Birchwood Care Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Minneapolis, Minnesota.
- Location
- 715 West 31st Street, Minneapolis, Minnesota 55408
- CMS Provider Number
- 24E166
- Inspections on file
- 31
- Latest survey
- July 29, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Birchwood Care Home during CMS and state inspections, most recent first.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. Surveyors observed environmental risks and insufficient oversight, resulting in unsafe conditions for residents.
The facility failed to properly store, label, and date food items in the kitchen, risking cross-contamination and foodborne illness. Unwrapped and undated trays of various food items were found in the refrigerator, with staff unaware of the need for proper wrapping. The absence of a Food Storage policy further highlighted the deficiency.
The facility failed to accurately code the MDS for several residents, leading to discrepancies in documentation of falls, restraints, dialysis, and PASARR. One resident's MDS inaccurately reported falls with injuries, another's indicated restraint use without evidence, and a third's omitted dialysis treatment. Staff interviews confirmed these errors, and the facility lacked a specific policy on MDS accuracy.
A resident with intact cognition reported missing clothing items upon arrival at the facility, but the grievance was not documented or resolved. Staff interviews revealed a lack of proper documentation and follow-up, with no grievance form completed despite the facility's policy requiring it. The resident's request for reimbursement was also not addressed, highlighting a failure to adhere to established grievance procedures.
A facility failed to ensure physician's orders were in place for a resident who self-catheterized. The resident's medical records lacked specific orders detailing the self-catheterization process, despite a history of urinary retention and BPH. Staff interviews revealed a lack of awareness and documentation regarding the resident's self-catheterization, and the facility's policy requiring nursing supervision was not followed. This deficiency was identified by surveyors.
A resident with a history of tobacco use and mild intellectual disabilities was observed smoking without a smoking apron and using a lighter with a flame, contrary to her care plan. Staff failed to ensure the use of safety interventions, and the resident was unsupervised while smoking outside. The facility's policy on safe smoking was not effectively implemented, leading to potential hazards.
The facility failed to post accurate nurse staffing information, omitting the daily census and actual RN hours worked, despite evidence of RN coverage. This affected all 56 residents or visitors who wished to review the information.
A medication error occurred when a nurse administered the wrong medications to a resident, leading to heavy sedation and hospitalization. The resident, who was cognitively intact and had multiple health conditions, received another resident's medications, including clozapine, resulting in acute toxic metabolic encephalopathy and respiratory failure. The error was due to the nurse not verifying the five rights of medication administration and presetting medications, which is against facility policy.
A resident with schizoaffective disorder and a history of eloping lacked a comprehensive care plan addressing command voices. The care plan did not specify interventions for when the resident heard voices or how to assess their intensity. Despite using a GPS tracker, the resident left the facility unsupervised twice, and staff were unclear on handling the resident's distress. The facility's missing resident procedure lacked guidance on preventing future incidents.
The facility failed to conduct ongoing QAPI and QAA activities, and did not develop or implement appropriate plans of action to correct repeated quality deficiencies. The interim administrator was unable to access previous QAPI meeting minutes or documentation of performance improvement projects, indicating a failure in the facility's QAPI processes.
The facility failed to maintain an effective QAPI committee and did not provide evidence of any active Performance Improvement Projects (PIPs), potentially affecting all 60 residents. The administrator was unable to provide quality tracking data or locate meeting minutes from previous QAPI meetings.
The facility failed to accurately assess two residents' eligibility for pneumococcal vaccinations according to CDC guidelines. One resident with diabetes mellitus and another with hypertension, renal insufficiency, and diabetes mellitus were not offered the required follow-up doses of PCV20 or PPSV23 and PCV20 or PCV15, respectively. Staff interviews and MIIC reports confirmed the deficiency, and the facility could not provide documentation of the residents being offered or declining the vaccinations.
The facility failed to ensure that the resident call light cord was within reach from the shower floor in a multi-resident bathroom. Observations and interviews revealed that the call light cord was tied with a string and hung approximately four feet from the ground, making it inaccessible if a resident fell or was sitting in the shower chair. Staff acknowledged the issue and confirmed that call lights should be within reach of residents, including when in the shower or using the toilet.
The facility failed to clean a multi-resident bathroom ceiling vent fan, resulting in thick dust covering 50 to 75% of the vent and no air flow felt. The administrator expected maintenance and housekeeping to handle cleaning, but a schedule was still being developed. Maintenance staff acknowledged the need for monthly cleaning and the importance of clean vents for air flow and equipment performance. The facility's cleaning procedure did not include vent and fan maintenance.
A resident with diabetes and schizophrenia consistently refused insulin and blood sugar checks for several months. Despite documentation of these refusals, the medical provider was not notified, violating the facility's policy. Staff interviews revealed awareness of the refusals but a lack of consistent communication with the medical provider.
The facility failed to document and address grievances from two residents, leading to ongoing conflicts and unresolved issues. Despite informing multiple staff members, the residents' concerns were not documented or addressed through the facility's grievance process. Interviews with staff revealed a lack of awareness and action regarding the grievances.
The facility failed to report and investigate abuse allegations in a timely manner, involving a resident with a history of schizophrenia who made racist and sexist comments towards another resident. Despite multiple reports, staff did not follow up or document the incidents properly, leading to a deficiency in ensuring resident safety.
A facility failed to investigate and address allegations of resident-to-resident verbal abuse involving a resident with schizophrenia and anxiety. Despite multiple reports from the affected resident, staff did not follow up appropriately, offer to file a grievance, or provide a formal complaint process. The facility's documentation lacked specific incidents or grievances, and the interdisciplinary team did not take adequate steps to address the situation or protect the affected resident.
The facility failed to accurately code PTSD in the MDS for two residents, despite multiple medical records confirming the diagnosis. Staff interviews revealed that PTSD was not included in the MDS because it was not being actively treated, contrary to the requirements of the RAI manual.
The facility failed to develop a comprehensive care plan for a resident receiving psychotropic medications. The care plan lacked documentation of specific medications, target symptoms, and non-pharmacologic interventions. The Director of Nursing and social services staff confirmed these deficiencies, acknowledging that the care plan was incomplete and did not meet expected standards.
The facility failed to implement appropriate interventions for a resident with multiple falls and comorbidities, leading to continued risk of falls. Despite a history of falls and environmental hazards, the care plan was not updated with specific interventions, and the resident's room remained cluttered. Staff relied on outdated care plans, contributing to the deficiency.
The facility failed to assess and identify PTSD triggers for two residents with a history of trauma. Despite documented diagnoses of PTSD, the facility did not conduct assessments to identify triggers, leading to deficiencies in providing trauma-informed care as per their policy.
The facility failed to monitor and notify the provider for a resident with type 2 diabetes, resulting in missed notifications for elevated blood sugar levels above 400 mg/dL. The RN and APRN confirmed the oversight, and the DON verified the deficiency, noting that the responsible nurse received coaching.
A resident identified as a vegetarian experienced difficulty receiving appropriate meal options, leading to dissatisfaction and potential nutritional risk. Despite the facility's policy to accommodate dietary preferences, the resident's care plan and progress notes indicated ongoing issues with meal satisfaction and availability of vegetarian options. Interviews revealed a lack of consistent communication and documentation regarding the resident's dietary needs.
The facility failed to administer medications according to physician orders and guidelines for three residents, resulting in a 12% medication error rate. Errors included missed doses, incorrect dosages, and nearly administering expired medication.
The facility failed to ensure mail was delivered to residents on Saturdays, affecting all residents who received personal mail. Two residents confirmed that mail received on weekends was not delivered until Monday when the medical records staff person returned to work. The interim administrator was unaware of this issue and stated that other staff could handle mail delivery on Saturdays. A policy on mail delivery was requested but not provided by the end of the survey period.
A resident with a history of elopement due to hallucinations left the facility without a GPS tracker, contrary to the safety plan. The facility failed to report the resident missing in a timely manner, with staff not consistently following the care plan or monitoring the resident's whereabouts. The resident's diagnoses included schizophrenia and schizoaffective disorder, and staff were unaware of the resident's behavioral triggers.
A resident with schizophrenia and audible hallucinations did not receive proper medication management or care coordination at the facility. The resident's care plan lacked a PRN medication for acute psychosis, and there was inconsistent documentation of hallucinations. Staff interviews revealed a lack of awareness of the resident's triggers and insufficient communication with mental health providers, leading to episodes of elopement and distress.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. Surveyors observed that the environment posed risks for accidents, and there was insufficient oversight to mitigate these hazards. The report specifically notes the lack of preventive measures and supervision necessary to maintain resident safety in the affected area.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The facility failed to ensure proper storage, labeling, and dating of food items in the kitchen, which could lead to physical cross-contamination and potential foodborne illness. During an initial kitchen tour, several trays of food items were found unwrapped and undated in the walking refrigerator. These included cheese and eggs English muffin sandwiches, tater tots, apple bran bowls, mint and chocolate desserts, and breaded pieces of chicken. The dietary aid confirmed that the trays were unwrapped and undated, and stated that the cook should have wrapped them before placing them in the freezer. The food on these trays was intended to be cooked and served for dinner that night or the following day. The director of nutritional services admitted to not knowing that the trays needed to be wrapped, acknowledging the risk of cross-contamination, especially if something drips. The administrator confirmed that all food should be labeled with dates and wrapped, citing infection control issues and the risk of foodborne illnesses. Despite the request, a Food Storage policy was not provided, indicating a lack of documented procedures to ensure compliance with food safety standards.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for several residents, leading to discrepancies in the documentation of falls, restraints, dialysis, and Preadmission Screening and Resident Review (PASARR). For one resident, the MDS inaccurately reported multiple falls with injuries, including major injuries, despite documentation and staff interviews indicating no injuries occurred. The care plan and progress notes did not support the MDS coding, and the registered nurse responsible for the MDS acknowledged the error. Another resident's MDS inaccurately indicated the use of a limb restraint, which was not supported by any documentation or staff interviews. The licensed practical nurse confirmed that no restraints were used in the facility, and the registered nurse admitted the coding was incorrect. Additionally, a resident receiving dialysis was not accurately documented in the MDS, despite clear evidence from care plans, treatment reports, and staff interviews confirming the dialysis treatments. The social worker also confirmed the error in the PASARR coding. The facility lacked a specific policy on MDS accuracy, which may have contributed to these errors. The registered nurse responsible for the MDS assessments was still in training and acknowledged multiple coding errors across different residents. These inaccuracies in the MDS coding could potentially impact the care and treatment plans for the residents involved.
Failure to Address Resident Grievance on Missing Items
Penalty
Summary
The facility failed to ensure grievances were acted upon, investigated, or resolved for a resident who reported missing clothing items. The resident, who had intact cognition, reported missing clothes upon arrival at the facility and believed he had completed a grievance form. However, there was no documentation in the grievance log or the resident's chart regarding the missing items. The resident expressed that he had requested reimbursement for the missing clothes but had not received any response. Interviews with staff revealed a lack of proper documentation and follow-up on the resident's grievance. The laundry assistant had a handwritten list of missing items reported by the resident but had not been able to locate them. The social worker and social services assistant were unaware of the resident's grievance and confirmed that no grievance form had been completed. The director of nursing emphasized the importance of completing a grievance form to ensure follow-up, but this procedure was not followed in this case. The facility's policies on handling missing items and grievances were not adhered to, as there was no documentation of the grievance or efforts to resolve it. The policy required staff to assist residents in searching for missing items, complete a grievance form if items were not found, and document the process in the resident's chart. The failure to follow these procedures resulted in the resident's grievance not being addressed or resolved, contrary to the facility's established policies.
Lack of Physician Orders for Resident Self-Catheterization
Penalty
Summary
The facility failed to ensure that physician's orders were in place for a resident, R46, who self-catheterized. The resident's medical records, including the Optional State Assessment (OSA), Minimum Data Set (MDS), and care plan, lacked specific physician orders detailing the self-catheterization process, such as the type of catheter used, frequency of catheterization, and source of catheter supplies. Despite the resident's history of urinary retention and benign prostatic hyperplasia (BPH), the facility did not have documented orders or assessments to guide the self-catheterization process. Interviews with staff revealed a lack of awareness and documentation regarding the resident's self-catheterization. Nursing Assistant (NA)-B was unaware of the resident's self-catheterization, and Licensed Practical Nurse (LPN)-A stated that the facility did not have catheters and that the resident obtained his own supplies. The Registered Nurse (RN)-A confirmed the absence of physician orders and emphasized the importance of having such orders to monitor the resident's catheter supply and potential issues. The Director of Nursing initially denied the resident's self-catheterization but later acknowledged the need for an order in the chart to ensure proper supervision and monitoring. The facility's policy on catheter use required nursing supervision for resident self-catheterization, yet this was not implemented for R46. The policy outlined specific procedures for self-catheterization, including hand hygiene, use of gloves, and proper positioning, which were not documented or followed in the resident's case. This lack of adherence to policy and absence of physician orders contributed to the deficiency identified by the surveyors.
Failure to Implement Safe Smoking Interventions
Penalty
Summary
The facility failed to implement safe smoking interventions for a resident with a history of tobacco use, mild intellectual disabilities, and schizophrenia. The resident, identified as R6, was noted to have burn holes in her clothing and had previously burned her fingertips and nose. Despite these observations, the resident's care plan indicated she was a safe smoker with proper safety interventions, including the use of a smoking apron and a no-flame lighter. However, during observations, R6 was seen smoking without a smoking apron and using a lighter with an obvious flame, contrary to the care plan's interventions. Interviews and observations revealed that staff did not consistently encourage or ensure the use of the smoking apron, and the resident was not supervised while smoking outside. The social worker and social services assistant acknowledged the lack of adherence to the care plan, noting that the resident's lighter was not a flameless lighter as required. Additionally, the resident's care plan and smoking assessments were not updated to reflect the current safety concerns, and staff failed to follow up on the resident's use of a smoking apron and appropriate lighter. The facility's policy on resident smoking, revised on the day of the survey, required that residents be safe while smoking and that smoking assessments be completed upon admission and annually. However, the policy was not effectively implemented, as evidenced by the resident's unsupervised smoking and the use of inappropriate smoking materials. The director of nursing acknowledged the importance of following care plans and the need for close monitoring to prevent potential hazards.
Inaccurate Nurse Staffing Information and Missing Daily Census
Penalty
Summary
The facility failed to ensure that the posted nurse staffing information included the daily census and accurately reflected the total number and actual hours worked per shift for licensed and registered staff. This deficiency was observed during a survey conducted on March 18, 2025, where the posted nurse staffing information was found to be lacking the facility's daily census. Further review of the facility's posted nurse staffing information from February 17, 2025, to March 18, 2025, revealed that there were no registered nurse (RN) hours recorded for several dates, despite evidence from staffing schedules and employee timecards indicating RN coverage on those dates. During an interview with the Director of Nursing (DON) on March 20, 2025, it was confirmed that the posted nurse staffing information did not accurately reflect the total number and actual hours worked by RNs, and it also lacked the facility's daily census. The facility did not have a policy pertaining to the posting of nurse staffing information, as confirmed by the administrator. This deficiency had the potential to affect all 56 residents or visitors who wished to review the staffing information.
Medication Error Leads to Hospitalization
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, resulting in actual harm. A registered nurse (RN) mistakenly administered another resident's medications to a cognitively intact resident with schizoid personality disorder, diabetes mellitus type II, chronic kidney disease stage 5, hyperlipidemia, and hypertension. The error occurred when the RN picked up the wrong medication cup, which contained clozapine, desmopressin, and olanzapine, leading to the resident becoming heavily sedated and requiring hospitalization. The medication error was discovered when a nursing aide noticed the resident heavily sedated and unresponsive to verbal stimuli. Emergency medical services were called, and the resident was transported to the hospital, where he was diagnosed with acute toxic metabolic encephalopathy and acute hypoxemic respiratory failure due to the high dose of clozapine. The resident was intubated and sedated for airway protection in the intensive care unit. Interviews with staff revealed that the RN did not follow the facility's policy of verifying the five rights of medication administration, which include the right patient, route, medication, dose, and time. The error was attributed to the practice of presetting medications in batches, which is not allowed according to the facility's policy. The incident was reported to the director of nursing, and the RN involved was terminated for not reporting the error immediately and not complying with the internal investigation.
Inadequate Care Plan for Resident with Elopement Risk
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with a history of eloping and wandering due to command voices associated with schizoaffective disorder. The resident, who was cognitively intact, had a care plan that lacked specific interventions for when he experienced command voices. The care plan included general interventions such as asking the resident about the voices and reminding him of certain behaviors, but it did not provide clear guidance on what staff should do when the resident was actively hearing command voices or how to assess the intensity of these voices. The care plan also indicated that the resident was not safe leaving the facility unsupervised when experiencing command voices, yet it did not specify actions for staff to take in such situations. The resident had previously left the facility without a GPS tracker on two occasions, and the care plan did not address how to prevent these incidents. Interviews with staff revealed a lack of clarity and training on how to handle the resident's distress and command voices, with some staff unsure of the appropriate interventions. The director of social services and the director of nursing acknowledged the challenges in managing the resident's condition, noting that increased activity in the facility could exacerbate the resident's symptoms. Despite the use of a GPS tracker and other monitoring measures, the care plan did not evolve to include new interventions following the resident's repeated elopements. The facility's missing resident procedure also lacked guidance on developing interventions to prevent future incidents.
Failure to Conduct Ongoing QAPI and QAA Activities
Penalty
Summary
The facility failed to conduct ongoing quality assessment and assurance activities, and did not develop or implement appropriate plans of action to correct repeated quality deficiencies. This failure had the potential to adversely affect all 60 residents in the facility. The facility's QAPI meeting minutes for the past 12 months were requested but not received. Additionally, documentation and evidence of the facility's ongoing performance improvement projects (PIPs) and a recent performance improvement plan (PIP) were also requested but not received. During an interview, the interim administrator stated that the facility held quarterly QAPI meetings but was unable to access the shared network where the previous administrator had saved the meeting minutes. The administrator also mentioned that the facility was involved in PIPs but could not locate the documentation. The facility's QAPI plan indicated that the QAPI committee, which included all department managers, the administrator, director of nursing, infection control and prevention officer, medical director, consulting pharmacist, and quality coordinator, would meet quarterly and review data to prioritize opportunities for improvement. However, the lack of accessible documentation and evidence of these activities indicates a failure in the facility's QAPI processes.
Failure to Maintain Effective QAPI Committee and Implement PIPs
Penalty
Summary
The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) committee. This committee was not successful in identifying and responding to quality deficiencies, nor in developing procedures for feedback, data collection, and monitoring systems. The facility also did not provide evidence of a Performance Improvement Project (PIP) focusing on high-risk or problem-prone areas. This deficiency had the potential to affect all 60 residents currently residing in the facility. During an interview, the administrator was unable to provide quality tracking data or locate meeting minutes from previous QAPI meetings. The administrator mentioned that the previous administrator might have held meetings but was unsure of their documentation. Additionally, although the facility had a QAPI plan dated April 2024, which outlined the implementation of PIPs to improve various aspects of care, there was no evidence of any active PIPs. The plan specified that PIPs should address high-risk, high-volume, or problem-prone areas, but no such projects were found during the survey.
Failure to Accurately Assess Pneumococcal Vaccination Eligibility
Penalty
Summary
The facility failed to accurately assess residents' eligibility to receive the pneumococcal vaccination according to CDC guidelines for two residents. One resident, aged [AGE] with diabetes mellitus, had received the PCV13 vaccine on 9/13/19 but was not offered the required follow-up dose of PCV20 or PPSV23 at least one year later. Another resident, aged [AGE] with hypertension, renal insufficiency, and diabetes mellitus, had received the PPSV23 vaccine on multiple occasions but was not offered the required follow-up dose of PCV20 or PCV15 at least one year after the most recent PPSV23 vaccination. Both residents' MDS indicated they were not up to date with pneumococcal vaccinations and had not been offered the vaccine, which was confirmed by their MIIC reports and interviews with staff members. The facility was unable to provide documentation of the residents being offered or declining the pneumococcal vaccination. Interviews with the facility's staff, including two registered nurses and the director of nursing, revealed that the process for assessing and updating residents' vaccination status involved accessing the MIIC and contacting previous care providers. However, the staff failed to ensure that the residents received the necessary follow-up vaccinations according to CDC guidelines. The infection preventionist stated that residents were asked about their vaccination status during assessment interviews and that the facility checked yearly to ensure residents were up to date. Despite these procedures, the facility did not have documentation to show that the residents were offered the required pneumococcal vaccinations, leading to the identified deficiency.
Inaccessible Call Light Cord in Resident Bathroom
Penalty
Summary
The facility failed to ensure that the resident call light cord was within reach from the shower floor in a multi-resident bathroom. During observations and interviews, it was found that the call light cord in the bathroom used by residents was tied with a string that was looped and hung approximately four feet from the ground, making it inaccessible if a resident fell or was sitting in the shower chair. This issue was identified for residents who had varying degrees of cognitive impairment and required different levels of assistance with activities of daily living (ADLs), including showering. Specifically, residents with diagnoses such as schizophrenia, cataracts, and diabetes mellitus were affected, and their care plans indicated the need for call light accessibility and assistance with showers. Staff interviews revealed that the call light system was not functioning as intended, with the string needing to be excessively pulled to activate the call light. Nursing assistants and registered nurses acknowledged the issue and confirmed that call lights should be within reach of residents, including when they are in the shower or using the toilet. The Director of Nursing (DON) also stated that staff might not be able to respond to or be aware of an emergency if a resident could not reach or turn on their call light. The facility's policy indicated that the nursing station should be equipped to receive resident calls from the resident room, bath, and bathrooms, but this was not effectively implemented in this case.
Failure to Clean Multi-Resident Bathroom Ceiling Vent Fan
Penalty
Summary
The facility failed to ensure a multi-resident bathroom ceiling vent fan was cleaned for four residents reviewed for cleanliness of the environment. During an observation, thick grayish-white dust covered 50 to 75% of the bathroom ceiling vent, and no air flow was felt despite the fan running. The administrator expected maintenance and housekeeping to keep vents and fans clean, but a cleaning schedule was still being developed due to a recent change to a contracted housekeeping company. The assistant director of maintenance stated they cleaned vents and fans when dust was observed or reported by residents, but sometimes checks did not happen as planned. The head of maintenance acknowledged that vents and fans should be cleaned monthly and noted the importance of keeping them clean for air flow and equipment performance. The facility's Room Order Cleaning Procedure did not include instructions to check and clean vents and fans.
Failure to Notify Medical Provider of Medication Refusals
Penalty
Summary
The facility failed to notify the medical provider of ongoing medication refusals for a resident with diabetes mellitus and schizophrenia. The resident, who had short- and long-term memory problems and made moderately impaired decisions, consistently refused insulin and blood sugar checks from late February through April. Despite multiple refusals documented in the administration records and progress notes, the medical provider was not notified of these refusals, which is a violation of the facility's policy requiring notification after three days of medication refusal. The resident's care plans and assessments indicated a history of delusions, inattention, and disorganized thinking, which contributed to their refusal of insulin. The resident believed they had an allergy to insulin and experienced delusional symptoms that made them resistant to diabetic care. Despite interventions such as reorientation, reassurance, and redirection, the resident continued to refuse insulin and blood sugar checks, leading to abnormal blood sugar levels and a visit to the emergency room. Interviews with facility staff, including nursing assistants, licensed practical nurses, and the nurse practitioner, revealed that the staff were aware of the resident's refusals but did not consistently notify the medical provider. The nurse practitioner confirmed that they had not been informed of the refusals and emphasized the importance of being notified to develop a plan for the resident's care. The facility's director of nursing also acknowledged the expectation for staff to notify providers about changes in residents' conditions, including medication refusals, as soon as possible.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to ensure that grievances from two residents were documented, responded to, and resolved in a timely manner. Resident 47, who had intact cognition but exhibited behaviors such as hallucinations, delusions, and verbal aggression, reported no issues initially but later expressed dissatisfaction with his roommate. Resident 53, who also had intact cognition and suffered from complex regional pain syndrome and other conditions, reported ongoing issues with Resident 47, including TV remote control interference and cleanliness issues in the shared bathroom. Despite informing multiple staff members, Resident 53's concerns were not documented or addressed through the facility's grievance process. Interviews with staff revealed a lack of awareness and action regarding the grievances. An LPN acknowledged the requirement for reporting abuse and the grievance process but was unaware of the specific issues between the two residents. The licensed social worker admitted to knowing about the conflict but had not provided a grievance form or assistance in completing one. The Director of Nursing was also unaware of any grievances or concerns between the residents and could not provide a log of grievances or the facility's grievance policy when requested. The facility's failure to document and address the grievances led to ongoing conflicts between the two residents. Resident 53 reported feeling fearful and frustrated due to the unresolved issues with Resident 47. The lack of a documented grievance process and the staff's unawareness of the residents' concerns highlight a significant deficiency in the facility's handling of resident grievances.
Failure to Report and Investigate Abuse Allegations
Penalty
Summary
The facility failed to ensure allegations of potential abuse were reported to the administrator and State Agency (SA) immediately, but not later than 2 hours after the allegation was made. This deficiency was identified in the case of a resident-to-resident verbal altercation involving a resident with a history of schizophrenia and anxiety, who made racist and sexist comments towards another resident. The affected resident reported feeling disrespected and abused by the comments, and stated that staff did not follow up with her or offer to file a grievance or provide a phone number for a formal complaint. Despite multiple reports to staff, the issue was not documented or reported to the appropriate authorities in a timely manner. The resident who made the abusive comments had a documented history of verbal behaviors directed towards others, including hallucinations and delusions. His care plan included interventions such as providing medications, redirection, and cueing. However, the facility's progress notes and care plan lacked specific documentation of the incidents or any grievances filed in relation to his behaviors. The interdisciplinary team (IDT) discussed the resident's behaviors but did not document any specific incidents or offer grievances to the affected resident. Interviews with staff revealed a lack of clarity and consistency in the reporting process for abuse allegations. The administrator and other staff members were aware of the incident but did not consider it reportable. The facility's policies on abuse reporting and investigation were not followed, as staff did not immediately report the incident to the administrator or SA, nor did they conduct a formal investigation. The facility's failure to report and investigate the abuse allegations in a timely manner resulted in a deficiency in ensuring the safety and well-being of the residents involved.
Failure to Investigate and Address Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to ensure allegations of resident-to-resident verbal abuse were thoroughly investigated and protection provided for a resident involved in a verbal altercation. The incident involved a resident with schizophrenia and anxiety, who displayed verbal behaviors directed towards others, including making racist and sexist comments. Despite multiple reports from the affected resident, staff did not follow up appropriately, offer to file a grievance, or provide a formal complaint process. The facility's documentation lacked specific incidents or grievances related to the abusive behaviors, and the interdisciplinary team did not take adequate steps to address the situation or protect the affected resident. The affected resident reported feeling disrespected and abused by the comments, which included racial slurs and derogatory terms. She stated that staff brushed off her complaints and did not take any protective measures. Interviews with staff revealed a lack of awareness and proper documentation of the incidents, as well as a failure to follow the facility's policies on abuse reporting and investigation. The administrator and other staff members acknowledged the need for better monitoring and reporting but did not implement a formal investigation process until the incident was deemed reportable. The facility's policies on abuse prevention and reporting were not followed, leading to inadequate protection for the affected resident. Staff interviews indicated a lack of training and understanding of the proper procedures for handling abuse allegations. The facility's failure to document and investigate the incidents thoroughly resulted in a lack of appropriate interventions and support for the affected resident, leaving her feeling vulnerable and unprotected.
Failure to Accurately Code PTSD in MDS
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was accurately coded to reflect a resident's diagnosis of post-traumatic stress disorder (PTSD) for two residents. The Resident Assessment Instrument (RAI) manual requires that active diagnoses, which have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death, be accurately documented. However, the MDS for both residents lacked the necessary check marks indicating PTSD, despite multiple medical records and evaluations confirming the diagnosis within the required look-back periods. For Resident 57, the admission and quarterly MDS did not indicate PTSD, even though psychiatric evaluations, physician progress notes, hospital progress notes, and other medical records consistently documented the diagnosis. Interviews with staff revealed that although PTSD was recognized, it was not included in the MDS because it was not being actively treated with medications or specific treatments. This oversight occurred despite the resident's care plan and medication administration record indicating PTSD. Similarly, for Resident 14, the annual and quarterly MDS failed to reflect the PTSD diagnosis, despite the resident's care plan, social service documentation, and nurse practitioner notes confirming the condition. Staff interviews indicated that PTSD was acknowledged but not included in the MDS due to the lack of active treatment. The Director of Nursing stated that PTSD should have been included in the MDS, emphasizing the importance of accurate documentation to manage and treat the residents effectively.
Failure to Develop Comprehensive Care Plan for Psychotropic Medications
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident (R56) who was receiving psychotropic medications. The resident's admission Minimum Data Set (MDS) indicated intact cognition and hallucinations, with diagnoses of diabetes, depression, and a psychotic disorder. The resident was prescribed Olanzapine and Mirtazapine. However, the care plan lacked documentation of the specific psychotropic medications being used, resident-specific target symptoms or behaviors to monitor, and non-pharmacologic interventions. Additionally, the care plan did not include the resident's antidepressant use or related interventions, despite the resident having a history of suicidal ideation and hospitalization. The Director of Nursing (DON) and social services staff confirmed these deficiencies during interviews, acknowledging that the care plan was incomplete and did not meet the expected standards for documenting resident-specific symptoms and interventions for psychotropic medication use. The Director of Nursing stated that the social services department was responsible for updating the care plan with behavioral aspects of psychotropic medications. The DON expected to see target behaviors and interventions in the care plan for residents on psychotropic medications, which were missing in R56's case. Social services staff also confirmed that the process for monitoring psychotropic medications and related symptoms involved reviewing notes to determine the medications and symptoms. They acknowledged that it might take time to develop resident-specific non-pharmacologic interventions due to the interdisciplinary approach. However, they verified that the care plan for R56 lacked resident-specific interventions and was not completed. A psychotropic drug use policy was requested but not received, further highlighting the facility's failure to adhere to proper care planning protocols.
Failure to Implement Appropriate Fall Interventions
Penalty
Summary
The facility failed to ensure appropriate interventions were identified and implemented for a resident (R2) who had multiple falls and comorbidities contributing to the risk of additional falls. R2 had a history of paranoid schizophrenia, end-stage renal disease, hypokalemia, bilateral myopia, presbyopia, hypertension, and osteoarthritis. Despite being at moderate risk for falls, R2 experienced several falls, including falling downstairs and fracturing ribs and fingers, falling on the stairs due to an out-of-service elevator, missing a chair while sitting, and falling in his room due to clutter and crowding. The care plan and nursing assistant caresheet lacked specific information on how R2 ambulated and did not ensure the room was free from clutter. The facility's incident reports and progress notes indicated that R2's falls were related to environmental factors such as clutter in the room and the use of stairs when the elevator was out of service. Despite these incidents, the care plan was not updated with new interventions to address these risks. Observations revealed that R2's room remained cluttered, with items on the floor and a narrow path between the bed and other furniture. Interviews with staff indicated that they relied on electronic medical records and care plans to know what care a resident required, but the care plan was not consistently updated after falls. The facility's Fall Management Policy aimed to ensure the resident environment remained free of accident hazards and that each resident was assessed for fall risk with preventative measures in place. However, the policy was not effectively implemented for R2, as the care plan did not include specific interventions to address the identified risks, such as keeping the room free from clutter and ensuring the use of the elevator. The lack of updated interventions and environmental modifications contributed to the continued risk of falls for R2.
Failure to Assess and Identify PTSD Triggers for Residents
Penalty
Summary
The facility failed to comprehensively assess and identify potential triggers to avoid re-traumatization for two residents with a history of trauma. Resident 57 (R57) had a documented history of PTSD, bipolar disorder, and other mental health conditions. Despite multiple medical records and evaluations indicating R57's PTSD, the facility did not conduct an assessment to identify PTSD triggers. Interviews with staff revealed that R57 was startled by loud noises such as the overhead intercom and city tornado alarm, but these triggers were not documented or addressed in R57's care plan. The facility's policy on trauma-informed care was not followed, as it required the identification and care planning of PTSD triggers, which was not done for R57. The Director of Nursing and other staff members acknowledged the lack of assessment and care planning for PTSD triggers for R57 during interviews. The facility's failure to assess and document PTSD triggers for R57 led to a deficiency in providing trauma-informed care as per their policy. Resident 14 (R14) also had a documented history of PTSD, schizophrenia, and major depressive disorder. Despite these diagnoses, R14's medical record lacked evidence of an assessment for PTSD triggers. Interviews with staff indicated that R14 exhibited behaviors such as refusing insulin and carrying belongings due to paranoid delusions. However, these behaviors were not linked to specific PTSD triggers in the care plan. Staff members, including the social worker and registered nurse, confirmed that no assessment for PTSD triggers had been conducted for R14. The facility's policy on trauma-informed care required the identification and care planning of PTSD triggers, which was not done for R14. The facility's failure to assess and document PTSD triggers for R14 led to a deficiency in providing trauma-informed care as per their policy.
Failure to Monitor and Notify Provider for Elevated Blood Sugar Levels
Penalty
Summary
The facility failed to ensure adequate monitoring and provider notification for insulin parameters for a resident with type 2 diabetes, depression, and schizoaffective disorder. The resident's care plan included specific insulin administration orders based on blood sugar readings, with instructions to notify the provider if blood sugar levels exceeded 400 mg/dL. However, the facility did not follow these orders on two occasions when the resident's blood sugar levels were significantly elevated, and there was no documentation of provider notification in the progress notes. During interviews, the registered nurse (RN) acknowledged that the resident's blood sugar levels were above the threshold and that the provider should have been notified. The RN admitted that the resident's blood sugar was checked after eating, which might have influenced the readings, but still confirmed that the provider update was necessary. The advanced practical registered nurse (APRN, CNP) overseeing the resident's care also confirmed the expectation of being notified about such elevated readings to manage the resident's long-acting insulin dose appropriately. The director of nursing (DON) verified the elevated blood sugar readings and confirmed that the staff should have administered the insulin as ordered and contacted the provider. The DON mentioned that the nurse responsible for the oversight received coaching on documentation and provider notification. Requests for the facility's medication monitoring, diabetic management, and change of status policies were made but not received.
Failure to Accommodate Dietary Preferences for Vegetarian Resident
Penalty
Summary
The facility failed to accommodate dietary preferences for a resident identified as a vegetarian. The resident, who had a regular diet order and was at risk for nutritional problems due to low protein intake, experienced difficulty receiving appropriate vegetarian meal options. Despite the facility's policy to accommodate dietary preferences, the resident's care plan and progress notes indicated ongoing issues with meal satisfaction and availability of vegetarian options. The resident's weight showed a downward trend, further indicating potential nutritional inadequacies. The resident's care plan and progress notes documented multiple instances where the resident expressed dissatisfaction with the meals provided, citing a lack of vegetarian options and occasional unavailability of peanut butter, a staple in their diet. The resident had to resort to purchasing food from Amazon to meet their dietary needs. Observations confirmed that the resident often did not receive a complete meal and sometimes only consumed desserts or limited food items during mealtimes. Interviews with the dietary manager and registered dietician revealed a lack of consistent communication and documentation regarding the resident's dietary preferences. The dietary manager was unaware of any residents on vegetarian diets, and the dietician did not document a recent conversation with the resident about their comfort with the provided foods. The facility's policy on nutritional assessment and meal preferences was not effectively implemented, leading to the resident's unmet dietary needs and potential nutritional risk.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure medications were administered in accordance with physician orders and manufacturer guidelines for three residents. For one resident, a registered nurse did not administer mucus relief medication as it was not available, despite the physician's order indicating it should be given twice a day. The nurse acknowledged the oversight and stated she would contact the pharmacy to reorder the medication. Another resident was given a whole 2 mg risperidone tablet instead of the prescribed 1 mg dose. The trained medication aide corrected the error after the resident pointed out the mistake. Additionally, a third resident was almost given expired calcium medication, but the error was caught and corrected after prompting from an observer. The trained medication aide admitted to not checking the expiration date before attempting to administer the medication. The director of nursing confirmed that medications should be ordered before the supply runs out and that staff are expected to follow the five rights of medication administration, including checking expiration dates. The facility's policies on ordering and administering medications were reviewed, indicating that medications should be administered safely and timely, as prescribed, and that expiration dates should be checked prior to administration. Despite these policies, the facility's medication error rate was found to be 12%, significantly higher than the acceptable rate of less than 5%.
Failure to Deliver Mail on Saturdays
Penalty
Summary
The facility failed to ensure mail was delivered to residents on Saturdays, affecting all residents who received personal mail, including two residents who confirmed this issue. During a Resident Council meeting, two residents reported that mail received on weekends was not delivered until Monday when the medical records staff person returned to work. The medical records staff person confirmed that she was responsible for mail delivery but did not work on weekends, resulting in delayed mail delivery. The interim administrator was unaware of this issue and stated that mail should be delivered six days per week, noting that other staff could handle mail delivery on Saturdays. A policy on mail delivery was requested but not provided by the end of the survey period.
Failure to Prevent Elopement and Timely Report Missing Resident
Penalty
Summary
The facility failed to implement interventions to prevent elopement and did not follow the safety plan for a resident with a history of multiple elopements due to audible hallucinations. The resident, who had diagnoses including schizophrenia and schizoaffective disorder, was able to leave the facility without a GPS tracker, which was part of the safety plan. The resident's care plan included measures such as obtaining a tracker from the charge nurse, ensuring the resident had a charged cell phone, and asking specific questions to assess the resident's mental state before leaving. However, these measures were not consistently followed by the staff. On multiple occasions, the resident left the facility without notifying staff or taking the GPS tracker, and the facility did not report the resident missing in a timely manner. For instance, on one occasion, the resident was discovered missing at 5:15 p.m., but the police were not notified until 10:07 p.m., which was not in accordance with the care plan. Staff interviews revealed a lack of awareness of the resident's behavioral triggers and an inconsistent application of the safety monitoring plan. The facility's policy for missing residents was not adhered to, as evidenced by the delayed reporting to the police and the failure to follow the outlined steps when a resident was considered missing. Staff members, including nurses and nursing assistants, did not consistently monitor the resident's whereabouts or document their observations as required. The facility's failure to implement the care plan and safety measures contributed to the resident's repeated elopements and the delayed response in reporting the resident missing.
Inadequate Mental Health Care Coordination and Medication Management
Penalty
Summary
The facility failed to provide appropriate services and treatment for a resident diagnosed with schizophrenia and experiencing audible hallucinations. The resident, who was under a court order for medication management, did not receive consistent medication monitoring or coordination of care between mental health providers. The resident's care plan included interventions for managing hallucinations, but there was a lack of a PRN medication for acute psychosis episodes, and the facility did not ensure the effectiveness of medication changes. The resident's records showed inconsistent documentation of hallucinations and psychosis, with discrepancies between the Point of Care documentation and Medication Administration Records. Interviews with staff revealed a lack of awareness of the resident's behavioral triggers and the absence of a PRN medication for managing command voices during the day. The resident's psychiatrist and care team were not adequately informed of the resident's behavioral history or medication changes, leading to insufficient management of the resident's condition. The facility's failure to coordinate care and monitor medication effectiveness resulted in the resident experiencing episodes of elopement and distress due to command voices. Staff interviews indicated a lack of communication and collaboration between the facility's nursing team and the resident's mental health providers. The facility's assessment tool claimed the ability to manage residents with psychosis and other mental disorders, but the lack of appropriate interventions and medication management for the resident demonstrated a deficiency in meeting these needs.
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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