Aurora On France
Inspection history, citations, penalties and survey trends for this long-term care facility in Edina, Minnesota.
- Location
- 6500 France Avenue, Edina, Minnesota 55435
- CMS Provider Number
- 245634
- Inspections on file
- 21
- Latest survey
- May 22, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Aurora On France during CMS and state inspections, most recent first.
Surveyors found that food was stored on racks less than six inches from the floor in the freezer and that boxes were placed directly on the refrigerator floor after delivery. Additionally, clean dishes and food storage containers were stacked while still wet, contrary to facility policy requiring air drying before stacking. Staff confirmed these practices did not meet infection control and food safety standards.
Staff did not consistently follow infection prevention protocols, including proper use of PPE and hand hygiene, for residents on enhanced barrier or contact precautions. Multiple staff members entered precaution rooms without required gowns and gloves, performed high-contact care without full PPE, and failed to perform hand hygiene after resident contact, despite facility policies and posted signage.
Two residents who required assistance with personal hygiene were not provided care in a manner that preserved their dignity, as staff failed to address unwanted facial hair despite resident preferences and facility policy. Both residents were observed with visible facial hair, expressed discomfort or embarrassment, and staff interviews revealed inconsistent practices and lack of awareness regarding grooming needs.
The facility failed to implement new medication orders for a resident with heart failure and did not administer PRN antihypertensive medication or notify the provider for another resident with hypertension, despite multiple elevated blood pressure readings. In both cases, staff did not follow facility policies for order transcription, verification, and response to changes in condition.
A resident with cognitive impairments and aphasia was allegedly subjected to an inappropriate gesture by a staff member, which was reported by the resident's family member to the social worker. The social worker did not report the incident to the State Agency, believing it was not a reportable event. The DON and administrator were informed of the resident's distress but did not identify it as an abuse allegation, resulting in a failure to report the incident within the required timeframe.
A resident with cognitive impairments and aphasia was allegedly subjected to an inappropriate gesture by a staff member, which was reported by a family member. The social worker and DON failed to investigate the allegation, leaving the alleged perpetrator with continued access to vulnerable residents. The facility's policy on abuse prevention and response was not followed.
The facility failed to ensure proper sanitization of dishware, with dish machine temperatures not consistently reaching required levels, potentially affecting all 42 residents. Observations showed wash temperatures between 140 to 174 degrees and rinse temperatures between 165 to 192 degrees, below the manufacturer's minimum requirements. Staff inconsistently checked and recorded temperatures, and there was a lack of adherence to the facility's policy, which required wash temperatures between 140 to 160 degrees and rinse temperatures of at least 180 degrees.
A resident with impaired cognition and mobility was not repositioned every two hours as required, leading to the development of a pressure ulcer. Despite being at high risk for skin breakdown, the facility failed to implement necessary interventions upon admission. Observations showed the resident remained in the same position for extended periods, and staff misunderstood proper repositioning practices.
A resident admitted with an indwelling Foley catheter did not receive a voiding trial as ordered by the physician, leading to a deficiency in care. The facility's documentation lacked any record of the trial, and staff interviews revealed unawareness of the order. The resident's care plan included catheter care and monitoring for infection, but the voiding trial was missed, contrary to the facility's catheter care policy.
The facility failed to monitor side effects and implement non-pharmacological interventions for two residents prescribed psychotropic medications. One resident, with depression, lacked side effect monitoring in their care plan despite recommendations from a pharmacist. Another resident, with dementia and anxiety, was prescribed an antipsychotic without documented side effect monitoring. The facility's policy requires such monitoring and interventions, but these were not in place.
A facility failed to ensure staff wore appropriate PPE for a resident with a Foley catheter, as required by Enhanced Barrier Precautions (EBP). The resident's care plan indicated the need for EBP, but there was no signage or isolation cart to alert staff. Observations showed nursing assistants did not wear gowns while handling the catheter, and interviews confirmed staff were unaware of the EBP requirement due to the absence of signage.
The facility failed to ensure that three residents were offered or received pneumococcal vaccinations per CDC guidelines. Their records lacked documentation of shared clinical decision-making for the PCV-20 vaccine. Staff interviews revealed gaps in tracking and decision-making processes, with one resident not listed on the vaccine spreadsheet and another's vaccination status uncertain. The facility's policy required adherence to CDC guidelines and documentation of refusals, which were not consistently followed.
A facility failed to ensure a resident received or was offered the COVID-19 vaccination, as required by their preparedness plan. The resident, with a history of multiple health conditions, had received previous COVID-19 vaccinations, but the facility's EHR lacked documentation of the latest immunization and whether a second dose was offered. Staff interviews revealed inconsistencies in the vaccination process, and the resident was not listed on the infection preventionist's tracking spreadsheet.
The facility failed to develop comprehensive care plans for two residents prescribed antipsychotic medications, lacking measures for side effect monitoring. One resident with dementia was prescribed quetiapine fumarate, and another with intact cognition was on fluoxetine for depression. Despite recommendations from the pharmacist, the care plans did not include necessary interventions for side effect monitoring, which was acknowledged by the DON.
Improper Food Storage and Wet Dish Stacking Identified
Penalty
Summary
Surveyors observed multiple deficiencies in food storage and dish handling practices within the facility. During a kitchen tour, it was noted that food items, including a prep pan of raw whole turkeys, were stored on racks in the walk-in freezer that were less than six inches from the floor, with one rack's bottom shelf touching the floor. Additionally, boxes of food were found sitting directly on the floor of the first-floor refrigerator following a recent delivery. The culinary manager and dietary manager confirmed that these storage practices did not comply with facility policy, which requires food to be stored at least six inches off the floor. Further observations revealed that clean dishes, including plastic glasses and food storage containers, were stacked while still wet, with visible moisture present between and inside the items. Both the culinary manager and dietary aide acknowledged that dishes should be completely air dried before stacking, as per facility policy, to prevent infection risks. These practices were confirmed through interviews and direct observation, indicating a failure to adhere to established food storage and dishwashing protocols.
Failure to Adhere to Infection Control Standards and PPE Use
Penalty
Summary
Staff failed to adhere to infection prevention and control standards, specifically regarding the use of personal protective equipment (PPE) and proper hand hygiene, for three residents under enhanced barrier precautions (EBP) or contact precautions. For one resident with a chronic right foot ulcer and multiple comorbidities, a therapy assistant was observed wearing gloves but not a gown during high-contact care activities, and also wore gloves outside the resident's room, contrary to facility policy. The therapy assistant acknowledged receiving infection prevention training and recognized the error in PPE use and glove handling. Another resident, with a history of recurrent Clostridium difficile infection and other medical conditions, was on contact precautions. Multiple staff members, including a physical therapy aide and nursing assistants, entered the resident's room without donning the required gown and gloves, and failed to perform hand hygiene after leaving the room. Staff interviews revealed awareness of the precautions but lapses in compliance, with some staff citing being in a hurry or believing PPE was unnecessary if the resident was not touched. A third resident, on EBP following joint replacement surgery and with several chronic conditions, received high-contact care from a nursing assistant who wore gloves but not a gown, and was unaware of the specific reason for the precautions. The facility's policies required gowns and gloves for high-contact care in EBP and contact precaution rooms, and mandated hand hygiene after glove removal and before leaving resident rooms. The director of nursing confirmed that staff were expected to follow these protocols and acknowledged the observed lapses.
Failure to Preserve Resident Dignity in Personal Grooming
Penalty
Summary
The facility failed to ensure that care was provided in a manner that preserved the dignity of two residents who required assistance with personal hygiene and had preferences regarding facial hair removal. One resident, who was moderately cognitively impaired and had multiple diagnoses including impaired vision, was observed on multiple occasions with several long chin hairs. The resident was unaware of the facial hair and stated they would have wanted it removed if they had known. Staff interviews revealed inconsistent practices and a lack of initiative in addressing unwanted facial hair, with some staff stating they would not offer to remove chin hairs and others indicating it was a personal issue. The resident's care plan included instructions for personal hygiene assistance and reminders to wear glasses, but did not address facial hair preferences. Another resident, who had intact cognition and required assistance with personal hygiene, was observed with significant facial hair despite a care plan indicating a preference for facial hair removal to maintain dignity. The resident expressed embarrassment and discomfort about the facial hair, stating that at home they would have removed it themselves. Staff were unaware of the resident's concerns and did not address the issue until after it was brought to their attention. Facility policies indicated that residents should be groomed as they wish and that both men and women should have facial hair shaved as part of morning care, but these policies were not consistently followed for the residents involved.
Failure to Implement Provider Orders and Respond to Abnormal Clinical Findings
Penalty
Summary
The facility failed to implement and document new medication orders and to recognize and respond to abnormal clinical findings for two residents. For one resident with a history of heart failure, hypertension, and other significant comorbidities, a provider issued a new order to increase the dose of furosemide due to weight gain and fluid retention. The order, sent via fax and email, was not entered into the electronic medical record (EMR) or administered as prescribed. Facility staff did not clarify the order with the provider or follow up over the weekend, resulting in the resident not receiving the intended increased dose. Documentation and interviews confirmed the order was missed, and the facility's policy requiring double verification and communication of new orders was not followed. For another resident with hypertension and renal insufficiency, the facility failed to administer as-needed (PRN) antihypertensive medication despite multiple blood pressure readings that met the criteria for intervention. The resident's medication administration record showed that the PRN medication was never given, and there was no documentation of provider notification or alternative interventions for the elevated blood pressures. Staff interviews confirmed that the process for responding to abnormal blood pressure readings was not followed, and the director of nursing acknowledged that each missed dose constituted a medication error. Facility policies required prompt transcription and verification of new orders, as well as immediate provider notification and intervention for changes in resident condition. In both cases, the facility did not adhere to these policies, resulting in failures to provide care and treatment according to provider orders and the residents' clinical needs.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to report an allegation of staff-to-resident abuse to the State Agency within the required two-hour timeframe. The incident involved a resident with cognitive impairments and aphasia, who required extensive assistance with activities of daily living. The resident's family member reported that the resident was upset after a staff member allegedly made an inappropriate gesture towards them. Despite the family member notifying the social worker about the incident, the social worker did not report it to the State Agency, believing it was not a reportable event since the allegation was not directly heard from the resident. The Director of Nursing and the administrator were informed that the resident was upset, but neither determined that an allegation of abuse had occurred. Consequently, the incident was not reported to the State Agency. The facility's policy mandates that all alleged violations involving abuse must be reported immediately, but this protocol was not followed. The policy also defines verbal abuse to include gestured language that is disparaging or derogatory, which was relevant to the incident in question.
Failure to Investigate Alleged Abuse and Protect Resident
Penalty
Summary
The facility failed to complete an investigation and ensure protection for residents following an allegation of staff-to-resident abuse involving a resident with cognitive impairments and aphasia. The resident, who required extensive assistance with activities of daily living, was reported by a family member to have been upset after a staff member allegedly made an inappropriate gesture towards her. The family member reported the incident to the social worker, who attempted to discuss the matter with the resident but was unable to understand her due to her aphasia. The social worker reported the allegation to the director of nursing but did not conduct further investigation. The director of nursing was unaware of the specific allegation of abuse and assumed the resident's distress was related to a previous hospital stay. Consequently, no investigation was initiated, and the alleged perpetrator continued to have access to the resident and other vulnerable individuals. The facility's administrator confirmed that no investigation had been conducted, and the facility's policy on abuse prevention and response was not followed. This policy required immediate reporting, protection of the resident, and suspension of the employee in question pending investigation.
Dishware Sanitization Deficiency
Penalty
Summary
The facility failed to ensure that dishware was cleaned and sanitized properly, which could potentially affect all 42 residents. During observations, it was noted that the dish machine temperatures were not consistently reaching the required levels for effective sanitation. The wash temperatures recorded were between 140 to 174 degrees, and rinse temperatures were between 165 to 192 degrees, which did not always meet the manufacturer's minimum requirements of 150 degrees for wash and 180 degrees for rinse. Staff members, including dietary aides and the director of culinary, were observed using the dish machine with temperatures below the required levels, and there was inconsistency in checking and recording these temperatures. The facility's policy required wash temperatures to be between 140 to 160 degrees and rinse temperatures to be at least 180 degrees, with staff instructed to monitor and record temperatures for each meal service. However, the logs showed discrepancies, and the dish machine's temperatures for dinner had not been recorded at the time of observation. Staff members were expected to notify supervisors if temperatures were not as specified, but there was a lack of consistent adherence to this protocol. The director of culinary acknowledged the importance of maintaining proper temperatures to prevent foodborne illness but relied on staff to report issues, which did not always occur promptly.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to develop and implement interventions to prevent pressure ulcers and ensure timely repositioning for a resident with existing pressure ulcers. The resident, identified as R13, had moderately impaired cognition and was diagnosed with hemiplegia, hemiparesis, chronic pain, and polyneuropathy. R13 required substantial assistance with bed mobility and was at risk for skin breakdown due to decreased mobility, bowel incontinence, and medication use. Despite these risks, the facility did not implement adequate interventions upon admission, and a deep tissue injury was noted on R13's right heel. Observations revealed that R13 was not repositioned every two hours as required. During a continuous observation period, R13 remained in the same position for extended periods, with staff entering the room for various tasks but not repositioning the resident. Interviews with staff indicated a lack of understanding of what constitutes repositioning, with some staff considering raising the head of the bed as repositioning, which is not sufficient to relieve pressure. The facility's policy required skin risk assessments and appropriate interventions upon admission, but these were not implemented for R13. Interviews with nursing staff and management highlighted a failure to add skin interventions upon admission and a misunderstanding of repositioning practices. The facility's director of nursing confirmed that interventions should be added immediately for residents at risk of skin breakdown, but this was not done for R13, leading to the development of a pressure ulcer.
Failure to Conduct Voiding Trial for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to remove a Foley catheter according to physician orders for a resident (R4) who was admitted with an indwelling catheter. R4's admission records indicated a need for a voiding trial within five days of admission, as per hospital discharge orders. However, the facility's documentation, including the Physician Orders form, medication administration record (MAR), and treatment administration record (TAR), lacked any record of a voiding trial being conducted. Interviews with staff, including a licensed practical nurse (LPN) and a registered nurse (RN), revealed that they were unaware of the voiding trial order, and no documentation was found to indicate that the trial had been completed. R4 was admitted with a diagnosis of urinary retention and had a history of urinary incontinence. The resident's care plan included catheter care every shift and monitoring for signs of urinary tract infection. Despite these interventions, the voiding trial order was missed, and the catheter remained in place longer than necessary. The RN acknowledged the importance of completing a voiding trial to reduce the risk of infection and noted that the order had been overlooked. The Director of Nursing (DON) also confirmed that the voiding trial should have been documented and that staff were expected to clarify and document orders. The facility's policy on catheter care emphasized the removal of indwelling catheters as soon as possible to minimize infection risks. However, the failure to conduct and document the voiding trial for R4 indicated a lapse in following this policy. The oversight was attributed to a lack of communication and verification of orders among the staff, as highlighted by the RN's and DON's statements during interviews.
Failure to Monitor Psychotropic Medication Side Effects and Implement Non-Pharmacological Interventions
Penalty
Summary
The facility failed to ensure proper monitoring and implementation of non-pharmacological interventions for residents prescribed psychotropic medications. Resident R4, who was admitted with intact cognition and depression, was prescribed fluoxetine and trazodone. However, the care plan for R4 lacked interventions for monitoring side effects of these medications. Despite recommendations from the consultant pharmacist to update the care plan with behavior, intervention, and side effect monitoring, these were not implemented. The Director of Nursing acknowledged the absence of non-pharmacological interventions and side effect monitoring in R4's care plan. Similarly, Resident R147, diagnosed with dementia and anxiety, was prescribed quetiapine fumarate for anxiety. The medication administration records for R147 did not include any side effect monitoring for the antipsychotic medication. Interviews with the LPN and RN confirmed that side effect monitoring was expected but not documented. The pharmacist had recommended side effect monitoring and non-pharmacological interventions, but these were not in place at the time of the survey. The facility's policy on psychopharmacological drug use requires monitoring for medication effectiveness and adverse consequences, with documentation in the resident's active record. It also emphasizes the use of behavioral interventions and non-pharmacological approaches. However, the facility did not adhere to these policies, as evidenced by the lack of side effect monitoring and non-pharmacological interventions for residents R4 and R147.
Failure to Implement Enhanced Barrier Precautions for Resident with Foley Catheter
Penalty
Summary
The facility failed to ensure that staff wore appropriate personal protective equipment (PPE) for a resident with a Foley catheter, which was reviewed for infection prevention and control. The resident, who had intact cognition and was dependent on staff for toileting hygiene and transfers, had an indwelling catheter due to urinary retention and other medical conditions. Despite the resident's care plan indicating the need for Enhanced Barrier Precautions (EBP) due to the catheter, there was a lack of signage and instructions for EBP in the resident's room. Observations revealed that nursing assistants were not wearing gowns while handling the resident's catheter, and there was no signage or isolation cart to indicate the need for EBP. Interviews with staff, including nursing assistants, a trained medication aide, and a licensed practical nurse, confirmed the absence of EBP signage and the lack of awareness among staff regarding the resident's need for EBP. The facility's policy on Enhanced Barrier Precautions required the use of gowns and gloves during high-contact resident care activities, but the policy did not specify where staff should look to determine if a resident was on EBP. The director of nursing stated that staff should be alerted to EBP through signage and isolation carts, which were not present in this case.
Failure to Ensure Pneumococcal Vaccination Compliance
Penalty
Summary
The facility failed to ensure that three out of five residents were offered or received pneumococcal vaccinations in accordance with CDC recommendations. The residents involved were identified as having received previous pneumococcal vaccinations, but their electronic health records lacked documentation of shared clinical decision-making regarding the administration of the PCV-20 vaccine. Specifically, the records for these residents did not reflect whether a decision had been made to administer the PCV-20 vaccine, which is recommended five years after the last pneumococcal vaccination under certain conditions. Interviews with facility staff revealed gaps in the vaccination tracking and decision-making process. The infection preventionist, responsible for tracking immunizations, had not included one of the residents on their vaccine spreadsheet and had not consulted with the provider about the need for the PCV-20 vaccine. Additionally, the infection preventionist was uncertain about the vaccination status of another resident and had not documented any refusal or declination of the PCV-20 vaccine. The facility's policy directed staff to follow CDC guidelines and document refusals, but these steps were not consistently followed, leading to the deficiency.
Failure to Document and Offer COVID-19 Vaccination
Penalty
Summary
The facility failed to ensure that the COVID-19 vaccination was offered and/or provided to a resident, identified as R16, to reduce the risk of severe illness. R16, who was admitted to the facility with intact cognition and a history of cancer, hypertension, diabetes mellitus, thyroid disorder, arthritis, and fracture, had received several COVID-19 vaccinations in the past. However, the facility's electronic health record (EHR) lacked documentation of the COVID-19 23-24 immunization and whether a second COVID-19 23-24 immunization was offered and accepted or declined. Interviews with staff revealed a lack of clarity and consistency in the process of checking vaccination records and obtaining consent. RN-C mentioned that the charge nurse or another unspecified person was responsible for checking vaccination records and obtaining consent, but RN-C had not administered COVID-19 vaccines to residents. RN-D stated that the infection preventionist (IP) tracked resident COVID vaccines and received pharmacy reviews, which were forwarded to the IP. The IP or nurses would administer the vaccines, and consents or refusals were documented in the residents' EHR. The infection preventionist (IP) explained that they reviewed residents' vaccine history and recommendations from the pharmacist, following CDC guidelines for vaccine timing. The IP maintained a spreadsheet listing resident names, vaccine information, consent status, and follow-up needs. However, R16 was not listed on the IP's vaccine spreadsheet, indicating a gap in the tracking and administration process. The facility's COVID-19 Preparedness Plan required staff to check residents' vaccination status upon admission and offer the vaccine to those who had not received it, but this was not adequately followed for R16.
Failure to Monitor Side Effects of Psychotropic Medications
Penalty
Summary
The facility failed to develop comprehensive care plans for monitoring side effects in two residents who were prescribed antipsychotic medications. One resident, identified as R147, had a diagnosis of dementia and was prescribed quetiapine fumarate for anxiety. However, the care plan for R147 did not include any measures for monitoring side effects of the antipsychotic medication. The Director of Nursing acknowledged that residents on antipsychotic medications should be monitored for side effects, and the facility's pharmacist had recommended such monitoring, along with non-pharmacological interventions and monthly orthostatic blood pressure checks, but these were not implemented in the care plan. Another resident, R4, who had intact cognition and was taking fluoxetine for depression, also lacked a care plan for monitoring side effects of psychotropic medications. The resident's Care Area Assessment indicated an increased risk for falling and depression due to antidepressant use, but the care plan did not include interventions for side effect monitoring. The facility's pharmacist had recommended updating the care plan to include behavior monitoring and side effect monitoring for psychotropic medications, but these recommendations were not followed. The Director of Nursing confirmed that the care plan should have included these interventions but did not.
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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