Benedictine Health Center Of Minneapolis
Inspection history, citations, penalties and survey trends for this long-term care facility in Minneapolis, Minnesota.
- Location
- 618 East 17th Street, Minneapolis, Minnesota 55404
- CMS Provider Number
- 245266
- Inspections on file
- 25
- Latest survey
- April 3, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Benedictine Health Center Of Minneapolis during CMS and state inspections, most recent first.
The facility failed to secure residents' PHI, leaving care sheets with sensitive information unattended in various areas. Staff acknowledged the oversight, confirming the presence of private information on these sheets, which should have been kept out of sight to protect resident privacy.
A facility failed to ensure a resident and their representative participated in care conferences for care planning. The resident, with severe cognitive impairment and multiple diagnoses, did not have a care conference conducted after a significant change in status. Staff interviews revealed that the care conference was overdue, and the family member confirmed no recent invitations to participate. This lapse violated the facility's policy on resident involvement in care planning.
A facility failed to update a resident's care plan to include a foley catheter placed during hospitalization and anxiety interventions from a psychology provider. The resident's care plan and work sheets lacked necessary updates, leading to staff being unaware of the resident's current needs. Interviews confirmed the absence of catheter-related information in the EMR, and the deficiency was attributed to a lack of real-time updates and communication among the care team.
The facility failed to provide adequate personal hygiene and self-care for residents dependent on staff, leading to deficiencies in maintaining a dignified appearance and reducing the risk of complications. A resident with severe cognitive impairment was observed with long, soiled fingernails, while another resident with significant cognitive impairment had long, jagged toenails and fingernails. A third resident, with moderate cognitive impairment, was not consistently shaved despite expressing a preference to be clean-shaven. Staff interviews revealed inconsistencies in care documentation and communication, and family members expressed concerns about the lack of basic care.
A facility failed to provide care-planned activities for a non-verbal resident with severe cognitive impairment. Despite having a care plan that included listening to music and watching TV, the resident was often left in a silent room. Staff interviews revealed poor communication and coordination between nursing and activities staff, resulting in minimal engagement with the resident. The therapeutic recreation director confirmed that the television should be on for the resident, but this was not consistently done.
A facility failed to ensure proper flushing of a gastrostomy tube for a resident with severe cognitive impairment and multiple medical conditions. The RN did not measure the prescribed 150 ml of water for flushing after administering medications, potentially leaving residual medication in the tube. Interviews with staff confirmed the deviation from expected procedures, and the facility's policy on flushing was not provided.
The facility failed to provide comprehensive pain management for two residents. One resident, who was non-verbal, showed signs of potential pain, but the facility did not conduct thorough assessments or implement consistent monitoring. Another resident, with multiple fractures, did not receive non-pharmacological interventions, and pain medication administration lacked proper documentation. Staff interviews revealed inconsistencies in pain assessment and documentation practices.
A facility failed to reassess the safety and appropriate use of bed rails for a resident with impaired cognition. Despite the resident's declining condition and increased need for assistance, the facility did not conduct updated assessments since September 2022. Interviews with staff revealed a lack of awareness and process for ongoing monitoring or reassessment of side rail use, and the facility's policy did not specify when ongoing assessments should be completed.
A facility failed to monitor the efficacy of antipsychotic medication for a resident with severe cognitive impairment. The resident was on Seroquel for psychosis and major depressive disorder, but staff did not track specific target behaviors. Interviews revealed uncertainty about the resident's symptoms, and the care plan lacked details on behaviors to monitor. The facility's policy required identifying and monitoring target behaviors, which was not followed.
A facility failed to follow proper infection control practices during tracheostomy care for a resident on enhanced barrier precautions. An RN did not change gloves between administering medications through a gastrostomy tube and performing tracheostomy care, contrary to CDC guidelines and facility policy. Interviews with staff confirmed the oversight, highlighting a lapse in infection prevention measures.
The facility failed to respond promptly to ventilator alarms for three residents who were ventilator-dependent and severely cognitively impaired. Alarms were not addressed in a timely manner, with delays ranging from several minutes to nearly half an hour. Staff acknowledged the importance of prompt responses but admitted that responses depended on staffing levels. The facility lacked a clear policy on ventilator alarm response times.
A facility failed to properly monitor and manage pressure ulcers for four residents, leading to deficiencies in care. One resident developed an unstageable sacral ulcer that was not treated timely, resulting in hospitalization. Another resident with multiple ulcers had inadequate documentation and improper wound care practices, including lack of hand hygiene and use of inappropriate materials. Similar issues were observed in two other residents, highlighting failures in wound care protocols and infection control.
A resident with a history of respiratory failure and septicemia was found with a heart rate of 156 bpm, but the nurse on duty did not notify a provider. The resident was later found unresponsive and died despite CPR efforts. The facility failed to follow standing orders and policies requiring provider notification for significant changes in condition.
A resident with multiple medical conditions, including quadriplegia and respiratory failure, was admitted with a stage 2 pressure ulcer. The facility failed to comprehensively assess and treat the ulcer, resulting in the development of a new pressure injury. Additionally, the lack of management and assessment of a cervical collar led to a pressure ulcer on the resident's head, discovered only after hospital transfer. Staff interviews revealed confusion and lack of communication regarding wound care and collar management.
A resident with cognitive impairments posted on social media about alleged abuse by facility staff, but the LTC facility failed to report the suspicion to the State Agency within the required timeframe. Despite awareness of the posts by the administrator and DON, the facility did not act promptly, violating their abuse prevention policy.
A resident with severe cognitive impairments alleged abuse by facility staff through social media posts. The facility's investigation was incomplete, lacking proper documentation and adherence to policy. A skin assessment showed no injuries, and plans for a room camera were not executed due to lack of consent. Interviews with other residents and staff were insufficiently documented.
The facility failed to implement enhanced barrier precautions (EBPs) for two residents with tracheostomies, ventilators, and indwelling urinary catheters. Care plans did not address infection risks or PPE use, and staff performed care tasks without gowns. Interviews revealed a lack of awareness about EBPs among staff, despite facility policy requiring them for residents with indwelling medical devices.
Unattended Care Sheets Violate Resident Privacy
Penalty
Summary
The facility failed to ensure the security and confidentiality of residents' personal health information (PHI) as required by HIPAA standards. During observations, care sheets containing sensitive information about residents, such as their names, room numbers, and specific care needs, were found unattended and exposed in various locations across the facility. On the third floor, a care sheet was left on a covered linen cart in a hallway alcove, accessible to anyone passing by. Similarly, on the fourth floor, a care sheet was left on a medication cart in a common area, and on the second floor, another care sheet was found in an alcove. These sheets contained detailed information about residents' assistance needs, infection control precautions, and other personal details. Interviews with staff members, including nursing assistants and the assistant director of nursing, confirmed the oversight and acknowledged the presence of private information on the unattended care sheets. Staff members admitted that these documents should not have been left unattended and recognized the potential for unauthorized access to sensitive information. The director of nursing also confirmed that care sheets should always be kept out of sight to protect resident privacy, highlighting a systemic issue in maintaining the confidentiality of resident information.
Failure to Conduct Timely Care Conferences
Penalty
Summary
The facility failed to ensure that a resident and/or their representative participated in care conferences for the planning and development of interventions. The resident in question, identified as R36, was noted to have severe cognitive impairment and was dependent on staff for various personal care activities. The resident's medical history included Alzheimer's, dementia, hemiplegia, and malnutrition. Despite the requirement for care conferences to coincide with the Minimum Data Set (MDS) assessments, the facility did not conduct a care conference for R36 after a significant change in status assessment in July 2024. Interviews with facility staff revealed that care conferences were expected to be conducted every three months, aligning with the MDS cycle. However, the director of social services acknowledged that R36's care conference was overdue by one to two months. The family member of R36 confirmed that they had not been invited to a care conference since the summer of 2024. The facility's policy mandates resident and representative involvement in care planning, yet documentation and staff interviews indicated a lapse in adherence to this policy, resulting in the deficiency.
Failure to Update Care Plan for Resident with Foley Catheter and Anxiety Interventions
Penalty
Summary
The facility failed to revise and update a comprehensive care plan for a resident who had a foley catheter, anxiety interventions, and refusals of care not identified in the care plan. The resident, who was admitted to the facility with moderate cognitive impairment and was dependent on staff for toileting and bathing, had a foley catheter placed during a recent hospitalization. However, the care plan was not updated to reflect the current catheter use, and there were no orders related to the catheter in the resident's active orders. Additionally, the care plan did not incorporate interventions from the resident's psychology provider to address anxiety and depression. Observations and interviews revealed that the resident's care plan and care work sheets lacked necessary updates, leading to staff being unaware of the resident's current needs. The nurse practitioner and registered nurse confirmed the absence of catheter-related information in the electronic medical record. The clinical manager and MDS nurse acknowledged the responsibility to update care plans and confirmed that the resident's catheter use should have been care planned. The deficiency was attributed to a lack of real-time updates and communication among the care team, resulting in inadequate care planning for the resident.
Deficiencies in Personal Hygiene and Self-Care for Residents
Penalty
Summary
The facility failed to ensure routine personal hygiene and self-care for residents who were dependent on staff for their care, leading to deficiencies in maintaining a dignified appearance and reducing the risk of complications. Resident R53, who had severe cognitive impairment and was dependent on staff for nearly all self-care, was observed with long fingernails pressing into the palm skin and dark-colored debris under the nails. Despite being identified as needing assistance with personal hygiene, R53's care plan lacked specific nail length preferences, and there was no evidence of nail care being attempted or refused since December 24, 2024. Interviews with staff revealed that nail care was not consistently documented, and R53's family expressed concerns about the lack of basic care. Resident R36, with significant cognitive impairment and dependent on staff for various activities of daily living, was observed with long, jagged toenails and fingernails with dark matter underneath. The care plan indicated that nail care should be done on bath days, but there was a lack of documentation for several weeks, and staff interviews revealed inconsistencies in the approach to nail care. Despite refusals from R36, there was no communication or plan to address these refusals, and the family was not involved in discussions about nail care approaches. Resident R23, with moderate cognitive impairment and dependent on staff for personal hygiene, was observed with disheveled hair and long facial hair, despite expressing a preference to be clean-shaven. The care plan indicated that R23 should be shaved on bath days, but this was not consistently done. Interviews with staff revealed that R23 had been readmitted to the facility with facial hair, and there was uncertainty about why shaving had not been completed. The facility's policy indicated that care and services should be provided for residents unable to carry out activities of daily living independently, but this was not adhered to in the cases of R53, R36, and R23.
Failure to Provide Care-Planned Activities for Non-Verbal Resident
Penalty
Summary
The facility failed to provide or offer care-planned interventions for activities of interest to a resident (R53) who was non-verbal and had severe cognitive impairment. R53's care plan, updated on 11/25/24, indicated preferences for listening to music, watching TV or movies, and social visits. However, observations on 1/14/25 and 1/15/25 revealed that R53 was often left in a silent room with no music or television turned on, despite having a CD player and a television with a list of favorite channels available. Interviews with staff, including a nursing assistant (NA-E) and a registered nurse (RN-D), indicated a lack of communication and coordination between nursing and activities staff. NA-E reported rarely seeing activities personnel engaging with R53 and stated that they were not instructed to play music or turn on the television for him. RN-D also confirmed that they did not turn on the CD player or television, assuming that R53's wife would do so during her visits, which were not consistent. The therapeutic recreation director (TRD) acknowledged that the television should be turned on for R53 as part of his care plan and that all staff should be involved in providing this stimulation. The one-to-one tracking form showed minimal engagement, with only five recorded visits from 12/1/24 to 1/10/25. The facility's policy emphasized involving residents in activities to enhance their psychosocial well-being, but this was not effectively implemented for R53, leading to the deficiency.
Failure to Properly Flush Gastrostomy Tube
Penalty
Summary
The facility failed to ensure that gastrostomy tube water flushes were provided according to physician orders for a resident who was severely cognitively impaired and dependent on staff for all activities of daily living. The resident had multiple diagnoses, including a stroke, diabetes, chronic obstructive pulmonary disease, respiratory failure, convulsions, a gastrostomy, and a tracheostomy. The physician's orders required 150 milliliters of water to be flushed through the feeding tube every four hours. However, during an observation, a registered nurse (RN) administered medications through the gastrostomy tube without measuring the required amount of water to flush the tube, potentially leaving residual medication in the tube. Interviews with the infection control preventionist and the director of nursing revealed that the RN did not follow the expected procedure of flushing the gastrostomy tube with clean water after medication administration. The RN used water from medication cups, which could contain residual thick medications, instead of measuring out the prescribed 150 milliliters of water. This practice was acknowledged by the director of nursing as likely to cause the gastrostomy tube to become plugged. The facility's policy for flushing gastrostomy tubes was requested but not provided.
Inadequate Pain Management for Two Residents
Penalty
Summary
The facility failed to provide comprehensive pain management for two residents, R53 and R70, who were reviewed for pain management. R53, who had severe cognitive impairment and was non-verbal, showed signs of potential pain through facial expressions and physical movements, such as grimacing and raising a clenched fist. Despite these indicators, the facility did not conduct a thorough assessment or implement consistent pain monitoring to ensure R53's comfort. The care plan for R53, which was outdated and lacked revisions, did not adequately address how to monitor or manage his pain, and there was no evidence of ongoing pain assessments or evaluations of the effectiveness of the interventions provided. For R70, who had intact cognition and multiple fractures, the facility also failed to assess and implement non-pharmacological pain interventions. R70's care plan included a list of potential non-pharmacological interventions, but there was no documentation of which interventions had been tried or their effectiveness. The Medication Administration Record (MAR) for R70 showed frequent administration of pain medications without consistent documentation of pain scales or locations of pain, and there was no evidence of non-pharmacological interventions being offered or documented. Interviews with staff revealed inconsistencies in pain assessment and documentation practices. Nursing staff acknowledged the lack of comprehensive pain assessments and monitoring for both residents, and the facility's pain management policy did not provide specific guidance for assessing pain in non-verbal residents. The facility's failure to adequately assess and manage pain for these residents resulted in a deficiency in providing appropriate pain management services.
Failure to Reassess Bed Rail Use for Resident with Impaired Cognition
Penalty
Summary
The facility failed to attempt alternatives and ensure ongoing assessments for safety and appropriate use of side rails for a resident with impaired cognition. The resident, identified as R18, had moderately to severely impaired cognition over time, as indicated by various Minimum Data Set (MDS) assessments. Despite the resident's declining condition and increased need for assistance with bed mobility, the facility did not conduct updated assessments for the safety and appropriate use of side rails since the last assessment in September 2022. The resident's care plan required staff to ensure the side rails were in the upright position and to provide cues for their use, but there was no documentation of attempts to use alternatives or reassessments for the continued need for side rails. Interviews with facility staff, including an LPN and the Director of Nursing (DON), revealed a lack of awareness and process for ongoing monitoring or reassessment of side rail use. The DON admitted that the facility did not have a process to ensure ongoing bed rail monitoring or reassessment of the resident's risk related to side rail use, especially after significant changes in the resident's condition. The facility's policy on bed safety and bed rails did not specify when or if ongoing resident assessments for safety and appropriate use of side rails were to be completed, contributing to the deficiency.
Failure to Monitor Antipsychotic Medication Efficacy
Penalty
Summary
The facility failed to conduct comprehensive and ongoing behavioral monitoring for a resident, identified as R62, who was administered antipsychotic medication. R62, who had severe cognitive impairment, was observed with facial scrapes due to a fall and was unable to verbally respond to questions. The resident's Medication Administration Record indicated the use of Seroquel for psychosis and major depressive disorder, but there was no evidence of specific target behaviors being tracked to ensure the medication's efficacy. Interviews with staff revealed a lack of clarity regarding the specific symptoms or target behaviors that warranted the use of Seroquel for R62. Nursing staff, including RN-D and NA-D, were unsure of any delusional thinking or hallucinations in R62, and noted that the resident was mostly non-verbal. Despite some observed behaviors such as crying when the significant other left, there was no routine charting of these behaviors, and the medical record lacked documentation of ongoing monitoring of target symptoms or behaviors. The facility's care plan for R62 identified a risk of adverse consequences due to antipsychotic medication use, but it did not specify the symptoms or target behaviors to be monitored. The registered nurse unit manager, RN-E, confirmed the absence of documented target behaviors in the medical record and acknowledged the importance of tracking behaviors to ensure the medication's effectiveness. The facility's policy on psychotropic medication use emphasized the need for identifying target behaviors and monitoring for efficacy, which was not adhered to in this case.
Inadequate Glove Use During Tracheostomy Care
Penalty
Summary
The facility failed to implement appropriate infection control practices during tracheostomy care for a resident on enhanced barrier precautions (EBP). The resident, who was in a persistent vegetative state and had multiple medical conditions including a tracheostomy and gastrostomy, required tracheal suction every shift. During an observation, a registered nurse (RN) administered medications through the resident's gastrostomy tube and then proceeded to perform tracheostomy care without changing gloves in between tasks. This action was contrary to the facility's infection control policy and the CDC guidelines, which require changing gloves when moving from a soiled body site to a clean body site to prevent the spread of infection. Interviews with the RN, another RN, the infection control preventionist, and the director of nursing confirmed that the RN should have changed gloves between the gastrostomy tube medication administration and the tracheostomy care. The facility's hand hygiene policy emphasized the importance of hand hygiene and glove changes to prevent the spread of potentially deadly germs. The failure to change gloves between tasks posed a risk of transferring infection from the gastrointestinal tract to the tracheostomy site, which was acknowledged as a concern by the facility staff.
Delayed Response to Ventilator Alarms for Residents
Penalty
Summary
The facility failed to respond promptly to ventilator alarms for three residents who were dependent on ventilators. Each resident had severe cognitive impairments and required total dependence for all cares and activities of daily living. The ventilator alarms for these residents were not addressed in a timely manner, with delays ranging from several minutes to nearly half an hour. For instance, R2's ventilator alarm sounded repeatedly due to high pressure caused by water condensation in the circuit tubing, which was not immediately addressed by the nursing staff. Similarly, R3's and R4's ventilator alarms were not promptly attended to, with staff acknowledging that alarms should be answered right away but admitting that responses depended on the day's staffing levels. The nursing staff, including RNs and the Director of Nursing, acknowledged the importance of responding to ventilator alarms promptly to assess the type of alarm and address any issues such as obstructions or water in the tubing. However, the facility lacked a clear policy on ventilator alarm response times, and the Director of Nursing could not provide a definitive answer on what constituted a prompt response. The report highlights the facility's failure to ensure timely responses to ventilator alarms, which is critical for the safety and well-being of ventilator-dependent residents.
Deficiencies in Pressure Ulcer Care and Infection Control
Penalty
Summary
The facility failed to adequately monitor and manage pressure ulcers for four residents, leading to deficiencies in care. Resident 1, who had multiple sclerosis, dementia, and functional quadriplegia, developed an unstageable sacral pressure ulcer that was not properly monitored or treated in a timely manner. The wound care nurse documented the ulcer as necrotic with a foul odor and declining healing status, yet there was a delay in obtaining wound care orders, and the resident's family was not notified until the condition worsened, requiring hospitalization and surgery. Resident 2, who was in a persistent vegetative state and dependent on a ventilator, had multiple pressure ulcers, including a Stage 4 ulcer. The facility failed to document nurses' notes for the wound care orders, and there were inconsistencies in the documentation of wound appearance. During an observation, the wound care nurse did not perform hand hygiene between glove changes and used inappropriate materials, such as washcloths, for wound care, which were not in line with infection control practices. Resident 3, who had a Stage 4 pressure ulcer, experienced similar issues with inadequate documentation and improper wound care practices. The wound care nurse used an unlabeled normal saline bottle and did not verify wound care orders before applying dressings. Resident 4, who had dementia, was also affected by the facility's failure to provide proper wound care, as evidenced by the use of tap water instead of normal saline for cleansing wounds. These deficiencies highlight the facility's failure to adhere to proper wound care protocols and infection control practices.
Failure to Notify Provider of Change in Condition Leads to Resident's Death
Penalty
Summary
The facility failed to assess and notify a provider of a change in condition for a resident, resulting in an immediate jeopardy situation. The resident, who had a history of respiratory failure, septicemia, and was ventilator-dependent, was found with a heart rate of 156 bpm, which was outside the acceptable range. Despite this, the registered nurse on duty did not take action or notify a provider. The resident was later found unresponsive with no pulse, and despite CPR being performed, the resident was pronounced dead at the facility. The resident's medical records indicated multiple instances of elevated heart rates that were not addressed or communicated to a provider. The facility's standing orders and hospital discharge summary required notification of a provider for specific changes in condition, such as elevated heart rate and temperature. However, these directives were not followed, and the resident's condition was not adequately monitored or documented, leading to a failure to recognize and respond to the resident's deteriorating condition. Interviews with facility staff revealed a lack of awareness and action regarding the resident's elevated heart rate and other vital signs. Staff members acknowledged that the provider should have been contacted for further direction, and the failure to do so was a deviation from expected nursing standards. The facility's policies required notification of a provider for significant changes in a resident's condition, but these were not adhered to, contributing to the resident's death.
Removal Plan
- All nursing staff on duty including agency/contract nursing staff will be re-educated by DON or designee in relation to: change in condition definitions and what to do when a change in condition occurs, documentation of change in conditions including vital signs, out of range vital signs, what parameters cause alerts in the EHR, and recheck and notify provider if outside of parameters.
- Nursing staff will be educated prior to beginning their next scheduled shift, time clock notifications in place, education emailed out to staff not currently present, and charge of building notified to verify completion of staff during their shift.
- This education will continue until completed with current nursing staff including agency/contract.
- Validation of understanding of education will be verified by random interviews of staff members conducted by DON or designee.
- Further 1:1 education will be provided as needed to reinforce understanding of education provided.
- The policy and procedure for change in condition and documentation of out of range vital signs and follow up with provider all have been reviewed.
Failure to Assess and Treat Pressure Ulcers Leads to Harm
Penalty
Summary
The facility failed to comprehensively assess and provide necessary treatment for pressure ulcers, resulting in harm to a resident who developed a new pressure injury. The resident, who was admitted with a stage 2 pressure ulcer on the right buttock, had multiple medical conditions including quadriplegia, respiratory failure, and dependence on a ventilator. The facility did not have comprehensive wound care orders upon the resident's admission, and there was a lack of documentation and assessment of the existing and new pressure ulcers. The resident's care was further compromised by the lack of management of a cervical collar, which was not removed or assessed for skin integrity due to the absence of orders. Despite the presence of a cervical collar, staff did not receive adequate instructions from the discharging facility or the resident's family, leading to a failure in assessing the skin underneath. This oversight resulted in the development of a pressure ulcer on the back of the resident's head, which was only discovered after the resident was transferred to a hospital. Interviews with facility staff revealed that there was confusion and a lack of communication regarding the management of the cervical collar and the resident's wounds. The facility's assistant director of nursing and director of nursing acknowledged the failure to assess and document the resident's wounds comprehensively. The facility's medical director and nurse practitioner also noted the absence of orders for the cervical collar and the need for specialist evaluation, which contributed to the delay in addressing the resident's skin integrity issues.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency (SA) for a resident who was reviewed for allegations of abuse. The resident, who had diagnoses including aphasia, dementia, and cognitive deficits following a stroke, posted on social media about being physically and emotionally abused by unknown facility staff. The posts included phrases such as 'violence' and 'woman head punch I cry.' Despite these concerning posts, the facility did not report the suspicion of abuse to the SA within the required two-hour timeframe. The administrator and the director of nursing (DON) were aware of the resident's social media posts and discussed the situation in an inter-disciplinary team meeting. However, the administrator did not initially see the posts as a cause for suspicion of abuse, and the DON did not recall how she became aware of the situation. The facility's policy required immediate reporting of suspected abuse, but there was no specific person responsible for filing reports, leading to a failure in reporting the incident to the SA as required.
Incomplete Investigation of Abuse Allegation
Penalty
Summary
The facility failed to conduct and maintain records of a thorough investigation into an allegation of abuse involving a resident with severe cognitive impairments. The resident, who had diagnoses including aphasia and dementia, posted on social media about being physically and emotionally abused by unknown facility staff. Despite the seriousness of the allegations, the facility's investigation was incomplete and lacked proper documentation. The facility's response included a skin assessment by a registered nurse, which found no signs of bruising or redness. An interdisciplinary team meeting was held, and a plan to install a camera in the resident's room was discussed but not implemented due to lack of consent from the resident's family. Interviews with other residents and staff were either not conducted or not documented, and the investigation did not follow the facility's policy for handling such allegations. Interviews with facility staff revealed confusion and lack of clarity about the investigation process. The director of social services and the director of nursing both indicated that the investigation was not thorough, and documentation was incomplete. The facility's policy required a systematic investigation with thorough documentation, which was not adhered to in this case.
Failure to Implement Enhanced Barrier Precautions for Residents
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBPs) for two residents who required them due to their medical conditions. Resident R3, who was in a persistent vegetative state with a history of multidrug-resistant organisms (MDROs), had a tracheostomy, was on a ventilator, and had an indwelling urinary catheter. The care plan for R3 did not address the risk for infection or include interventions for infection prevention, such as the use of personal protective equipment (PPE). During observations, staff members entered R3's room to perform care tasks without using gowns, and there was no signage or PPE cart available to indicate the need for EBPs. Similarly, Resident R4, who had severely impaired cognition and similar medical conditions, also did not have a care plan addressing infection risks or PPE use. Staff performed care tasks for R4 without wearing gowns, and there was a lack of awareness among staff about when EBPs should be implemented. Interviews with staff, including registered nurses and the assistant director of nursing, revealed a lack of knowledge and implementation of EBPs, despite the facility's policy requiring them for residents with indwelling medical devices or chronic wounds.
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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