Cerenity Care Center On Humboldt
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Paul, Minnesota.
- Location
- 512 Humboldt Avenue, Saint Paul, Minnesota 55107
- CMS Provider Number
- 245255
- Inspections on file
- 33
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Cerenity Care Center On Humboldt during CMS and state inspections, most recent first.
A resident with Parkinson's disease and moderate cognitive impairment, who required assistance for transfers, was left unattended during a transfer by a nursing assistant. The resident attempted to turn near a nightstand, became entangled, and fell, resulting in a femur fracture. The care plan did not clearly specify the required level of assistance prior to the incident, and staff did not follow the established plan of care.
Multiple residents with significant care needs experienced prolonged call light response times, sometimes waiting over an hour or more for assistance with toileting, hygiene, and mobility. These delays, caused by insufficient staffing and staff being pulled to other duties, led to actual harm for a resident with multiple sclerosis and anxiety, who waited nearly three hours for incontinence care and experienced increased distress and feelings of helplessness. Other residents also reported emotional distress and incontinence episodes due to delayed responses.
The facility's QAPI committee did not adequately identify, analyze, or respond to ongoing issues with prolonged call light response times, despite multiple resident grievances and audit data indicating persistent delays. Leadership acknowledged incomplete and inaccurate audits, lack of clear goals, and failure to include call light data in QAPI reviews, resulting in no targeted improvement plan for this concern.
The facility failed to administer medications as ordered and did not identify or report medication errors for two residents. One resident missed multiple doses of pain medication and antifungal cream due to unavailability, while another missed doses of an inhaler for COPD. Staff did not notify providers of the missed doses, and the errors were not documented or reported according to facility policy.
A resident with rheumatoid arthritis, who required built-up utensils for self-feeding as documented in her care plan and dietary records, was not provided with these adaptive utensils during meals. The resident reported ongoing difficulty and was observed eating without the necessary equipment, while staff confirmed the omission despite prior education of dietary personnel.
Two residents' EHRs lacked primary care provider visit notes from their current admissions, with the missing documentation only available through an external system. Facility staff confirmed that provider notes were not uploaded as required, resulting in incomplete and inaccessible medical records, contrary to facility policy.
The facility failed to provide adequate staffing, resulting in delayed call light responses and late medication administration. Residents experienced prolonged wait times for assistance with activities of daily living, and staff reported being unable to meet care demands due to understaffing, especially during nights and weekends. Staffing decisions were based on census and budget rather than resident needs, and the facility lacked audits for care plans and call light response times.
The facility failed to maintain proper food storage and cleanliness in its kitchen and kitchenettes, resulting in expired food items not being removed, unlabeled and undated food, and cross-contamination risks. Observations showed grime and dirt in the main kitchen, and a leaking refrigerator was not repaired despite multiple work orders. Staff interviews revealed unclear responsibilities for food safety and cleanliness, and the facility lacked a cleaning schedule.
The facility failed to follow transmission-based precautions and infection control protocols during medication administration and glucose monitoring. A resident with MRSA did not have proper contact precautions during medication administration, and an LPN did not perform hand hygiene between glove changes. Another resident's glucose meter was not disinfected per guidelines. Additionally, resident clothing was transported uncovered, contrary to policy, potentially affecting all residents on the third floor.
The facility failed to assess residents' ability to self-administer medications before leaving them unsupervised with medications. A resident with multiple diagnoses was left with medications without a SAM assessment, another resident was left with a lidocaine patch without proper assessment, and a third resident self-administered IV medications without supervision or a SAM order. Staff interviews confirmed the facility's policy requiring SAM orders was not followed.
A resident with chronic diarrhea and a history of gastroenteritis did not receive consistent bowel management, as loperamide was not administered as ordered, and bowel movements were inadequately documented. The resident's care plan required regular toileting and barrier cream application, but staff failed to notify the physician about ongoing diarrhea, leading to worsening skin conditions. The facility's bowel management policy lacked specific guidance for diarrhea cases.
A facility failed to assess trauma history and identify potential triggers for a resident with PTSD, despite having a care plan in place. The resident's Behavioral Symptoms Care Plan and social services assessments lacked identification of PTSD triggers. Staff interviews revealed a lack of awareness about the resident's trauma history and triggers, contrary to the facility's Trauma Informed Care policy.
A resident with multiple medical conditions, including hemiplegia and a history of falls, was found to have an inaccessible call light system in their room. The call light box was placed on a bedside table without a cord, contrary to the care plan that required it to be within reach. Staff interviews confirmed the inaccessibility and lack of documentation of the resident's preference regarding the call light cord. The facility's policy mandates accessible call systems, which was not followed.
The facility failed to maintain the dignity of two residents. One resident, with intact cognition, was not addressed by her preferred name despite it being documented, causing her distress. Another resident, with multiple diagnoses including diabetes, was not properly groomed, specifically not shaved, despite having noticeable chin hairs. Staff interviews revealed confusion and lack of documentation regarding these care needs, indicating a lapse in maintaining resident dignity.
Two residents requiring substantial assistance with toileting were not checked or changed for extended periods, contrary to facility policy. One resident was observed sitting in a wheelchair for several hours without being offered toileting assistance, while another was found with a dried bowel movement, indicating prolonged exposure. Staff interviews revealed challenges in meeting toileting schedules due to high workloads and the need for Hoyer lifts.
A resident with multiple medical conditions, including autism and legal blindness, was not provided with a consistent toileting program as outlined in their care plan. Despite being always incontinent and requiring substantial assistance, staff failed to offer regular toileting, leaving the resident's call light unanswered and not adhering to the scheduled toileting every 2 to 3 hours. This deficiency was confirmed through observations and staff interviews, highlighting a failure to follow the facility's policy on Activities of Daily Living.
A resident with chronic pain and multiple health conditions experienced delays in receiving scheduled and as-needed pain medications, as documented in the MAR. Interviews with the resident and staff revealed systemic issues in timely medication administration, with delays sometimes requiring reminders to nursing staff. The facility's policy for individualized pain management was not followed, leading to increased pain and distress for the resident.
A facility failed to implement physician-prescribed wound care orders and notify the physician of infection signs for a resident with diabetes and peripheral vascular disease. The resident's treatment orders were delayed, and lab results indicating inflammation were not communicated, leading to osteomyelitis and amputation of two toes. The process for handling treatment orders was not followed, contributing to the deficiency.
A resident with multiple chronic ulcers experienced a worsening condition when a tendon became exposed, requiring hospitalization. Despite regular wound care, the facility failed to notify the family and physician of this change. Staff interviews revealed a lack of communication and awareness regarding the resident's baseline condition, contributing to the deficiency.
A resident with multiple medical conditions, including morbid obesity, was transferred using an inappropriate large harness on an EZ Stand, despite exceeding the weight limit specified by the manufacturer. Facility staff were unaware of the resident's actual weight and the correct harness size, and the care plan lacked specific guidance. The facility's policy on safe patient handling was unclear, leading to inconsistent assessments and documentation.
A facility failed to maintain an EZ Stand for a resident with multiple sclerosis and other conditions, as per manufacturer guidelines. The EZ Stand, due for maintenance in May, had no records of being serviced, and the checklist was marked N/A. The Environmental Services Director admitted to not finding maintenance records and acknowledged a lapse in following up on the device's status.
The facility failed to provide meals that met residents' nutritional needs and preferences. Observations showed residents received incorrect meals, struggled to eat due to food being too dry or cold, and were not offered suitable alternatives. Interviews revealed ongoing complaints about meal quality and confusion among staff regarding meal options. The facility's policy to follow menus and provide equal nutritional substitutions was not adhered to.
The facility failed to maintain a safe and clean environment, particularly on the 3rd floor, where cleaning practices and chemical storage were inadequate. Housekeeping staff left cleaning carts with hazardous chemicals unattended, posing safety risks. Disinfectants were used improperly near residents during meals, causing discomfort. Cleaning logs showed many rooms were not cleaned daily, leading to unsanitary conditions. Residents and staff confirmed these issues, highlighting the facility's failure to comply with its own policies.
A resident with a post-surgical cast was admitted to a facility with orders to keep the cast dry. The facility failed to implement measures to ensure this, resulting in the cast becoming soiled with urine and feces. The resident, who had a history of chronic infections, was frequently incontinent, and the care plan did not address toileting needs or methods to keep the cast dry. This oversight led to the resident developing septic shock, and the cast was found soaked and odorous, contributing to the need for amputation.
A resident with a complex medical history and high risk for pressure ulcers did not receive adequate care, resulting in worsening and new pressure ulcers. The care plan lacked specific interventions, and staff were unaware of the resident's skin condition. The resident was discharged with multiple stage II pressure ulcers, indicating neglect in skin care management.
A resident was admitted with multiple pressure ulcers and other skin conditions, but the facility failed to accurately assess and address these issues. Despite hospital discharge orders indicating the presence of these conditions, the facility's initial assessment and care plan did not reflect them. Interviews revealed a lack of awareness and communication among staff, leading to inadequate care for the resident's skin conditions.
The facility failed to serve food at palatable temperatures to several residents, leading to widespread complaints about cold meals. Despite appropriate temperatures when leaving the kitchen, food was served significantly colder, with the Director of Culinary Services acknowledging the issue and working on a plan to address it. The Director of Nursing confirmed the importance of serving food at safe temperatures, as per the facility's policy.
The facility failed to maintain a clean, safe, and homelike environment for residents on the third floor. A resident expressed concerns about cleanliness, and observations revealed a strong smell of urine and cluttered hallways. Another resident hired a friend to clean her bathroom due to inadequate housekeeping. The DON acknowledged the unclean conditions and lack of a cleaning schedule for equipment. Staff confirmed the shortage of housekeeping staff, contributing to the unsafe environment. The facility's cleaning policy was not being followed, impacting residents' quality of life.
Two residents who required assistance with bathing did not receive their scheduled baths due to staffing shortages. One resident, dependent on staff for bathing, missed several baths over two months, while another resident, requiring supervision, also missed multiple baths. Both residents expressed dissatisfaction, citing neglect and lack of respect. Nursing assistants reported insufficient staffing, with one assistant caring for 30 residents at times. The DON was unaware of the missed baths, despite policies requiring adequate staffing.
A resident admitted with multiple diagnoses did not receive medications as ordered due to transcription errors in the EHR and failure to utilize available medications in the ADU. The MAR did not match physician orders, and missed doses were not reported to the provider. The DON acknowledged the discrepancies, and the pharmacy consultant noted the facility's failure to report missed doses.
Failure to Provide Adequate Supervision and Assistance During Resident Transfer Resulting in Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with Parkinson's disease, depression, and anxiety, who was at risk for falls, did not receive adequate supervision and assistance during a transfer. The resident's physical therapy evaluation indicated a need for contact guard assistance for transfers, and the admission Minimum Data Set (MDS) documented a requirement for supervision or touching assistance. However, the resident's care plan did not specify the required level of transfer assistance, and the nursing assistant care sheet indicated assist of one with a gait belt and walker. On the day of the incident, the resident was being assisted in her room by a nursing assistant who placed a gait belt on her and allowed her to stand near the nightstand to brush her hair. The nursing assistant then left the resident unattended to retrieve her walker. During this time, the resident attempted to turn, became entangled with the nightstand, lost her balance, and fell, resulting in a right femur fracture. The staff member was not within close reach to prevent the fall. Interviews with staff confirmed that the resident was supposed to be assisted by one staff member with a gait belt and walker for transfers and ambulation, but the care plan had not been updated to reflect this until after the fall. The facility's fall management policy required interventions to be implemented through a resident-centered plan of care, but the lack of clear documentation and failure to follow the established plan of care contributed to the incident.
Failure to Provide Sufficient Staffing Results in Prolonged Call Light Response Times and Resident Harm
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in prolonged call light response times for multiple residents. Several residents, including those with significant physical and psychosocial needs, experienced extended waits for assistance, sometimes exceeding one to three hours. These delays were documented through call light logs and corroborated by resident interviews, which described repeated instances of unmet needs for toileting, hygiene, and mobility assistance. Staff interviews confirmed that inadequate staffing levels, particularly when only two nursing assistants were present instead of the expected three, contributed to the inability to respond to call lights in a timely manner. One resident with multiple sclerosis, anxiety, depression, and a history of trauma was left waiting for nearly three hours for incontinence care, leading to increased anxiety, distress, and feelings of helplessness. This resident was dependent on staff for transfers and personal care, and her care plans emphasized the importance of timely assistance to prevent urinary tract infections and support her psychosocial well-being. Despite these documented needs, call light logs showed frequent delays, and the resident reported feeling unsafe and emotionally affected by the lack of prompt care. Other residents with conditions such as Parkinson's disease, functional quadriplegia, and pressure ulcers also experienced similar delays, sometimes resulting in incontinence episodes and emotional distress. Staff interviews revealed that the shortage of nursing assistants made it difficult to answer call lights promptly, especially during times when staff were pulled to cover other duties or when scheduled staff left due to illness. Residents and their representatives described feelings of helplessness, frustration, and loss of dignity due to the prolonged waits. The facility's own grievance logs and staff acknowledged the negative impact of these delays on residents' psychosocial well-being, including increased anxiety and diminished trust in staff. The documented call light response times and resident accounts demonstrate a pattern of insufficient staffing leading to unmet resident needs.
Failure to Address and Analyze Prolonged Call Light Response Times
Penalty
Summary
The facility failed to ensure its Quality Assurance and Performance Improvement (QAPI) committee effectively identified, investigated, analyzed, and responded to ongoing issues with excessively long call light response times. Despite having a QAPI Program Plan that outlined systematic analysis and corrective action for quality issues, the committee did not conduct a thorough investigation or causal analysis regarding call light response times, nor did it develop or implement a specific action plan to address the problem. Meeting minutes and PowerPoint presentations from Quality Council meetings lacked detailed data analysis, specific goals, or monitoring of the effectiveness of any actions related to call light concerns, even though grievances and audit data indicated persistent issues. Multiple grievances were filed by residents over a period of several months, citing long waits for call light responses, sometimes exceeding 30 minutes to over an hour. Some residents reported that their needs were not addressed even after staff responded, and in one case, a resident had to go in their brief due to delayed assistance. Audit sheets intended to monitor call light response times were inconsistently completed, lacked clear definitions of timeliness, and did not always align with call light logs. The data collected was incomplete and not systematically analyzed, and there was no evidence that the QAPI committee used this information to drive improvement. Interviews with facility leadership, including the administrator and DON, confirmed awareness of ongoing call light response issues. However, they acknowledged that audits were not accurate or complete, and that there was no established measurable goal for response times. The QAPI committee did not include call light data in its regular reviews, nor did it conduct a root cause analysis or develop a targeted improvement plan, despite policy requirements to do so. This lack of systematic response and oversight had the potential to affect all residents in the facility.
Failure to Administer Medications as Ordered and Report Medication Errors
Penalty
Summary
The facility failed to ensure that medications were administered in accordance with physician orders and did not identify or report medication errors for two residents. One resident, who had diagnoses including acute pain due to trauma and dorsalgia, was on a scheduled pain medication regimen and also received PRN pain medications. This resident had physician orders for miconazole nitrate 2% topical cream to be applied twice daily and tramadol 25 mg to be administered four times daily. Review of the medication administration records (MAR) showed multiple missed doses of both miconazole and tramadol, with documentation indicating the medications were unavailable on several occasions. There was no evidence in the progress notes that the provider was notified of these missed doses or the ongoing lack of medication supply, and the medication errors were not reported as required by facility policy. Another resident, with a history of chronic obstructive pulmonary disease (COPD), had physician orders for albuterol sulfate aerosol inhaler to be administered as two puffs four times daily. The MAR indicated that two doses of albuterol were missed due to the medication being unavailable. There was no documentation in the progress notes regarding the missed doses or provider notification. The DON confirmed that these missed doses were not reported as medication errors and that the medication was not administered as ordered. Interviews with the LPN and DON revealed that medications should be available for administration as ordered and that providers should be notified if medications are not available. Both staff members acknowledged that missed doses without a provider order to hold the medication constitute medication errors. Facility policies require that medication errors, including omissions, be reported and tracked for quality improvement, and that appropriate notifications be made to providers and residents or their representatives. Despite these policies, the facility did not identify, report, or document the medication errors for the affected residents.
Failure to Provide Adaptive Eating Utensils as Care Planned
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of rheumatoid arthritis, which affected her hand function, was not provided with adaptive eating utensils as specified in her care plan. Documentation, including the resident's care plan, nursing assistant care sheet, meal cards, and registered dietician notes, all indicated that built-up utensils were to be provided with every meal to assist with self-feeding. Despite these documented requirements, the resident reported not receiving the adaptive utensils for an extended period and was observed eating a meal without them, instead using her fingers to eat salad due to difficulty holding regular utensils. Interviews with facility staff, including an LPN and the registered nurse regional director, confirmed that the resident did not receive the required built-up silverware with her meal and that this was an ongoing issue despite previous education of dietary staff. The facility's policy required culinary staff to ensure the accuracy of tray assembly and the inclusion of all necessary utensils, but this was not followed in the resident's case.
Failure to Maintain Complete and Accessible Medical Records
Penalty
Summary
The facility failed to maintain complete, accurately documented, and readily accessible medical records for two residents. For both residents, their electronic health records (EHRs) did not contain any primary care provider visit notes from the time of their current admissions. The absence of these notes was confirmed during interviews with the director of nursing (DON), who acknowledged that the records were incomplete and did not meet expectations for accuracy and completeness. The missing provider notes were later retrieved from an external medical records system, revealing multiple visits that had not been uploaded into the facility's EHR. Interviews with facility staff, including the DON and the administrator, confirmed that provider notes are expected to be uploaded into the EHRs to ensure staff have access to complete resident information. The facility's own policy requires objective, accurate, timely, and clinically complete documentation in the medical record, including provider notes. However, the process for uploading these notes was not followed, resulting in incomplete records for the two residents reviewed.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of its residents, as evidenced by delayed response times to call lights and late medication administration. The Payroll-Based Journal (PBJ) Staffing Data Report highlighted excessively low weekend staffing as a significant concern. Multiple residents, including those with cognitive impairments and physical disabilities, experienced prolonged wait times for assistance with toileting and other activities of daily living (ADLs). For instance, one resident with hemiplegia and bowel incontinence was not assisted with toileting for over 12 hours, resulting in sitting in dried bowel movement. Interviews with residents and staff revealed consistent issues with staffing levels. Residents reported that call lights were not answered promptly, often exceeding the facility's expected response time of 15 minutes. Staff members, including nursing assistants and registered nurses, expressed that they were unable to respond to call lights quickly or administer medications on time due to understaffing. This was particularly problematic during nights and weekends when call-ins were frequent, and replacement staff were difficult to secure. The facility's staffing practices were based on census and budgeted hours rather than resident acuity or diagnosis, which contributed to the inadequate staffing levels. The administrator confirmed that the facility did not perform care plan audits, task completion audits, or track late medication administration. Additionally, the facility did not routinely audit call light response times, further exacerbating the issue of delayed resident care.
Deficiencies in Food Storage and Kitchen Cleanliness
Penalty
Summary
The facility failed to ensure proper food storage and cleanliness in its kitchen and kitchenettes, leading to several deficiencies. Observations revealed expired food items, such as Molly's Kitchen premade egg salad and prune juice, were not removed from service. Additionally, food items were not labeled or dated, and there was evidence of cross-contamination risks, such as ice packs stored with food items. The facility also lacked a cleaning log for the kitchen and kitchenettes, and there was no clear responsibility between nursing and dietary staff for monitoring expired items and maintaining cleanliness. The facility's main kitchen was found to have unlabeled and undated food items, such as a tray of salad items, and the dishwasher area was noted to have grime and dirt, indicating a lack of routine maintenance and cleanliness. The Culinary Director was unsure of the last maintenance date for the dishwasher and acknowledged the need for regular inspections. The leaking refrigerator on the 4th floor had not been repaired despite multiple work orders, causing further issues with food storage. Interviews with staff, including LPNs, RNs, and the Culinary Director, revealed a lack of clarity regarding responsibilities for food storage and cleanliness. The Director of Nursing and the administrator acknowledged the absence of a cleaning schedule and the need for a collaborative effort between kitchen and nursing staff to ensure food safety. Facility policies directed staff to maintain clean and sanitary conditions in storage areas and ensure equipment was in good working order, but these were not followed, leading to the observed deficiencies.
Infection Control and TBP Failures in LTC Facility
Penalty
Summary
The facility failed to adhere to transmission-based precautions (TBP) and proper infection control protocols during medication administration and glucose monitoring for residents. One resident, who required TBP due to a Methicillin-resistant Staphylococcus aureus (MRSA) infection, did not have appropriate contact precautions implemented during medication administration. The Licensed Practical Nurse (LPN) involved did not wear a gown when entering the resident's room to obtain supplies, despite signage indicating the need for gowning and gloving. Additionally, the LPN did not perform hand hygiene between glove changes and after handling the intravenous (IV) site, which is against the facility's infection control policy. Another resident, who required regular blood glucose monitoring, was observed to have their glucose meter used without proper disinfection between uses. The LPN used an Assure Platinum glucometer for multiple residents without cleaning it with the recommended disinfectant wipes, as they were unavailable. Instead, the LPN attempted to clean the glucometer with an alcohol wipe, which was not in accordance with the manufacturer's guidelines or the facility's policy. Furthermore, the facility failed to ensure that resident clothing was transported in a manner that maintained cleanliness and protected it from dust and soil. An observation revealed that a nursing assistant was transporting resident clothing on an open rack without covering, contrary to the facility's policy that requires linens and clothing to be covered during transport. This oversight in infection control practices had the potential to impact all residents on the third floor who received laundry services from the facility.
Failure to Assess Residents' Ability to Self-Administer Medications
Penalty
Summary
The facility failed to ensure that residents' ability to self-administer medications (SAM) was assessed before leaving medications with them. For Resident R10, who had multiple diagnoses including Parkinsonism, mild cognitive impairment, and bipolar disorder, there was no SAM assessment conducted. Despite the absence of a SAM assessment, medications were left in R10's room, and the resident was not supervised while taking them. Observations revealed that R10 was unsure about the purpose of the medications and that staff did not consistently confirm medication intake. Resident R278, who had recently been admitted with diagnoses including kidney failure and prostate cancer, also did not have a SAM assessment. Despite this, a nurse left a lidocaine patch at the bedside for the resident to apply later, assuming it was safe to do so without a formal assessment or order. The nurse's actions were based on the belief that the medication was harmless, despite the facility's policy requiring a SAM order for self-administration. Resident R59, with a history of cellulitis, MRSA infection, and other serious conditions, was observed self-administering IV medications without a SAM order. The resident was left to disconnect and flush his PICC line, a task that should have been supervised by staff. Interviews with staff confirmed that the facility's policy required a SAM order for such actions, which was not in place for R59. The facility's policy, dated February 2019, mandates that each resident must be evaluated for SAM, but this was not adhered to in these cases.
Inadequate Bowel Management for Resident with Chronic Diarrhea
Penalty
Summary
The facility failed to adequately address and assess a resident's symptoms of loose stools, which were not acted upon to determine necessary interventions for bowel management. The resident, identified as R11, had a history of noninfective gastroenteritis, colitis, and chronic diarrhea, and was frequently incontinent of urine and bowel. Despite having physician orders for loperamide to be administered as needed for diarrhea, the medication was inconsistently given, and the effectiveness of the treatment was not properly documented or communicated to the physician. R11's care plan indicated a need for regular toileting and application of barrier cream due to the risk of skin integrity issues from diarrhea. However, the documentation showed inconsistencies in the administration of loperamide and a lack of comprehensive monitoring and documentation of bowel movements. Interviews with staff revealed that the resident felt her needs were not adequately addressed, as she had to request the medication and felt that the dosage was insufficient. Additionally, the staff did not consistently document bowel movements or notify the physician about the ongoing diarrhea, which contributed to the resident's skin condition worsening. The facility's policy on bowel management lacked specific guidance for handling cases of diarrhea, which may have contributed to the inadequate response to R11's condition. Interviews with nursing staff and the director of nursing highlighted a lack of communication and documentation regarding the resident's bowel management, leading to a failure to provide appropriate care and interventions for the resident's chronic diarrhea and associated skin issues.
Failure to Assess Trauma History and Identify Triggers for Resident with PTSD
Penalty
Summary
The facility failed to assess the trauma history and identify potential triggers for a resident diagnosed with post-traumatic stress disorder (PTSD). The resident, who had intact cognition and diagnoses of anxiety, depression, mild cognitive impairment, and PTSD, was on antipsychotic medication. Despite the presence of a care plan to minimize risks, the resident's Behavioral Symptoms Care Plan lacked identification of potential PTSD triggers. Social services assessments conducted throughout the year also failed to assess PTSD and its triggers, and notes from the Associated Clinic of Psychiatry identified the diagnosis but did not assess triggers. Interviews with staff revealed a lack of awareness regarding the resident's trauma history and potential triggers. Nursing assistants and a registered nurse were unaware of specific triggers, and the social services designee acknowledged that a trauma assessment was not completed. The facility's Trauma Informed Care policy required a comprehensive assessment to identify trauma history and triggers, which was not adhered to in this case. The director of nursing confirmed that trauma-informed care assessments should have been completed to guide resident care.
Inaccessible Call Light System for Resident
Penalty
Summary
The facility failed to ensure that a working call system was accessible for a resident, identified as R9, who was reviewed during the survey. R9 had intact cognition and several medical conditions, including hemiplegia and hemiparesis following a cerebral infarction, repeated falls, chronic pain, and a history of traumatic brain injury. R9 required substantial assistance with activities of daily living and was dependent on a wheelchair. The care plan for R9, last reviewed on December 16, 2024, indicated that the call light should be within reach at all times due to the resident's risk for falls. However, during an observation on January 13, 2025, it was noted that R9's call light box was on the bedside table without a cord, making it inaccessible if R9 were to fall. Interviews with staff, including a nursing assistant and LPNs, confirmed that the call light box was not accessible to R9, and the preference for not having a cord was not documented in the care plan. The LPNs acknowledged the importance of having a call light accessible, especially in emergencies, and stated that resident preferences should be documented. The Director of Nursing verified that the call light boxes did not have cords, citing that the cord length would not reach the entire room. The facility's policy required the call system to be accessible to residents, including those lying on the floor, which was not adhered to in this case.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to maintain the dignity of two residents, R11 and R277, as observed during a survey. R11, who had intact cognition, expressed a preference to be called by a name different from her given name. Despite this preference being documented in her physician's progress notes, the facility's care plan and signage on her door continued to use her given name, causing her distress. Interviews with staff revealed a lack of awareness or misunderstanding of R11's preferred name, indicating a failure to respect her dignity and self-determination. For R277, the facility did not ensure proper grooming, specifically shaving, which is crucial for maintaining dignity. R277, who had multiple diagnoses including diabetes, required assistance with personal hygiene. The care plan and records lacked specific instructions for shaving, and observations showed that R277 had noticeable chin hairs, which were not addressed over several days. Staff interviews revealed confusion about who was responsible for shaving diabetic residents, and there was no documentation of any refusal by R277 to be shaved, indicating a lapse in care and respect for her dignity. The facility's policy on resident rights emphasizes the importance of respect and dignity, yet the actions and inactions observed in these cases demonstrate a failure to uphold these standards. The lack of clear communication and documentation regarding residents' preferences and care needs contributed to the deficiencies noted in the survey.
Failure to Provide Timely Toileting Assistance
Penalty
Summary
The facility failed to provide timely assistance with toileting for two residents, R50 and R127, as observed and documented by surveyors. R50, who has intact cognition and multiple diagnoses including hemiplegia, hemiparesis, and chronic pain, requires substantial assistance with toileting and is frequently incontinent. Despite these needs, R50 was observed sitting in a wheelchair in the dining room for several hours without being checked or changed by staff. Nursing assistant NA-L confirmed that R50 had not been checked or offered toileting assistance since the morning, citing a high workload as a barrier to providing timely care. R127, who also has intact cognition and requires assistance with toileting due to hemiplegia and abnormalities of gait, was not assisted with toileting from morning until late evening, as indicated in the Point of Care history report. Nursing assistant NA-T reported finding R127 with a dried bowel movement, suggesting prolonged exposure. The facility's policy requires residents to be checked and changed every 2-3 hours, but this was not adhered to in the cases of R50 and R127. Interviews with staff, including nursing assistants and the director of nursing, revealed that while there is an expectation to assist residents every 2-3 hours, staffing challenges and the need for Hoyer lifts for transfers make it difficult to meet these requirements consistently. The director of nursing acknowledged that the observed duration without toileting assistance was too long and emphasized the importance of regular toileting to prevent skin issues.
Failure to Implement Toileting Program for Resident
Penalty
Summary
The facility failed to implement necessary interventions to maintain continence for a resident, identified as R72, who was reviewed for bowel and bladder care. R72 had multiple medical conditions, including brachial plexus disorders, carpal tunnel syndrome, sepsis, prostate cancer, autism, rhabdomyolysis, and legal blindness. Despite these conditions, the facility did not attempt a toileting program for R72, who was always incontinent of bowel and bladder and required substantial assistance with personal hygiene. The care plan indicated that R72 should be toileted every 2 to 3 hours to prevent skin breakdown and maintain dignity, but this was not consistently followed. Observations and interviews revealed that staff did not consistently offer toileting assistance to R72, who was dependent on staff for toileting needs. Documentation showed that out of 330 opportunities, toileting activities were unanswered 212 times, and R72 was incontinent of bladder 81 times out of 98 opportunities. During an observation period, R72's call light was left unanswered for 15 minutes, and staff did not offer to take R72 to the bathroom, despite the care plan's instructions. Interviews with staff indicated a lack of adherence to the care plan, with some staff unaware of the specific toileting schedule for R72. The facility's policy on Activities of Daily Living emphasized the importance of providing care and services to maintain or improve residents' abilities to carry out ADLs, including elimination support. However, the facility did not follow this policy for R72, as staff failed to implement a toileting program or consistently offer toileting assistance. This deficiency in care was confirmed through interviews with nursing staff and the director of nursing, who acknowledged the importance of a toileting program for R72 to prevent falls and maintain independence.
Failure in Timely Pain Management Administration
Penalty
Summary
The facility failed to ensure timely administration of pain medications for a resident, identified as R25, who was reviewed for pain management. R25, with intact cognition, had a history of hypertension, diabetes, arthritis, and COPD, and was receiving both scheduled and as-needed pain medications for chronic pain syndrome and a non-displaced oblique fracture of the right fibula. The resident's care plan required scheduled pain medications to be administered per physician order and as-needed medications upon request. However, the medication administration record (MAR) showed multiple instances of late administration of scheduled medications, including Acetaminophen, Celebrex, Lyrica, and a Lidocaine patch, as well as delays in administering as-needed medications like Cyclobenzaprine and Oxycodone. Interviews with the resident and staff revealed systemic issues in the timely administration of pain medications. R25 reported difficulty in receiving scheduled pain medications on time, leading to increased pain and distress, and often requiring additional pain relief, which could take 2-3 hours to be administered. Nursing staff, including a nursing assistant and a trained medication aide, confirmed that there were delays in administering requested pain medications, sometimes requiring reminders to the responsible nurse. The director of nursing stated that the expectation was for call lights to be answered within 15 minutes and for pain medications to be administered within 20-25 minutes of a request. The facility's policy required the interdisciplinary team to develop and implement individualized measures to promote comfort, which was not adhered to in this case, resulting in the deficiency.
Failure to Implement Wound Care Orders Leads to Amputation
Penalty
Summary
The facility failed to implement physician-prescribed treatment orders for wound care and did not notify the physician of signs and symptoms of infection and lab results for one resident reviewed for wound care. This resulted in a delay of treatment for the resident, whose right great toe and left second toe trauma injuries developed osteomyelitis and required amputation. The resident had a history of type 2 diabetes with diabetic neuropathy, peripheral vascular disease, and end-stage renal disease with renal dialysis. The resident's care plan indicated that wounds should be monitored for changes and signs of infection, with updates to the medical provider and lab monitoring as ordered. However, the Treatment Administration Record (TAR) lacked identification of dressing change orders for the resident's left second toe for October, and treatment orders were not placed in the TAR until 21 days after the initial order. Lab results indicating inflammation were not communicated to the ordering physician, and changes in the wound condition were not reported to the physician or family. The facility's process for handling treatment orders involved the director of nursing writing down orders and giving them to the nurse manager, who would then enter them into the electronic medical record. However, this process was not followed, leading to the absence of treatment orders in the resident's records until mid-November. The medical director acknowledged the probability that the lack of following orders and treatments contributed to the infection and subsequent amputations.
Removal Plan
- All residents with wounds were reviewed for accuracy of orders.
- All wounds were monitored daily in morning meeting.
- The facility re-educated all licensed nurses on the expectation of wound care, and what to do if a wound has changed.
- The facility completed audits to monitor wound orders and progress notes to ensure providers were updated with signs of infection.
- Results will be brought to the Quality Assurance and Performance Improvement (QAPI) committee.
Failure to Notify Family and Physician of Resident's Worsening Condition
Penalty
Summary
The facility failed to notify the family and physician of a resident's change in condition when the resident's venous ulcer worsened, leading to hospitalization. The resident, who had a primary diagnosis of venous insufficiency and multiple chronic ulcers, was admitted to the facility with several skin conditions, including a non-pressure chronic ulcer on the right lower leg. Despite regular wound care treatments documented in the treatment administration record, the resident's condition deteriorated, with the exposure of the peroneal tendon on the right foot noted by a registered nurse. The resident's medical records indicated that the facility was monitoring and following the care plan for venous and arterial ulcers. However, there was a failure in communication and documentation regarding the worsening condition of the resident's wounds. The registered nurse who first observed the tendon exposure did not notify the family or the physician, and there was no report received from the transitional care unit when the resident was transferred to the long-term care unit. This lack of communication and failure to notify the appropriate parties of the change in condition contributed to the deficiency. Interviews with staff revealed that there was confusion and a lack of awareness regarding the resident's baseline wound condition. The clinical manager and other nursing staff did not take action to notify the family or physician about the exposed tendon, assuming that the necessary notifications had already been made. The facility's change in condition policy required notification of the attending provider and the resident's representative, but this protocol was not followed, leading to the deficiency identified in the report.
Inappropriate Harness Use for Resident Exceeding Weight Limit
Penalty
Summary
The facility failed to reduce the risk of harm for a resident who required the use of an EZ Stand for transfers. The resident, who had multiple medical conditions including morbid obesity, was observed being transferred using a large harness that was not appropriate for her weight. The EZ Stand manufacturer's guidelines specified that a large harness should be used for individuals weighing between 190 to 320 pounds, but the resident's weight exceeded this limit, as she weighed 394 pounds and later reported weighing 409 pounds. Observations revealed that facility staff, including an occupational therapy assistant and nursing assistants, consistently used the large harness on the resident despite her exceeding the weight limit. Interviews with staff members indicated a lack of awareness regarding the resident's actual weight and the appropriate harness size. The care plan for the resident did not specify the correct harness size, and there was confusion among staff about who was responsible for determining the appropriate harness size. The facility's policy on safe patient handling and movement was undated and did not provide clear guidance on assessing and selecting the correct harness size based on a resident's weight. Interviews with various staff members, including the clinical manager and health information manager, highlighted inconsistencies in the assessment process and a lack of proper documentation regarding the resident's harness size. This deficiency in ensuring the correct equipment was used for the resident's transfers posed a risk of harm.
Failure to Maintain EZ Stand as per Manufacturer Guidelines
Penalty
Summary
The facility failed to maintain an EZ Stand in accordance with manufacturer guidelines for a resident with multiple sclerosis, dizziness, morbid obesity, and muscle weakness. The EZ Stand, with serial number 907725, was observed outside the resident's room with a maintenance sticker indicating the next check was due in May 2024. However, there was no record of the EZ Stand being maintained, and the Safety Program Checklist for the device was marked as N/A without any completion marks. Interviews revealed that the facility's maintenance department had only recently begun maintaining EZ Stands every other month since June, with the EZ Stand company conducting yearly inspections. The Environmental Services Director (ESD) admitted to not finding any records of the EZ Stand's maintenance prior to his tenure and acknowledged that a maintenance member could not locate the device, leading to the N/A marking on the checklist. The facility's policy required mechanical lift devices to be maintained according to manufacturer recommendations, but this was not adhered to in this instance.
Failure to Provide Palatable and Appropriate Meals
Penalty
Summary
The facility failed to meet the nutritional needs of its residents by not following meal tickets, providing unpalatable meals, and not offering appropriate meal alternatives. Observations revealed that residents received meals that did not match their requests or dietary needs. For instance, one resident requested a butterscotch square and French bread but received chocolate cake and no bread. Other residents struggled to eat their meals due to the food being too dry or difficult to consume without teeth. The report highlights specific instances where residents were unable to eat their meals. One resident had difficulty cutting and eating a pork chop, while another resident did not eat her pork chop at all. The surveyor also noted that the food served was cold and unappetizing, with carrots being cold and the pork chop being dry. Additionally, there was a lack of available cranberry sauce, which was supposed to be part of the meal. Interviews with residents and staff revealed ongoing issues with meal service. Residents frequently complained about cold and overcooked food, and there was confusion among staff about meal ticket processing and alternative meal options. The facility's policy stated that menus should be followed as written, and any substitutions should provide equal nutritional value, but this was not adhered to, leading to dissatisfaction and unmet nutritional needs among residents.
Deficiencies in Cleaning Practices and Chemical Safety
Penalty
Summary
The facility failed to maintain a safe, clean, and home-like environment for its residents, particularly on the 3rd floor, where issues with cleaning practices and chemical storage were observed. Housekeeping staff left cleaning carts unattended with hazardous chemicals accessible to residents, which posed a significant safety risk. The chemicals included potent disinfectants that were not meant for use in areas where residents were present, especially during meal times. Observations revealed that housekeeping staff used these chemicals inappropriately, spraying them near residents and their food, which led to complaints of eye irritation and discomfort among the residents. The report highlights several instances where housekeeping staff did not follow proper cleaning protocols. For example, a housekeeper was observed spraying disinfectant cleaner over dining tables while residents were seated and eating, which is against the facility's policy. The housekeeper acknowledged that residents should have been removed from the area before using such potent chemicals. Additionally, the facility's cleaning logs indicated that many resident rooms were not cleaned daily as required, with some rooms being left uncleaned for several days. This neglect resulted in unsanitary conditions, such as dirty floors and unemptied trash, contributing to an unpleasant living environment for the residents. Interviews with staff and residents further confirmed the deficiencies in cleaning practices. Residents expressed dissatisfaction with the cleanliness of their living spaces, noting that their rooms were not cleaned regularly. Staff members also reported that housekeeping carts were often left unlocked and unattended, allowing residents access to potentially harmful cleaning chemicals. The facility's administrator and environmental services director acknowledged these issues, recognizing the safety concerns posed by the improper use and storage of cleaning products. Despite having policies in place, the facility failed to ensure compliance, leading to the observed deficiencies.
Failure to Maintain Dry Cast Leads to Resident's Infection
Penalty
Summary
The facility failed to comprehensively assess and follow hospital discharge orders for a resident who was admitted with a post-surgical cast on his right leg. The discharge instructions explicitly stated that the cast must remain completely dry, and if it became wet, the orthopedic surgeon should be notified immediately. However, the facility did not implement adequate measures to ensure the cast remained dry, leading to it becoming soiled with urine and feces. This oversight contributed to continuous infections in the resident, who had a history of chronic bacteremia and was already dealing with a complex medical condition. The resident's care plan did not address critical aspects of his care, such as toileting, transferring, and assistance required for activities of daily living. It also failed to include strategies to keep the cast dry, despite the resident being frequently incontinent of bowel and occasionally incontinent of urine. Interviews with staff revealed that the resident often used a urinal, which would spill, and no alternative toileting methods were attempted. The lack of a comprehensive care plan and failure to assess the resident's needs led to the cast becoming saturated with bodily fluids, exacerbating the resident's condition. The situation escalated when the resident was sent to the emergency room with septic shock, and the cast was found to be soaked and emitting a strong odor. The orthopedic surgeon noted that while it could not be definitively stated that the soiled cast caused the infection requiring amputation, it was certainly a contributing factor. Interviews with various staff members, including nursing assistants, occupational therapists, and the director of nursing, highlighted a lack of communication and failure to report the soiling of the cast, which ultimately led to the resident's severe health deterioration.
Inadequate Pressure Ulcer Care Leads to Resident Harm
Penalty
Summary
The facility failed to provide adequate care for a resident with pre-existing pressure ulcers, leading to the worsening of these ulcers and the development of new ones. The resident, who was admitted with a complex medical history including a recent knee surgery and multiple infections, was not given care consistent with professional standards to prevent pressure ulcers. Despite being at high risk for pressure ulcers, as indicated by a Braden score of eight, the resident's care plan did not include specific interventions for pressure ulcer care, such as turning and repositioning, application of dressings, or nutritional interventions. The resident's condition was further compromised by inadequate skin assessments and lack of proper documentation. The care plan failed to address the resident's existing pressure ulcers and did not include strategies for managing the resident's incontinence, which contributed to skin breakdown. Interviews with staff revealed a lack of awareness and understanding of the resident's skin condition, with some staff members unaware of the documented wounds from the hospital discharge. The resident's family member expressed concerns about the resident's skin care, noting that the resident was often found incontinent and wearing an incontinence pad, contrary to the recommended care. The facility's failure to implement a comprehensive care plan and conduct thorough skin assessments resulted in the resident's skin condition deteriorating significantly. The resident was eventually discharged with multiple stage II pressure ulcers and other skin issues, indicating neglect in the management of the resident's skin integrity. Interviews with facility staff, including the nurse practitioner and director of nursing, highlighted a lack of communication and oversight in addressing the resident's skin care needs, contributing to the deficiency.
Failure to Accurately Assess Resident's Skin Conditions
Penalty
Summary
The facility failed to accurately assess a resident upon admission, leading to a deficiency in care. The resident was admitted with multiple pressure ulcers, a deep tissue injury, and a shearing wound, none of which were properly assessed or addressed by the facility. The hospital discharge orders clearly indicated the presence of these conditions, yet the facility's initial skin assessment and subsequent care plan did not reflect these issues. The resident's Braden Scale assessment indicated a very high risk for pressure ulcers, but the necessary interventions were not implemented. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's condition. Nursing assistants reported the resident's skin was in poor condition, with redness and bleeding due to incontinence, yet these concerns were not adequately addressed by the nursing staff. The nurse practitioner and other nursing staff were unaware of the resident's wounds, and the resident's care plan failed to include necessary interventions for pressure ulcer care. The facility's policy on skin integrity assessment was not followed, as the resident's skin was not properly assessed upon admission or during their stay. The deficiency was further compounded by the lack of coordination and communication among the facility's staff. The resident's nurse practitioner and unit manager were not informed of the documented wounds from the hospital discharge, and the resident was not seen by wound care due to scheduling issues. The facility's director of nursing and administrator expressed expectations for accurate assessments and care plans, but these were not met in the resident's case. The failure to accurately assess and address the resident's skin conditions upon admission and throughout their stay led to a significant deficiency in care.
Failure to Serve Food at Palatable Temperatures
Penalty
Summary
The facility failed to serve food at a palatable temperature to four residents who were reviewed for dietary and nutrition concerns. Observations and interviews revealed that residents consistently received meals that were cold, which was a prevalent complaint among them. The Director of Culinary Services (DCS) acknowledged the issue, noting that food was transported in a hot box from a nearby building and sat on a cart for distribution, which contributed to the temperature drop. Despite the kitchen logs indicating appropriate temperatures when the food left the kitchen, the actual serving temperatures were significantly lower, with oatmeal at 100 degrees F, scrambled eggs at 82 degrees F, and potatoes at 72 degrees F. The DCS admitted that these temperatures were not palatable and had been working on a plan to address the issue for nine months. Interviews with residents confirmed their dissatisfaction with the cold meals. One resident expected breakfast at 8 a.m. but received it an hour late, and it was very cold. Another resident stated that lunch was cold as usual, and they often had to request reheating. The Director of Nursing (DON) confirmed that food should be served at the correct and palatable temperature and acknowledged the risk of serving food that was not at a safe temperature. The facility's policy from 2012 required hot food to be served at 135 degrees F, which was not adhered to in these instances.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to provide a clean, safe, and homelike environment for residents on the third floor, as evidenced by multiple observations and interviews. Resident 1, who was cognitively intact, expressed concerns about the cleanliness of the facility and considered moving to another facility due to these issues. Family members and social workers confirmed Resident 1's complaints about the dirty conditions, including a dirty tray table and general maintenance issues. Observations revealed a strong smell of urine near the entrance to the staircase, and the hallway was cluttered with various equipment, making it unsafe for residents, especially those in wheelchairs. Resident 4, also cognitively intact, reported hiring a friend to clean her bathroom due to the facility's inadequate housekeeping. She pointed out food particles, thick dust, and debris behind her furniture. The Director of Nursing (DON) acknowledged the unclean conditions in Resident 4's room and the foul odor from the nearby trash room. The DON also noted that the EZ Stand equipment was dirty and sticky, and there was no cleaning schedule for such equipment. Resident 11 reported that her windowsill had never been cleaned, and her floor was visibly dirty with debris. She could not recall when her room was last cleaned, indicating a prolonged period of neglect. Interviews with staff, including a nursing assistant and a housekeeper, confirmed the lack of housekeeping staff on the third floor, contributing to the unclean and unsafe environment. The administrator acknowledged the shortage of housekeeping staff and the absence of a housekeeper for the third floor. The facility's Environmental Services - Cleaning policy, which mandates regular cleaning and maintenance, was not being followed, as evidenced by the dirty conditions and cluttered hallways. The report highlights the facility's failure to maintain a clean and safe environment, impacting the residents' quality of life.
Failure to Provide Scheduled Baths Due to Staffing Shortages
Penalty
Summary
The facility failed to ensure that baths were given as ordered for two residents who required assistance with activities of daily living. Resident R4, who was cognitively intact and fully dependent on staff for bathing, was supposed to receive two showers weekly due to a history of urinary tract infections. However, documentation indicated that R4 missed several scheduled baths over a period of nearly two months, with no reasons recorded for these omissions. R4 expressed dissatisfaction with the care received, noting that she did not get the prescribed two showers weekly. Similarly, Resident R10, who was cognitively intact and required supervision for bathing, missed several scheduled baths over a similar timeframe. R10 reported feeling neglected and disrespected due to the lack of assistance with bathing and bed linen changes. Interviews with nursing assistants revealed that staffing shortages often prevented them from providing the necessary care, with one assistant noting that there was sometimes only one nursing assistant available to care for 30 residents. The Director of Nursing was unaware of the missed baths and believed that staff had sufficient time to perform them, despite the facility's policy requiring adequate staffing to meet residents' care needs.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that medications were appropriately transcribed into the electronic health record (EHR), ordered timely, and administered in accordance with physician orders for a resident. The resident was admitted with multiple diagnoses, including enterocolitis due to clostridium difficile, cirrhosis of the liver, acute gastric ulcer with hemorrhage, ascites, and reflux disease. The medication administration record (MAR) did not match the physician's orders, missing doses of Vancomycin, pantoprazole, and cholestyramine. Additionally, doses of Vancomycin and linezolid were not administered as scheduled, and there was no evidence that the resident's physician was notified of these missed medications. Interviews revealed that the pharmacy received the medication request prior to admission but could not fill it until admission confirmation was received. The medications were sent on an overnight delivery, but some were available in the facility's automated dispensing unit (ADU) and were not utilized. The director of nursing (DON) acknowledged the discrepancies in the MAR and the failure to administer medications as ordered. The pharmacy consultant stated that the facility should have reported the missed doses to the provider, although they did not have a negative impact on the resident. The facility's policy indicated that medications should be administered as ordered and any irregularities should be appropriately notified.
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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