Warroad Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Warroad, Minnesota.
- Location
- 1401 Lake Street Northwest, Warroad, Minnesota 56763
- CMS Provider Number
- 245329
- Inspections on file
- 30
- Latest survey
- December 18, 2025
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Warroad Care Center during CMS and state inspections, most recent first.
A resident with dementia and a history of inappropriate sexual behavior toward female residents was not consistently monitored as required by his care plan. Staff failed to activate motion sensors and properly position floor alarms, and did not provide the mandated one-to-one supervision, resulting in an incident where the resident reached toward another resident's breast. Staff interviews confirmed lapses in supervision and monitoring, despite facility policy prohibiting abuse and requiring protective measures.
A resident with dementia and behavioral symptoms, including wandering and altercations with others, did not have a behavior care plan developed despite documented incidents and staff awareness. The care plan lacked interventions to address these behaviors, contrary to facility policy requiring comprehensive, individualized care planning.
A resident with cognitive impairment and limited communication abilities was found on the floor after a fall, following a recent hospital stay that left him sedated and lethargic. Staff, including an LPN and RN, were instructed by the IDT to leave the resident on the floor, making him comfortable with a pillow and blanket, rather than assisting him back to bed. The resident remained on the floor for several hours, contrary to the facility's policy requiring residents to be treated with dignity and respect.
A resident with a history of inappropriate sexual behavior was not adequately monitored or managed, leading to multiple incidents of sexual abuse towards two other cognitively impaired residents. Despite staff awareness, the facility failed to implement effective interventions or update care plans, resulting in continued risk to residents.
The facility failed to ensure staff followed care-planned interventions for ceiling lift transfers, resulting in immediate jeopardy for three residents. Staff did not adhere to the requirement of two staff members for transfers and lacked proper assessments for sling sizes, putting residents at risk of injury. Observations showed residents were transferred with inappropriate sling sizes, causing discomfort and potential harm.
The facility failed to provide sufficient staffing, impacting resident transfers, supervision to prevent abuse, and restorative therapy. Residents requiring ceiling lift transfers were often assisted by one staff member instead of two, and a resident with a history of inappropriate sexual behavior was not adequately monitored, leading to abuse of two other residents. Additionally, range of motion services were inconsistently provided due to staffing shortages, affecting the quality of care.
The facility failed to update its assessment and implement safety measures, leading to immediate jeopardy. A resident with known inappropriate sexual behaviors was not properly assessed, resulting in the abuse of two cognitively impaired residents. Additionally, staff did not follow care-planned interventions for transferring residents, affecting three individuals. The facility assessment did not address staff turnover, infection prevention changes, or leadership risks.
The facility failed to develop a policy defining the medical director's responsibilities and ensure their role in implementing resident care policies and coordinating medical care. The medical director visited the facility twice monthly for rounds and paperwork but lacked control over staffing. The interim administrator, unable to find the necessary documents, noted several administration changes. This deficiency potentially impacted all 46 residents.
The facility failed to address quality deficiencies, including inadequate assessment and intervention for a resident with known sexual behaviors, leading to abuse of two cognitively impaired residents. Additionally, there were failures in infection control practices and insufficient staffing to ensure safe resident care. The facility's QAPI meetings lacked goals and measurable actions to address these issues.
The facility failed to develop, monitor, and evaluate performance measures, affecting all 46 residents. Despite reviewing various topics in QAPI meetings, no action plans with measurable goals were implemented. The interim administrator noted missing data and administration changes, hindering improvement efforts.
The facility failed to implement an effective infection control program, including inadequate tracking and analysis of infections, non-compliance with CDC COVID-19 testing guidelines, and improper use of PPE for residents with multidrug-resistant organisms. Staff interviews revealed a lack of education and communication regarding infection prevention, leading to potential risks for all residents.
The facility failed to ensure completion of infection control training and education for several staff, including LPNs, RNs, and the DON. The DON did not complete any assigned education, and RN-E, NA-I, and NA-B were also behind on required training. Interviews revealed a lack of structured processes for assigning and ensuring completion of training, with the DON unaware of the need for staff education. The facility's assessment identified general orientation and annual training needs but failed to specify the requirement for nursing assistants' continuing education.
The facility did not ensure that mandatory communication training was completed by key staff members, including the DON and two Nursing Assistants. Personnel records showed non-compliance, and interviews revealed a lack of awareness and access to training resources. Additionally, the facility's assessment did not address communication strategies for non-English speaking residents, despite serving a Laotian community.
The facility did not ensure mandatory training on resident rights for three staff members, including the DON, RN, and NA, potentially affecting all 46 residents. Personnel records showed incomplete training, and interviews revealed a lack of awareness and compliance with education requirements. The facility's policy required annual training, but a related policy was not provided.
The facility failed to provide mandatory QAPI training to several staff members, including the DON, an RN, an LPN, and two NAs. Personnel records showed non-compliance with education requirements, and interviews revealed that the DON was unaware of the need for training until recently. The facility's policy on staff training was not provided upon request.
The facility failed to provide adequate infection control training to staff, impacting the safety of 46 residents. Key staff, including the DON and several nurses, did not complete necessary training, leading to confusion about infection precautions. The facility's infection prevention plan lacked specific education requirements, and staff interviews revealed a lack of understanding of PPE use and precautions.
The facility failed to ensure that four staff members, including the DON, RN, LPN, and NA, received required annual training on Alzheimer's disease behaviors, problem-solving, and communication skills, potentially affecting all 46 residents. Personnel records showed non-compliance with training requirements, and interviews revealed awareness of the issue. The facility's assessment did not address the need for behavioral health training, and a related policy was not provided.
The facility failed to ensure two nursing assistants completed the required 12 hours of annual in-service training, potentially affecting all 46 residents. NA-I, who transferred from dietary to nursing, lacked specific dementia training, while NA-B had not completed any training since it was assigned. Interviews revealed confusion over responsibility for staff education, with RN-C acknowledging non-compliance. The facility's assessment did not specify the 12-hour requirement, and no training policy was provided.
The facility did not provide specific abuse prevention training to key staff members, including the DON, RN, LPN, and Nursing Assistants, potentially affecting all 46 residents. Personnel records showed incomplete training, and interviews revealed a lack of compliance with education requirements. The facility's assessment required annual orientation, but a related policy was not provided.
The facility failed to ensure that the DON, an RN, and an NA received required annual training on Alzheimer's disease behaviors, problem-solving, and communication skills. Personnel records showed incomplete training, and interviews revealed confusion over training responsibilities. The facility's assessment did not specify the need for behavioral health training, and a related policy was not provided.
The facility failed to provide adequate ROM services for four residents due to staffing issues, resulting in a deficiency. Residents with cognitive impairments and various medical conditions were not consistently offered their prescribed restorative nursing programs. The restorative therapy aide was only available three days a week, despite the need for services five days a week, and informed the administration of the issue, but no corrective plan was implemented.
A resident, who was severely cognitively impaired and dependent on staff for toileting, was left alone in a ceiling lift in the bathroom for at least 20 minutes, causing distress and feelings of neglect. Staff interviews revealed concerns about inadequate staffing, leading to residents being left unattended and call lights not being answered promptly. The facility's administrator acknowledged the expectation of dignified care, but no policy on dignity was provided.
A resident reported a missing nightgown during a council meeting, but the facility failed to act on the grievance. Despite a change in laundry procedures, staff were unaware of the issue, and no formal process was in place to resolve it. The facility did not provide a written grievance policy, highlighting a deficiency in handling grievances.
A resident with severe cognitive impairment was observed inappropriately touching two other residents on multiple occasions. Despite these incidents, the facility failed to report the allegations to the administrator or state agency as required. The facility's social service designee and DON did not report the incidents, believing there was no willful intent to harm due to the residents' cognitive impairments. The facility's policy required filing a vulnerable adult report, which was not done.
The facility failed to investigate allegations of resident-to-resident sexual abuse involving two residents who were abused by another resident. Despite staff observations of inappropriate touching, no investigation was conducted as required by the facility's policy. The administrator was not informed until much later, and no investigation files were produced.
A facility failed to accurately code the MDS for a resident with an indwelling urinary catheter and severely impaired cognition, omitting the presence of a multi-drug resistant organism (MDRO). The care plan also lacked this information, despite the resident having an open wound and MRSA precautions noted. Interviews revealed staff were unaware of the resident's MDRO status and the importance of accurate MDS documentation.
The facility failed to develop comprehensive care plans for two residents with catheter needs, leading to deficiencies in care. One resident's care plan did not include family involvement preferences or MDRO status, and care conference documentation was incomplete. Another resident's care plan lacked goals for catheterization, and an LPN did not follow infection control protocols. Communication breakdowns were noted, and a care planning policy was not provided.
A facility failed to follow catheterization orders for a resident with neurogenic bladder, leading to a high risk of infection. The resident was supposed to receive catheterization four times daily but was only receiving it once per shift due to incorrect orders. Additionally, another resident with a suprapubic catheter had their catheter bag placed on the floor, violating infection control protocols. The facility's policy did not address catheter care after placement, contributing to the deficiency.
The facility failed to provide documentation for contracted services, potentially affecting all 46 residents. Only an outdated hospice services agreement was available, and the administrator confirmed the absence of other current agreements, indicating a deficiency in maintaining necessary documentation.
The facility did not have an in-effect transfer agreement with a local Medicare hospital, as discovered during a survey. The interim administrator, new to the role, could not find any documentation of such an agreement, which is crucial for the quick transfer of residents needing hospital care. This issue potentially affected all 46 residents.
A resident with Alzheimer's and osteoporosis was found with unexplained bruising, but the facility failed to conduct a thorough investigation. Despite the resident's inability to recall the incident, the facility's investigation lacked comprehensive staff and resident interviews. The emergency department and the resident's physician suggested the bruising might be from a recent incident, but the facility concluded it was related to an old fracture without sufficient evidence.
A resident with Alzheimer's, dementia, and osteoporosis experienced extensive bruising, and the facility failed to assess the cause or implement interventions to prevent further injury. Despite requiring substantial assistance for transfers, staff did not use a transfer belt, and no reassessment of the resident's transfer abilities was conducted. The director of nursing admitted there was no assessment for transfer safety following the injuries, and a related policy was not provided.
A resident with dysphagia was served a regular diet instead of a pureed diet, leading to a choking incident requiring the Heimlich Maneuver. Staff failed to verify and serve the correct diet, highlighting a lack of training and understanding of diet textures.
Failure to Implement Abuse Prevention Interventions for Resident with Inappropriate Sexual Behavior
Penalty
Summary
The facility failed to implement care planned interventions to reduce the risk of abuse for a resident with a known history of inappropriate sexual behavior toward female residents. The resident, who had diagnoses including adjustment disorder with depressed mood, vascular dementia, and muscle weakness, was identified in his care plan as having poor impulse control and a pattern of inappropriately touching female residents. The care plan specified the use of a motion sensor, floor alarms, and one-to-one staff supervision in common areas to ensure the safety of other residents. Despite these interventions being documented, staff interviews and observations revealed that the motion sensor in the resident's room was not activated, the floor mat was not positioned correctly, and staff were not consistently providing the required supervision. On one occasion, a nursing assistant observed the resident reaching toward a female resident's breast, and staff acknowledged that he was known to be "grabby" and required close monitoring. Multiple staff interviews confirmed that the alarms intended to alert staff to the resident's movements were either not functioning or not in use, and the resident was able to ambulate independently without adequate supervision. Facility policy prohibits all forms of abuse, including sexual abuse, and requires monitoring to protect residents, but these measures were not effectively implemented for this resident.
Failure to Develop Behavior Care Plan for Resident with Behavioral Symptoms
Penalty
Summary
The facility failed to develop and implement care planned interventions for a resident who exhibited behavioral symptoms, including physical and verbal behaviors toward other residents. The resident, who had diagnoses of adjustment disorder, delusional disorders, and dementia, was noted in progress notes to wander into other residents' rooms, collect items, and have altercations, including slapping another resident during supper. Despite these documented behaviors and the use of psychotropic medications for behavioral symptoms, the resident's care plan did not include a specific behavior care plan addressing these issues. Observations and interviews confirmed ongoing behavioral concerns, such as the resident entering other residents' rooms and displaying agitation. Staff interviews indicated awareness of the resident's behavioral interactions with others, including incidents of swearing and physical altercations. Facility policy requires the development of a comprehensive, person-centered care plan with measurable objectives and interventions based on assessment findings, but this was not completed for the resident in question.
Failure to Promote Resident Dignity After Fall
Penalty
Summary
A resident with diagnoses including dementia, agitation, restlessness, mood disorder, and neurocognitive disorder was admitted to the facility and had a baseline care plan indicating cognitive impairment, limited communication abilities, and independence with transfers and ambulation. After a recent hospitalization, the resident returned to the facility in a sedated and lethargic state. The following morning, staff found the resident on the floor next to his bed, disoriented, non-verbal, and unable to stand. Multiple staff members, including a nursing assistant, LPN, and RN, reported that the interdisciplinary team (IDT) instructed them to leave the resident on the floor, making him comfortable with a pillow and blanket, rather than transferring him back to bed or providing further assistance. Staff interviews revealed that concerns about the resident's sedation and transfer needs were raised but not addressed by management. The social services designee and the IDT agreed to leave the resident on the floor, and the resident remained there until he got up later in the afternoon. The facility's policy on dignity and quality of life states that residents should always be treated with respect and dignity, and demeaning practices are prohibited. The director of nursing acknowledged that it was not appropriate to leave the resident on the floor, indicating a failure to uphold the facility's own standards for resident dignity.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect residents from sexual abuse by not comprehensively assessing and implementing interventions for a resident with known inappropriate sexual behaviors. A resident with severe cognitive impairment and a history of sexual behaviors towards others was not adequately monitored or managed, leading to multiple incidents of sexual abuse towards two other cognitively impaired residents. The facility did not have interventions in place to prevent these incidents, and the care plans for the affected residents did not include measures to protect them from such abuse. The incidents involved a resident who repeatedly engaged in inappropriate sexual behavior, including fondling the breasts of two other residents. Despite staff witnessing these behaviors and reporting them to the Director of Nursing (DON) and Social Service Designee (SWD), no comprehensive assessments or effective interventions were implemented to mitigate the risk of further abuse. The facility's staff, including nursing assistants and licensed practical nurses, were aware of the resident's behaviors but did not take sufficient action to prevent further incidents. The facility's failure to address the resident's inappropriate behaviors and protect other residents was compounded by a lack of communication and documentation. The DON and SWD did not fully investigate the incidents or update care plans to reflect the need for increased supervision and safety measures. Additionally, family members and medical professionals were not informed of the incidents, preventing them from taking any action to address the situation. This lack of action and oversight allowed the resident's inappropriate behaviors to continue, putting other residents at risk.
Removal Plan
- Separated R6 and R31 from R39
- Referred R39 for psychological assessment
- Completed a comprehensive behavior assessment for R39
- Implemented increased supervision of R39
- Placed alarm outside R39's door
- Assessed R6 and R39 for psychological support
- Updated care plans to include safety measures
- Filed VA reports
- Updated abuse policy to include assessments and individualized interventions
- Educated staff on sexual abuse
- Educated nurses on reporting, assessment and intervention
Failure to Follow Care Plans for Ceiling Lift Transfers
Penalty
Summary
The facility failed to ensure that staff followed care-planned interventions for transferring residents using ceiling lifts, resulting in immediate jeopardy for three residents. Specifically, staff did not adhere to the requirement of having two staff members assist with transfers, and there was a lack of proper assessments to determine the appropriate sling sizes for the residents. This deficiency was observed in the cases of three residents who were transferred using ceiling lifts, putting them at risk of serious injury. One resident, who had severe cognitive impairment and was dependent on staff for transfers, was left alone in a ceiling lift in the bathroom, contrary to the care plan that required two staff members for assistance. The resident reported feeling neglected and unsafe, as they were left hanging in the lift for an extended period. Observations revealed that the resident was transferred using a sling that was not appropriately sized, causing discomfort and potential risk of injury. Another resident, also with severe cognitive impairment, was transferred by a single staff member despite the care plan indicating the need for two staff members. The staff member was unaware of the correct care plan requirements and used a sling without knowing its size. The resident experienced pain during the transfer, which was attributed to a previous medical condition. The facility's staff expressed concerns about the lack of adequate staffing to safely perform transfers, leading to inconsistent adherence to care plans and potential safety risks for residents.
Removal Plan
- Assess R12, R7 and R2 for correct amount of staff to ensure safe transfers
- Assess for the appropriate sling size per manufacturers recommendations
- Educate nursing staff and create a policy for ceiling lift assessments
- Ensure there are enough staff to transfer residents according to their care plans
Staffing Deficiencies Lead to Inadequate Care and Supervision
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of residents, particularly in the areas of transfers, supervision to prevent abuse, and restorative therapy. Observations and interviews revealed that residents requiring assistance with ceiling lift transfers were often handled by a single staff member instead of the care-planned two, due to staffing shortages. This was evident in the cases of residents with severe cognitive impairments who were dependent on staff for transfers. The lack of adherence to care plans, including the use of incorrect sling sizes, was noted, and staff admitted to not having enough time to check care plans due to insufficient staffing. The facility also failed to provide adequate supervision to prevent resident-to-resident abuse. A resident with a known history of inappropriate sexual behavior was not comprehensively assessed, and interventions were not implemented to mitigate the risk of abuse. This resulted in incidents where two cognitively impaired residents were sexually abused by the resident with known behaviors. Despite multiple documented incidents, the facility did not take adequate steps to address the behavior or protect other residents. Additionally, the facility did not provide consistent range of motion services for residents requiring restorative therapy. Documentation showed that residents were not receiving the prescribed therapy sessions, with many marked as not applicable or unavailable. Staffing issues in the restorative therapy department were cited as a reason for the lack of services, with the department unable to cover all required days. Interviews with staff and family members highlighted ongoing concerns about insufficient staffing, which affected the quality of care and response times to resident needs.
Failure to Update Facility Assessment and Implement Safety Measures
Penalty
Summary
The facility failed to update its facility-wide assessment to ensure an effective plan was in place to maintain the highest practicable care for residents. This deficiency was identified during a survey conducted from 10/28/24 through 11/6/24, where an immediate jeopardy level deficiency was noted. The facility did not conduct comprehensive assessments or implement interventions to mitigate risks associated with a resident known for inappropriate sexual behaviors. This failure resulted in the sexual abuse of two cognitively impaired residents who were dependent on staff for their care. Additionally, the facility did not ensure staff followed care-planned interventions when transferring residents with a ceiling lift. There was a lack of complete therapy or nursing assessments to determine appropriate sling sizes according to manufacturer guidelines, affecting three residents and resulting in immediate jeopardy. The facility assessment from 2023 failed to identify interventions to improve staff turnover rates, address infection prevention changes, or mitigate risks due to leadership changes. The interim administrator, who began on 10/9/24, acknowledged the lack of updated facility assessment documents since 12/1/23 and could not provide a policy related to the facility assessment review and revision.
Lack of Medical Director Policy and Responsibilities
Penalty
Summary
The facility failed to develop a policy and procedure defining the responsibilities of the medical director and ensure the medical director assisted in the implementation and guidance of resident care policies, and coordination of resident medical care. This deficiency had the potential to impact all 46 residents residing in the nursing home at the time of the survey. During an extended survey, the medical director's policy and job description or contract were requested but not provided. The medical director stated in a telephone interview that he visited the facility twice per month for resident rounds and paperwork, including signing orders and attending quality meetings. He was informed of staffing concerns but was not in control of staff. The medical director provided medical care and reviewed resident incident reports, such as falls. The interim administrator, who began his role on 10/9/24, stated during an interview that the facility had undergone several administration changes since the previous survey, and he was unable to find the medical director's job description or policy related to the medical director's responsibilities. The administrator expected the facility to have all the required policies and job descriptions, but no further information was provided.
Facility Fails to Address Quality Deficiencies and Staffing Issues
Penalty
Summary
The facility failed to develop and implement appropriate plans of action to correct quality deficiencies identified during the survey. This failure had the potential to adversely affect all 46 residents residing in the facility. The deficiencies included a lack of comprehensive assessment and intervention for a resident with known sexual behaviors, which resulted in the sexual abuse of two cognitively impaired residents. Additionally, the facility did not ensure staff followed care-planned interventions when transferring residents with a ceiling lift, nor did they complete necessary assessments to determine appropriate sling sizes, resulting in immediate jeopardy for three residents. The facility also failed to develop and implement an infection control surveillance plan, which included identifying, tracking, monitoring, and reporting infections and communicable diseases. There was a failure to conduct COVID-19 testing per CDC guidelines and to implement necessary precautions for residents with multi-drug resistant organisms and chronic wounds. Furthermore, the facility did not update their infection control policies annually, which had the potential to affect all residents. Staffing issues were prevalent, with insufficient staff to transfer residents according to their care plans and to provide appropriate supervision to prevent resident-to-resident abuse. The facility's assessment identified a high staff turnover rate and failed to implement interventions to improve this rate or ensure safe resident care. The QAPI meetings lacked goals and measurable actions regarding abuse, staffing concerns, accidents, and infection prevention, indicating a systemic issue in addressing and rectifying these deficiencies.
Failure to Develop and Monitor Performance Measures
Penalty
Summary
The facility failed to develop, monitor, and evaluate their identified performance measures, which had the potential to affect all 46 residents residing in the facility. The February QAPI Education Report indicated a staff education compliance rate of 72.8%, but did not specify any actions taken to improve compliance. Additionally, the Quality and Safety Meetings held in the first quarter, April, and May reviewed various topics such as emerging infectious diseases, staff influenza vaccination programs, and emergency preparedness, but did not develop or implement action plans with measurable goals or identify actions taken. The QAPI Meeting Minutes from August revealed that 26 falls were documented in July, and although a Performance Improvement Project (PIP) was written and reviewed in April for fall reduction, the data did not show any developed or implemented action plans with measurable goals. The facility also held a Resident Council meeting in July, where all concerns were communicated and completed, and no formal grievances were reported in July. However, the facility assessment from December 2023 identified a staff turnover rate of 22.95% and noted the need for interventions to improve this rate, but failed to identify specific interventions or how to ensure safe resident care. During an interview, the interim administrator, who began in October 2024, stated that the facility had undergone several administration changes and was unable to find substantial data reflecting how the facility was working towards improvement. The administrator found an agenda but no data to show progress. The facility's QAPI plan, dated February 2017, outlined the need for ongoing monitoring and revisions, but the report did not indicate that these were being effectively implemented or communicated to stakeholders.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to develop and implement an effective infection control surveillance plan, which included identifying, tracking, monitoring, and reporting infections and communicable diseases. The Monthly Infection Control Logs for September and October 2024 did not document infections not treated with antibiotics, such as viral infections, and lacked analysis of infection patterns or interventions to reduce further incidences. The logs also failed to document resolved dates for infections and did not identify signs and symptoms of potential infections for certain residents. Interviews revealed that the registered nurse responsible for infection control had not been tracking or trending resident or staff illnesses and symptoms, and the facility did not isolate residents for symptoms of illness unless they tested positive for COVID-19. The facility also failed to conduct COVID-19 testing of staff and residents according to CDC guidelines. The facility's records showed that testing was not completed on the required days following known exposures, and there was no evidence of tracking which residents and staff were tested or their results. Interviews with staff indicated a lack of formal contact tracing and documentation of testing, with reliance on staff to self-report exposures and test accordingly. The facility's response plan for COVID-19 testing was not followed, and there was no documentation of staff testing prior to working their shifts. Additionally, the facility failed to implement contact precautions and enhanced barrier precautions for residents with multidrug-resistant organisms and chronic wounds. Observations showed that staff did not consistently wear personal protective equipment when providing care to these residents, and there was a lack of understanding among staff about when and why PPE was required. Interviews with staff revealed a lack of education and communication regarding infection prevention precautions, with some staff unaware of residents' infection statuses and the necessary precautions to take.
Deficiency in Staff Training and Education
Penalty
Summary
The facility failed to ensure that employee infection control training and education were completed for several staff members, including LPNs, RNs, and the Director of Nursing (DON). This deficiency was identified through interviews and document reviews, revealing that the DON had not completed any assigned staff education, including critical areas such as dementia care, abuse, resident rights, and infection prevention. Additionally, RN-E had only partially completed required education, and NA-I and NA-B had not completed necessary training, with NA-I lacking specific dementia training after transferring from dietary to nursing. Interviews with HR personnel and RN-C highlighted a lack of a structured process for assigning and ensuring completion of annual training. HR-A and RN-C acknowledged the oversight in assigning and following up on the required education for staff members. The DON was unaware of the need for staff education and had not received login information to complete the assigned training. The facility's assessment identified the need for general orientation and annual training, but it failed to specify the requirement for nursing assistants to complete 12 hours of continuing education annually. A facility policy related to staff training and education was requested but not provided.
Failure to Complete Mandatory Communication Training
Penalty
Summary
The facility failed to ensure that mandatory communication training was completed by four out of ten staff members reviewed, including the Director of Nursing (DON), a Registered Nurse (RN-E), and two Nursing Assistants (NA-B and NA-I). This deficiency was identified through a review of personnel records, which showed that these staff members had not completed the required education on effective communication. Interviews with staff revealed that RN-C, responsible for staff training, was aware of the non-compliance, and the DON was only recently informed of the need for such training. The DON had mistakenly believed that providing her continuing education transcripts was sufficient and had not received login information to complete the training until recently. Additionally, the facility's assessment from 2023 highlighted the presence of a Laotian community in the surrounding area and noted that the facility had served Laotian residents over the past five to ten years. While cultural considerations were addressed during admissions and care conferences, the assessment did not specify how staff would effectively communicate with residents who were non-English speakers. This oversight in the facility's assessment process further contributed to the deficiency in staff training on effective communication.
Failure to Complete Mandatory Resident Rights Training
Penalty
Summary
The facility failed to ensure that staff completed mandatory training on resident rights, affecting three out of ten staff members reviewed, including the Director of Nursing (DON), a Registered Nurse (RN-E), and a Nursing Assistant (NA-I). This deficiency had the potential to impact all 46 residents in the facility. Personnel records revealed that the DON had not completed the required staff education on resident rights, RN-E had not completed the training since September 20, 2023, and NA-I had not completed it at all. During interviews, RN-C, responsible for staff training, acknowledged the non-compliance with education requirements. The DON stated she was unaware of the need for staff education and had not received login information to complete the training. The facility's policy required staff to attend General Orientation, which included resident rights, upon hire and annually. However, a facility policy related to resident rights was requested but not provided.
Failure to Provide Mandatory QAPI Training
Penalty
Summary
The facility failed to provide mandatory training on its Quality Assurance and Performance Improvement (QAPI) program to several staff members, including the Director of Nursing (DON), a Registered Nurse (RN), a Licensed Practical Nurse (LPN), and two Nursing Assistants (NAs). The personnel records review revealed that the DON, RN, and both NAs did not complete any assigned staff education related to quality assurance. The LPN had last completed quality assurance training several months prior. This lack of training was identified during interviews with staff members, where it was acknowledged that the staff were not compliant with the education requirements. During interviews, the RN responsible for staffing training admitted awareness of the non-compliance with QAPI training requirements. The DON stated she was only recently informed of the need for staff education and had not been provided with the necessary login information to complete the training. The facility's administrator confirmed that staff were expected to complete education as per the facility policy. Despite a request, the facility did not provide a policy related to staff training/education. The facility's 2023 assessment indicated that staff were required to attend General Orientation, which included QAPI training, upon hire and annually.
Inadequate Staff Training on Infection Control Procedures
Penalty
Summary
The facility failed to ensure that staff were adequately educated on infection control policies and procedures, impacting the potential safety of all 46 residents. Personnel records revealed that key staff members, including the Director of Nursing (DON), a Registered Nurse (RN-E), a Licensed Practical Nurse (LPN-C), and a Nursing Assistant (NA-B), did not complete necessary infection prevention training. Interviews with staff members, such as NA-B, NA-C, and LPN-A, highlighted a lack of understanding and education regarding standard, transmission-based, and enhanced barrier precautions (EBP). Staff expressed confusion and a lack of clear guidance on when and why personal protective equipment (PPE) should be used, indicating a significant gap in infection control education. The facility's Infection Prevention Plan Policy, revised in April 2024, designated an infection preventionist responsible for the infection prevention and control program (IPCP). However, the plan did not specify the required staff education or training related to infection prevention and transmission-based precautions. The Facility Assessment from December 2023 identified general orientation and annual training for infection control but failed to address specific education requirements for transmission-based precautions. Interviews with the newly appointed infection preventionist and the DON revealed that staff were expected to follow CDC guidance, but there was no evidence of prior education provided to staff, leading to a deficiency in infection control practices.
Failure to Provide Required Staff Training
Penalty
Summary
The facility failed to ensure that four out of ten staff members, including the Director of Nursing (DON), a Registered Nurse (RN-E), a Licensed Practical Nurse (LPN-C), and a Nursing Assistant (NA-B), received annual training on behaviors in Alzheimer's disease or related disorders, problem-solving with challenging behaviors, and communication skills. This deficiency had the potential to affect all 46 residents residing in the facility. Personnel records revealed that the DON and NA-B completed no assigned staff education, including compliance and ethics training. RN-E did not complete compliance and ethics training, while LPN-C last completed such training on April 20, 2023. Interviews conducted on November 6, 2024, revealed that RN-C, responsible for staff training, was aware of the non-compliance with staff education requirements. The DON stated she was only recently informed of the need for staff education and believed she only needed to provide her continuing education transcripts upon starting her role. The facility's 2023 assessment identified the need for general orientation upon hire and annually but failed to address the need for behavioral health training. A facility policy related to staff training/education was requested but not provided.
Deficiency in Nursing Assistant Training Compliance
Penalty
Summary
The facility failed to ensure that two of the five nursing assistants reviewed for in-service requirements completed the mandated 12 hours of annual in-service training. This deficiency had the potential to affect all 46 residents residing in the facility. Specifically, Nursing Assistant (NA)-I, who transferred from a dietary position to nursing, did not complete the required 12 hours of continuing education, including specific dementia training. NA-I's last dementia training was in 2022, and there was no evidence that additional courses were assigned to her. Similarly, NA-B, hired in 2016, had not completed any training since it was assigned in November 2023. Interviews with facility staff revealed a lack of clarity and responsibility regarding the assignment and completion of staff education. Human Resources (HR)-A, who previously assigned annual staff education, indicated that Registered Nurse (RN)-C was now responsible for this task. However, RN-C acknowledged that staff were not compliant with education requirements, including compliance and ethics training. The Director of Nursing (DON) and the administrator were both aware of the deficiency but did not provide a facility policy related to staff training/education when requested. The facility's 2023 assessment identified general orientation and dementia education requirements but failed to specify the 12-hour continuing education requirement for nursing assistants.
Failure to Provide Abuse Prevention Training
Penalty
Summary
The facility failed to provide specific abuse prevention training to five out of ten employees reviewed, including the Director of Nursing (DON), a Registered Nurse (RN-E), a Licensed Practical Nurse (LPN-C), and two Nursing Assistants (NA-I and NA-B). This deficiency had the potential to affect all 46 residents in the facility. Personnel records revealed that the DON and NA-B had not completed any assigned staff education on abuse, while RN-E, LPN-C, and NA-I had not completed abuse training since 2023 or earlier. Interviews with staff indicated a lack of compliance with education requirements, with the DON unaware of the need for staff education and lacking access to complete the required training. The facility's 2023 assessment indicated that staff should attend General Orientation, which includes abuse prevention, upon hire and annually. However, a facility policy related to staff training was requested but not provided.
Deficiency in Staff Behavioral Health Training
Penalty
Summary
The facility failed to ensure that three out of ten staff members, including the Director of Nursing (DON), a Registered Nurse (RN-E), and a Nursing Assistant (NA-B), received the required annual training on behaviors in Alzheimer's disease or related disorders, problem-solving with challenging behaviors, and communication skills. Personnel records revealed that the DON had not completed any assigned staff education, including behavioral health training. RN-E had last completed behavioral health training on 8/3/23, and was overdue for the annual training. NA-B had not completed any assigned staff education, including behavioral health, since 2024. Interviews with facility staff revealed a lack of clarity and responsibility regarding the assignment and completion of staff education. Human Resources (HR)-A stated that RN-C was now responsible for assigning annual training, but it appeared that RN-E had not been assigned the necessary training. RN-C acknowledged the non-compliance with staff education requirements. The DON was unaware of the need for staff education and had not received login information to complete the training. The facility's 2023 assessment identified the need for general orientation upon hire and annually but failed to specify the need for behavioral health training. A facility policy related to staff training was requested but not provided.
Inadequate Range of Motion Services Due to Staffing Issues
Penalty
Summary
The facility failed to provide adequate range of motion (ROM) services for four residents, leading to a deficiency in maintaining or improving their mobility. Resident 7, with severe cognitive impairment and multiple diagnoses including multiple sclerosis and diabetes, was supposed to receive a restorative nursing program (RNP) five times a week. However, documentation showed that R7 only received services three times over a period where 17 sessions were expected. Similarly, Resident 19, with Alzheimer's disease and heart failure, was to receive seated exercises three times a week but only participated three times out of 11 opportunities. Resident 22, who had severe cognitive impairment and chronic pain from arthritis and lumbago with sciatica, was ordered to receive a functional maintenance program (FMP) involving active ROM five times a week. Despite 21 opportunities, only one session was documented as completed. Resident 43, with moderate cognitive impairment and Parkinson's disease, was to engage in lower extremity exercises three times a week but only participated in three out of 13 sessions. Observations confirmed that these residents did not have visible contractures, but the lack of consistent ROM services was evident. The deficiency was attributed to staffing issues within the restorative therapy department. The restorative therapy aide (RT-A) was only available three days a week, despite the need for services five days a week. RT-A reported being unable to complete the required tasks due to limited staffing and had informed the administration, but no plan was implemented to address the issue. The director of nursing (DON) acknowledged the staffing problem but had not taken steps to resolve it. A policy regarding restorative therapy was requested but not provided.
Resident Left Unattended in Ceiling Lift Due to Staffing Shortages
Penalty
Summary
The facility failed to provide toileting care in a dignified manner for a resident who was severely cognitively impaired and dependent on staff for toileting and transfers. The resident reported being left alone in a ceiling lift in the bathroom, with feet dangling and going numb, for at least 20 minutes. The resident expressed feelings of neglect and distress, stating that this was not the first time they had been left in such a situation, although not for as long. The resident had a history of depression, which could have been exacerbated by the incident. Interviews with staff revealed concerns about inadequate staffing levels, which led to residents being left unattended in lifts and call lights not being answered promptly. A licensed practical nurse and nursing assistants confirmed the incident and the ongoing issue of staff shortages. The social worker designee acknowledged the expectation that residents should not be left unattended, but there was no documented grievance or follow-up for the resident's concerns. The facility's administrator stated that care should be provided in a dignified manner, but a policy regarding dignity was not provided upon request.
Failure to Address Resident Grievance on Missing Property
Penalty
Summary
The facility failed to act upon a grievance voiced by a resident, identified as R20, regarding a missing nightgown. R20, who was cognitively intact, reported the missing item during a resident council meeting and followed up with staff but did not receive any resolution or follow-up. The facility had changed its laundry process, requiring all personal and facility laundry to be done in a central laundry room, and instructed staff and families to label clothing. Unlabeled items were returned to units for identification. Despite these procedures, R20's grievance was not addressed, and there was no evidence of a formal process to track or resolve the issue. Interviews with staff revealed a lack of awareness and communication regarding the missing item. The activities director noted the grievance in meeting minutes and forwarded them to relevant managers, but did not follow up further. The environmental services manager and laundry aide were unaware of R20's missing nightgown, and the nursing assistant was uncertain about the process for reporting missing items. The facility did not provide a written grievance policy when requested, indicating a deficiency in their grievance handling procedures.
Failure to Report Allegations of Sexual Abuse
Penalty
Summary
The facility failed to ensure timely reporting of allegations of potential sexual abuse involving a resident with severe cognitive impairment, identified as R39, who was observed inappropriately touching other residents, R6 and R31, on multiple occasions. R6 and R31 both had cognitive impairments and exhibited behaviors such as grabbing, hitting, and scratching. Despite these incidents, the facility did not report the allegations to the administrator or the state agency as required. On several occasions, staff observed R39 engaging in inappropriate behavior, such as fondling the breasts of R31 and R6. These incidents were documented in progress notes, but the facility's social service designee (SWD) and director of nursing (DON) did not report them to the state agency. The SWD and DON determined that the incidents did not need to be reported because the residents involved had severe cognitive impairments and there was no willful intent to harm. However, the facility's policy required filing a vulnerable adult report for such incidents, which was not done. The facility's failure to report these incidents was compounded by administrative changes and staffing challenges, which led to a lack of follow-up and assessment of the residents involved. The administrator was not made aware of the incidents until much later, and the facility did not implement adequate interventions to prevent further occurrences. The facility's Resident Abuse Prohibition Policy required immediate reporting of abuse to the supervisor and the administrator, but this protocol was not followed.
Failure to Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to provide immediate protection and investigate allegations of resident-to-resident sexual abuse involving two residents who were abused by another resident. The incidents involved inappropriate touching and fondling, which were observed by staff members on multiple occasions. Despite these observations, the facility did not conduct a thorough investigation into the incidents, as required by their Resident Abuse Prohibition Policy. The policy mandates that a nurse should begin an investigation immediately, including a root cause analysis and interviews with involved parties, but this was not done. The facility's staff, including the social worker designee and the director of nursing, were aware of the incidents but did not take appropriate action to investigate or report them. The administrator was not informed of the incidents until much later, and no investigation files were produced. The facility's failure to investigate these incidents is a clear violation of their policy, which requires a comprehensive investigation and documentation of any allegations of abuse.
Inaccurate MDS Coding for Resident with MDRO
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for a resident reviewed for catheters. The resident, who had severely impaired cognition and an indwelling urinary catheter, was diagnosed with multiple sclerosis, type 2 diabetes, and a history of urinary tract infection. However, the MDS did not identify that the resident had a multi-drug resistant organism (MDRO). Additionally, the resident's care plan, revised on a specific date, did not include the presence of an MDRO, despite the resident having an open wound and being at increased risk of infection, with precautions for methicillin-resistant staphylococcus aureus (MRSA) noted in a physical therapy treatment note. Interviews with facility staff revealed a lack of awareness and understanding regarding the importance of accurate MDS documentation. The Director of Nursing stated that staff were expected to document and submit the MDS accurately and timely, as it was crucial for resident care and facility reimbursement. However, a registered nurse admitted to not reviewing the resident's MDRO status during the MDS assessment, as the focus was on the resident's COVID-19 diagnosis. The nurse expressed uncertainty about the impact of an accurate MDS on resident care. A facility policy regarding MDS assessments was requested but not provided.
Deficiencies in Care Planning and Communication for Residents with Catheter Needs
Penalty
Summary
The facility failed to develop a comprehensive care plan for two residents, R7 and R99, which led to deficiencies in their care. R7, who had severely impaired cognition and an indwelling urinary catheter, was not provided with a care plan that included her preferences for family involvement or her condition of having a multi-drug resistant organism (MDRO). Additionally, the care conference summaries for R7 lacked documentation of when the meetings were held, who attended, and who was invited. The facility also failed to notify R7's daughter about care conferences, which was a previously established practice. Interviews revealed that the care coordinator responsible for updating care plans and notifying families was unavailable, leading to communication breakdowns. For R99, the facility did not establish a care plan goal or measurable objectives for the resident's intermittent catheterization needs. R99 required catheterization every shift due to neurogenic bladder and dementia, but the care plan did not reflect this requirement. During an observation, an LPN failed to wear a gown while performing catheter care for R99, which was against the facility's infection control policy. The Director of Nursing acknowledged that care plans should be updated timely and accurately, but a policy regarding care planning was not provided upon request.
Failure to Follow Catheterization Orders and Infection Control Protocols
Penalty
Summary
The facility failed to follow the provider's orders for intermittent catheterization for a resident with neurogenic bladder, Alzheimer's disease, and dementia. The resident required catheterization four times a day, as per the original orders, but was only receiving catheterization once per shift. This discrepancy was due to incorrect orders entered into the computer system by the nursing staff. The Director of Nursing confirmed that the orders were incorrect and acknowledged the high risk of infection due to the failure to follow the prescribed catheterization schedule. The medical doctor was not informed of the deviation from the original orders. Another resident with severe cognitive impairment, multiple sclerosis, type 2 diabetes, and a history of UTIs had a suprapubic indwelling urinary catheter. During an observation, a nursing assistant was found to have placed the resident's catheter bag on the floor, which is against infection control protocols. The nursing assistant acknowledged the potential for infection but expressed skepticism about the necessity of such protocols. The facility's policy on suprapubic catheter placement did not address catheter care after placement, contributing to the deficiency in infection control practices.
Deficiency in Contracted Services Documentation
Penalty
Summary
The facility failed to provide documentation of agreements for contracted services, which could potentially affect all 46 residents in the facility. During an extended survey, the surveyors requested copies of agreements for services such as dental, hospital transfer, and psychiatric services. However, the only agreement the facility could provide was a Nursing Facility Services Agreement with LifeCare Medical Center for hospice services, dated 8/26/13. On 11/6/24, the administrator confirmed that no other current agreements could be located, indicating a deficiency in maintaining necessary documentation for contracted services.
Lack of Transfer Agreement with Medicare Hospital
Penalty
Summary
The facility failed to develop and maintain an in-effect transfer agreement with a local Medicare participating hospital, which is necessary to ensure residents can be transferred quickly for medical care when needed. This deficiency was identified during an extended survey conducted from October 30, 2024, through November 6, 2024. During this period, the surveyors requested evidence of such an agreement, but the facility was unable to provide any documentation. The interim administrator, who began his role on October 9, 2024, acknowledged the absence of a transfer agreement and noted that the facility had experienced several administrative changes since the last survey. This lack of a transfer agreement had the potential to affect all 46 residents who might require hospitalization on an emergent basis.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for a resident who sustained significant unexplained bruising. The resident, diagnosed with Alzheimer's disease, dementia, and osteoporosis, was found with bruising on her left axillary area and between her breasts. Despite the resident's inability to recall any incident leading to the bruising, the facility's investigation was insufficient as it lacked comprehensive staff and resident interviews to determine if an incident occurred that may have resulted in the injury. The facility's investigation concluded that the bruising was related to a previous fracture, but this was not corroborated by the emergency department's findings or the resident's physician. The emergency department notes indicated that the bruising was more recent and not related to the old shoulder injury. The physician and registered nurse involved expressed doubts about the facility's conclusion, suggesting the bruising might have resulted from the resident hitting her side during a transfer. The director of nursing acknowledged that no further interviews were conducted to ascertain the cause of the bruising. The facility's policy on reporting and internal review of injuries of unknown origin was not adequately followed, as the internal review did not include a thorough evaluation to determine the cause of the injury.
Failure to Assess and Prevent Bruising in Resident
Penalty
Summary
The facility failed to perform an assessment to determine the potential causes of extensive bruising on a resident with Alzheimer's disease, dementia, and osteoporosis. The resident required substantial assistance for toileting and transfers and had upper extremity impairments. Despite the presence of significant bruising on the resident's left side, the facility did not conduct a thorough investigation to identify the cause. The resident's care plan directed staff to observe skin conditions daily and notify nurses of any changes, but there was no evidence of a reassessment of the resident's transfer abilities or implementation of new interventions to prevent further injury. Observations and interviews revealed that the resident had extensive bruising, which was not addressed with appropriate interventions. Nursing assistants and registered nurses noted the bruising but did not use a transfer belt during assistance, which could have contributed to the injuries. The director of nursing acknowledged the lack of assessment for transfer safety following the injuries. Additionally, a policy related to non-pressure related skin injuries was requested but not provided, indicating a gap in the facility's procedures for handling such incidents.
Failure to Provide Correct Diet Leads to Choking Incident
Penalty
Summary
The facility failed to provide the physician-ordered mechanically altered diet for a resident who was at risk for choking. The resident, diagnosed with dysphagia, quadriplegia, and dementia, was supposed to receive a pureed diet with nectar thick liquids. However, on a specific date, the resident was served a regular diet, which led to a choking incident involving a corn dog. The resident required the Heimlich Maneuver to dislodge the food, indicating a serious lapse in following dietary orders. The deficiency was identified through observations, interviews, and document reviews. Staff members, including dietary aides and nursing assistants, were involved in the meal service process but failed to ensure the correct diet was served. The activity director and aides relied on posted diet information and personal knowledge rather than verifying the specific dietary needs of each resident. This lack of verification and understanding of diet textures contributed to the resident receiving the incorrect meal. Interviews with staff revealed a lack of clarity and training regarding diet textures and the importance of adhering to prescribed diets. The dietary aide responsible for serving the meal was unable to correctly identify pureed food and mistakenly served a mechanical soft diet. The incident highlighted a systemic issue in the facility's meal service process, where staff did not consistently check diet orders or understand the differences between diet textures, leading to the resident's choking incident.
Removal Plan
- Reviewed and revised policies and procedures related to serving resident meals and ensuring residents receive correct textured meals.
- Educated to procedures and revisions as appropriate.
- Educated dietary and all staff who serve resident food to recognize each specific diet type/textured meal.
- Educated dietary staff related to the importance of serving the correct diets to residents.
- Educated all staff who serve resident food items on the importance of checking the diet slip, ensure the resident is getting the correct textured food, and then delivering the correct diet order to the resident.
- Developed and implemented a plan to complete all training before each staff worked their next shift.
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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