Bayshore Residence And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Duluth, Minnesota.
- Location
- 1601 St Louis Avenue, Duluth, Minnesota 55802
- CMS Provider Number
- 245227
- Inspections on file
- 33
- Latest survey
- December 4, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Bayshore Residence And Rehabilitation Center during CMS and state inspections, most recent first.
Two residents had their leave of absence (LOA) privileges revoked by physician order due to concerns about substance use and safety, without evidence that less restrictive alternatives were considered. Staff interviews confirmed that suspicions of drug and alcohol use, refusal of urinalysis, and unsafe behaviors led to the restrictions, and facility policy was interpreted as allowing LOA privileges to be revoked as a matter of safety.
A resident with a history of substance abuse and revoked LOA privileges left the facility with family against medical advice. Despite being informed that her LOA privileges were revoked, the resident departed, and staff processed the discharge as AMA. Attempts to obtain signatures on the AMA form from the resident and her family were unsuccessful, so staff signed with a witness. Staff interviews confirmed the discharge was due to the resident leaving without authorization, in accordance with physician orders and facility policy.
Surveyors observed that an LPN was unable to identify the owner of an insulin aspart pen found in a medication cart, which lacked proper labeling and had not been removed after its beyond-use date. The DON confirmed that insulin should be labeled with the resident's name and opened-on date, and removed after the BUD, in accordance with facility policy.
A resident with dementia and Parkinson's disease, who was not approved for self-administration of medication, was found with a bottle of nystatin powder at their bedside on two occasions. SAM assessments indicated the resident could not identify medication expiration dates and was not cleared to self-administer. Staff interviews confirmed that facility policy required a SAM assessment and provider order for bedside medication storage, but the medication remained accessible to the resident in violation of policy.
Two residents had their rooms and personal belongings searched by staff without consistently obtaining voluntary consent, despite facility policy requiring resident understanding and approval. One resident, who was cognitively intact and her own responsible party, experienced repeated searches after visits or absences, sometimes only consenting after persistent staff requests. Staff interviews revealed confusion about the need for consent, and documentation showed searches occurred even when the resident was not present.
A resident with a recent surgical amputation reported that his room was too dark, had wall damage, and visible stains, which were confirmed during observations. Staff interviews revealed a lack of routine maintenance and cleaning schedules, and responsibilities for repairs and cleaning were unclear. The facility's policy did not address wall repairs, and the administrator was aware of the room's condition but did not inspect it.
Two residents' MDS assessments were inaccurately coded, including one case where a non-insulin injectable medication was recorded as insulin, and another where a resident's dysphagia diagnosis, swallowing disorder symptoms, and need for supervision with eating were omitted from the assessment, despite supporting documentation in the medical record and care plan.
The facility did not consistently monitor or document fluid restrictions for two residents with kidney and heart conditions, resulting in missed or incomplete intake records. Additionally, a resident with multiple chronic illnesses refused diuretic medication and experienced significant weight gain, but provider notification and documentation were lacking as required by policy. Staff interviews confirmed gaps in documentation and communication regarding these care issues.
A resident with quadriplegia and a history of pressure ulcer risk developed an unstageable pressure ulcer after weekly skin checks were not consistently performed and the care plan was not updated to reflect the new wound or individualized interventions. Staff were inconsistently educated on the maintenance of the resident's Roho cushion, which was found deflated, and documentation of wound assessments and care plan updates was incomplete.
A resident with significant cognitive and physical impairments was provided bed rails without a comprehensive assessment addressing all FDA-recommended entrapment zones, and there was no documentation of alternatives attempted prior to use. Staff interviews revealed that only limited measurements were taken, and maintenance installed the rails without performing required safety assessments, contrary to facility policy.
A resident with multiple chronic conditions was prescribed several medications without documented indications for use in the medical record. Nursing staff and the DON confirmed that medication orders should include the reason for administration, but this was not done, resulting in a failure to ensure the resident's drug regimen was free from unnecessary drugs.
Staff did not follow proper hand hygiene and glove change protocols during peri care for a dependent resident, failed to disinfect a shared glucometer according to manufacturer instructions after blood sugar testing, and did not use gloves or perform hand hygiene during eye drop administration for a resident. These actions were inconsistent with facility policies and infection control standards.
A resident with severe cognitive and physical impairments was found to have bedrails in use without evidence of regular, comprehensive inspections of the bed, mattress, and bedrails for safety and entrapment risks. Maintenance staff only performed monthly checks for looseness, and there was no documentation of routine inspections or ongoing risk assessments, contrary to facility policy.
The facility did not make the most recent state survey results easily accessible or post required signage about inspection reports. Survey results were kept in a binder secured at the front desk, limiting privacy for review, and only included results up to the previous year until more recent documents were added after surveyors arrived. No related policies were provided when requested.
A nursing assistant in a LTC facility took and shared humiliating photos and videos of residents on social media, violating their privacy and dignity. The assistant was aware of the facility's policies against such actions but continued to engage in abusive behavior, including physical aggression and inappropriate gestures. The residents involved had various medical conditions, making them vulnerable to abuse.
A facility failed to accurately document a resident's advance directives, leading to a discrepancy between the EHR and the POLST. The resident's care conference identified them as full code, but the POLST indicated DNR. The facility changed the EHR to DNR without verifying with the family, against the resident's wishes to be resuscitated. This led to an immediate jeopardy situation due to inconsistent documentation and lack of communication.
The facility failed to provide 56 residents with access to their personal funds after hours and on weekends. Residents could only access their money during specific weekday hours, and staff were generally unaware of any arrangements for access outside these times. The facility did not maintain petty cash, contrary to its policy, leading to the deficiency.
The facility failed to monitor the nurse aide registry, allowing an inactive nurse aide to continue working with residents. A nurse aide, hired in December, was found to have an inactive status as of May, yet continued to work shifts during a survey. The facility administrator was unaware of the inactive status, despite procedures for registry checks and notifications.
The facility failed to ensure proper PPE use and hand hygiene, leading to infection control deficiencies. Staff did not wear gowns for a resident under Enhanced Barrier Precautions, citing lack of PPE in the dementia unit. Additionally, a nurse failed to sanitize hands between treatments and used another resident's medication, posing cross-contamination risks. The DON confirmed the need for proper PPE and hand hygiene practices.
A facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) to a resident who stayed after their Medicare Part A coverage ended. The resident's medical record lacked evidence of the SNFABN, which should have explained the cost and rationale for continued care. Interviews confirmed the oversight, and the facility did not provide a beneficiary policy, though they had a CMS form with SNFABN instructions.
A facility failed to accurately code the MDS for a resident, marking their vision as adequate despite multiple diagnoses indicating impairment. The resident had conditions such as diabetic retinopathy and cataracts, and their care plan noted vision impairment. The ADON confirmed the coding error, stressing the importance of MDS accuracy for care and reimbursement.
A resident with severe cognitive impairment received Nystatin powder from another resident's supply due to a registered nurse's inability to locate the correct medication. This action violated the facility's policy, which requires medications to be administered as per prescriber orders and prohibits sharing between residents. The incident was confirmed by the RN and the DON.
The facility failed to follow medical orders and document necessary information for residents with specific health conditions. A resident with heart failure did not have weight changes reported as ordered, and another resident missed doses of prescribed pain medication. Additionally, the facility did not document behaviors related to PRN medication administration for a resident with schizophrenia. The DON confirmed the expectation for proper medication administration and documentation.
A resident's room contained four oxygen tanks, with two unsecured, posing a potential hazard. The resident, on oxygen therapy, was using an oxygen concentrator, and the tanks were intended for discharge. Staff confirmed the tanks should not be free-standing, and the DON acknowledged the fire hazard risk.
A resident with dementia and GERD experienced significant weight loss over several months, dropping from 163.9 to 147.1 pounds. Despite the facility's policy requiring notification of the physician and dietician for nutritional problems, the provider was not informed of the weight loss. The registered dietician recommended nutritional supplements, but the facility failed to update the provider, as confirmed by RN-B and the DON.
A resident with bipolar disorder and metabolic encephalopathy, known for exit-seeking behavior, eloped from the facility despite wearing a wanderguard. Staff, including a nursing assistant and a maintenance worker, mistook the resident for a visitor when the wanderguard alarm activated and did not conduct a thorough search. Approximately 1.25 hours passed before a code 99 was called, and the resident was found two miles away. The report highlights lapses in staff response to the wanderguard alarm and delayed recognition of the resident's absence, raising concerns about supervision protocols for residents at risk for elopement.
Failure to Honor Residents' Rights to Leave Facility
Penalty
Summary
The facility failed to honor the rights of two residents to leave the facility, as required, by restricting their leave of absence (LOA) privileges through physician orders. One resident, who had diagnoses including type 2 diabetes, infection, pain, weakness, and substance abuse, was assessed as low risk for elopement but had her LOA privileges revoked due to suspected drug and alcohol use. The care plan and physician order specifically indicated that the resident was not allowed to leave the facility, and staff interviews confirmed that the restriction was based on suspicions of substance use and refusal to comply with urinalysis requests. There was no evidence that less restrictive alternatives were considered prior to revoking the resident's right to leave. Another resident, with diagnoses including depression, head laceration, anemia, tobacco use, and alcohol dependence, also had his LOA privileges revoked due to a history of impaired decision-making and risk for self-harm related to chemical dependency. The care plan and physician orders documented the suspension of LOA privileges due to safety concerns. Despite this, written agreements were made between the resident and the administrator to allow limited, supervised outings, which were to be reported to the physician. Staff interviews indicated that the resident had previously engaged in unsafe behaviors and had not returned to the facility on time, leading to the revocation of LOA privileges. Facility policy recognizes residents' rights to leave the facility for therapeutic reasons and outlines procedures for granting and documenting LOA privileges. However, the policy also allows for the revocation of these privileges by the physician. Staff interviews revealed a belief that leaving the facility is a privilege rather than a right, and that the facility's safety policy could override resident rights. There was no documentation or evidence that less restrictive measures were explored before restricting the residents' ability to leave, resulting in a failure to fully honor their rights to self-determination and a dignified existence.
Failure to Ensure Resident Discharge Rights During Unauthorized Leave
Penalty
Summary
The facility failed to ensure appropriate discharge rights for a resident who was discharged following a leave of absence (LOA) despite having her LOA privileges revoked by physician order. The resident, who had diagnoses including diabetes mellitus type II, infection of the left hip, pain, weakness, and gait abnormalities, was identified as low risk for elopement but had a history of substance abuse and dependence. Her care plan and physician orders specifically indicated that LOA privileges were revoked due to substance use, and she was not allowed to leave the facility. On the day of the incident, the resident left the facility with her family against medical advice (AMA), despite being aware that her LOA privileges had been revoked. Facility staff documented that the resident and her family were informed of the revoked privileges and that leaving under these circumstances was considered an AMA discharge. The resident later contacted the facility and was told she had violated the physician's order and was officially considered to have left AMA. When staff attempted to have the resident and her daughter sign the AMA form, both refused, and staff signed the form with a witness instead. Interviews with facility staff, including the RN, social services designee, administrator, DON, and social worker, confirmed that the resident's LOA privileges were revoked due to substance use and that the decision to proceed with an AMA discharge was based on her leaving the facility without authorization. The administrator and staff indicated that the resident had previously left the facility without permission and had been re-educated, but the final decision to discharge her AMA was made after she left despite the revoked LOA order. Facility policy requires a 30-day advance notice for discharge except in specific circumstances, but in this case, the discharge was processed as AMA due to the resident's actions.
Failure to Properly Label and Remove Expired Insulin
Penalty
Summary
Surveyors found that the facility failed to ensure biologic medications, specifically insulin aspart, were properly labeled with a pharmacy label indicating the resident's name and prescription information. During an observation of a medication cart in the Harbor Light community, an LPN confirmed the presence of an insulin aspart mix pen in the top drawer without knowledge of its owner. The LPN also acknowledged that the cart was checked regularly for expired or beyond-use medications, but the insulin pen was not labeled with the required information and had not been removed after its beyond-use date (BUD). Further interviews revealed that the DON expected insulin to be labeled with the resident's name, the date it was opened, and to be removed from use after reaching its BUD. The facility's policy on labeling medication containers required all medications to be properly labeled with specific information, including the resident's name, prescriber's name, pharmacy details, drug information, prescription number, dispensing date, cautionary statements, expiration date, and directions for use. The policy also required checking the expiration or BUD prior to medication administration. These requirements were not met for the insulin aspart pen found in the medication cart.
Medication Storage at Bedside Without Self-Administration Approval
Penalty
Summary
A deficiency occurred when a resident with diagnoses of dementia and Parkinson's disease, who had intact cognition but was not approved for self-administration of medication, was found to have a bottle of nystatin powder at their bedside on two separate occasions. The resident's Self Administration of Medication (SAM) assessments indicated that the resident could not identify the expiration date of medications and either did not want to or was unable to self-administer medications. The care plan lacked documentation related to the SAM assessment. Interviews with nursing staff, including an LPN, RN, and the DON, confirmed that facility policy required a completed SAM assessment and a provider order before a resident could self-administer or keep medications at bedside. Despite this, the medication remained accessible to the resident, contrary to policy and assessment findings. The facility's policy stated that if a resident was not safe to self-administer, nursing staff would administer the medications, but did not address storage of medications at bedside for residents not cleared for self-administration.
Failure to Obtain Resident Consent for Room Searches
Penalty
Summary
The facility failed to honor the rights of two residents to be treated with respect and dignity regarding their personal space and possessions. Specifically, one resident, who was her own responsible party and had intact cognition, was subjected to repeated room and personal property searches without her voluntary consent. Documentation showed that searches were conducted after visits from family or when the resident returned from a leave of absence, as per physician orders. The resident's care plan identified room searches as a trigger for behavioral issues, and progress notes detailed multiple instances where searches were performed, sometimes after the resident initially refused consent and only acquiesced after persistent staff requests. In some cases, searches were conducted while the resident was not present, including during a period when she was hospitalized. Interviews with staff, including an LPN, social services designee, RN, and the administrator, revealed inconsistent understanding and application of the facility's policy, which required reasonable suspicion, administrator approval, and documented verbal consent from the resident or representative before conducting searches. Staff acknowledged that consent was not always obtained voluntarily and that searches were sometimes justified by facility policy or physician orders rather than resident agreement. The facility's written policy emphasized the necessity of resident understanding and consent, which was not consistently followed in practice.
Failure to Maintain Clean and Homelike Resident Room Environment
Penalty
Summary
A deficiency was identified when a resident with a primary diagnosis of orthopedic care following a right lower leg amputation reported that his room was too dark, had stains and holes in the walls, and that one of the blinds was not functioning. Observations confirmed several screw holes between the windows, multiple brownish-black streaks on the wall behind the bed and chair, and dried brown substances on the light fixture over the sink. The resident stated these issues bothered him and that he had complained to staff. Interviews with maintenance and housekeeping staff revealed there was no routine schedule for checking rooms for maintenance issues, and deep cleaning was performed only when a room was vacated or annually. Maintenance staff were unaware of the holes in the wall and deferred responsibility for stains to housekeeping, while housekeeping staff acknowledged the stains but indicated that cleaning the light fixture would require maintenance. The facility's policy on a homelike environment did not address wall repairs, and the administrator confirmed knowledge of the room's condition but did not inspect it at the time.
Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents. For one resident with intact cognition and a diagnosis of morbid obesity, the MDS incorrectly identified the administration of insulin when the resident was actually receiving Trulicity, a non-insulin injectable medication. The registered nurse responsible for the MDS confirmed that Trulicity was the only injectable medication administered during the assessment period and acknowledged that it was mistakenly coded as insulin. The facility was unable to provide a policy for MDS completion when requested. For another resident with diagnoses including cancer, atrial fibrillation, and generalized muscle weakness, the MDS assessment failed to document an active diagnosis of dysphagia, did not identify symptoms of a swallowing disorder, and did not indicate the need for supervision with eating, despite clear documentation in the medical record and care plan. The resident had a history of oropharyngeal dysphagia, a choking episode, and specific dietary and supervision orders. The nurse responsible for the MDS acknowledged that these items should have been coded and that accurate coding is important for updating the care plan and staff instructions.
Failure to Monitor Fluid Restrictions and Notify Provider of Medication Refusals and Weight Changes
Penalty
Summary
The facility failed to properly monitor and document fluid restrictions for two residents with significant medical conditions requiring such interventions. One resident with anemia and end stage renal disease on hemodialysis had a care plan and provider order for a 1200 ml fluid restriction, but records showed an intake of 1580 ml on one day and multiple shifts where fluid intake was either not documented or marked as 'NA' or 'X' instead of recording the actual amount. Another resident with anemia, heart failure, and renal insufficiency had a care plan and orders for a 1920 ml daily fluid restriction, but over several months, numerous shifts lacked any documentation of intake or used 'NA' instead of actual numbers. Interviews with nursing staff confirmed the lack of consistent documentation and the importance of tracking fluid intake for residents with such restrictions. Additionally, the facility did not notify the provider when a resident with multiple chronic conditions, including atrial fibrillation, morbid obesity, chronic kidney disease, hypertension, and COPD, refused prescribed diuretic medication and experienced significant weight gain. The resident's orders required notification of the heart center for weight changes of five pounds or more in a week and documentation of refusals. However, the electronic medical record did not reflect provider notification for either the medication refusals or the weight gain, despite the resident refusing the diuretic for several days and gaining over 14 pounds in a short period. Interviews revealed that some notifications may have been made outside the EMR, but there was no consistent documentation as required by policy. The facility's own policy on refusal of treatment required detailed documentation of refusals, including the resident's response, reason for refusal, and provider notification, but this was not consistently followed. The director of nursing and nurse manager both stated expectations for documentation and provider notification in such cases, but the records did not support that these actions were taken according to policy.
Failure to Perform Weekly Skin Checks and Update Care Plan for Pressure Ulcer
Penalty
Summary
A resident with multiple sclerosis, quadriplegia, and muscle weakness developed an unstageable pressure ulcer to the left buttock while in the facility. The resident was identified as being at risk for pressure ulcers, requiring maximum assistance with bed mobility, and using a Roho cushion in the wheelchair and a pressure-reducing mattress. Despite provider orders for weekly skin checks and care plan interventions for pressure ulcer prevention, documentation revealed that weekly skin checks were not consistently performed, and the presence of an actual pressure ulcer was not promptly reflected in the care plan. Progress notes indicated that staff observed redness and later an open wound on the resident's left buttock, with the Roho cushion found to be flat and reportedly having been that way for some time. The cushion was reinflated only after the wound was discovered. Staff interviews revealed inconsistent knowledge and education regarding the proper maintenance and inflation of the Roho cushion, with some nursing assistants unaware of specific requirements and others relying on informal checks or verbal instructions. The care plan lacked individualized interventions such as specific repositioning frequency and did not include the presence of the actual pressure ulcer or integrated wound therapies in a timely manner. Further, the facility's documentation and assessments were incomplete, with missing sections in wound evaluation forms and a lack of detailed care plan updates following the development of the pressure ulcer. Staff interviews confirmed that repositioning and skin checks were not always performed or documented as required, and education materials regarding the Roho cushion were not provided. The facility's policy required individualized repositioning schedules and weekly skin inspections, but these were not consistently implemented for the resident.
Failure to Comprehensively Assess Bed Rail Use and Entrapment Risk
Penalty
Summary
The facility failed to conduct a comprehensive assessment prior to the use of bed rails for a resident with moderate to severe cognitive impairment, Huntington's disease, and depression, who was dependent for all mobility needs. The resident's care plan indicated the use of bed rails to promote independence, but the Bedrail Risk Assessment (BRA) did not address all required safety zones as outlined by FDA guidance, specifically lacking information for zones 1, 2, the footboard portion of zone 6, and zone 7. Additionally, the BRA did not document what alternatives to bed rails were attempted before their use. Observations confirmed that half bedrails were installed on both sides of the resident's bed. Interviews with facility staff revealed that maintenance installed bedrails after confirming provider orders but did not perform measurements or assessments related to entrapment risks. The physical therapy assistant, responsible for bedrail assessments, acknowledged that only limited measurements were taken and that the most recent assessment did not fully address all entrapment zones. Facility policy required compatibility checks and adherence to FDA safety dimensions, but these were not fully documented or implemented in this case.
Failure to Document Indications for Use on Medication Orders
Penalty
Summary
The facility failed to ensure that medication orders for a resident included clear indications for use, as required to prevent unnecessary drug administration. Review of one resident's medication orders revealed that multiple prescribed drugs, including aspirin, atorvastatin, finasteride, levothyroxine, pantoprazole, psyllium, solifenacin, tamsulosin, thiamine, and vibegron, did not have documented indications for use in the medical record. This omission was confirmed during interviews with a trained medication aide, a registered nurse, and a licensed practical nurse, all of whom acknowledged that medication orders should specify the reason or diagnosis for each drug prescribed. The resident in question had a complex medical history, including moderately impaired cognition, dementia, muscle weakness, Wernicke's encephalopathy, hypertension, hypothyroidism, urinary incontinence, type 2 diabetes, and alcohol use in remission. Despite these diagnoses, the medication administration records lacked specific indications linking each medication to the resident's conditions. The director of nursing and nursing staff verified during interviews that the facility's expectation is for all medication orders to include an appropriate indication, which was not met in this case.
Infection Control Deficiencies in Hand Hygiene, Glucometer Disinfection, and Medication Administration
Penalty
Summary
Staff failed to perform appropriate hand hygiene and glove changes during peri care for a resident with severe cognitive impairment and total incontinence. Two nurse assistants washed their hands and donned gloves before beginning care, but did not change gloves or wash hands after removing a soiled brief and cleaning the resident's peri area. They proceeded to place a clean brief and dress the resident without changing gloves or performing hand hygiene, only removing gloves and washing hands at the end of the process. The nurse assistants stated they only changed gloves or washed hands if there was visible stool, contrary to facility policy and infection preventionist guidance, which required glove changes and hand hygiene when moving from dirty to clean tasks. A shared glucometer was not cleaned and disinfected according to the manufacturer's instructions after use for blood sugar testing. An LPN used the glucometer for a resident with diabetes, then cleaned it with an alcohol wipe before returning it to the medication cart. The LPN stated this was her usual process, but the manufacturer's instructions required a two-step process: cleaning with detergent and then disinfecting with a validated bleach wipe, ensuring the device remained wet for the required contact time. The assistant director of nursing confirmed that shared glucometers should be disinfected with the appropriate wipes, and was unaware that a shared device was in use. During eye drop administration for a resident with moderately impaired cognition and multiple diagnoses, a trained medication aide did not wear gloves or perform hand hygiene. The aide used bare hands to hold the resident's eyelids open and administer the drops, repeating the process when the first attempt was unsuccessful. The aide acknowledged that gloves should be worn to prevent germ transmission but did not do so in this instance. Facility policy required staff to follow infection control procedures, including hand hygiene and glove use, during medication administration.
Failure to Conduct Regular Bed and Bedrail Safety Inspections
Penalty
Summary
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails as part of a routine maintenance program for a resident with significant cognitive and physical impairments. The resident had diagnoses including dementia, Huntington's disease, and depression, and was dependent on staff for all mobility needs. The care plan indicated the use of bedrails to promote independence, and observations confirmed the presence of half bedrails on both sides of the bed. However, interviews revealed that maintenance staff only checked bedrails for looseness and tightened them monthly, without performing measurements or assessments related to entrapment risks. There was no established schedule for comprehensive inspections of beds, mattresses, or bedrails beyond this limited check. Further, while a physical therapy assistant performed initial bedrail assessments when rails were first installed, there were no ongoing evaluations to monitor changes in the resident's risk of entrapment. The facility's policy required routine inspections to identify risks, including entrapment, and mandated that inspection results be reported to the administrator and QAPI committee. Despite this, maintenance records documenting regular bed inspections and maintenance were requested but not provided, indicating a lack of documentation and follow-through on required safety checks.
Survey Results Not Readily Accessible or Properly Posted
Penalty
Summary
The facility failed to ensure that the most recent state agency survey results were readily accessible to residents, visitors, and families, and did not post appropriate signage or notice of the inspection reports within the campus. During observation and interviews, it was found that no posted signs were available for survey results, and the survey results were kept in a green binder secured with a cable on a shelf near the front desk, requiring review at the front desk rather than in private. The binder was organized by year, but only contained survey results up to June 2023 at the time of observation. The administrator confirmed responsibility for maintaining the binder and acknowledged that more recent survey results and complaints from 2024 and 2025 were only added after the survey team arrived. No policies related to survey results were provided when requested.
Nursing Assistant's Abusive Actions and Social Media Violations
Penalty
Summary
The facility failed to protect residents from mental, emotional, and physical abuse, as evidenced by the actions of a nursing assistant (NA-A) who took humiliating photographs and videos of four residents and posted them on social media. NA-A was observed setting up a camera to record interactions with a resident, during which she aggressively threw the resident into bed, hit them with a shoe, and made obscene gestures. These actions were captured on video and shared on Snapchat, violating the residents' privacy and dignity. The report details that NA-A took and shared inappropriate images of residents, including one resident in their underwear, another with exposed private areas, and a third holding a phone displaying an inappropriate image. These actions were not only a breach of privacy but also constituted mental and emotional abuse. The residents involved had various medical conditions, including cognitive impairments, which made them particularly vulnerable to such abuse. Interviews with staff and residents revealed that NA-A was aware of the facility's policies prohibiting the use of cell phones during care and the posting of residents' images on social media. Despite this, NA-A continued to engage in these abusive practices, which were not reported by other staff members who witnessed some of the behavior. The facility's failure to enforce its policies and protect residents from abuse resulted in an immediate jeopardy situation, highlighting significant lapses in oversight and staff compliance with established protocols.
Removal Plan
- Policy review
- Appropriate education and training of all employees
Discrepancy in Resident's Code Status Documentation
Penalty
Summary
The facility failed to ensure that a resident's advance directives were accurately and consistently documented in the electronic health record (EHR), the Provider Order for Life Sustaining Treatment (POLST), and physician orders. This discrepancy involved a resident whose code status was not accurately documented, leading to an immediate jeopardy situation. The resident's care conference initially identified them as a full code, but the POLST in the EHR indicated a Do Not Resuscitate (DNR) status. When the facility became aware of the discrepancy, they changed the EHR banner to DNR to match the POLST, which was against the resident's wishes to be resuscitated. The issue was identified when a licensed practical nurse (LPN) and the assistant director of nursing (ADON) reviewed the POLST book and the EHR, finding that they did not match. The ADON stated that code status should be reviewed at each care conference, but the actual POLST was not reviewed unless there was a concern. The resident's family member recalled that the resident's code status was originally DNR but was changed to full code per the resident's wishes. However, the facility had not communicated with the family member before changing the order to DNR. The care conference notes consistently identified the resident's code status as full code, and the social service progress note confirmed that the resident's current wishes were to be resuscitated. Despite this, the facility had changed the order to DNR without verifying with the family member. The discrepancy in documentation and lack of communication led to the immediate jeopardy situation, as the resident's wishes were not accurately reflected in the facility's records.
Removal Plan
- Corrected the code status for R86 to full code per R86's wishes.
- Updated R86's POLST in the EHR to full code per R86's wishes.
- Completed a facility-wide audit to ensure there were no other code status discrepancies.
- Reviewed policies and procedures.
- Provided education for staff involved with care conferences.
Deficiency in Resident Access to Personal Funds
Penalty
Summary
The facility failed to ensure that 56 residents with personal funds accounts had access to their funds after hours and on weekends. Interviews with residents, including those who were cognitively intact, revealed that they could only access their money during specific hours on weekdays, typically between 1:30 p.m. and 3:30 p.m. This limitation was inconvenient for residents, as they had to plan ahead to have the money they needed, and there was no access to funds on weekends. Observations confirmed that a sign at the front desk indicated restricted banking hours, and staff interviews corroborated the limited access to funds. Staff members, including registered nurses, trained medication aides, and licensed practical nurses, were generally unaware of any arrangements for residents to access their funds outside the specified hours. The business office manager stated that residents could request money during open banking hours or by talking with staff, who would then relay the request to the business office manager or administrator. However, there was no petty cash available in the facility, and the facility's policy indicated that resident requests for access to their funds should be honored as soon as possible. The facility's failure to maintain petty cash and provide access to funds outside of the limited banking hours led to the deficiency.
Failure to Monitor Nurse Aide Registry for Inactive Status
Penalty
Summary
The facility failed to monitor the nurse aide registry for inactive nursing assistants during their employment, resulting in an inactive nurse aide continuing to work directly with residents. Specifically, a review of the personnel file for a nurse aide identified a hire date of December 7, 2023. However, a search on the Minnesota Nurse Aid Registry revealed that the nurse aide's status became inactive as of May 16, 2024. Despite this, the facility schedule showed that the nurse aide was actively working day shifts during the survey conducted on May 20th, 21st, 22nd, and 23rd of 2024. During an interview, the facility administrator stated that both the staffing agency and the facility check the nurse aide registry upon hire, and the agency was responsible for notifying the facility of upcoming expirations. The administrator was unaware that the nurse aide no longer had an active registration.
Infection Control Deficiencies in PPE Use and Hand Hygiene
Penalty
Summary
The facility failed to ensure proper use of personal protective equipment (PPE) and hand hygiene, leading to deficiencies in infection prevention and control. For one resident with severe cognitive impairment and a vascular wound, staff did not wear gowns as required under Enhanced Barrier Precautions during high-contact care activities. Despite a sign indicating the need for gloves and gowns, nursing assistants only donned gloves while changing the resident's soiled brief and providing hygiene care. The nursing assistants acknowledged the requirement to wear gowns but cited the absence of PPE in the dementia unit as a reason for non-compliance. The Director of Nursing confirmed the expectation for staff to wear appropriate PPE during personal care. In another instance, a registered nurse failed to perform hand hygiene during medication administration for a resident with severe cognitive impairment and multiple diagnoses. The nurse did not sanitize hands or change gloves between different treatments, leading to potential cross-contamination. Additionally, the nurse used another resident's medication, which was not acceptable and posed an infection prevention concern. The Director of Nursing emphasized the importance of hand sanitization after glove removal and before applying new gloves to prevent cross-contamination.
Failure to Provide SNFABN to Resident After Medicare Coverage Ended
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) to a resident who remained in the facility after their Medicare Part A covered services ended. The resident's CMS-10123 form indicated that their last covered day was 3/7/24, but their medical record lacked evidence of an SNFABN being provided to explain the estimated cost per day or the rationale for the extended care services. Interviews with the business manager and administrator confirmed that the resident did not receive the SNFABN, despite having remaining Medicare Part A days. The facility did not provide a beneficiary policy but did have a CMS form with instructions for SNFABN completion, which states that an SNFABN must be issued prior to providing services that Medicare may not cover.
Inaccurate MDS Coding for Resident's Vision
Penalty
Summary
The facility failed to accurately code section B of the Minimum Data Set (MDS) for a resident, identified as R67, who was reviewed for MDS accuracy. R67's significant change MDS indicated that the resident's vision was marked as adequate, despite having multiple diagnoses that suggested otherwise. These diagnoses included type 2 diabetes mellitus with stable proliferative diabetic retinopathy, bilateral posterior synechiae, bilateral iridocyclitis, and cataract with neovascularization of the right eye. The resident's care plan also identified a vision impairment, with interventions to assist the resident in locating items. Additionally, R67 had an order for timolol maleate ophthalmic solution to treat high pressure inside the eye, further indicating a vision issue. The assistant director of nursing (ADON) confirmed that the MDS was incorrectly coded, stating that R67's vision was impaired and not adequate as marked. The director of nursing (DON) also emphasized the importance of MDS accuracy, as it influences care and reimbursement. The discrepancy in the MDS coding was identified during a review of R67's significant change MDS, highlighting a failure in the facility's assessment process to accurately reflect the resident's condition.
Medication Administration Error Due to Policy Violation
Penalty
Summary
The facility failed to adhere to standard practices for safe medication administration for a resident with severe cognitive impairment and multiple diagnoses, including major depression, anxiety, osteoarthritis, and diabetes. During a medication pass observation, a registered nurse (RN) was seen using Nystatin powder from another resident's supply to treat the resident's groin area, as the RN could not locate the resident's own medication. This action was contrary to the facility's policy, which mandates that medications ordered for a specific resident must not be administered to another. The incident was confirmed through interviews with the RN involved and the Director of Nursing (DON). The RN admitted to using another resident's Nystatin powder and acknowledged that it was inappropriate, even though the dosage was the same. The DON reiterated that each resident should have their own designated medication and that it was unacceptable to use medication from one resident for another. The facility's policy on administering medications clearly states that medications must be administered in accordance with prescriber orders and should not be shared between residents.
Deficiencies in Medication Administration and Documentation
Penalty
Summary
The facility failed to follow medical orders and document necessary information for residents with specific health conditions. For one resident with heart failure, the facility did not adhere to the order to report weight changes to the cardiology heart failure program. The resident's care plan did not address heart failure, and there were missing daily weight records and communications with the heart failure program, despite significant weight fluctuations. The assistant director of nursing acknowledged the importance of monitoring weights for medication adjustments, especially after the resident's recent heart surgery. Another resident, who was cognitively intact and diagnosed with malignant neoplasm of the liver, hypertension, and diabetes mellitus, did not receive prescribed pain medication doses as ordered. The electronic medication record showed missed doses of hydrocodone-acetaminophen, and the resident reported inconsistent medication administration depending on the staff. The director of nursing confirmed the expectation for all medications to be administered and documented as ordered. Additionally, the facility failed to document behaviors related to as-needed medication administration for a resident with severe cognitive impairment and schizophrenia. The medication administration record did not consistently reflect behavior charting, and there was a lack of documentation for the use of PRN medications. The director of nursing expected charting to accompany PRN behavior medication administration, and the facility's protocol emphasized documenting new or changed behaviors and utilizing non-pharmacologic approaches before antipsychotic medications.
Oxygen Tanks Unsecured in Resident Room
Penalty
Summary
The facility failed to secure oxygen tanks in a resident's room, leading to a potential accident hazard. The resident, identified as R75, was cognitively intact and on oxygen therapy due to conditions such as morbid obesity and chronic respiratory failure. During an observation, four oxygen tanks were found in R75's room, with two tanks unsecured and free-standing. The resident mentioned that the tanks were delivered by the oxygen company and were intended for use upon discharge. Staff members, including an LPN and a nursing assistant, confirmed that the tanks were full and should not be free-standing. The LPN noted that the resident was using an oxygen concentrator, and the tanks should not have been stored in the room. The assistant director of nursing and a licensed social worker later removed the tanks, and the director of nursing acknowledged that storing oxygen tanks in resident rooms is a potential fire hazard. The facility's policy on oxygen administration and medical gas cylinder storage emphasized the importance of securing portable oxygen cylinders to prevent mechanical damage and potential hazards.
Failure to Notify Provider of Significant Weight Loss
Penalty
Summary
The facility failed to notify the provider of a significant weight loss in a resident, identified as R56, who was under review for nutrition and weight loss. R56 had a history of dementia without behavior and gastroesophageal reflux disease (GERD) and required partial assistance with eating. The resident's care plan aimed to maintain a weight of 163 pounds within five percent, with no signs of malnutrition and consuming at least 50 percent of meals. However, the resident experienced a significant weight loss over several months, dropping from 163.9 pounds in January to 147.1 pounds in May. Despite this, there was no notification to the provider about the weight loss, as confirmed by RN-B during an interview. The registered dietician noted significant unplanned weight loss at various intervals, with a recommendation for nutritional supplements three times daily due to the weight loss. The facility's policy required nursing services to notify the physician and dietician when a nutritional problem was identified, but this was not followed. The director of nursing stated that her expectation was for the provider to be notified in such cases. The failure to update the provider about the resident's significant weight loss constitutes a deficiency in the facility's care practices.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision for a resident (R1) who was at risk for elopement, resulting in an immediate jeopardy situation. R1, diagnosed with bipolar disorder and metabolic encephalopathy, had a history of exit seeking and attempting to leave the building, putting him at high risk for elopement. Despite having a wanderguard on his wrist, R1 was able to elope from the facility unnoticed. Staff members, including a nursing assistant and a maintenance worker, mistook R1 for a visitor when the wanderguard alarm went off, failing to conduct a thorough search for the missing resident. It took approximately 1.25 hours before a code 99 (missing resident) was called, and R1 was found two miles away from the facility. The report highlighted lapses in staff response to the wanderguard alarm and the delayed realization of R1's absence. The nursing assistant and maintenance worker failed to properly investigate the alarm, assuming R1 was a visitor outside the building. Nurses and management were only alerted to R1's disappearance after a significant delay, raising concerns about the facility's supervision protocols for residents at risk for elopement.
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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