Anoka Rehabilitation And Living Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Anoka, Minnesota.
- Location
- 3000 4th Avenue, Anoka, Minnesota 55303
- CMS Provider Number
- 245205
- Inspections on file
- 35
- Latest survey
- November 13, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Anoka Rehabilitation And Living Center during CMS and state inspections, most recent first.
A resident with chronic pain conditions experienced significant pain during daily care, but staff did not administer prescribed PRN morphine sulfate for breakthrough pain. Despite clear signs of pain and a care plan requiring pain management interventions, staff were unaware of the medication regimen, did not inform the resident about PRN options, and lacked a system to monitor PRN medication use. The resident's pain was not effectively managed or documented, and the physician was unaware the PRN medication was not being given.
The facility failed to ensure proper PPE use for infection control, as staff did not consistently wear N95 masks or eye protection when caring for COVID-19 positive residents. Observations showed nursing assistants wearing surgical masks and lacking eye protection, contrary to facility policy and CDC guidelines. Interviews revealed a lack of awareness or adherence to PPE protocols, despite staff training and signage indicating necessary precautions.
The facility failed to maintain proper food temperatures and sanitary ice machines, affecting residents' meals and water quality. A dietary aide was unaware of the required holding temperatures, leading to cold food being served. Additionally, calcium buildup on ice machines resulted in poor-tasting water, with no cleaning logs available to verify maintenance.
The facility failed to properly reconcile medications during the discharge of several residents, leading to medication errors. One resident received another's medication due to incomplete discharge summaries that lacked documentation of medications sent home. Staff interviews revealed inconsistencies in the discharge process, with time constraints leading to incomplete forms. The director of nursing and administrator acknowledged the deficiencies, highlighting a failure to adhere to the facility's discharge planning policy.
The facility failed to maintain cleanliness in the Cornerstone unit kitchenette, with significant residue buildup on the ice and water dispenser and refrigerator. Family members and residents reported concerns about the water's taste and cleanliness, which were not adequately addressed despite daily cleaning attempts by staff. No facility policy was provided for cleaning procedures.
The facility failed to maintain proper food storage, labeling, and sanitation in the kitchen, risking foodborne illness for residents, staff, and guests. Observations revealed dietary staff without hairnets, unsealed and undated food items, and unsanitary conditions. The CDM cited multiple roles and policy changes as reasons for missed tasks, with no set cleaning schedule in place. A follow-up visit confirmed ongoing issues, and the administrator acknowledged the lack of a cleaning log, indicating systemic non-compliance with food safety regulations.
The facility failed to assess residents for self-administration of medications, resulting in five residents having medications at their bedside without necessary assessments or physician orders. Observations revealed residents using medications independently, such as nasal sprays, eye drops, and nebulizers, without staff supervision or proper authorization. Interviews with staff indicated a lack of adherence to the facility's policy, which requires assessments and orders for safe medication management.
The facility failed to conduct and document care conferences for several residents, despite having multiple MDS submissions. Interviews revealed that residents and family members could not recall attending any care conferences, and the facility's records lacked documentation. The licensed social worker confirmed the absence of required care conferences, which are essential for resident rights and care collaboration.
The facility failed to ensure that four residents were offered, educated, and/or provided the pneumococcal vaccination series as recommended by the CDC. The residents' records lacked evidence of shared clinical decision-making with a physician for the PCV20 vaccine, which should be considered at least five years after the last pneumococcal dose. The infection preventionist and RN believed the residents were up to date, but there was no documentation of discussions, education, or consent regarding the PCV20.
A facility failed to provide a resident with the required Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN-CMS-10055) after their Medicare Part A coverage ended. Although the resident received a Medicare-A Non-Coverage form, there was no evidence of the SNFABN-CMS-10055 form in their medical record. Registered nurses and the facility administrator confirmed the oversight, which was against the facility's policy revised in September 2022.
The facility failed to notify the Ombudsman of hospital transfers for two residents, R106 and R107, who had various medical conditions. Despite sending bed hold policies with the residents, there was no evidence of written notification to the Ombudsman. The facility's documentation did not list R106, and the report for R107 could not be located. An email from the Ombudsman confirmed no notification was received for either transfer.
A resident with severe cognitive impairment and multiple medical conditions experienced several unwitnessed falls. Although neurological assessments were initiated, they were not completed as required by the facility's protocol. Interviews with staff confirmed missing documentation for these assessments, highlighting a failure to monitor for potential head injuries.
A facility failed to coordinate dialysis care for a resident with end-stage renal disease, who reported never receiving necessary paperwork for dialysis appointments. An LPN confirmed the absence of communication sheets, and a health unit coordinator noted no communication with the dialysis center for five years, contrary to facility policy requiring ongoing collaboration and documentation.
The facility failed to limit PRN psychotropic medications to 14 days or have a physician-specified order for two residents in hospice care. One resident with moderate cognitive impairment and another with severe cognitive impairment had open-ended orders for Lorazepam without reassessment or stop dates. Interviews with staff revealed a lack of adherence to the facility's policy requiring reevaluation of PRN psychotropic medications every 14 days.
A resident, who was cognitively intact and able to express her needs, did not receive assistance in obtaining routine dental services. Despite expressing interest in seeing a dentist, her medical record lacked an oral assessment or referral for a dental evaluation. The facility's policy required dental needs assessment upon admission, but this was not followed, leading to a deficiency in care.
A resident with multiple diagnoses, including MRSA and chronic ulcers, required enhanced barrier precautions. However, a nursing assistant failed to don a gown while providing care, and a registered nurse did not remove their gown before exiting the room. Both actions were contrary to the facility's infection control policy, which required PPE removal before leaving the work area.
The facility did not post required daily staffing information, affecting all 112 residents and visitors. Documentation review revealed missing postings on specific dates, including weekends and a holiday period. The staffing manager confirmed the lapse, and the administrator was unaware, expecting daily postings per policy.
A facility failed to implement care-planned interventions for a resident at risk for pressure ulcers. Despite orders for heel-protecting boots, staff did not consistently apply them, leading to inadequate management of the resident's pressure ulcers. Interviews revealed a lack of awareness and adherence to the care plan, and the Director of Nursing acknowledged gaps in communication and responsibility.
A resident with a history of stage 3 pressure ulcers did not receive consistent comprehensive assessments and interventions to prevent recurrence. The care plan lacked a turning/repositioning program, and there were discrepancies in care, such as improper floating of heels and inadequate repositioning. Observations noted issues like redness and tissue damage, with gaps in documentation and incomplete wound assessments. These lapses led to the development of new pressure ulcers on the resident's right heel.
The facility failed to ensure a dignified living experience for two residents, as observed through video footage and interviews. One resident was seen crying during care and exposed to the hallway and courtyard while on the commode. Another resident was left in the same nightgown and socks for several days and had her nonverbal expressions of discomfort ignored by staff. The facility's policies on resident rights and dignity were not adequately enforced.
The facility failed to implement a comprehensive toileting care plan for a resident, leading to missed toileting times and the use of incorrect incontinence products. Despite clear directives in the care plan, staff did not consistently follow the scheduled toileting routine or use the specified briefs, resulting in prolonged periods without being changed.
The facility failed to use mechanical standing lifts correctly for two residents, leading to unsafe transfer practices and significant discomfort. Additionally, the wander-guard system was not operational, allowing three residents to elope. Staff did not follow proper procedures, and the system's auditory alert was insufficient.
Failure to Administer PRN Pain Medication and Monitor Pain Management
Penalty
Summary
The facility failed to identify, treat, monitor, and manage pain for a resident with multiple chronic pain conditions, including rheumatoid arthritis, polymyalgia rheumatica, and chronic pain, as outlined in the resident's care plan and physician orders. Despite the resident experiencing and expressing significant pain during routine care activities such as dressing, cleaning, and transferring, staff did not administer the prescribed PRN (as needed) morphine sulfate for breakthrough pain. Observations showed the resident wincing, screaming, and flailing in pain during care, and interviews with staff confirmed that pain was reported but not adequately addressed with medication. The resident's care plan included specific interventions for pain management, such as administering pain medication per physician order for breakthrough pain and monitoring pain characteristics. However, the medication administration records indicated that while scheduled morphine was given, the PRN morphine sulfate was not administered at all during the review period, despite clear evidence of pain. Staff interviews revealed a lack of awareness regarding the resident's pain medication regimen and an absence of a system to monitor PRN medication usage. Nursing staff and management were not certain why the PRN medication was not used, and the resident was not informed that he could request pain medication when experiencing pain. Family members and staff expressed concern about the resident's uncontrolled pain, and the primary care physician was unaware that the PRN morphine was not being administered. The facility's pain management policy required a systematic approach to pain recognition, assessment, treatment, and monitoring, but this was not followed in the resident's case. The deficiency was further compounded by the lack of documentation and communication regarding the resident's pain and the absence of a process to ensure PRN pain medications were utilized as ordered.
Inadequate PPE Use for Infection Control
Penalty
Summary
The facility failed to ensure appropriate personal protective equipment (PPE) was worn to prevent the spread of infection among residents. Specifically, two residents under COVID-19 transmission-based precautions and one resident under enhanced barrier precautions were not provided with the necessary PPE by the staff. Observations revealed that nursing assistants did not consistently wear eye protection or N95 masks when caring for COVID-19 positive residents, despite the facility's policy and CDC guidelines requiring such measures. During the observations, one nursing assistant was seen wearing a surgical mask instead of an N95 mask and lacked eye protection while caring for a COVID-19 positive resident. Another nursing assistant also failed to wear eye protection and did not change the surgical mask between resident rooms, which is against the recommended PPE protocol. Interviews with the nursing assistants confirmed a lack of awareness or adherence to the PPE guidelines, despite the presence of precaution signs on the residents' doors. The director of nursing and other staff members acknowledged that the facility's policy required the use of N95 masks, eye protection, gowns, and gloves for COVID-19 positive residents. They also confirmed that staff were educated on proper PPE use and received updates on residents' precautionary statuses. However, the observations and interviews indicated a failure in the implementation and monitoring of these infection control practices, potentially affecting all residents in the facility.
Deficiencies in Food Temperature and Ice Machine Sanitation
Penalty
Summary
The facility failed to maintain proper holding temperatures for food served to residents in the Reflections unit. During an observation, it was noted that the food temperatures were significantly below the required range, with spaghetti noodles at 102 degrees F, hamburger meat sauce at 114 degrees F, and peas and carrots at 115 degrees F. A dietary aide, who was on his first day of work, was unaware of the proper holding temperatures for hot food, which should have been between 135 and 165 degrees F according to the dietary manager. This failure to maintain appropriate food temperatures was confirmed by a family member who reported that a resident refused to eat the cold food, leading the family member to bring in food from outside the facility. Additionally, the facility did not maintain the ice machines in a sanitary manner, affecting residents in multiple units. Observations revealed a white flaky substance, identified as calcium buildup, on the ice and water spouts of the machines. A resident reported that the ice and water tasted terrible and had to discard several glasses before obtaining drinkable water. Despite notifying a licensed practical nurse about the issue, the ice machines remained uncleaned, and there were no available cleaning logs to verify maintenance. The dietary manager acknowledged the potential for residents to become ill from the calcium buildup breaking off into the ice or water.
Medication Reconciliation Failure at Discharge
Penalty
Summary
The facility failed to provide a proper medication reconciliation process during the discharge of several residents, leading to medication errors. Specifically, the discharge summaries for seven residents did not include a reconciliation of pre-discharge medications with post-discharge medications. This omission resulted in one resident receiving another resident's medication, Mirtazapine, which was not prescribed to them. The discharge summaries lacked documentation of the medications and their quantities sent home with the residents, which is a critical step in ensuring safe transitions of care. Interviews with staff revealed inconsistencies in the discharge process. A registered nurse and a licensed practical nurse described a protocol where medications should be reviewed and explained to the resident before discharge. However, it was noted that due to time constraints, the section of the discharge form detailing the medications sent home was often left incomplete. This lack of thoroughness in the discharge process contributed to the medication error experienced by the residents. The director of nursing and the facility administrator acknowledged the deficiencies in the discharge process. The director of nursing stated that the medication disposition should be documented in the discharge summary, but this was not consistently done. The administrator expressed the expectation that the discharging nurse should provide a list of medications to the resident and document the details in the discharge summary. Despite these expectations, the facility's failure to adhere to its own discharge planning policy resulted in significant lapses in medication management during resident discharges.
Sanitation Issues in Cornerstone Unit Kitchenette
Penalty
Summary
The facility failed to maintain the ice and water dispenser and refrigerator in the Cornerstone unit kitchenette in a clean and sanitary manner, affecting the potential health of 60 residents. Observations revealed a significant buildup of whitish-gray residue on the ice and water dispenser, including the drip tray, stainless steel surface, and chutes. Additionally, the refrigerator had a light brown substance in the rubber door seal grooves and a white substance at the base. Family members and residents expressed concerns about the cleanliness and taste of the water, which were reported to management in August 2024. Despite attempts by the maintenance and dietary staff to clean the equipment, the residue remained. The director of maintenance acknowledged the difficulty in removing the hard water buildup, while the dietary aide and assistant culinary director confirmed that the equipment was supposed to be cleaned daily. However, there was no facility policy provided regarding the cleaning of kitchenette equipment, indicating a lack of clear guidelines or procedures for maintaining sanitation standards.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure proper food storage, labeling, and sanitation in the kitchen, which posed a risk of foodborne illness to all 112 residents, staff, and guests. During an initial kitchen tour, several issues were observed, including dietary staff not wearing hairnets, unsealed and undated food items in the refrigerator, and unsanitary conditions such as dried food particles on shelves and debris in floor drains. The walk-in cooler and freezer contained undated and improperly stored food items, with some showing signs of spoilage and contamination. The Certified Dietary Manager (CDM) acknowledged the poor condition of the kitchen, citing multiple roles and recent policy changes as reasons for missed routine tasks. The CDM was responsible for directing kitchen staff and ensuring food sanitation and preparation were conducted to minimize foodborne pathogens. However, there was no set cleaning schedule, and the CDM was unaware of the current policies. The facility's food storage policy required proper labeling, dating, and storage to prevent contamination, but these standards were not met. During a follow-up visit, additional concerns were noted, including a cook without a hairnet and unchanged unsanitary conditions. The administrator confirmed the lack of a cleaning log and stated that the staff was in the process of deep cleaning the kitchen and discarding undated food items. The facility's policies required maintaining cleanliness and sanitation through a comprehensive cleaning schedule, which was not provided, indicating a systemic failure in adhering to food safety regulations.
Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents were comprehensively assessed for self-administration of medications, as evidenced by observations and interviews with staff and residents. Five residents were identified as having medications at their bedside without the necessary assessments or physician orders to self-administer. For instance, one resident, R3, was found with a nasal spray and arthritis pain-relieving cream in his room, which he used independently despite not having an order to self-administer these medications. Similarly, R14 had multiple bottles of eye drops at his bedside, which he used frequently without an order for self-administration. Another resident, R74, who had moderate cognitive impairment, was observed using a nebulizer without staff supervision, despite not having an order to self-administer the treatment. Staff confirmed that they set up the nebulizer and left the room, returning only to turn off the machine. This practice was inconsistent with the facility's policy, which requires an assessment and a physician's order for residents to self-administer medications safely. Additionally, R36 and R95 were found with medications at their bedside, including topical creams and Tylenol, without the necessary assessments or orders, indicating a systemic issue in the facility's medication management practices. Interviews with nursing staff and management revealed a lack of awareness and adherence to the facility's policy on self-administration of medications. Staff members, including LPNs and RNs, acknowledged that no residents had current orders for self-administration, and they were unaware of any residents who were permitted to self-administer medications. The facility's policy requires an interdisciplinary team assessment and a physician's order to ensure residents can safely manage their medications, but this process was not followed, leading to potential safety risks for the residents involved.
Failure to Conduct and Document Care Conferences
Penalty
Summary
The facility failed to conduct care conferences for five out of seven residents reviewed for care planning. These residents, identified as having either intact cognition or severe cognitive impairment, did not have documented care conferences in their medical records despite having multiple Minimum Data Set (MDS) submissions. Interviews with residents and family members revealed that they could not recall attending any care conferences, and the facility's records corroborated the absence of such documentation. The licensed social worker confirmed that care conferences were not held as required by the facility's policy, which mandates quarterly conferences or more frequently if needed, within seven days of MDS completion. The social worker acknowledged that regular care conferences are crucial for resident rights and care collaboration, and even if residents or their families chose not to attend, the conferences should still have been conducted and documented. The facility's policy emphasizes the importance of involving residents and their representatives in care planning to promote autonomy and dignity.
Failure to Administer and Document Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that four out of five residents reviewed for immunizations were offered, educated, and/or provided the pneumococcal vaccination series as recommended by the CDC. Specifically, residents R24, R56, R80, and R102 did not have evidence of shared clinical decision-making with a physician regarding the administration of the PCV20 vaccine, which should be considered at least five years after the last pneumococcal dose. The immunization records for these residents lacked documentation of being offered, educated on, or receiving the PCV20 vaccine. The infection preventionist and RN stated they believed the residents were up to date with their vaccinations and did not require the PCV20. However, there was no documentation in the medical records of discussions, education provided, or consent obtained or declined for the PCV20. The assistant director of nursing expected that upon admission, residents' vaccination records would be reviewed, and appropriate vaccinations offered and administered. The facility's policy indicated that for adults who have received PCV13 and PPSV23, shared clinical decision-making should occur regarding the administration of PCV20.
Failure to Provide SNFABN-CMS-10055 Form
Penalty
Summary
The facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN-CMS-10055) to a resident, identified as R86, who was reviewed for beneficiary notification. R86 was admitted to the facility and had their Medicare Part A coverage end on May 23, 2024. Although R86 received a Medicare-A Non-Coverage (CMS-10123) form indicating the end of covered services, there was no evidence in R86's medical record that the SNFABN-CMS-10055 form was provided as required. On July 18, 2024, registered nurses confirmed the absence of the SNFABN-CMS-10055 form, and the facility administrator acknowledged the expectation that the form should have been provided to ensure residents were aware of the end date of their services and their right to appeal. The facility's policy, revised in September 2022, indicated that the SNFABN-CMS-10055 should be issued before providing care or services that do not meet Medicare coverage criteria.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to ensure that a written notification of transfer was sent to the office of the Ombudsman for long-term care for two residents who were transferred to the hospital. Resident R106, who had intact cognition and multiple medical diagnoses including a displaced bimalleolar fracture, anemia, hypertension, and chronic kidney disease, was transferred to the emergency room for evaluation of new concerns. Although a bed hold was signed and sent with the resident, and the family was notified, there was no evidence that a written notification of transfer was sent to the ombudsman. Similarly, Resident R107, with moderately impaired cognition and medical conditions such as osteoarthritis, hypertension, and atrial fibrillation, was transferred to the ER due to new concerns. A bed hold policy was sent with the resident, but the family declined it. Again, there was no evidence of notification to the ombudsman. The facility's documentation, referred to as the Monthly Notice to the MN Office of Ombudsman for Long-Term Care for Emergency Acute Care Transfers and Discharges, did not list R106 for the month of May, and the facility was unable to locate the fax or report for April to confirm R107's notification. The Licensed Social Worker (LSW) confirmed that no fax confirmation pages were retained and acknowledged that if the report is not generated correctly, the information is not accurate. An email from the Ombudsman confirmed that no notification was received for either resident's hospital transfer. The facility's policy requires that in emergent situations, notice to the LTC Ombudsman must be sent as soon as practicable, including in the form of a monthly list of residents.
Failure to Complete Neurological Assessments After Unwitnessed Falls
Penalty
Summary
The facility failed to complete neurological assessments following unwitnessed falls for a resident with severe cognitive impairment and multiple medical conditions, including a progressive neurological condition and repeated falls. The resident experienced several unwitnessed falls over a period of time, and although neurological assessments were initiated, they were not completed as required. The facility's protocol for neurological assessments following unwitnessed falls includes checks at specific intervals, but documentation was missing for these assessments on multiple occasions. Interviews with facility staff, including an LPN manager and the assistant director of nursing, confirmed that the neurological assessments were not thoroughly completed, with missing documentation on the flow sheets. The staff acknowledged the importance of completing these assessments to monitor for potential head injuries, especially in cases of unwitnessed falls. Despite the facility's policy requiring comprehensive neurological assessments, the policy document was not provided upon request.
Failure in Dialysis Care Coordination
Penalty
Summary
The facility failed to ensure proper coordination of dialysis care for a resident who required such services. The resident, identified as having intact cognition and independence in all activities of daily living, had diagnoses including end-stage renal disease and was dependent on renal dialysis. Despite having a provider order indicating dialysis treatments three times a week, the resident reported that the facility never sent any paperwork with him to his dialysis appointments. This was confirmed by an LPN who stated that although a communication sheet was usually sent with residents, there were no such sheets for this resident, and none had been sent with him. Further investigation revealed that the health unit coordinator confirmed the absence of communication between the facility and the dialysis center for the past five years. The resident reportedly refused to take or bring back any communication sheets, considering dialysis his personal responsibility. The facility's policy required ongoing communication and collaboration with the dialysis facility, including sending a dialysis binder with essential information to each appointment. However, this protocol was not followed, leading to a lack of documented evidence of collaboration and communication as required by the facility's agreement with the dialysis services.
Failure to Reassess PRN Psychotropic Medications
Penalty
Summary
The facility failed to ensure that the use of PRN psychotropic medications was limited to 14 days or had a physician-specified, time-limited order for two residents under hospice care. Resident R74, who had moderate cognitive impairment and multiple diagnoses including anxiety disorder and depression, had an open-ended order for Lorazepam 0.5 mg PRN every four hours for anxiety, initiated on June 14, 2024. The medication was used four times in July without a reassessment or a stop date. Similarly, Resident R85, with severe cognitive impairment and various diagnoses including depression and anxiety, had an open-ended order for Lorazepam 0.5 mg PRN every four hours, initiated on June 21, 2024, and used twice in July without reassessment or a stop date. Interviews with facility staff, including a registered nurse case manager, a licensed practical nurse case manager, the assistant director of nursing, and a consultant pharmacist, revealed a lack of awareness and adherence to the requirement for reassessment and documentation of PRN psychotropic medications every 14 days. The facility's Psychoactive Medication Use policy, reviewed in August 2023, stipulated that PRN psychotropic medication orders must be reevaluated after 14 days, with a documented rationale and specified duration. However, this policy was not followed, leading to the deficiency in medication management for the residents involved.
Failure to Assist Resident in Obtaining Dental Services
Penalty
Summary
The facility failed to assist in obtaining routine dental services for a resident who was cognitively intact and able to express her needs. The resident's quarterly Minimum Data Set (MDS) indicated she required supervision and verbal cues for oral care, but did not show any dental concerns. Despite expressing interest in seeing a dentist and not recalling any dental appointments since admission, the resident's medical record lacked an oral assessment or referral for a dental evaluation. The care plan directed staff to assist with oral care and schedule dental exams as needed, but these actions were not taken. Interviews with facility staff revealed that the facility had an in-house dental provider, and the process for dental referrals involved obtaining consent from the resident or family. The Licensed Practical Nurse (LPN) responsible for coordinating dental referrals confirmed that the resident's record lacked a dental consent and that the resident had not expressed a desire to see the dentist. However, the resident later signed the consent, and her family was contacted. The Assistant Director of Nursing (ADON) confirmed that the resident had not received a dental referral or examination since admission, despite the facility's policy to assess dental needs upon admission and make appropriate referrals.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure enhanced barrier precautions were used for a resident reviewed for infection control. The resident, who had intact cognition, required assistance with dressing and transfers, and had multiple diagnoses including surgical amputation, diabetes, osteomyelitis, MRSA, a colostomy, and chronic ulcers. The care plan indicated the resident met the criteria for enhanced barrier precautions, requiring staff to don gown and gloves during high-contact activities. However, a nursing assistant was observed entering the resident's room without donning a gown, despite signage indicating enhanced barrier precautions and gowns being available outside the room. The nursing assistant provided morning hygiene care without wearing a gown, believing it was only necessary if the resident had an active infection like COVID. Additionally, a registered nurse was observed failing to remove their gown before exiting the resident's room after completing a medication pass. The nurse acknowledged the mistake when prompted, admitting they should have removed both gloves and gown before leaving the room to prevent infection spread. The assistant director of nursing and the infection preventionist both stated that staff were expected to remove gloves and gowns before exiting rooms with enhanced barrier precautions. The facility's policy indicated that personal protective equipment should be removed before leaving the work area.
Failure to Post Daily Staffing Information
Penalty
Summary
The facility failed to ensure the required staffing information was posted daily, which had the potential to affect all 112 residents and their visitors. During a review of staff posting documentation from June 3, 2024, through July 18, 2024, the facility could not provide evidence of staff postings for several specific dates, including weekends and a holiday period. On July 18, 2024, the staffing manager confirmed that staff postings were not being done on weekends. The administrator was unaware of this lapse and stated that their expectation was for the postings to be completed daily, as per the facility's Staffing Hours Posting Policy, which was last revised in January 2015.
Failure to Implement Pressure Ulcer Care Plan
Penalty
Summary
The facility failed to ensure that assessed and/or care-planned interventions for pressure ulcer care were implemented for a resident who was at risk for additional and/or worsened pressure ulcers. The resident, who was cognitively intact and required substantial assistance with mobility, had a stage 3 pressure ulcer on the left heel and a deep tissue injury on the right heel. Despite care plans and treatment orders directing the use of heel-protecting boots while the resident was in bed and in a wheelchair, these interventions were not consistently followed by the staff. On multiple occasions, the resident was observed without the required heel-protecting boots while seated in a wheelchair, with his feet resting on the wheelchair pedals. Interviews with staff revealed a lack of awareness and adherence to the care plan. One LPN was unsure of the resident's ulcer treatments and interventions, and a nursing assistant admitted to not replacing the boots after morning care, despite knowing the resident had skin integrity concerns. The group sheets used by the nursing assistants did not include all necessary interventions, and the staff did not consistently review the care plans or Kardexes. The Director of Nursing acknowledged that the nursing assistants were updated on pressure ulcers during daily huddles but admitted that not all interventions were included on the group sheets. The responsibility to ensure the implementation of the care plan and treatment orders was placed on the nurses. The failure to consistently apply the heel-protecting boots as directed in the care plan and treatment orders led to the resident's pressure ulcers not being adequately managed, increasing the risk of further skin breakdown and complications.
Inconsistent Pressure Ulcer Prevention and Care for At-Risk Resident
Penalty
Summary
The facility failed to ensure comprehensive assessments were consistently completed and interventions were provided to prevent recurrent pressure ulcers for a resident (R13) with a history of facility-acquired stage 3 pressure ulcers. Despite being identified as at risk for pressure ulcers, R13's care plan did not include a turning/repositioning program, which is crucial in preventing pressure ulcers. The resident had multiple pressure ulcers, including on the right heel, left coccyx, and right buttock, with varying stages of healing and recurrence. The facility's lack of consistent interventions, such as floating heels in bed, off-loading the wound, and implementing a turning/repositioning program, led to the development of new pressure ulcers on R13's right heel. Documentation revealed discrepancies in the care provided to R13, with instances where the resident's heels were not properly floated or protected, despite physician orders and care plan directives. Family members raised concerns about lapses in care, including prolonged periods without diaper changes or repositioning, indicating a failure to adhere to the established care plan. Observations on multiple occasions showed inadequate positioning of R13's heels, leading to pressure on the affected areas and potential harm. The facility's policies emphasized the importance of daily skin observations, weekly skin audits, and individualized turning and repositioning schedules to prevent pressure ulcers, all of which were not consistently implemented in R13's care. During assessments and observations, healthcare providers noted issues such as redness, scabbing, and tissue damage on R13's heels, indicating the progression of pressure ulcers. Despite these findings, there were gaps in documentation, with incomplete wound assessments and lack of reporting on skin issues in the weekly skin checks. The facility's failure to accurately document and address R13's pressure ulcers, provide appropriate interventions, and ensure consistent monitoring and care in line with the established protocols resulted in the recurrence and development of new pressure ulcers, particularly on the right heel.
Failure to Ensure Dignified Care for Residents
Penalty
Summary
The facility failed to ensure a dignified living experience for two residents, R1 and R13, as observed through video footage and interviews. R1, who has multiple sclerosis, vascular dementia, and hemiplegia, was seen crying and grimacing during care. The LPN attending to R1 spoke loudly and used strong body language, which was distressing to R1. Additionally, R1 was exposed to the hallway and courtyard while on the commode, compromising her privacy and dignity. R1 expressed frustration that staff did not listen to her preferences, including proper leg positioning during care. R1's family member also reported concerns about staff yelling and not respecting R1's needs and preferences, further highlighting the lack of dignified care provided to R1. R13, who has severe cognitive impairment and requires maximal assistance for daily activities, was also subjected to undignified care. R13's family member reported that R13 was left in the same nightgown and socks for several days and that staff failed to follow the care plan. Video footage showed that R13 was left with an unopened breakfast tray for over an hour, and when the tray was finally placed within reach, the food was cold. Additionally, R13's nonverbal expressions of discomfort during a transfer were ignored by staff, further compromising her dignity and care. The facility's policies on resident rights and dignity were not adequately enforced, as evidenced by the repeated grievances and care concerns reported by the residents' family members. The Director of Nursing acknowledged that staff should follow up-to-date care plans and treat residents with dignity and respect, but the facility failed to ensure that these standards were consistently met. The lack of individualized care and respect for residents' preferences and needs led to a failure in maintaining a dignified living experience for R1 and R13.
Failure to Implement Toileting Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive toileting care plan for a resident (R13) who was always incontinent of both bowel and bladder. Despite the care plan specifying a routine for toileting and the use of specific incontinence products, staff did not consistently follow these directives. Observations and interviews revealed that R13 was not toileted according to the scheduled times, and the appropriate incontinence products were not used, leading to prolonged periods without being changed and the use of incorrect briefs that did not meet the resident's needs. R13's care plan included detailed instructions for toileting and incontinence management, such as offering toileting/bedpan at specific times throughout the day and night and using green overnight briefs for better moisture absorption. However, documentation and staff interviews indicated that these interventions were not consistently implemented. For instance, R13 was observed to be left unchanged for extended periods, and staff admitted to missing scheduled toileting times due to being busy. Additionally, the correct type of briefs specified in the care plan was not used, as staff reported using gray briefs instead of the green overnight briefs. Family members also expressed concerns about the lack of adherence to the care plan, noting instances where R13 was not checked or changed for several hours. Video footage and email communications from the family corroborated these concerns, showing significant gaps in care. The facility's management acknowledged the discrepancies and the potential for skin breakdown due to missed toileting times and improper use of incontinence products. Despite the care plan's clear directives, the facility failed to ensure that staff followed through with the necessary interventions to meet R13's needs.
Improper Use of Mechanical Lifts and Wander-Guard System Failures
Penalty
Summary
The facility failed to use mechanical standing lifts in accordance with manufacturer recommendations for two residents, leading to unsafe transfer practices. One resident with multiple sclerosis and hemiplegia was observed being transferred with an incorrect harness size and left unattended on a commode while attached to a mechanical lift. The resident was also seen struggling to reach a call light, and the commode used was unstable due to improper setup. Staff failed to follow proper procedures, leaving the resident in a potentially dangerous position and using equipment that was not fit for use. Another resident with severe cognitive impairment was also subjected to improper use of mechanical lifts. The resident's family member reported ongoing issues with the use of mechanical lifts, including a specific incident where the resident was left in pain due to incorrect strap placement. Video footage confirmed that staff did not follow proper procedures, leading to the resident being in a V-like position and experiencing significant discomfort. The facility's staff were observed not applying the lower leg strap and not ensuring the resident's feet were on the platform of the lift. Additionally, the facility failed to ensure the wander-guard system was operational to prevent elopement for three residents. One resident was able to elope from a secured unit due to the wander-guard doors not locking when alarmed. Another resident's wander-guard was found to have a low battery, and the system did not trigger when the resident approached the door. The maintenance director demonstrated that the system's auditory alert was only audible at the nurses' station and not throughout the unit, leading to a failure in preventing elopement. Staff were not adequately checking the functionality of the wander-guard devices, relying solely on the blinking light indicator, which was inconsistent with the system's actual performance.
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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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