Auburn Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Chaska, Minnesota.
- Location
- 501 Oak Street, Chaska, Minnesota 55318
- CMS Provider Number
- 245604
- Inspections on file
- 21
- Latest survey
- April 2, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Auburn Manor during CMS and state inspections, most recent first.
A resident with diabetes and cognitive impairment received insulin despite physician orders to hold the medication for blood sugar levels below 150 mg/dl. Multiple nurses administered insulin when the resident's blood sugar was below this threshold, due in part to incomplete review of electronic medical records. This resulted in severe hypoglycemia, requiring emergency intervention and hospitalization.
The facility failed to provide sufficient nursing staff, resulting in deficiencies such as inadequate pressure ulcer prevention, insufficient assistance with activities of daily living, and dignity concerns. Residents and family members reported long wait times for care, and staff confirmed that staffing levels were insufficient to meet resident needs. Observations showed call lights often went unanswered, highlighting the facility's inability to provide timely care.
The facility failed to secure medication carts, leaving them unlocked and unattended in hallways across multiple units. Staff admitted to neglecting to lock the carts, which contained potentially dangerous medications, despite the facility's policy requiring secure storage.
A resident was left exposed and nude on the toilet facing a courtyard window, compromising their dignity. The nursing assistant left the room without closing the blinds, leaving the resident feeling exposed. Another resident with an indwelling catheter was transported with an uncovered urine drainage bag, violating privacy standards. The facility's policy emphasizes maintaining resident privacy and dignity.
The facility failed to provide a SNFABN to a resident whose Medicare Part A coverage ended while they remained in the facility. Despite notices indicating the last covered day, the resident's medical record did not show that a SNFABN was given. A licensed social worker confirmed the oversight, acknowledging that the SNFABN had been missed. Additionally, a policy regarding SNFABNs was not received during the review.
A privacy breach occurred when an unattended laptop displaying sensitive information about three residents was left open in a facility. Staff members acknowledged the breach, noting that the information should not have been visible. The DON confirmed this was a HIPAA violation, as it exposed private resident information to unauthorized individuals.
A facility failed to maintain a comprehensive care plan for a resident at risk of pressure ulcers. The resident required assistance with ADLs and had a deep tissue injury upon admission. The care plan lacked specific interventions for pressure ulcer prevention and did not document ongoing assessments. Nursing staff interviews revealed a lack of communication and documentation regarding the resident's wound care needs.
A resident with severe cognitive impairment and dependent on staff for personal hygiene care did not receive routine bathing as scheduled. The care plan lacked specific bathing frequency, and staffing challenges led to inconsistencies in providing showers. Documentation was insufficient, with missing records of completed showers, contributing to the deficiency.
A facility failed to assess and address constipation concerns for a resident who reported feeling constipated. Despite the resident's request for proactive interventions, staff only provided medication upon request without discussing other options like prune juice or fiber supplements. The resident's care plan lacked ongoing medications for regular bowel movements, and the facility's bowel management protocol did not provide guidance on comprehensive assessment or documentation.
The facility failed to prevent pressure ulcers in two high-risk residents. One resident was left lying on her back for extended periods without repositioning, contrary to care instructions. Another resident was observed sitting in a recliner for hours without repositioning. Staff were unaware of the last repositioning times, and there was no documentation in the EMR. The DON acknowledged the lack of a system to ensure regular repositioning and missing documentation for refusals.
Two residents with severe cognitive impairments experienced multiple falls without appropriate updates to their care plans or implementation of new interventions. Despite the facility's policy requiring IDT review and intervention updates, these were not consistently completed, leading to a deficiency in fall management.
A facility failed to assess a resident for entrapment risk and did not attempt alternatives before installing grab bars on their bed. The resident, with moderately impaired cognition and requiring substantial assistance, had grab bars affixed without documented attempts of alternative methods. Staff interviews revealed that grab bars were applied on admission without assessing individualized entrapment risks, contrary to facility policy.
A facility failed to limit and re-evaluate the use of PRN Ativan for a resident with severe cognitive impairment and anxiety. The medication was administered without a stop date or timely re-evaluation, and non-pharmacological interventions were not documented. Staff interviews revealed lapses in communication and review processes, leading to the deficiency.
A facility failed to offer a recommended pneumococcal vaccination to a resident with dementia and high blood pressure, as per CDC guidelines. The resident's medical record showed previous vaccinations but lacked evidence of the PCV20 vaccine being offered or administered. An LPN, serving as the infection preventionist, confirmed the oversight, citing a lack of documentation and frequent work demands as reasons for the delay. The facility's policy required offering and documenting immunizations, which was not followed in this instance.
The facility inaccurately coded the MDS for four residents regarding restraint use, as grab bars were incorrectly marked as restraints despite not restricting movement. Additionally, a BIMS assessment was improperly completed for a resident, resulting in an incorrect summary score. The offsite MDS coordinator's reliance on incomplete records and lack of communication with onsite staff contributed to these errors.
A long-term care facility failed to implement a system to monitor antibiotic use, leading to inappropriate administration of antibiotics to a resident with multiple diagnoses, including pressure ulcers and diarrhea. The facility lacked comprehensive documentation and monitoring, as antibiotic stewardship logs were incomplete, and 72-hour antibiotic time outs were often not conducted. Interviews with staff revealed inconsistencies in following the facility's policies on antibiotic use and infection control.
The facility failed to implement a QAPI plan and address repeated quality deficiencies, potentially affecting all 50 residents. Despite holding quarterly QAPI meetings, the facility did not develop performance improvement projects or document corrections for identified issues. The DON stated that QAPI activities were on hold due to new management awaiting further instructions.
The facility failed to adhere to infection control practices, including proper management of catheter bags and ports, and the use of PPE and hand hygiene for residents on enhanced barrier precautions. Observations revealed a lack of signage and inconsistent use of PPE, with staff not following protocols for high-contact care activities, leading to potential risks of spreading multi-drug resistant organisms.
A resident with a history of falls and incontinence was left exposed in their room with the door open, visible from the hallway, when a nursing assistant left to put on PPE. The facility's policy required staff to ensure privacy by closing doors and keeping residents covered, which was not followed in this instance.
A facility failed to prevent accident hazards and assess fall risks for two residents. One resident, with cognitive impairment and hemiplegia, fell from a remote-controlled recliner without a safety assessment. Another resident, post-stroke and on fall precautions, fell while self-transferring, lacking documented interventions. Staff interviews revealed gaps in awareness and documentation of fall interventions, contrary to facility policy.
Two residents had grab bars installed on their beds without comprehensive assessments, discussions of risks and benefits, or informed consent. The facility relied on therapy recommendations and often completed necessary documentation after installation, contrary to policy requirements.
The facility failed to ensure dishware was safe and sanitary, as chipped and cracked dishes were observed in use. A resident reported the issue, and dietary staff had inconsistent practices regarding the disposal of damaged dishware. The facility's policy required immediate discarding of such dishware to prevent cuts and ensure sanitation.
Failure to Follow Insulin Administration Parameters Leads to Significant Medication Error
Penalty
Summary
A deficiency occurred when nursing staff failed to follow physician orders regarding insulin administration parameters for a resident with diabetes, dementia, and mild cognitive impairment. The resident had specific orders to hold insulin aspart if blood sugar (BS) was less than 150 mg/dl. Despite this, insulin was administered multiple times when the resident's BS was below the ordered threshold, including readings of 137, 97, 144, and 82 mg/dl. The medication administration record (MAR) reflected these administrations, and interviews with nursing staff revealed a lack of awareness or failure to review the full order details, which were located in a section of the electronic medical record that required additional navigation. The facility had recently implemented a new electronic medical record system, and some staff, including agency nurses, were not fully informed about how to access all relevant order parameters. As a result of these medication errors, the resident experienced severe hypoglycemia, becoming unresponsive with a BS as low as 32 mg/dl. Emergency interventions were required, including administration of glucagon and glucose gel, and the resident was ultimately transported to the hospital for further treatment. The hospital discharge summary confirmed admission for hypoglycemia and related complications. Interviews with facility staff, including the DON and pharmacist, confirmed that the insulin should have been held and that the incident constituted a significant medication error.
Inadequate Staffing Leads to Multiple Deficiencies in Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff and leadership to meet the needs of residents, resulting in several deficiencies. Observations, interviews, and document reviews revealed that the facility did not have enough staff to adequately care for residents, leading to issues such as pressure ulcer prevention failures, inadequate assistance with activities of daily living, and dignity concerns. Specific incidents included a resident being left exposed and nude on the toilet without privacy, and another resident with an indwelling catheter not receiving dignified care. Additionally, the facility did not reassess and implement proactive interventions to reduce the risk of falls for residents who had previously fallen. Residents and family members expressed concerns about the lack of staff and long wait times for care. Interviews with staff members, including a trained medication aide, licensed practical nurses, and a registered nurse, confirmed that staffing levels were insufficient to meet resident needs. Staff reported being unable to complete necessary tasks such as range of motion exercises and personal care due to being pulled to cover other duties. The facility's staffing coordinator and director of nursing acknowledged the staffing challenges, with the director noting that call lights were not being answered promptly, sometimes taking up to an hour. The facility's resident council meeting minutes from several months also highlighted ongoing concerns about inadequate staffing. During interviews, residents described long wait times for assistance, with one resident stating that it could take up to an hour for a call light to be answered. Observations during the survey showed that call lights were often ignored by staff, further indicating the facility's inability to provide timely care. The facility's assessment identified a high percentage of residents requiring total dependence on staff for mobility and other needs, yet the staffing plan did not adequately address these requirements.
Medication Cart Security Lapses
Penalty
Summary
The facility failed to ensure that medications were securely stored, as evidenced by multiple observations of unattended and unlocked medication carts in various units. On Eagle Lane, a medication cart was left unlocked and unattended in the hallway between two resident rooms. A registered nurse (RN-E) admitted to leaving the cart unsecured while attending to a resident who was calling for help. Similarly, on Bluejay Lane, an unlocked and unattended medication cart was observed in the hallway, with numerous residents and family members passing by. A licensed practical nurse (LPN-B) confirmed the cart was unlocked and subsequently secured it, acknowledging the importance of keeping medication carts locked to prevent unauthorized access. On Cardinal Lane, another unattended and unlocked medication cart was observed in the hallway. A registered nurse (RN-C) admitted to forgetting to lock the cart, emphasizing the importance of securing it due to the presence of potentially dangerous medications. The director of nursing (DON) reiterated that all unattended medication carts should be locked to prevent unauthorized access. The facility's policy on the storage of medications and biologicals mandates that all such items be securely stored in locked cabinets or carts, which was not adhered to in these instances.
Failure to Maintain Resident Dignity During Personal Care
Penalty
Summary
The facility failed to provide toileting and personal care in a dignified manner for a resident who was left exposed and nude on the toilet facing a window to the facility courtyard. The resident, who had intact cognition and required assistance with toileting and upper body dressing, was left alone by a nursing assistant who left the room to obtain supplies. The window blinds were not closed, leaving the resident exposed to the courtyard. A trained medication aide later entered the room and closed the blinds, noting the resident's discomfort. The resident expressed feeling exposed and having lost dignity during their stay at the facility. Additionally, the facility did not maintain dignity for a resident with an indwelling catheter. The resident, who had moderate cognitive impairment and was dependent on staff for toileting, was observed being transported in a wheelchair with a visible and uncovered urine drainage bag. The nursing assistant responsible for the transport acknowledged the importance of covering the bag for privacy but was unable to locate a privacy cover in the resident's room. The director of nursing confirmed that urine drainage bags should always be covered, and the facility policy emphasized the importance of maintaining resident privacy and dignity.
Failure to Provide SNFABN to Resident
Penalty
Summary
The facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) to a resident whose Medicare Part A coverage ended while they remained in the facility. The resident's Notice of Medicare Non-Coverage indicated that their last covered day under Medicare A was signed by a family member, but the SNFABN was not provided as the resident won an appeal. Despite a subsequent notice indicating a new last covered day, the resident's medical record did not show that a SNFABN was given before the Medicare Part A coverage ended. A licensed social worker confirmed the oversight, acknowledging that the SNFABN had been missed for the resident. Additionally, a policy regarding SNFABNs was not received during the review.
Resident Privacy Breach Due to Unattended Laptop
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of resident records, as observed during a survey. An unattended laptop was found displaying sensitive information about three residents, including their names, diagnoses, assistance needs, and other personal care details. This laptop was left open and unattended, allowing unauthorized personnel to potentially view the information. Multiple staff members, including nursing assistants and a trained medication aide, acknowledged the breach of privacy, noting that the information should not have been visible. The Director of Nursing confirmed that this incident constituted a violation of HIPAA regulations, as it exposed private resident information to unauthorized individuals. The facility's policy on HIPAA privacy was not adhered to, as staff failed to protect patient information appropriately.
Failure to Maintain Comprehensive Care Plan for Resident at Risk of Pressure Ulcers
Penalty
Summary
The facility failed to develop and maintain an individualized comprehensive care plan for a resident, identified as R42, who required staff assistance with activities of daily living (ADLs) and was at risk for pressure ulcers. The resident's Minimum Data Set (MDS) assessment indicated that R42 had intact cognition and required varying levels of assistance for personal hygiene, dressing, and mobility. Despite these needs, the care plan lacked specific interventions for pressure ulcer prevention and did not reflect the resident's history of pressure injury or the presence of a deep tissue injury upon admission. Observations and interviews revealed that R42 was seated in a wheelchair with a cushion and was aware of a sore on the bottom, which was being treated by staff. However, the care plan did not include necessary interventions such as the use of an air mattress or cushion in the wheelchair to prevent further pressure ulcer development. Additionally, the care plan did not document ongoing assessments or updates regarding the resident's pressure ulcer status, and there was a lack of evidence that the deep tissue injury had healed. Interviews with nursing staff indicated a lack of communication and documentation regarding the resident's wound care needs. Licensed Practical Nurse (LPN)-B, responsible for wound assessments, acknowledged that no further wound assessments had been completed after the initial assessment. The Director of Nursing (DON) confirmed that the care plan did not reflect the resident's care needs, including specific interventions for pressure ulcer prevention. The facility's policy on person-centered care planning required comprehensive care plans to be reviewed and revised as needed, but this was not adhered to in the case of R42.
Failure to Ensure Routine Bathing for Resident
Penalty
Summary
The facility failed to ensure routine bathing was completed in accordance with the identified wishes of a resident who was dependent on staff for bathing care. The resident, who had severe cognitive impairment and was dependent on staff for personal hygiene, reported not receiving her baths every week. Her care plan indicated a need for assistance with activities of daily living due to weakness and other medical conditions, but it lacked specific information on the frequency of bathing. Interviews with a nursing assistant revealed that the resident was scheduled for a twice-weekly shower, but staffing challenges, particularly during the summer months, often resulted in only quick bed baths being provided instead of showers. Documentation in the resident's medical record showed inconsistencies in recording completed showers. The Point of Care Response History for a 14-day period had two entries marked as 'Not applicable,' and progress notes indicated that a shower was not completed on one occasion without any rationale provided. The registered nurse manager confirmed the lack of documentation for the second weekly shower and acknowledged that staff did not consistently report issues with completing showers. The facility's standard ADL protocol did not include information on how completed baths or showers should be recorded or tracked, contributing to the deficiency in ensuring the resident's bathing needs were met.
Failure to Assess and Address Constipation Concerns
Penalty
Summary
The facility failed to adequately assess and address potential signs of constipation for a resident, identified as R41, who reported feeling constipated. Despite R41's admission Minimum Data Set (MDS) indicating no history of constipation, the resident expressed concerns about bowel irregularity and a desire for proactive interventions. The resident reported that staff provided medication upon request but did not discuss other options like prune juice or fiber supplements. The Continence Evaluation for R41 did not indicate any proactive measures for bowel management, and the care plan lacked ongoing medications to promote regular bowel movements. Interviews with staff revealed that R41 had requested a suppository and had experienced periods with multiple days between bowel movements. The Point Of Care (POC) Response History showed irregular bowel patterns, with some days having no recorded movements and others showing loose or formed stools. The Medication Administration Record (MAR) indicated the use of as-needed laxatives, but there was no evidence of a comprehensive reassessment to determine necessary proactive interventions. The registered nurse manager acknowledged the irregular bowel patterns and the use of as-needed laxatives but noted that no concerns had been reported to them. The facility's Protocol For Bowel Management required a bowel movement every 72 hours and stated that the primary physician should be informed if nursing intervention was needed three or more times in a month. However, the policy lacked guidance on assessing or documenting a comprehensive bowel management program, contributing to the deficiency in addressing R41's constipation concerns.
Failure to Prevent Pressure Ulcers in High-Risk Residents
Penalty
Summary
The facility failed to provide adequate care to prevent pressure ulcers for two residents identified as high risk. Resident R5, who was dependent on staff for all activities of daily living, was observed lying on her back for extended periods without being repositioned, despite care instructions requiring repositioning every two hours. Nursing staff, including a nursing assistant and an LPN, were unaware of when R5 was last repositioned, and there was no documentation in the electronic medical record (EMR) to confirm that repositioning had occurred. R5 expressed that she had not been turned since lunchtime, and staff interviews confirmed a lack of adherence to the care plan. Similarly, Resident R37, who had significant cognitive impairment and was also at high risk for pressure ulcers, was observed sitting in a recliner for several hours without repositioning. Nursing staff admitted that R37 was not on a turning and repositioning program, and there was no documentation of repositioning efforts in the EMR. The Director of Nursing acknowledged the absence of a system to ensure regular repositioning and the lack of documentation for refusals. The facility's policy on pressure ulcer prevention was requested but not provided, indicating a potential gap in policy adherence or availability.
Failure to Update Care Plans and Implement Fall Interventions
Penalty
Summary
The facility failed to comprehensively reassess and develop proactive interventions to reduce the risk of further falls and injury for two residents who had sustained falls. Resident R44, with severe cognitive impairment, had a history of falls prior to admission and continued to experience falls after admission. Despite multiple falls, the care plan for R44 was not updated with new interventions, and incident reports lacked documentation of any new strategies to prevent further falls. Interviews with staff revealed that fall reports were not consistently reviewed by the interdisciplinary team (IDT), and new interventions were not documented or implemented. Resident R26, also with severely impaired cognition, experienced an unwitnessed fall from his bed. Although the fall scene investigation form identified potential environmental factors and immediate interventions, the IDT review section was left blank, indicating a lack of follow-up. The care plan for R26 had not been updated with new interventions since a previous fall, and staff interviews confirmed that the expected updates to the care plan and nursing assistant care sheet were not completed. The facility's policy on managing resident falls required evaluation and analysis of fall risks and the implementation of interventions by the IDT. However, the policy was not followed, as evidenced by the lack of IDT review and updates to care plans following falls. Staff interviews highlighted challenges in completing fall reports and implementing new interventions due to staffing issues, which contributed to the deficiency in fall management.
Failure to Assess Entrapment Risk and Alternatives for Grab Bar Use
Penalty
Summary
The facility failed to comprehensively assess a resident, identified as R15, for entrapment risk and did not attempt alternatives before installing grab bars on the resident's bed. R15, who had moderately impaired cognition and required substantial assistance with transferring out of bed, was observed to have grab bars affixed to their bed. The facility's assessment for grab bar use, conducted upon R15's admission, did not document any alternative methods or products attempted prior to the installation of the grab bars. Additionally, the medical record lacked evidence of an assessment for individualized entrapment risk factors, such as R15's medical diagnosis, medications, cognition, or fall risk. Interviews with facility staff revealed that the grab bars were applied on admission without attempting alternatives due to the resident's weight and the need for two staff members to assist with turning in bed. The unit manager acknowledged that while the risks and benefits of grab bar use were reviewed with R15 and consent was obtained, individualized entrapment risk factors were not assessed. The director of nursing confirmed that a nursing assessment should be completed to determine the appropriateness of bedrails, but the facility's policy was not followed in this case, as the necessary assessments and documentation were incomplete.
Failure to Limit and Re-evaluate PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure the use of a PRN psychotropic medication was limited to a 14-day period and re-evaluated by the provider for a resident with severe cognitive impairment and anxiety. The resident, who was on hospice care, had an active order for PRN Ativan without a stop date, which was not reviewed or renewed by the provider within the required timeframe. The resident's Medication Administration Record showed that Ativan was administered twice, with both instances recorded as effective, but the progress notes lacked documentation of non-pharmacological interventions attempted prior to medication administration. Interviews with facility staff revealed that the registered nurse and consulting pharmacist were aware of the missing stop date and the need for re-evaluation, but the oversight occurred due to a lapse in communication and review processes. The consulting pharmacist acknowledged the need for a 14-day re-evaluation and had obtained a six-month extension for the medication. The registered nurse manager noted that the hospice agency should have ensured a stop date was listed, but this was not consistently done, leading to the deficiency.
Failure to Offer Pneumococcal Vaccination
Penalty
Summary
The facility failed to ensure that recommended pneumococcal vaccinations were offered and/or provided in a timely manner to a resident, as outlined by the CDC guidelines. The resident, who was admitted to the care center in August 2024, had a history of dementia and high blood pressure. The resident's electronic medical record indicated that they had received the PCV13 vaccine in December 2017 and the PPSV23 vaccine in March 2019, but there was no evidence that the PCV20 vaccine had been offered or administered, despite CDC recommendations for shared clinical decision-making regarding this vaccine. An interview with the facility's infection preventionist (IP), an LPN, revealed that the resident's family member preferred to sign consent forms for vaccinations, but there was no signed consent or refusal for the PCV20 vaccine in the resident's record. The LPN acknowledged that the PCV20 vaccine had not been offered due to a lack of documentation and stated that they had been unable to follow up with the family member due to being frequently pulled to work on the floor. The facility's pneumococcal immunization policy, last reviewed in April 2024, stated that immunizations would be offered in accordance with professional standards and documented in the resident's medical record, which was not adhered to in this case.
Inaccurate MDS Coding for Restraint Use and BIMS Assessment
Penalty
Summary
The facility failed to ensure the accurate coding of the Minimum Data Set (MDS) regarding restraint use for four residents. The MDS inaccurately indicated that these residents had bed rails used as restraints daily, despite observations and interviews revealing that the grab bars did not restrict the residents' freedom of movement. The nursing assistant and residents themselves confirmed that the grab bars were used for assistance and did not act as restraints. The offsite MDS coordinator admitted to coding the grab bars as restraints due to a lack of assessment documentation and without further clarification from onsite staff. Additionally, the facility did not accurately complete a Brief Interview for Mental Status (BIMS) assessment for one resident. The BIMS assessment was not stopped after nonsensical responses were given, leading to an incorrect summary score and the absence of a required Staff Assessment for Mental Status. The offsite MDS coordinator acknowledged that the staff member conducting the BIMS assessment was unsure of the procedure and did not stop the assessment as required. These deficiencies highlight a lack of proper assessment and documentation practices within the facility, leading to inaccuracies in the MDS coding for both restraint use and cognitive assessments. The offsite MDS coordinator's reliance on incomplete electronic records and lack of communication with onsite staff contributed to these errors.
Failure to Monitor Antibiotic Use in LTC Facility
Penalty
Summary
The facility failed to develop and implement a comprehensive system to monitor antibiotic use, which led to the inappropriate administration of antibiotics to a resident, identified as R198. The resident had multiple diagnoses, including diarrhea and pressure ulcers, and was prescribed antibiotics such as amoxicillin-pot clavulanate and cephalexin. Despite the presence of loose stools and a foul odor from the wounds, there was no documentation of infection symptoms or a clear rationale for the antibiotic use. The facility did not provide the necessary antibiotic stewardship logs for April and May 2024, indicating a lack of systematic tracking and monitoring of antibiotic use. Interviews with facility staff revealed inconsistencies in the monitoring and documentation of antibiotic use. The Infection Prevention Manager (IPPM) admitted that the 72-hour antibiotic time outs were often not completed, and there was no process for daily documentation of antibiotic treatment and resident symptoms. The Director of Nursing (DON) acknowledged the importance of monitoring resident symptoms and temperatures but noted that the facility lacked a structured process for ensuring this was done consistently. The absence of a comprehensive antibiotic stewardship program and the failure to document and monitor antibiotic use contributed to the deficiency. The facility's policies on antibiotic stewardship and infection control were not effectively implemented. The policies required tracking antibiotic use and outcomes, as well as educating staff and residents about appropriate antibiotic use. However, the facility did not adhere to these policies, as evidenced by the incomplete antibiotic stewardship logs and the lack of documentation for antibiotic time outs. The failure to follow these policies and procedures resulted in the inappropriate use of antibiotics, potentially affecting all residents in the facility.
Failure to Implement QAPI Plan and Address Deficiencies
Penalty
Summary
The facility failed to implement a Quality Assurance and Performance Improvement (QAPI) plan to maintain acceptable levels of performance and continual improvement. The facility did not conduct ongoing quality assessment and assurance activities, nor did it develop and implement appropriate plans of action to correct repeated quality deficiencies. These deficiencies were identified during the survey and had the potential to adversely affect all 50 residents residing in the facility. During document review, it was noted that the QAPI quarterly meeting minutes from various dates included a section on survey results and plans of correction, highlighting issues with pharmacy review, vaccinations, and TB testing. However, during an interview, the Director of Nursing (DON) stated that the facility had not developed performance improvement projects and lacked formal documentation for correcting previously identified deficiencies. The DON mentioned that QAPI activities were on hold due to new management awaiting further instructions on processes.
Infection Control Deficiencies in PPE and Catheter Management
Penalty
Summary
The facility failed to adhere to evidence-based practices in infection prevention and control, specifically in the management of catheter bags and ports for two residents, whose catheter bags were observed on the ground. Additionally, the facility did not ensure the proper use of personal protective equipment (PPE) and hand hygiene for two residents on enhanced barrier precautions (EBP) and contact precautions. The facility also failed to identify and track potential infections for a resident reviewed for antibiotic use. One resident, who had impaired cognition and multiple medical conditions including a stage 3 pressure ulcer and an indwelling catheter, was not properly managed under enhanced barrier precautions. Observations revealed a lack of signage indicating the need for EBP, and staff did not consistently use PPE or perform hand hygiene as required. The resident's care plan and orders lacked documentation of EBP or updated transmission-based precautions, and there was no signage or isolation supplies outside the resident's room. Another resident, who had a foley catheter and was on enhanced barrier precautions, was also not managed according to infection control protocols. Staff were observed not wearing gloves during high-contact care activities, and there was a lack of consistent hand hygiene practices. The facility's policies on hand hygiene and EBP were not adequately followed, leading to potential risks of spreading multi-drug resistant organisms (MDROs) among residents.
Failure to Maintain Resident Privacy and Dignity
Penalty
Summary
The facility failed to maintain the privacy and dignity of a resident, identified as R146, during care. R146, who had a history of falls, a nondisplaced intertrochanteric fracture of the right femur, and was incontinent, was observed on a transitional care unit with their room door open and uncovered, visible from the hallway. This occurred when a nursing assistant, NA-B, left the room to put on personal protective equipment, leaving R146 exposed. R146 expressed discomfort with being exposed, stating they felt bare naked. Interviews with staff, including NA-B, NA-G, RN-A, RN-B, and the director of nursing (DON), revealed that the facility's policy was to ensure residents' privacy by closing doors and keeping residents covered during care. NA-B acknowledged the oversight and expressed surprise at not closing the door. The DON confirmed that leaving a resident uncovered with the door open was a dignity issue and did not respect the resident's modesty. The facility's policy on Resident Rights directed staff to protect and promote the rights of each resident.
Failure to Prevent Accident Hazards and Assess Fall Risks
Penalty
Summary
The facility failed to ensure residents were free from accident hazards, specifically for a resident who used a remote-controlled recliner. The resident, who had mild cognitive impairment, hemiplegia, and other health issues, was found on the floor after an unwitnessed fall. The recliner was in a raised position, and it appeared the resident had used the remote to raise it, leading to the fall. The care plan did not document an assessment of the resident's safety with the recliner, nor was there a discussion of the risks and benefits of using such equipment. Another resident, who had a recent stroke and was on fall precautions, experienced an unwitnessed fall with a head strike while attempting to self-transfer. The resident's baseline care plan lacked interventions related to the physical therapy evaluation that determined a fall risk. The facility's documentation did not include a nursing fall risk assessment for this resident, and no immediate interventions were documented following the fall. Interviews with staff revealed a lack of awareness and documentation regarding specific fall interventions for both residents. The facility's policy required evaluation and analysis of fall risks upon admission and as needed, but this was not adequately implemented. The interdisciplinary team was expected to discuss falls and determine interventions, but immediate measures were not consistently applied or documented.
Failure to Assess and Obtain Consent for Grab Bars
Penalty
Summary
The facility failed to comprehensively assess, discuss risks and benefits, obtain informed consent, and attempt alternatives prior to the installation of grab bars for two residents. Resident R96, who was severely cognitively impaired and at risk for falls, had grab bars installed on their bed without a comprehensive nursing assessment or documented discussion of risks, benefits, and alternatives. The resident's medical record lacked evidence of informed consent prior to the installation of the grab bars, and the grab bars were installed before the required assessments were completed. Resident R146, who had a history of falls and was admitted with a nondisplaced intertrochanteric fracture, also had grab bars installed without a comprehensive nursing assessment or documented discussion of risks, benefits, and alternatives. The resident's medical record did not contain evidence of informed consent prior to the installation of the grab bars. The grab bars were noted on the resident's baseline care plan, but the necessary assessments and documentation were completed after the installation. Interviews with facility staff, including nursing assistants, registered nurses, and the director of nursing, revealed that the facility relied on therapy recommendations for the installation of grab bars and often completed the necessary assessments and documentation several days after installation. The facility's policy required that residents be screened for the need for special equipment, including bed rails, and that risks and benefits be reviewed with the resident or representative, informed consent obtained, and a physician order secured prior to installation. However, these steps were not followed for the residents in question, leading to the deficiency.
Failure to Maintain Safe and Sanitary Dishware
Penalty
Summary
The facility failed to maintain dishware in a safe and sanitary manner, as evidenced by the presence of chipped and cracked dishware being used within the facility. An unidentified resident reported that the facility had a lot of chipped ceramic dishware, including bowls and cups, which they had brought to the staff's attention, but the issue had not been corrected. Observations confirmed the presence of chipped bowls in the dining room, with one nursing assistant assisting a resident to eat oatmeal from a chipped bowl, and another chipped bowl was found in the clean pile ready for use. Interviews with dietary staff revealed inconsistencies in the handling of damaged dishware. Dietary aide (DA)-B stated that chipped and cracked dishes were supposed to be discarded, but upon inspection, a resident was found eating from a cracked bowl. DA-A mentioned that they would remove broken dishware but considered dishes with small chips still usable. The dietary manager (DM) confirmed that chipped or cracked dishware should be discarded to prevent cuts and ensure proper sanitation. The facility's administrator expected dishware to be free of chips and cracks to maintain cleanliness and minimize the risk of foodborne illness. The facility's policy indicated that chipped or cracked dishware should be discarded immediately.
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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