Auburn Home In Waconia
Inspection history, citations, penalties and survey trends for this long-term care facility in Waconia, Minnesota.
- Location
- 594 Cherry Drive, Waconia, Minnesota 55387
- CMS Provider Number
- 245583
- Inspections on file
- 15
- Latest survey
- November 25, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Auburn Home In Waconia during CMS and state inspections, most recent first.
A resident with impaired cognition and serious medical conditions had an updated POLST indicating DNR status, but staff reference materials and the care plan incorrectly listed the resident as full code. Multiple staff confirmed they would have initiated CPR based on these inaccurate documents, resulting in a failure to honor the resident's advance directive.
Grievance forms and procedures were not posted in prominent locations, and residents were unaware of how to file grievances. Staff confirmed that forms were only available in the social service office, and the facility's policy lacked clear instructions for anonymous or independent grievance submission.
Surveyors found that food items were not properly labeled, dated, or discarded after expiration, and kitchen and kitchenette areas were not maintained in a clean and sanitary condition. The dietary manager confirmed that food storage and cleaning procedures were not consistently followed, with undated, uncovered, and expired food items present and visible spills and crumbs in multiple areas.
Staff failed to use required PPE during high-contact care for a resident with an indwelling catheter under enhanced barrier precautions, and did not perform hand hygiene or use proper technique when handling food and beverages during dining service. Staff lacked training on EBP, PPE use, and safe food handling, and facility policies did not address these areas, resulting in infection control deficiencies affecting all residents.
A resident with multiple chronic conditions received Bactrim DS for an extended period without appropriate review or documentation of ongoing need. Staff interviews revealed that the antibiotic was not monitored under an antibiotic stewardship program, and the facility had not established a process for regular review with the consultant pharmacist. The facility also lacked an infection preventionist to oversee antibiotic use, and relevant policies were not provided upon request.
Following the resignation of the infection preventionist, the DON and two nurse managers assumed infection control duties without having completed specialized infection prevention and control training, as required by facility policy. This lack of training was confirmed by interviews with the DON, a nurse manager, and the administrator, potentially impacting all residents.
A resident with multiple health conditions and a history of falls experienced several incidents where they were found on the floor. Although the resident's emergency contact or guardian was sometimes notified, there was no documentation that the provider was informed of these falls. Staff and DON interviews confirmed that provider notification was expected, but the facility's policy only required it under certain conditions, leading to missed notifications.
A resident with impaired cognition and multiple health conditions was found to have significant bruising of unknown origin on two occasions. Facility staff, including LPN, RN, DON, and the administrator, were unaware of the injuries, and no investigation or report to the State Agency was completed as required. The care plan lacked documentation on skin care and monitoring, and the facility's reporting policy was not provided when requested.
A resident with multiple health conditions and impaired cognition developed significant bruises of unknown origin on two occasions. Despite documentation of these injuries, staff including LPNs, RNs, the DON, and the administrator were unaware of the bruises and did not initiate an investigation or incident report as required. The care plan lacked documentation on skin care and monitoring, and the facility's policy on reporting and investigation was not provided.
A resident with impaired cognition and multiple chronic conditions developed several large bruises of unknown origin over several months. The care plan lacked documentation on skin care and monitoring, and nursing staff, including LPNs, RNs, and the DON, were unaware of the bruises. Required incident reports, comprehensive assessments, and investigations were not completed, and the facility could not provide a policy on comprehensive assessments.
A resident with impaired cognition and multiple comorbidities experienced repeated falls, but staff did not complete fall scene investigations or update fall prevention interventions as required. Despite the resident's need for supervision and assistance, documentation and staff interviews confirmed that after each fall, there was no assessment of the root cause or adjustment to the care plan, contrary to facility policy.
A resident with chronic heart failure, chronic kidney disease, and atrial fibrillation received Bactrim DS for an extended period without a documented diagnosis or ongoing need. Staff interviews confirmed the antibiotic was not reviewed monthly, and the facility lacked an active antibiotic stewardship program and infection preventionist to monitor unnecessary medication use.
Three residents who required assistance with ADLs, including shaving, were observed with significant facial hair growth and reported a preference for daily shaving. Staff were unaware of individual grooming preferences and typically provided shaving only on bath days, which occurred once a week. The DON and RN expected daily shaving, but this was not consistently practiced, and no grooming policy was available.
Survey results and plans of correction for the past three years were not readily accessible to residents or visitors. The survey binder only contained the most recent results without the required plan of correction, and previous years' documents were missing. The administrator and DON confirmed this was their standard process, and no policy on survey inspection results was available.
Failure to Accurately Document and Communicate Advance Directives
Penalty
Summary
The facility failed to ensure that a resident's advance directives were accurately documented and reflected the resident's current wishes. Specifically, a resident with moderately impaired cognition and multiple medical diagnoses, including atrial fibrillation, anemia, and coronary artery disease, had an updated Physician's Order for Life Sustaining Treatment (POLST) indicating a Do Not Resuscitate (DNR) status, as signed by a family member and the medical provider. However, the resident's care plan did not document resuscitation status, and both the report form used by staff and the three-ring binder at the nurses' station incorrectly indicated that the resident wanted cardiopulmonary resuscitation (CPR). Multiple staff interviews confirmed that in the event of an emergency, they would have referred to these inaccurate documents and initiated CPR, contrary to the resident's documented wishes in the electronic health record (EHR) and the updated POLST. The Director of Nursing (DON) acknowledged the discrepancy between the EHR, the report form, and the binder, confirming that staff would have followed the incorrect code status and performed CPR against the resident's wishes. The facility's policy required that the POLST be documented in both the EHR and the household binder, and that code status be reviewed at least quarterly and documented in the medical record. Despite these requirements, the lack of accurate and consistent documentation across all sources led to the deficiency, placing the resident at immediate risk of receiving unwanted life-sustaining treatment.
Removal Plan
- All residents' records were reviewed to ensure the POLST form and the electronic health records were updated to ensure resident's wishes for advance directives were accurate.
- R29's three ring binder was updated to match the current POLST and the code status for all residents was removed from the report form.
- All current licensed staff were educated on the policy for advance directives, updating the POLST, the EHR, and the three ring binder to reflect the resident's wishes.
- A process was implemented to assure all other nursing staff completed mandatory education prior to the start of their next shift, by notification of required education via phone/text. All staff would sign off once education had been completed.
- The advance directive policy was reviewed and determined no changes were required.
Grievance Forms and Procedures Not Accessible to Residents
Penalty
Summary
The facility failed to ensure that grievance forms and procedures were posted in prominent locations throughout the building, making it difficult for residents and their representatives to file grievances, including anonymously. During a resident council meeting, four residents reported being unaware of how to file a grievance. Observations by the surveyor confirmed that grievance forms were not visible or accessible in common areas of the facility. Interviews with the administrator, DON, SSD, and an RN revealed that grievance forms were kept in the social service office and were not available in other areas for residents or their representatives to access independently or anonymously. The facility's grievance policy did not provide clear instructions on how to file grievances anonymously or how to obtain a grievance form without staff assistance. This lack of accessible information and forms directly contributed to residents' lack of awareness and ability to file grievances.
Deficient Food Labeling, Storage, and Kitchen Sanitation
Penalty
Summary
Surveyors observed multiple deficiencies in food storage, labeling, and kitchen sanitation during a tour of the facility's kitchen and kitchenettes. Food items such as a large pan of fruit crisp and a tray of fruit cups were found covered but not dated in the walk-in refrigerator. Several refrigerators in the kitchenettes contained undated or expired food items, including sandwiches, Caesar dressing, Boost supplement, pistachio pudding, tomato slices, lettuce, and butter. Some items were not properly covered, and others were kept beyond the facility's stated policy of discarding unused food after five days. The dietary manager confirmed these findings and acknowledged that items should have been dated and discarded as per policy. Additionally, the kitchen and kitchenette areas were found to be unsanitary, with stainless steel cupboards and counters showing smears, spots, fingerprints, and crumbs. Refrigerators had irregular shaped spills and crumbs on shelves and bottoms. The dietary manager was unable to produce a cleaning schedule for the main kitchen and confirmed that cleaning expectations were not being met. The facility's policy required proper covering, dating, and timely disposal of food, as well as regular cleaning to maintain food safety, but these procedures were not consistently followed.
Deficient Infection Control: PPE and Food Handling Lapses
Penalty
Summary
The facility failed to ensure appropriate use of personal protective equipment (PPE) and safe food handling practices, resulting in deficiencies in infection prevention and control. During an observation, a nursing assistant assisted a resident with an indwelling catheter, who was under enhanced barrier precautions (EBP), by changing the catheter drainage bag and helping the resident get dressed. The nursing assistant only wore gloves and did not use a gown as required for high-contact care activities under EBP. The assistant was unaware of the resident's EBP status and had not received adequate training on PPE use for EBP. Documentation in the resident's care plan and care area assessment also lacked references to EBP requirements, despite the presence of an EBP sign and PPE bin outside the resident's room. Additionally, during a dining observation, another nursing assistant placed clothing protectors on multiple residents, touched their skin, and then proceeded to handle food and beverages without performing hand hygiene. The assistant touched the top rims of glasses while pouring and serving drinks, which could lead to contamination. The assistant admitted to not having received training on proper food and utensil handling and was unaware of the infection risks associated with touching the rims of glasses. The director of nursing confirmed that staff had not received formal training on EBP or PPE use beyond posted signs and acknowledged the expectation for proper PPE use and food handling to prevent infection. Facility policies reviewed did not include guidance on EBP or specific PPE use, and the hand hygiene policy referenced CDC recommendations but did not address the observed lapses. A requested policy on handling food and utensils was not provided. These deficiencies had the potential to affect all residents in the facility.
Failure to Monitor and Review Antibiotic Use
Penalty
Summary
The facility failed to establish and implement a process for reviewing antibiotic use, resulting in the ongoing administration of Bactrim DS to a resident without appropriate oversight. The resident, who had diagnoses including chronic heart failure, chronic kidney disease, and atrial fibrillation, was receiving Bactrim DS three times a week due to high-dose steroid use. However, there was no documentation of the diagnosis or ongoing need for the antibiotic on the medication administration record, and the order had not been reviewed for appropriateness since its initiation. Interviews with nursing staff, the pharmacy consultant, and the nurse practitioner confirmed that the antibiotic had not been reviewed as part of an antibiotic stewardship program, and the facility had not established a process for monthly antibiotic review with the consultant pharmacist. Further, the nurse practitioner noted that the Bactrim order was not present on the current medication list at the clinic, and if it had been, it would have been reviewed for possible discontinuation, especially since the resident's steroid use had decreased. The director of nursing confirmed that the resident was not being monitored for antibiotic stewardship and that the facility lacked an infection preventionist to track unnecessary antibiotic use. Requested policies on medication administration and unnecessary medication use were not provided, and the existing antibiotic stewardship policy identified responsibilities for oversight that were not being fulfilled.
Untrained Staff Assigned to Infection Preventionist Role
Penalty
Summary
The facility failed to ensure that the acting infection preventionist (IP) had completed specialized training in infection prevention and control. After the resignation of the previous IP, the director of nursing (DON) and two nurse managers assumed the infection control responsibilities. However, none of these individuals were enrolled in the Centers for Disease Control (CDC) infection preventionist course or any other specialized IP training at the time of the survey. This was confirmed through interviews with the DON, one of the nurse managers, and the facility administrator, all of whom acknowledged the lack of required training for those currently fulfilling the IP role. The facility's own infection control policy requires effective oversight of the Infection Prevention and Control program, including the development of an education component and training in infection prevention and control practices to ensure compliance with facility, state, and federal regulations. Despite this policy, the individuals responsible for the infection control program had not received the necessary specialized training, potentially affecting all 32 residents in the facility.
Failure to Notify Provider of Resident Falls
Penalty
Summary
The facility failed to provide timely notification to a provider regarding changes in condition related to falls for a resident with a history of falls and multiple comorbidities, including moderately impaired cognition, type two diabetes with chronic kidney disease, anemia, coronary artery disease, arthritis, and anxiety. The resident required supervision or assistance with mobility and toileting, as documented in the care plan. Progress notes revealed multiple incidents where the resident was found on the floor, including being found next to the bed and in front of the toilet on several occasions. While documentation showed that the resident's emergency contact or guardian was notified after some falls, there was a lack of documentation indicating that the provider was notified of these incidents. Interviews with nursing staff and the Director of Nursing confirmed that staff were expected to ensure resident safety after a fall, complete incident reports, and notify both the provider and the resident's representative. However, the Director of Nursing verified that the provider had not been updated on the resident's falls as required. The facility's policy on managing resident falls required provider notification only if injury was suspected, a head strike occurred, or the resident was on anticoagulants, and did not specify provider notification for all falls regardless of injury. This contributed to the failure to notify the provider in a timely manner following the resident's falls.
Failure to Report Bruises of Unknown Origin to State Agency
Penalty
Summary
The facility failed to report a bruise of unknown origin to the State Agency for a resident who was reviewed for falls. The resident had moderately impaired cognition and multiple medical diagnoses, including diabetes, chronic kidney disease, anemia, coronary artery disease, arthritis, and anxiety. The care plan identified mobility and self-care deficits but did not include documentation on skin care and monitoring. Progress notes documented two separate incidents of significant bruising to the resident's hip and sacral areas, with the resident unable to recall how the injuries occurred. Despite these findings, there was no evidence of an investigation into the causative factors or analysis of the bruises. Interviews with facility staff, including an LPN, RN, DON, and administrator, revealed that none were aware of the resident's bruises. Staff stated that their protocol would be to report such injuries to supervisory staff and complete an investigation report, but this was not done. The DON confirmed that a report to the State Agency had not been filed, as required. Additionally, the facility's policy on reporting was requested but not provided.
Failure to Investigate Bruises of Unknown Origin
Penalty
Summary
The facility failed to investigate and respond appropriately to bruises of unknown origin for a resident with multiple medical conditions, including moderately impaired cognition, diabetes, chronic kidney disease, anemia, coronary artery disease, arthritis, and anxiety. The resident required supervision and assistance with mobility and self-care. Despite documentation in progress notes of significant bruising on two separate occasions, there was no evidence that an investigation into the cause of the bruises was conducted. The resident was unable to recall how the injuries occurred, and the care plan lacked documentation on skin care and monitoring. Interviews with facility staff, including an LPN, RN, DON, and administrator, revealed that none were aware of the resident's bruises, and all confirmed that no investigation or incident report had been completed. The facility's policy on reporting and investigation was requested but not provided. The expectation, as confirmed by the DON, was that staff should complete an incident report, notify the physician and resident representative, and follow up with an investigation, none of which occurred in this case.
Failure to Assess and Monitor Bruises of Unknown Origin
Penalty
Summary
The facility failed to comprehensively assess and monitor bruises of unknown origin for a resident with moderately impaired cognition and multiple medical conditions, including diabetes, chronic kidney disease, anemia, coronary artery disease, arthritis, and anxiety. The resident required supervision and assistance with mobility and self-care. The care plan did not include documentation on skin care or monitoring, despite the resident's risk factors. Progress notes documented several large bruises on the resident's hips, buttock, and lower back over several months, with the resident often unable to recall the cause of the injuries. There was no evidence of comprehensive assessments or ongoing monitoring of these bruises in the resident's records. Interviews with nursing staff and the director of nursing revealed that they were unaware of the resident's bruises and confirmed that required incident reports, comprehensive assessments, and investigations had not been completed. The facility was unable to provide a policy on comprehensive assessments when requested. The lack of assessment and monitoring was acknowledged by staff as contrary to expectations for resident safety and care.
Failure to Complete Fall Scene Investigations and Update Interventions After Multiple Resident Falls
Penalty
Summary
The facility failed to provide a comprehensive assessment and review or adjustment of fall prevention interventions for a resident with a history of multiple falls. The resident, who had moderately impaired cognition and multiple diagnoses including diabetes, chronic kidney disease, coronary artery disease, arthritis, and an intellectual disorder, required supervision and assistance with mobility and toileting. Despite these needs, documentation revealed that after each of several falls, there was no evidence of a fall scene investigation to determine the root cause or to update the care plan with new or revised interventions. Progress notes spanning several months detailed repeated incidents where the resident was found on the floor in various locations, including the bathroom and next to the bed. In each instance, staff either assisted the resident after the fall or reminded them to use the call light, but there was a consistent lack of documented fall scene investigations or changes to the care plan. Some falls resulted in minor injuries, such as a contusion and pain, but still did not prompt a documented assessment or intervention review. Interviews with staff, including an LPN, RN, PT, and the DON, confirmed that the expected protocol was to complete a fall scene investigation after each fall and to implement or update interventions on the care plan. However, staff acknowledged that these steps were not taken following the resident's falls. The facility's own policy required immediate assessment and intervention review after a fall, but this was not followed, as evidenced by the lack of documentation and care plan updates.
Failure to Review and Discontinue Unnecessary Antibiotic Use
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications. One resident with diagnoses of chronic heart failure, chronic kidney disease, and atrial fibrillation was receiving Bactrim DS 800-160 mg three times a week since mid-January, with the order initiated due to high-dose steroid use. However, there was no documented diagnosis or ongoing indication for the continued use of this antibiotic on the medication administration record. Physician's orders and oncology notes were requested but not provided, and the medication had not been reviewed for necessity since its initiation. Interviews with facility staff, including a registered nurse, pharmacy consultant, nurse practitioner, and the director of nursing, confirmed that the resident's antibiotic use was not being monitored or reviewed monthly as required. The pharmacy consultant stated that an antibiotic stewardship program had not yet been established, and the nurse practitioner noted the medication was not on the current clinic medication list and should have been discontinued as steroid use decreased. The director of nursing acknowledged the lack of monthly review and monitoring for unnecessary medication use, and the facility did not have an infection preventionist to track antibiotic use. The facility's policy on medication administration and unnecessary medication use was requested but not received.
Failure to Provide Routine Grooming and Shaving Assistance
Penalty
Summary
The facility failed to provide adequate assistance with routine grooming care, specifically facial hair removal, for three residents who required help with activities of daily living (ADLs). Observations revealed that each of these residents had significant facial hair growth, despite their care plans indicating a need for moderate to maximal assistance with personal hygiene, including shaving. Interviews with the residents and their representatives confirmed that daily shaving was preferred, and the presence of facial hair was bothersome to them. Staff interviews indicated a lack of awareness regarding the residents' grooming preferences and the frequency with which shaving should be offered. Multiple nursing assistants, some of whom were new to the facility, reported that shaving was typically performed only on residents' bath days, which occurred once a week. None of the nursing assistants interviewed were aware of the specific preferences of the residents regarding shaving frequency, and they assumed that additional shaving would only be provided upon request. Further interviews with the RN and DON revealed that the expectation was for residents to be shaved every morning, but this was not being consistently implemented. The DON was unaware if residents' shaving preferences were assessed upon admission or included in their care plans. Additionally, when requested, the facility was unable to provide a policy for grooming or ADL care, indicating a lack of formal guidance for staff regarding these essential care practices.
Survey Results and Plan of Correction Not Accessible
Penalty
Summary
The facility failed to ensure that three years of survey results and corresponding plans of correction were readily accessible to residents or visitors. During an observation, the survey results binder was found on a shelf in a sitting area by the front door, but it only contained the most recent survey results and lacked the required plan of correction for those results. Additionally, the binder did not include survey results or plans of correction from previous years as required. The administrator and DON confirmed that their process was to keep only the most recent survey results in the binder and not the past three years. When asked, the facility was unable to provide a policy regarding survey inspection results.
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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