Bethesda
Inspection history, citations, penalties and survey trends for this long-term care facility in Willmar, Minnesota.
- Location
- 901 Southeast Willmar Avenue, Willmar, Minnesota 56201
- CMS Provider Number
- 245427
- Inspections on file
- 25
- Latest survey
- December 10, 2025
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Bethesda during CMS and state inspections, most recent first.
A resident with severe cognitive impairment experienced a 20-pound weight loss over 18 days due to the facility's failure to monitor and assess for dehydration and weight loss. Despite being at risk, the facility did not implement interventions or notify the physician or heart failure clinic. Incomplete documentation and lack of communication among staff contributed to the resident's hospitalization and subsequent death.
A facility failed to notify a medical provider of significant weight changes for a resident with severe cognitive impairment and multiple health conditions, including heart failure. Despite documented weight fluctuations that met the criteria for notification, the facility did not inform the physician or heart failure clinic. Interviews confirmed the oversight, which prevented necessary evaluation and potential medication adjustments.
A facility failed to develop a comprehensive care plan within the required timeline for a resident with severe cognitive impairment and multiple health conditions. The resident's care plan did not address all identified risks and needs, such as pressure ulcers, falls, and medication use. Staff interviews revealed a misunderstanding of the timeline for completing the care plan, which should have been done within seven days after the CAAs were completed.
A resident's wheelchair was found to be in poor condition, with shredded fabric that was difficult to clean, posing a potential risk for injury. The resident, who has Parkinson's disease and polyneuropathy, relies on the wheelchair for mobility. Staff interviews revealed a lack of specific cleaning or maintenance schedules for wheelchairs, and facility documents lacked protocols for ongoing maintenance and repair.
A resident with multiple medical conditions, including a lung mass and knee pain, did not have her pain management needs addressed in her care plan. Despite receiving medications like Tylenol and Tramadol, the facility failed to document these interventions in the care plan, as confirmed by nursing staff. This oversight was contrary to the facility's policy requiring comprehensive care plans within 21 days of admission.
A facility failed to provide necessary adaptive supports for a resident with neurological conditions, resulting in improper wheelchair positioning. Additionally, the facility did not administer prescribed medication for a resident with COPD due to a failure in communication and follow-up with the pharmacy, despite the medication being available. These actions violated the facility's policies on resident care and medication administration.
A resident who was discharged from dialysis continued to receive unnecessary treatments and dietary restrictions due to the facility's failure to update medical orders and coordinate care with healthcare providers. The resident's central line and port were not promptly removed, posing an infection risk, and there was a lack of communication with the nephrologist and primary care physician to adjust the care plan.
A facility failed to monitor orthostatic blood pressures for a resident on Quetiapine Fumarate, an antipsychotic medication, for six months. Despite the resident's severe cognitive impairment and the known risk of postural hypotension, no orthostatic blood pressures were recorded. Staff interviews confirmed the oversight, with the consultant pharmacist, RN, and DON acknowledging the importance of monthly monitoring to detect side effects affecting mobility.
A resident did not receive the PCV20 vaccine despite consenting to it during an immunization fair. The infection preventionist was not informed of the updated consent, leading to a lapse in vaccine administration. The facility's policy to offer pneumococcal vaccines was not effectively implemented.
A resident with Type 1 Diabetes Mellitus received an incorrect insulin dose due to a misinterpretation of dosing instructions. Instead of the prescribed 5 units of Novolog insulin, the resident was administered 32 units, leading to a significant medication error. The error was discovered the following day, and staff acknowledged the mistake, citing unfamiliarity with carbohydrate counting as a contributing factor.
Failure to Monitor and Address Resident's Dehydration and Weight Loss
Penalty
Summary
The facility failed to identify, monitor, and comprehensively assess a resident for dehydration and significant weight loss, which resulted in harm. The resident, who had severe cognitive impairment and was dependent on staff for all activities of daily living, experienced a 20-pound weight loss over 18 days. Despite being at risk for dehydration and weight loss due to multiple medical conditions and medications, the facility did not implement appropriate interventions or notify the resident's physician or heart failure clinic of the significant weight loss. The resident's care plan identified the risk for dehydration but lacked specific interventions. The facility's documentation showed inconsistent and incomplete records of the resident's food and fluid intake, and there was no evidence of a comprehensive assessment to determine the cause of the weight loss. Staff interviews revealed that changes in the resident's condition, such as decreased alertness and food intake, were reported to nursing staff, but no further assessments or actions were taken. The facility's failure to report the resident's weight loss and change in condition to the appropriate medical personnel contributed to the resident's hospitalization for dehydration, acute renal failure, and ultimately, the resident's death. Interviews with staff and family members highlighted a lack of communication and follow-up on the resident's declining condition, which was not addressed in a timely manner according to the facility's policies.
Failure to Notify Medical Provider of Significant Weight Changes
Penalty
Summary
The facility failed to adhere to a physician's order to notify the medical provider of significant weight changes for a resident with severe cognitive impairment and multiple health conditions, including heart failure and chronic kidney disease. The resident was on diuretics and required daily weight monitoring due to the risk of fluid imbalance. Despite documented weight fluctuations that met the criteria for notification, the facility did not inform the physician or the heart failure clinic of these changes. The resident's Treatment Administration Record indicated significant weight losses over several days, which should have been reported according to the physician's orders. Interviews with the Director of Nursing, the resident's primary care physician, and a registered nurse from the heart failure clinic confirmed that the weight changes were not communicated as required. This lack of communication prevented the necessary evaluation and potential adjustment of the resident's medication to manage their heart failure effectively.
Failure to Develop Comprehensive Care Plan in Timely Manner
Penalty
Summary
The facility failed to develop a comprehensive care plan within the required timeline for a resident with severe cognitive impairment and multiple health conditions. The resident, who was dependent on staff for all activities of daily living, had a history of cerebral vascular accident, heart failure, chronic kidney disease, diabetes mellitus, aphasia, hemiparesis, and urinary tract infections. The resident was also at risk for pressure ulcers and falls, was on a texture-modified diabetic diet, and was taking high-risk medications including antianxiety, antidepressant, diuretic, and antiplatelet medications. Despite these complexities, the facility did not complete a comprehensive care plan that addressed all identified risks and needs. The resident's Communication, Cognitive Loss/Dementia, Visual Function, Urinary Incontinence, Falls, Pressure Ulcer, and Psychotropic Drug Use Care Area Assessments (CAAs) indicated the need for care planning to ensure continuity of care. However, the care plan developed only included a baseline assessment and a nutrition care plan, failing to incorporate goals or interventions for the other identified risk areas. Interviews with facility staff, including a registered nurse and the director of nursing, revealed a misunderstanding of the timeline for completing the comprehensive care plan, which should have been completed within seven days after the CAAs were finished, rather than the 21 days from admission as the staff believed.
Failure to Maintain Clean and Safe Wheelchair Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for a resident's wheelchair, which is essential for promoting resident well-being. The resident, who has progressive neurological conditions including Parkinson's disease and polyneuropathy, relies on a wheelchair for mobility. Observations revealed that the wheelchair had significant wear and tear, particularly on the right side, with shredded fabric that was difficult to clean. This condition posed a potential risk for injury and compromised the ability to maintain hygiene. Interviews with staff, including a registered nurse and the director of nursing, confirmed the lack of a specific cleaning or maintenance schedule for wheelchairs. The facility's documents directed staff to clean wheelchairs after meals if needed, but there was no indication of ongoing maintenance or repair protocols for the physical structure of wheelchairs. The director of nursing acknowledged the potential for injury and the difficulty in cleaning the damaged wheelchair, highlighting a gap in the facility's procedures for ensuring a safe and clean environment for residents.
Failure to Address Pain Management in Resident Care Plan
Penalty
Summary
The facility failed to ensure a comprehensive, person-centered care plan was developed and readily available to promote acceptable pain management for a resident identified as R199. The resident, who was admitted to the care center from an acute care hospital, had multiple medical conditions including malignant neoplasm of the left lower lung lobe, repeated falls, essential hypertension, and bilateral primary osteoporosis of the knees. Despite these conditions, the facility did not address the resident's pain issues in the care plan, which is a critical component for continuity of care. Interviews and document reviews revealed that R199 had been experiencing increasing pain in her left chest and shoulder due to her lung mass, as well as knee pain. The resident was self-administering Voltaren Gel for knee pain and receiving Tylenol and Tramadol for chest and shoulder pain. However, the care plan did not reflect these pain management interventions, which were confirmed by the registered nurse/case manager and the assistant director of nursing as missing from the care plan. The director of nursing stated that it was her expectation for any resident with pain issues to have these addressed in the care plan to educate direct care staff on the prescribed interventions. The facility's policy on care planning emphasized the importance of developing a comprehensive care plan within 21 days of admission, involving an interdisciplinary care team. Despite this policy, the care plan for R199 did not include the necessary pain management interventions, leading to a deficiency in the resident's care.
Deficiencies in Resident Positioning and Medication Administration
Penalty
Summary
The facility failed to provide appropriate adaptive supports or assistive devices for a resident with moderate cognitive impairment and multiple neurological conditions, including Parkinson's disease and polyneuropathy. The resident was observed on multiple occasions seated in a rock-n-go wheelchair without lateral support, leaning to one side, and not interacting with others. Despite the resident's care plan indicating the use of a Gel cushion, it did not address positioning concerns or potential positioning aids. A registered nurse acknowledged the need for lateral support, and a therapy referral was eventually made. Additionally, the facility did not administer medications according to a physician's order for a resident with severe cognitive impairment and chronic obstructive pulmonary disease (COPD). The resident's medication administration record showed that several doses of Advair inhalation aerosol were documented as unavailable, although the medication had been delivered by the pharmacy. A trained medication aide admitted to not following up with the pharmacy promptly and failing to notify the nurse. The registered nurse confirmed that the medication was available but had not been administered, constituting a medication error. The facility's policies on wheelchair positioning and medication administration were not adhered to, leading to deficiencies in resident care. The director of nursing confirmed that the documentation in the medication administration record was inaccurate and acknowledged the medication error. The facility's pharmacy services policy indicated that medications should be received timely, but this was not reflected in the actions taken by the staff.
Failure to Coordinate Care Post-Dialysis Discontinuation
Penalty
Summary
The facility failed to properly coordinate care for a resident, identified as R102, who had recently been discharged from dialysis. Despite the resident's kidney function returning and dialysis being discontinued, the facility did not update or discontinue related medical orders, such as fluid restrictions, renal diet, and phosphorus-binding medication. This oversight was discovered through observations, interviews, and document reviews, revealing that the resident continued to receive treatments and dietary restrictions that were no longer necessary. Interviews with various staff members, including registered nurses, nursing assistants, and the assistant director of nursing, highlighted a lack of communication and understanding of the process for managing a resident coming off dialysis. The facility did not promptly arrange for the removal of the resident's central line and port, which posed a risk of infection. Additionally, there was no immediate follow-up with the nephrologist or primary care physician to adjust the resident's care plan and medication orders, leading to continued administration of unnecessary treatments. The facility's failure to update the care plan and communicate effectively with the dialysis clinic and healthcare providers resulted in the resident being subjected to unnecessary medical interventions. The director of nursing and medical director acknowledged the need for better communication and follow-up procedures to ensure that residents' care plans are accurately updated when significant changes, such as the discontinuation of dialysis, occur.
Failure to Monitor Orthostatic Blood Pressures for Resident on Antipsychotic Medication
Penalty
Summary
The facility failed to monitor orthostatic blood pressures for a resident who was prescribed Quetiapine Fumarate, an antipsychotic medication, for delusional disorders. The resident, identified as having severe cognitive impairment and requiring supervision with activities of daily living, had been on the medication since July 26, 2024. Despite the known side effects of antipsychotic medications, such as postural hypotension, which can increase the risk of falls, the facility did not obtain orthostatic blood pressures for the resident over a six-month period. Interviews with facility staff, including a consultant pharmacist, a registered nurse, and the director of nursing, confirmed the oversight. The consultant pharmacist and RN stated that orthostatic blood pressures should be monitored monthly for residents on antipsychotic medications to detect side effects that could affect mobility. The director of nursing acknowledged that the failure to monitor was a lapse in protocol, which should have been identified by the consulting pharmacist or the nurse manager. The facility's policy on antipsychotic medications emphasizes the residents' right to be free from unnecessary medications and the importance of monitoring for side effects.
Failure to Administer Pneumococcal Vaccine After Consent
Penalty
Summary
The facility failed to ensure that a resident, identified as R88, received the pneumococcal vaccine series as recommended by the CDC. R88, who is over the age of 65, had previously received the PCV13 and PPSV23 vaccines but refused the PCV20 vaccine on a prior occasion. However, during the facility's annual fall immunization fair, R88 consented to receive the PCV20 vaccine, as indicated by a signed consent form. Despite this consent, there was no evidence in the records that R88 received the PCV20 vaccine. The infection preventionist (IP) stated that immunizations are reviewed upon admission and that any wanted vaccines are administered after review with the provider. The IP was not notified of the updated consent for the PCV20 vaccine, which was a lapse in communication. The director of nursing (DON) expressed that her expectation was for RN case managers to relay all vaccination requests to the IP. The facility's policy indicated that all residents should be offered pneumococcal vaccines to prevent infections, but this policy was not effectively implemented in R88's case.
Significant Insulin Administration Error
Penalty
Summary
The facility failed to administer insulin according to the physician's orders for a resident with Type 1 Diabetes Mellitus. The resident was supposed to receive insulin based on carbohydrate intake and a sliding scale for blood sugar levels. On a specific day, the resident's blood sugar was recorded at 204 before supper, and she was administered 32 units of Novolog insulin instead of the correct dose of 5 units. This error was due to a misinterpretation of the insulin dosing instructions related to carbohydrate counting. The error was discovered by a licensed practical nurse the following morning, who then informed a registered nurse. The director of nursing and assistant director of nursing confirmed that the resident should have received only 5 units of insulin. The pharmacist and other staff acknowledged that administering 32 units was a significant medication error. The facility's policies directed that all medications should be given as prescribed, but the staff was not adequately familiar with counting carbohydrate grams, leading to the error.
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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