Benedictine Health Center Innsbruck
Inspection history, citations, penalties and survey trends for this long-term care facility in New Brighton, Minnesota.
- Location
- 1101 Black Oak Drive, New Brighton, Minnesota 55112
- CMS Provider Number
- 245310
- Inspections on file
- 28
- Latest survey
- April 16, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Benedictine Health Center Innsbruck during CMS and state inspections, most recent first.
A resident with Vietnamese as a preferred language and multiple medical conditions, including intracranial hemorrhage, hemiplegia, CKD, hypertension, aphagia, and pain, did not have communication or language needs addressed in the comprehensive care plan despite documentation of language preference in the record. The resident reported not understanding what was happening with their care and requested an interpreter, while staff described relying on broken English and hand gestures, noting the absence of communication guidance in the care plan. The DON and administrator acknowledged that communication needs and language preferences were expected to be included in each resident's care plan, consistent with facility policy requiring assessment of communication needs for care planning.
A resident with acute respiratory failure and pneumonitis was mistakenly given food and drink despite being NPO, leading to aspiration pneumonia and hospitalization. The nursing assistant provided a pastry, orange juice, and coffee, unaware of the resident's dietary restrictions. The oversight was discovered after the resident showed signs of respiratory distress, highlighting a failure to adhere to physician orders and facility policy.
The facility failed to properly store, label, and dispose of refrigerated food items and ensure the use of hair restraints in the kitchen. Observations revealed expired milk, undated nutrition supplements, and a cook preparing food without a beard net. The dietary manager confirmed the responsibility of nursing staff to label and date items, but facility policies were not followed.
The facility failed to monitor vital signs and weights as ordered for residents, leading to gaps in documentation and care. A resident on antipsychotic medication did not have vital signs recorded for several months, while another resident at risk for nutritional issues was weighed only once in a month. Additionally, skin alterations were not monitored, medications were missed due to residents sleeping, and skin assessments were inaccurately documented. Staff interviews confirmed these deficiencies and a lack of adherence to protocols.
The facility failed to adequately assess and address the wandering behaviors of residents, particularly a resident with severe cognitive impairment on hospice care. This resident eloped from the facility to obtain traditional medication, highlighting deficiencies in monitoring and intervention. The care plan lacked information on community safety, and staff were not fully aware of the resident's elopement risk, leading to inadequate supervision and intervention.
The facility failed to implement enhanced barrier precautions for two residents with indwelling catheters and did not ensure proper hand hygiene during care. Observations showed a lack of signage for precautions and improper handwashing by staff. Additionally, ice packs were improperly stored with food in unit refrigerators.
The facility failed to ensure a clean and sanitary dining room environment in the Villa unit, with observations revealing a sticky and soiled floor despite scheduled cleaning. Staff interviews confirmed the inadequate cleaning, and the facility was unable to provide documentation of cleaning protocols.
A facility failed to create a comprehensive and individualized care plan for a resident with cognitive impairments and on psychotropic medication. The care plan lacked non-pharmacological interventions for delirium, and staff were unaware of specific behavioral concerns or interventions. The Director of Nursing confirmed the deficiency, highlighting the need for personalized care plans.
A resident with medical conditions requiring assistance for personal hygiene did not receive routine showers as scheduled. The care plan indicated weekly bathing assistance, but documentation discrepancies led to the resident not receiving a shower for almost two weeks. Interviews revealed inconsistencies in the documentation of bath days, and the Director of Nursing acknowledged the miscommunication.
A resident with a history of stroke and aphasia did not receive the prescribed walking program to maintain mobility, as documented in their care plan. Despite having intact cognition and expressing a desire to walk more, the resident was not consistently assisted with ambulation as required. Nursing assistants failed to notice and document the walking program, and observations confirmed missed opportunities for walking during meals. The facility's DON acknowledged the lack of documentation and adherence to the care plan.
A facility failed to provide trauma-informed care for a resident with PTSD, who experienced flashbacks after a male caregiver provided personal care. The resident's care plan lacked individualized interventions and did not identify triggers to prevent re-traumatization. Staff interviews revealed a lack of awareness about the resident's PTSD and the absence of trauma-informed strategies in care documentation.
A facility failed to assist a family in determining a resident's mental capacity, leading to confusion about the resident's decision-making abilities. The resident, on hospice care with severe cognitive impairment, exhibited elopement and combativeness. Despite these behaviors, the facility did not conduct a BIMS assessment and lacked clarity in staff understanding of the resident's cognitive status. Social services did not provide adequate support to the family, contrary to facility policies.
A facility failed to update a resident's medical records and orders to reflect a new diagnosis for antipsychotic medication use, as recommended by a pharmacist. The resident, with moderate cognitive impairment and several diagnoses, was prescribed quetiapine for delirium, but the records were not updated to 'delusional disorder' as selected by the nurse practitioner. Additionally, there was no monitoring for target behaviors or side effects, contrary to facility policy.
A facility failed to ensure a resident on antipsychotic medication had an appropriate diagnosis and monitoring. The resident, with cognitive impairment and a history of delirium, was prescribed quetiapine without proper behavior monitoring or non-pharmacological interventions. Staff interviews revealed a lack of awareness of the resident's behaviors, and the care plan lacked specific monitoring instructions, contrary to facility policy.
A resident with severe cognitive impairment and a history of pressure ulcers was not provided with the necessary care planned interventions, such as Prevalon heel protectors and an air mattress, to prevent the worsening of existing pressure ulcers. Observations showed the resident was not wearing the required boots, and the air mattress was missing. Staff interviews confirmed the resident was supposed to wear the boots, but there was no documentation of refusal. The facility's policy required care plan evaluation and revision, which was not adequately followed.
A resident with a history of falls and cognitive deficits experienced multiple falls due to the facility's failure to conduct thorough root cause analysis and implement effective, individualized interventions. Despite several falls, the care plan lacked detailed analysis and effective measures, and staff were unfamiliar with the resident's fall interventions.
A resident with severe cognitive impairment was repeatedly observed with soiled clothing and dirty fingernails, despite requiring assistance with personal hygiene. Staff and family members acknowledged the resident's preference for cleanliness, but the facility failed to maintain his dignity.
The facility failed to implement the care plan for a resident with severe cognitive impairment who required assistance with eating. Observations and interviews revealed that staff did not provide the necessary supervision and encouragement during meals, leading to the resident not receiving adequate assistance as outlined in their care plan.
The facility failed to provide quarterly IDT care conferences for a resident with severe cognitive impairment. Care conferences were last held on 3/23/23 and 6/22/23, with none scheduled since. Staff acknowledged the oversight and confirmed that care conferences should be held quarterly and as needed.
A resident with severe cognitive impairment did not receive adequate nail care and feeding assistance as required by their care plan. Staff failed to consistently encourage or assist the resident with meals, and the resident's nails were observed to be dirty. The DON acknowledged the deficiencies, and the facility's policy on ADLs was not followed.
A resident with glaucoma received the wrong eye drops after an LPN left the incorrect medication on the resident's tray table without verifying it. The resident administered the drops, realized the mistake, and flushed her eyes, experiencing no ill effects. The incident was confirmed by nursing staff and the director of nursing.
Failure to Care Plan for Resident Communication and Language Needs
Penalty
Summary
The facility failed to update and implement a comprehensive care plan addressing a resident's communication and language needs. Record review showed that the resident's face sheet identified Vietnamese as the resident's language, with diagnoses including intracranial hemorrhage, hemiplegia and hemiparesis, chronic kidney disease, hypertension, aphagia, and pain, and a social services assessment documented Vietnamese as the preferred language. Despite this, review of the resident's care plan on 2/3/25 showed no identification of, or interventions related to, the resident's language or communication needs, even though facility policy required assessment of communication needs and use of that assessment to develop and revise a person-centered care plan. During an interview, the resident immediately requested an interpreter, stating they could not understand the interviewer and felt the facility did not care for them. The resident reported not understanding what was happening with their care and not knowing how to communicate with staff, which they found very frustrating. A nursing assistant reported they typically communicated with the resident using broken English and hand gestures and confirmed there was nothing in the care plan about communication methods, stating such information would be useful. The DON acknowledged that while the resident could express needs, it was the resident's right to fully understand what was happening, and that communication needs should be included in the care plan. The administrator confirmed the expectation that communication and language preferences be included in each resident's care plan.
Failure to Follow NPO Orders Leads to Resident Hospitalization
Penalty
Summary
The facility failed to adhere to physician orders for a resident who was designated as nothing by mouth (NPO) due to risks of aspiration. Despite the care plan indicating the resident was at risk for aspiration and required tube feedings for nutrition, a nursing assistant provided the resident with a pastry, orange juice, and coffee. This action was contrary to the physician's directive, which explicitly stated no food, water, or ice chips by mouth. The resident, who had diagnoses including acute respiratory failure and pneumonitis, later exhibited symptoms of respiratory distress, including emesis, crackles in the lungs, and low oxygen saturation, leading to hospitalization for probable recurrent aspiration pneumonia and acute hypoxia respiratory failure. The incident occurred when the nursing assistant, unaware of the resident's NPO status, served the resident food and drink. The oversight was discovered when a coworker informed the nursing assistant, who then notified a registered nurse. The nurse assessed the resident's lung sounds, which were initially clear, but later noted crackles and other symptoms of respiratory distress. The facility's policy required staff to check assignment sheets for dietary orders, but this protocol was not followed, resulting in the resident receiving inappropriate food and drink, contributing to the resident's subsequent medical emergency.
Removal Plan
- Education to all staff regarding dietary orders
- Review of dietary policy and procedure
- Audits on all residents to ensure those with NPO status did not receive anything by mouth
- Ensure residents on special textured diets received the proper diet texture foods
Deficiencies in Food Storage and Personal Hygiene Practices
Penalty
Summary
The facility failed to ensure proper storage, labeling, and disposal of refrigerated food items, as well as the use of hair restraints in the kitchen. During an observation, a gallon of 1% milk was found in the refrigerator past its best-by date, which the dietician acknowledged needed to be discarded. Additionally, a cook was observed preparing food without a beard net, which was confirmed by the dietician as a violation of the facility's personal hygiene policy. Further observations in the Villa and transitional care unit kitchenettes revealed several food items that were either undated or past their recommended storage duration. These included a nutrition supplement and a nutritional shake, both of which lacked open dates, making it impossible to determine their expiration. The dietary manager confirmed that while the kitchen provides supplements, it is the nursing staff's responsibility to label, date, and dispose of items according to the directions on the container. The facility's policies on food storage and personal hygiene were not adhered to, contributing to these deficiencies.
Deficiencies in Monitoring and Documentation of Resident Care
Penalty
Summary
The facility failed to ensure that vital signs were taken as ordered for a resident receiving antipsychotic medication. The resident, who had severe cognitive impairment and required substantial assistance with activities of daily living, was supposed to have vital signs monitored weekly due to the risk of complications from psychotropic drug use. However, there was a significant gap in the documentation of vital signs, with no records from March to August, except for one instance in May. Interviews with nursing staff confirmed that vital signs should have been taken weekly, and the lack of documentation was acknowledged by the Director of Nursing. Another deficiency involved the failure to monitor a resident's weight as ordered. The resident, who was cognitively intact and at risk for nutritional issues, was supposed to have their weight monitored weekly. However, only one weight measurement was documented over a month-long period. The resident expressed concern about potential weight loss, and staff interviews confirmed that weights should have been taken weekly, even if the resident refused a shower. The Registered Dietician and Director of Nursing both confirmed that the protocol was not followed. The facility also failed to monitor and document skin alterations and administer medications as ordered. One resident with facial bruising did not have their skin alterations monitored after an initial assessment, and another resident repeatedly missed scheduled medications due to sleeping, with no documentation of these omissions in the progress notes. Additionally, skin assessments for several residents were inaccurately documented, missing critical information about existing conditions and required treatments. Interviews with nursing staff and the Director of Nursing highlighted inconsistencies in documentation and a lack of adherence to protocols for monitoring and documenting skin conditions.
Failure to Assess and Address Wandering Behaviors
Penalty
Summary
The facility failed to comprehensively assess and address the wandering behaviors of several residents, leading to a deficiency in ensuring resident safety. One resident, identified as R15, exhibited behaviors indicating potential wandering, yet the facility did not conduct a thorough assessment of these behaviors or implement adequate interventions. R15, who had severe cognitive impairment and was on hospice care, attempted to leave the facility to obtain traditional Hmong medication, resulting in an elopement incident. Despite being on hospice and having a history of cognitive impairment, R15's care plan lacked information on whether he was safe to go out into the community. The facility's documentation and interviews revealed that R15's wandering behavior was not adequately monitored or addressed. R15's care plan did not include interventions for wandering, and the facility failed to ensure the placement and monitoring of a wander guard, which R15 repeatedly removed. The facility's staff, including registered nurses and nursing assistants, were not fully aware of R15's elopement risk, and there was a lack of consistent communication and documentation regarding R15's cognitive status and decision-making capacity. The facility's failure to conduct a proper elopement risk assessment and implement appropriate interventions contributed to R15's ability to leave the facility unsupervised. Additionally, the facility did not have a clear process for assessing residents' capacity to make decisions or determining their safety to leave the facility. Interviews with staff indicated confusion and inconsistency in the procedures for handling elopement risks and assessing residents' cognitive abilities. The lack of a comprehensive assessment and care plan for R15, combined with inadequate staff training and communication, resulted in a deficiency in ensuring a safe environment for residents prone to wandering.
Failure to Implement Enhanced Barrier Precautions and Ensure Proper Hand Hygiene
Penalty
Summary
The facility failed to implement enhanced barrier precautions for two residents, R83 and R24, who were observed to have indwelling catheters. R83's care plan did not include interventions for the Foley catheter or enhanced barrier precautions, and there was no signage outside R83's room to indicate the need for such precautions. Staff interviews confirmed the absence of signage, which is typically used to inform staff of precautionary measures. Despite the presence of a new infection preventionist, the issue remained unresolved as of the last observation. For resident R24, the facility failed to ensure appropriate hand hygiene during assistance with activities of daily living. Observations revealed that a nursing assistant did not consistently use soap when washing hands and donned gloves without properly cleansing hands. This was despite R24 being on enhanced barrier precautions due to the presence of an indwelling urinary catheter. Interviews with staff confirmed the expectation for proper hand hygiene and the use of personal protective equipment during resident care. Additionally, the facility did not store ice packs separately from food in two unit refrigerators, which was observed in the Villa kitchenette and the transitional care unit. Ice packs were found next to food items such as ice cream and lasagna, which was acknowledged by the dietician and a registered nurse as unsanitary. The director of nursing was informed of the issue but did not provide a policy on ice pack storage.
Failure to Maintain Clean Dining Room Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in one of its dining rooms, specifically the Villa unit. Observations on multiple occasions revealed that the dining room floor was covered with dried food, spilled liquids, and was sticky to walk on. Despite the presence of housekeeping staff who were supposed to clean the area, the floor remained visibly soiled and sticky. Interviews with staff, including a licensed practical nurse and environmental services personnel, confirmed the condition of the floor and indicated that the cleaning schedule was not being effectively followed. The environmental services staff were observed mopping the floor, but sticky spots and spills remained. The director of environmental services acknowledged the poor condition of the floor, noting a buildup of dirt and food spills over more than one day. The facility's cleaning schedule indicated that dining rooms were to be mopped twice daily, but sign-off sheets to confirm this were not provided. Additionally, a facility policy regarding cleaning was requested but not received, further highlighting the lack of adherence to cleaning protocols.
Failure to Develop Individualized Care Plan for Resident on Psychotropic Medication
Penalty
Summary
The facility failed to develop a comprehensive and individualized care plan for a resident identified as R88, who was reviewed for psychotropic medication use. R88's admission Minimum Data Set (MDS) indicated moderate cognitive impairment and diagnoses including sepsis, metabolic encephalopathy, delirium, and age-related cognitive decline. The care plan, revised after the survey began, noted the use of quetiapine for delirium but lacked non-pharmacological or personalized interventions to support signs of delirium or delusions. The nursing task sheet did not indicate any behaviors or confusion for R88. Interviews with staff revealed a lack of awareness and documentation regarding R88's behavioral concerns and interventions. A nursing assistant acknowledged R88's occasional confusion but noted no alerts or interventions on the task sheet. A registered nurse mentioned using distraction techniques for agitation but was unaware of any specific behaviors or personalized interventions for R88. The Director of Nursing confirmed the care plan's lack of individualized interventions and emphasized the expectation for care plans to be tailored to each resident. The facility's policy on comprehensive assessment and care planning directed that person-centered care plan interventions be implemented by qualified personnel and communicated through various means.
Failure to Provide Routine Showers for Resident
Penalty
Summary
The facility failed to provide routine showers for a resident, identified as R90, who was reviewed for activities of daily living (ADLs). R90 was cognitively intact and had medical conditions including cellulitis, lymphedema, and a fracture of the right foot. The resident required substantial assistance for lower body dressing and supervision for personal hygiene. Despite these needs, R90's care plan indicated that staff were to assist with bathing weekly, but the treatment administration record showed that R90 did not receive a bath on the scheduled days. The discrepancy in the documentation led to R90 not receiving a shower for almost two weeks, which was confirmed by the resident during interviews. Interviews with nursing assistants and a registered nurse revealed inconsistencies in the documentation of R90's bath days. The care sheet and nursing order did not match, leading to confusion about the correct bath day. The Director of Nursing acknowledged the miscommunication and confirmed that the shower day should have been coordinated with occupational therapy due to R90's edema wraps. The facility's policy directed staff to assist residents with ADLs, including bathing, but this was not adhered to in R90's case.
Failure to Implement Resident Walking Program
Penalty
Summary
The facility failed to implement a walking program as prescribed for a resident, identified as R73, who was reviewed for walking programs. R73 had intact cognition, no behaviors or rejection of care, and required partial to moderate assistance for transfers. Diagnosed with stroke and aphasia, R73's care plan included a walking program to be conducted at specific times with the use of a gait belt, right AFO, and quad cane. However, documentation from the Point of Care (POC) system revealed that the walking program was not consistently carried out as ordered, with significant gaps in the frequency of ambulation recorded. Interviews and observations further highlighted the deficiency. R73 expressed a desire to walk more often and confirmed that staff did not walk with her daily. Nursing assistants admitted to not noticing the walking program on assignment sheets and failing to document the ambulation activities. Observations showed that R73 was not offered opportunities to walk during meal times as per the care plan. The facility's physical therapy assistant and outpatient physical therapist emphasized the importance of the walking program for R73's functional improvement, yet the program was not executed as required. The Director of Nursing (DON) and regional registered nurse acknowledged the lack of documentation and completion of the walking program. Despite the nursing order for the walking program being acknowledged, it was not effectively implemented by the nursing assistants responsible for its execution. The facility's policy required that care and services be provided in accordance with the plan of care, including mobility support, but this was not adhered to in R73's case, leading to the identified deficiency.
Failure to Implement Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to comprehensively assess and implement a trauma-informed care plan for a resident with PTSD symptoms. The resident, who had a history of depression and bipolar disorder, was admitted to the facility and had previously indicated a preference to be left alone when upset. However, the trauma screening was incomplete, lacking information on triggers and management strategies, and there was no follow-up screening. The care plan did not include individualized trauma-informed interventions or identify triggers to prevent re-traumatization. The deficiency was highlighted when the resident experienced PTSD symptoms after a male caregiver provided personal care, triggering flashbacks of childhood abuse. Despite the resident's request to avoid male caregivers, this preference was not documented in the care plan or communicated to all staff. Interviews with staff revealed a lack of awareness about the resident's PTSD and the absence of trauma-informed care strategies in the care documentation. The facility's social services director acknowledged the need for updated trauma screenings and care plan interventions, as per the facility's policy on trauma-informed care.
Failure to Assist in Determining Resident's Mental Capacity
Penalty
Summary
The facility failed to provide adequate assistance to a family member in determining the mental capacity of a resident, identified as R15, who was on hospice care. R15 had a complex medical history, including anxiety disorder, cardiogenic shock, acute respiratory failure, and heart failure, and was receiving hospice services. Despite these conditions, the facility did not conduct a Brief Interview for Mental Status (BIMS) upon admission, which would have helped assess R15's cognitive abilities. The care plan lacked information on whether R15 could make his own decisions, and there was confusion about R15's decision-making capacity, as noted in various medical and progress notes. R15 exhibited behaviors such as elopement and combativeness, which raised concerns about his safety and decision-making abilities. On one occasion, R15 left the facility unaccompanied, intending to purchase traditional Hmong medication, and was intercepted by police. The facility placed a wander guard on R15, but it was later removed, and there was inconsistency in staff understanding of R15's cognitive status and decision-making capacity. Interviews with staff revealed a lack of clarity and communication regarding assessments of R15's ability to make decisions and the appropriate interventions to ensure his safety. The facility's social services department did not adequately address the family's request for assistance in determining R15's mental capacity. The social services director acknowledged that R15 had severe cognitive impairment but did not provide clear guidance or support to the family. The facility's policies and job descriptions indicated that social services should assist with legal and financial matters, including decision-making capacity, but these services were not effectively provided in R15's case.
Failure to Update Medication Records and Monitor Antipsychotic Use
Penalty
Summary
The facility failed to ensure that the provider's response to a pharmacist's medication review recommendation was followed and that appropriate monitoring was in place for a resident using antipsychotic medication. The resident, who had moderate cognitive impairment and several diagnoses including sepsis and delirium, was prescribed quetiapine for delirium. However, the pharmacist noted that the medication lacked an allowable diagnosis and recommended an update. The nurse practitioner selected 'delusional disorder' as the diagnosis, but the resident's medical records and orders were not updated to reflect this change. Additionally, the facility did not implement monitoring for target behaviors or side effects associated with the use of quetiapine. The care plan for the resident was revised after the survey began, but it still did not specify which behaviors to monitor. Interviews with the consulting pharmacist and the Director of Nursing revealed that there was a lack of monitoring in place, and the necessary updates to the resident's records were not made, possibly due to staff oversight during a vacation period. The facility's policy required that recommendations be acted upon and documented, which was not adhered to in this case.
Failure to Monitor Antipsychotic Medication Use
Penalty
Summary
The facility failed to ensure that a resident receiving antipsychotic medication had an appropriate indication and diagnosis for the medication. The resident, who had moderate cognitive impairment and a history of sepsis, metabolic encephalopathy, and delirium, was prescribed quetiapine for delirium. However, the facility did not monitor the resident for target behaviors or side effects related to the medication, nor did they implement non-pharmacological interventions. The resident's care plan was revised after the survey began, indicating the use of quetiapine for delirium, but it lacked specific behaviors to monitor. Despite recommendations from the hospital to consider stopping the medication and a pharmacist's suggestion to review the diagnosis, the facility continued the medication without proper documentation of behaviors or non-pharmacological strategies. Interviews with staff revealed a lack of awareness and monitoring for delusional or delirium-related behaviors, and the resident was noted to be pleasant and oriented without delusions or hallucinations. The Director of Nursing confirmed that there was no order for behavior monitoring related to quetiapine use and acknowledged the absence of non-pharmacological interventions in the care plan. The facility's policy required collaboration with medical providers to ensure the lowest possible dose of psychotropic medication for the shortest period, with a care plan that includes both pharmacological and non-pharmacological interventions. However, these steps were not adequately followed for the resident in question.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to implement care planned interventions to prevent the worsening of existing pressure ulcers for a resident with severe cognitive impairment and a history of dementia, anxiety, muscle weakness, and a stage II pressure ulcer. The resident's care plan included the use of an air mattress and bilateral Prevalon heel protectors to prevent further pressure injuries. However, observations revealed that the resident was not wearing the Prevalon boots while seated in a wheelchair in the dining room on multiple occasions, and the air mattress was not present on the resident's bed. Interviews with staff confirmed that the resident was supposed to be wearing the Prevalon boots, but there was no documentation of the resident refusing to wear them. The facility's policy on the prevention and treatment of skin breakdown required licensed nurses to evaluate and revise care plans for residents with impaired skin integrity. Despite this, the resident's medical record lacked evidence of refusal to wear the Prevalon boots, and the air mattress had not been replaced after being removed when the resident was discontinued from hospice care. The failure to adhere to the care plan and document refusals contributed to the deficiency in providing appropriate pressure ulcer care and preventing new ulcers from developing.
Failure to Prevent Falls Due to Inadequate Analysis and Interventions
Penalty
Summary
The facility failed to conduct a thorough root cause analysis and implement individualized interventions to prevent falls for a resident who experienced multiple falls since admission. The resident, who had a history of falls, cognitive deficits, and required assistance with mobility and toileting, was not identified as at risk for falls despite sustaining several falls. The care plan included interventions such as keeping the call light within reach and offering toileting assistance, but these measures were not effective in preventing further falls. The resident experienced multiple falls, often while attempting to use the bathroom or retrieve personal items, and did not consistently use the call light for assistance. Despite meetings by the interdisciplinary team to review each fall, the facility did not identify effective interventions or address the resident's impaired cognition, which contributed to the falls. The care area assessment and care plan lacked detailed analysis of the root causes and contributing factors for the falls, leaving many sections blank. Interviews with staff revealed a lack of familiarity with the resident's fall interventions and inconsistent application of the care plan. The director of nursing acknowledged the need for further analysis and intervention but had not yet implemented additional measures. The facility's policy required individualized care plans based on fall risk assessments, but this was not adequately followed, leading to repeated falls and injuries for the resident.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to maintain the dignity of a resident (R2) who required assistance with activities of daily living. R2, who had severe cognitive impairment and required moderate assistance with personal hygiene, was observed on multiple occasions with soiled clothing and dirty fingernails. Despite having a care plan that indicated the need for assistance with grooming and bathing, R2 was seen in the dining room with food stains on his clothes and a brown substance under his nails. Family members and staff acknowledged that R2 would not have liked to be seen in such a state and that it affected his sense of pride and well-being. Interviews with nursing assistants and the director of nursing revealed that nail care was expected to be performed during bath time and as needed, and that soiled clothing should be changed promptly. However, R2's nails remained dirty, and his clothes were not changed even after staff acknowledged the issue. The facility did not provide a policy on dignity when requested, further indicating a lapse in maintaining the resident's dignity and self-respect.
Failure to Implement Comprehensive Care Plan for Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to implement the comprehensive care plan for a resident (R2) who had severe cognitive impairment and required assistance with eating. Despite the care plan indicating that R2 needed supervision and encouragement during meals, observations on multiple occasions showed that staff did not provide the necessary assistance. On one occasion, R2 was observed in the dining room with a plate of food, but only managed to eat a bun and drink water and milk without any staff encouragement to eat the rest of the meal. Similarly, during another meal, R2 spilled soup on his shirt and attempted to clean it himself without any staff intervention or encouragement to eat his fruit. Interviews with staff and family members further highlighted the lack of adherence to the care plan. A family member noted that staff only assisted residents they were seated next to, and a nursing assistant stated that they were unaware R2 needed encouragement with meals. The Director of Nursing confirmed that staff should assist residents who require help with eating, as per the facility's policy on care planning. This failure to follow the care plan resulted in R2 not receiving the necessary assistance and encouragement during meals, as required by their care plan and provider orders.
Failure to Provide Quarterly Care Conferences
Penalty
Summary
The facility failed to provide quarterly interdisciplinary team (IDT) care conferences for one resident (R6) who had severe cognitive impairment. The resident's medical record indicated that care conferences were held on 3/23/23 and 6/22/23, but none were held since that time. Registered Nurse (RN)-C acknowledged that R6 missed several care conferences, and the social worker (SW)-A confirmed that there were no notes for R6's care conferences after 6/22/23 and no future care conferences were scheduled. The Director of Nursing (DON) also stated that care conferences should be held quarterly and as needed. The facility's policy dated 11/28/2017 directed that residents have the right to participate in planning their care and treatment.
Failure to Provide Adequate Nail Care and Feeding Assistance
Penalty
Summary
The facility failed to ensure nail care and feeding assistance was provided for a resident (R2) with severe cognitive impairment. R2's care plan and provider orders indicated the need for supervision and assistance with eating and personal hygiene, including nail care. However, observations revealed that R2 was not consistently encouraged or assisted with meals. On multiple occasions, staff did not provide the necessary support, resulting in R2 eating only parts of his meal or not eating at all. Additionally, R2's nails were observed to be dirty, and staff acknowledged the issue but did not address it adequately. Interviews with staff and family members confirmed that R2 required assistance with eating and nail care. Despite this, staff failed to provide the necessary support during meals, and R2's nails remained unclean. The Director of Nursing (DON) acknowledged that residents requiring assistance should be helped according to their care plans and that nail care should be performed on shower days and as needed. The facility's policy on Activities of Daily Living directed that residents unable to carry out ADLs independently should receive services to maintain good grooming and personal hygiene, which was not adhered to in R2's case.
Medication Error Due to LPN's Failure to Verify Medication
Penalty
Summary
The facility failed to follow safeguards to ensure residents received the correct medications, resulting in a medication error for one resident (R4). R4, who was cognitively intact and diagnosed with glaucoma, was supposed to receive brimonidine eye drops as per the provider's orders. However, on one occasion, R4 administered dorzalamide eye drops, which were intended for another resident. This error occurred because an LPN left the wrong eye drops on R4's tray table and did not verify the medication before leaving the room. R4 realized the mistake after administering the drops and flushed her eyes, experiencing no ill effects. The incident was confirmed by both R4 and the nursing staff. RN-B acknowledged that R4 had not been assessed to ensure she could safely administer her own eye drops and that the LPN should not have left the room before verifying the medication. The director of nursing also verified the medication error. The facility's policy on administering medications, which requires licensed nurses or trained associates to ensure the right resident receives the right medication, was not followed in this instance.
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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