided in a timely manner to four out of five residents reviewed for immunizations. The residents involved had various medical conditions, including cerebral infarction, Alzheimer's disease, diabetes, kidney failure, stage four pressure ulcer, atrial fibrillation, heart failure, and dementia. Despite having received previous pneumococcal vaccinations (PPSV23 and PCV13), there was no evidence in their medical records that the newer recommended PCV15 or PCV20 vaccinations had been offered or administered. Interviews with facility staff revealed that the registered nurse responsible for infection prevention was aware that the residents were due for updated pneumonia vaccinations but had not yet offered them. The nurse had recently resumed the infection preventionist role and was attempting to catch up on various tasks, including offering the PCV15 or PCV20 vaccinations. The Director of Nursing was unaware that these vaccinations were not being offered, despite CDC recommendations. Additionally, the facility's policy on pneumococcal vaccines had not been updated to reflect the new CDC guidelines, contributing to the oversight.
Failure to Document Rationale for Continued Antidepressant Use
Penalty
Summary
The facility failed to ensure that a provider documented a thorough rationale for the continued use of antidepressant medications for one resident. The resident had active physician orders for sertraline and trazadone, but the medical record lacked evidence of depression symptoms. The consulting pharmacist recommended a trial reduction of the medications, but the primary physician responded that a dose reduction was contraindicated without providing further documentation or justification in the medical record. Interviews revealed that the registered nurse was unaware of the need for rationale to deny a gradual dose reduction and did not question the physician's decision. The Director of Nursing acknowledged struggles with certain providers addressing pharmacy recommendations and had discussed the issue with the providers' group. The consulting pharmacist confirmed that he had made recommendations to taper the medications but had not followed up due to other concerns with the resident's condition. The Medical Director was aware of the issue and planned to address it with the providers.
Failure to Implement Gradual Dose Reduction for Psychotropic Medications
Penalty
Summary
The facility failed to ensure a process for gradual dose reduction (GDR) or adequate medical justification for the continued use of psychotropic medications for a resident. The resident, identified as having moderate cognitive impairment, was receiving daily doses of sertraline and trazodone, despite the absence of documented symptoms of depression. A consultant pharmacist recommended a trial reduction of these medications, but the primary physician indicated that a dose reduction was contraindicated without providing further documentation or justification in the resident's medical record. Interviews with facility staff revealed a lack of awareness and follow-up regarding the pharmacist's recommendations. The registered nurse was unaware of any further discussion about the need for rationale to deny a GDR since the initial recommendation. The director of nursing acknowledged ongoing issues with providers not addressing pharmacy recommendations and had recently discussed these expectations with the providers. However, there was no clear nursing process identified to address GDRs or obtain rationale from providers, and the facility did not provide a policy for psychotropic medication dose reduction when requested.
Failure to Securely Store Medications for a Resident
Penalty
Summary
The facility failed to ensure the safe and secure storage of medications for a resident with moderate cognition and multiple health conditions, including stage IV pressure ulcers and type 2 diabetes. During an observation, it was noted that Vashe (Dakin's) solution wound cleanser and Nystatin powder were left unsecured on the dresser in the resident's room. The resident's medical records included an order for the wound cleanser but did not have any orders for the Nystatin powder. Additionally, there was no assessment or care plan indicating that medications should be stored at the bedside. Interviews with the resident and nursing staff revealed that the medications were routinely left in the room for dressing changes, and the resident was unsure of the medication names. A Licensed Practical Nurse confirmed the presence of an order for the wound cleanser but not for the Nystatin powder, and acknowledged that medications should not be left unsecured. A Registered Nurse also confirmed awareness of the unsecured medications and stated that they should be stored safely and out of reach. The facility's policy on self-administration of medications requires that medications be stored securely, which was not adhered to in this case.
Failure to Provide Timely INR Results for Resident on Warfarin
Penalty
Summary
The facility failed to provide timely INR level results for a resident, identified as R52, who was on warfarin sodium, a blood-thinning medication. R52 had multiple diagnoses, including end-stage renal disease, heart failure, and vascular disease, and was on anticoagulant medication. The care plan for R52 included monitoring for symptoms such as dizziness and irregular heartbeat and required staff to administer medications and draw labs as ordered, reporting any abnormalities promptly. However, there was a delay in communicating the INR results to the medical provider, which was crucial for managing the resident's condition. On several occasions, the INR results for R52 were not communicated promptly to the medical provider. For instance, the INR result obtained on 7/29/24 was not faxed to the medical provider until 7/30/24, and the response was not documented in the electronic medical record (EMR) until later. The registered nurse (RN) responsible for R52's care admitted to forgetting to enter the response into the EMR and did not investigate the cause of the subtherapeutic INR result. This oversight potentially placed the resident at risk for a blood clot or stroke, as the INR was below the therapeutic range. Interviews with facility staff, including the trained medication aide, licensed practical nurse, registered nurse, assistant director of nursing, and director of nursing, revealed inconsistencies in the process of handling INR results. The facility's policy did not adequately address the timely reporting of INR results or provide clear guidelines for staff on how to proceed when a response from the medical provider was not received. The medical director expressed dissatisfaction with the current fax system and emphasized the need for guidelines to ensure timely communication of INR results, especially when they are out of range.
Failure to Implement Enhanced Barrier Precautions for Residents with Catheters
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents with indwelling catheters, leading to a deficiency in infection prevention and control. Resident 1, who had severe cognitive impairment and an indwelling catheter, was not identified as being on EBP in their care plan. Observations revealed that there was no personal protective equipment (PPE) cart in or outside Resident 1's room, and staff did not wear gowns while providing care. Similarly, Resident 69, with moderate cognitive impairment and an indwelling catheter, also lacked EBP implementation, as evidenced by the absence of a PPE cart and staff not wearing gowns during care activities. Interviews with staff, including a nursing assistant and the facility's infection preventionist, highlighted a lack of clarity and understanding regarding the implementation of EBP. The infection preventionist acknowledged that EBP was intended for residents with indwelling medical devices, such as catheters, but could not explain why it was not applied to Residents 1 and 69. The facility's policy on EBP, dated March 28, 2024, specified that EBP should be used for residents with indwelling medical devices to decrease the transmission of multi-drug resistant organisms, yet this was not adhered to for the residents in question.
Failure to Complete Significant Change MDS for Two Residents
Penalty
Summary
The facility failed to complete a significant change in status Minimum Data Set (MDS) for two residents, leading to deficiencies in care planning and service provision. Resident R64, who had moderate cognitive impairment and required varying levels of assistance with daily activities, experienced a decline in mobility and became dependent on staff for transfers and unable to ambulate. Despite these changes, a significant change MDS was not completed. Interviews revealed that the registered nurse responsible for R64's MDS relied on notifications from a licensed practical nurse, who failed to recognize the need for a significant change assessment due to ongoing therapy. Similarly, Resident R296, who had moderate cognitive impairment and required substantial assistance with daily activities, experienced a significant decline in mobility and was admitted to hospice care following a fall that resulted in a lumbar fracture. Despite these significant changes, a significant change MDS was not initiated. The registered nurse responsible for R296's MDS was unaware of the need for a significant change assessment, and the licensed practical nurse did not schedule it, even though hospice admission was recognized as an automatic trigger for such an assessment. The director of nursing confirmed the expectation for significant change MDS assessments to ensure accurate care planning.
Failure to Supervise Resident with Marijuana Use
Penalty
Summary
The facility failed to develop and implement interventions to ensure adequate supervision for a resident (R5) who had multiple incidents of unsafe behavior related to marijuana use. R5 had a history of schizo-affective disorder, dementia, mood disturbance, and anxiety, and was identified as having moderate cognitive impairment. Despite having a care plan and a marijuana use contract in place, R5 was frequently observed using marijuana unsupervised, leading to multiple falls and unsafe behaviors such as sleepwalking and entering other residents' rooms. R5's care plan indicated that she should not be unaccompanied when ambulating outside the facility due to her marijuana use, but staff interviews revealed that this directive was not consistently followed. Staff members were aware of R5's marijuana use but did not monitor her adequately, allowing her to go to the smoking area unsupervised even when she appeared intoxicated. R5's progress notes documented several instances where she was found in unsafe conditions, such as being on the floor after smoking marijuana or being inadequately dressed while outside. Interviews with various staff members, including nursing assistants and registered nurses, indicated a lack of clear communication and understanding of R5's fall interventions and marijuana use contract. Staff members were not consistently monitoring R5's marijuana use or ensuring her safety when she went outside to smoke. The facility's director of nursing acknowledged that there was no designated person to supervise R5, and the facility did not have a specific marijuana use policy in place. This lack of supervision and clear guidelines contributed to R5's repeated falls and unsafe behaviors.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
