Cokato Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Cokato, Minnesota.
- Location
- 182 Sunset Avenue, Cokato, Minnesota 55321
- CMS Provider Number
- 245412
- Inspections on file
- 15
- Latest survey
- April 25, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Cokato Manor during CMS and state inspections, most recent first.
The facility did not ensure that residents or their representatives were included in care conferences or consulted before changes were made to care plans. Multiple residents with severe cognitive impairment and complex medical conditions had care plan summaries completed by staff without documented input from the residents or their families. Family members reported not being informed or included in care planning discussions, and staff confirmed that care plan summaries were sent to families only after revisions were made, without prior engagement.
A resident's advance directive indicating Do Not Resuscitate (DNR) was not consistently documented across the medical record, with the signed DNR form conflicting with physician orders in the EMR that listed the resident as FULL CODE. Staff relied on multiple sources to verify code status, and the DON confirmed the inconsistency, which did not align with the facility's policy requiring accurate reflection of resident wishes.
A resident with severe cognitive impairment and psychiatric diagnoses experienced an increase in involuntary movements, as indicated by a higher AIMS score after receiving escalating doses of quetiapine. Despite this change, there was no documentation that the physician was notified, as confirmed by interviews with the consulting pharmacist and DON. The facility could not provide a relevant policy, and the clinical record lacked evidence of required physician notification.
A resident admitted with schizophrenia, arthritis, and diabetes did not have a required Level II PASARR completed, despite a Level I PASARR indicating it was necessary. The social services director used documentation from a previous facility and was unaware of the need for a Level II PASARR until notified by surveyors. No related facility policy was available.
A resident with severe cognitive impairment and a history of multiple falls did not have a comprehensive or regularly updated care plan to address fall prevention. Despite numerous falls, the care plan contained limited interventions, and staff were unaware of specific fall prevention measures. Observations showed the resident was left unsupervised with safety risks present, and facility policy requiring timely care plan updates was not followed.
A resident with severe cognitive impairment and behavioral symptoms received PRN lorazepam on several occasions without evidence that non-pharmacological interventions were attempted or documented beforehand, despite care plan requirements and staff expectations. Facility records and behavior monitoring logs lacked documentation of both the target behaviors and the interventions used prior to medication administration.
A resident with severe cognitive impairment and multiple psychiatric diagnoses was prescribed psychotropic medications, but target behavior monitoring was inconsistently documented and absent for several months. The consulting pharmacist conducted monthly medication regimen reviews but failed to identify or address the lack of behavior monitoring, despite facility policy and expectations for such oversight.
The facility did not hold QAPI meetings at least quarterly as required, with documentation and staff interview confirming that meetings were not conducted at the mandated frequency.
A trained medication aide was observed administering medications to three residents without performing hand hygiene before, after, or between each medication pass. The aide later acknowledged the lapse, and the DON confirmed that facility policy requires hand hygiene at these times to prevent infection.
A resident with a history of Parkinson's disease, dementia, and an indwelling urinary catheter was prescribed antibiotics for a UTI, but the facility did not ensure the prescription met established criteria or assess the continued need for antibiotics. Nursing staff did not document review of urine culture results or notify the provider when sensitivities were not received, and a 72-hour antibiotic time-out was not completed as required by the facility's stewardship policy.
Failure to Involve Residents or Representatives in Care Conferences
Penalty
Summary
The facility failed to ensure that care conferences included the input of residents or their representatives for five residents who were reviewed for care conferences. Each of these residents was identified as being severely cognitively impaired, with diagnoses including dementia, Alzheimer's disease, hypertension, arthritis, seizure disorder, Parkinson's disease, heart failure, and hemiparesis or hemiplegia. Despite their cognitive impairments, there was no documentation in the medical records that the residents, their representatives, or family members had been contacted prior to care conferences or the implementation of changes to their care plans. Care plan summaries for these residents showed input from nursing, social services, and dietary staff, but consistently lacked any indication of involvement from the resident, their representative, or family members. Interviews with facility staff revealed that the social services director was responsible for care conferences and typically sent out care plan summaries to staff for input, then mailed the completed summary to families for review. If families did not respond or request a meeting, no in-person care conference was conducted, and one-to-one meetings with residents occurred only after care plan revisions. Family members confirmed they had not been made aware of or included in care conferences, nor asked to provide input regarding treatment and services. The facility's own policy required that care plans be reviewed at a care planning meeting with the resident and/or representative, and a summary shared with them. However, the process in practice did not ensure resident or representative participation prior to care plan changes, as evidenced by the lack of documentation and family reports of not being included. The administrator acknowledged the need for a process change to involve families more in guiding care, confirming that the current approach did not meet expectations for resident and family involvement.
Inconsistent Documentation of Advance Directives for Emergency Treatment
Penalty
Summary
The facility failed to ensure that a resident's advance directives for emergency treatment were consistently and accurately reflected across all areas of the medical record. Specifically, for one resident who was cognitively intact and had diagnoses including hyperlipidemia and schizophrenia, there was a discrepancy between the documented code status in different parts of the medical record. The resident's signed code status form, which was also signed by a family member and physician, indicated a Do Not Resuscitate (DNR) order. However, the physician orders in the electronic medical record (EMR) listed the resident as FULL CODE. Interviews with facility staff, including a trained medical assistant, a registered nurse, and the director of nursing (DON), revealed that staff relied on various sources such as the hard chart, face sheet, and medication administration record (MAR) to determine code status. The DON confirmed that the resident's wishes were not consistently documented, as the physician orders did not match the signed DNR form. The facility's policy required that emergency care, including CPR, be provided according to physician orders and resident choice as indicated in advance directives, but this was not accurately implemented in this case.
Failure to Notify Physician of Change in Condition Following Increased AIMS Score
Penalty
Summary
The facility failed to notify the attending physician of a significant change in condition for a resident with severe cognitive impairment and multiple psychiatric diagnoses, including Alzheimer's disease, delusional disorders, and anxiety disorder. The resident was prescribed increasing doses of quetiapine, an antipsychotic medication, over several months. An initial Abnormal Involuntary Movement Scale (AIMS) assessment showed no involuntary movements, but a follow-up assessment revealed a notable increase in symptoms, with the AIMS score rising from 0 to 4. Despite this documented change, there was no evidence in the clinical record that the physician had been notified of the new onset of tardive dyskinesia symptoms. Interviews with the consulting pharmacist and the director of nursing confirmed that changes in AIMS scores should be communicated to the provider, and that nurses are expected to document such notifications in the clinical record. Both the pharmacist and DON emphasized the importance of notifying the physician to ensure resident safety and appropriate medication management. The facility was unable to provide a policy regarding this process, and the clinical record lacked documentation of physician notification following the resident's increased AIMS score.
Failure to Complete Required Level II PASARR Screening
Penalty
Summary
The facility failed to ensure that a Level II Pre-Admission Screening and Resident Review (PASARR) was completed for one resident who was admitted with diagnoses including schizophrenia, arthritis, and diabetes. Documentation showed that a Level I PASARR was completed prior to admission, which indicated the need for a Level II PASARR, but no evidence of a completed Level II PASARR was found. The social services director confirmed that they relied on the PASARR from the resident's previous facility and were unaware that a Level II PASARR was required until informed by the survey team. The administrator stated that PASARR screenings were expected to be completed by social services or delegated staff upon admission. No facility policy related to PASARR was provided when requested.
Failure to Update and Implement Comprehensive Fall Prevention Care Plan
Penalty
Summary
The facility failed to develop and maintain a comprehensive care plan with appropriate interventions to prevent falls or reduce the likelihood of injury for a resident with a history of multiple falls. The resident, who had severe cognitive impairment, osteoarthritis, weakness, and mixed incontinence, was identified as being at high risk for falls. Despite having 23 documented falls over a six-month period, the care plan was not updated after each incident and contained limited interventions. Observations revealed that the resident's call light was frequently out of reach, wheelchair brakes were unlocked, and the resident was left unsupervised while attempting to reach for objects, all of which increased the risk of falls. Interviews with CNAs indicated a lack of awareness regarding specific fall interventions for the resident, and staff were unable to identify or locate the interventions in the care plan. The DON confirmed that the care plan had not been updated as required and acknowledged the importance of keeping care plans current to ensure resident safety. Facility policy required care plans to be updated quarterly and as needed, reflecting close evaluation of problems, goals, and approaches, but this was not followed in the resident's case.
Failure to Attempt and Document Non-Pharmacological Interventions Before PRN Psychotropic Use
Penalty
Summary
The facility failed to ensure that non-pharmacological interventions were attempted and documented prior to the administration of PRN psychotropic medications for a resident with severe cognitive impairment and behavioral symptoms. The resident, who had diagnoses including dementia, delusional disorders, and depression, had a care plan that included non-pharmacological approaches such as reassurance, encouraging activities of choice, 1:1 visits, and redirection. Despite these care plan interventions, documentation showed that lorazepam was administered on multiple occasions for behavior issues or other reasons, but there was no evidence in the clinical record or behavior monitoring logs that non-pharmacological interventions were attempted before medication was given. The facility's records, including the Medication Administration Record and Target Behavior Monitoring logs, lacked documentation of target behavior episodes and management interventions for the relevant dates when the PRN psychotropic was administered. Interviews with the consulting pharmacist and the DON confirmed that non-pharmacological interventions should have been attempted and documented prior to administering PRN psychotropics, except in severe situations. The facility was unable to provide a policy regarding this practice when requested.
Failure to Identify Lack of Target Behavior Monitoring in Psychotropic Medication Review
Penalty
Summary
The facility failed to ensure that the consulting pharmacist identified the lack of target behavior monitoring for a resident receiving psychotropic medications during the monthly medication regimen review (MRR). The resident, who had severe cognitive impairment and diagnoses including Alzheimer's disease, delusional disorders, and anxiety disorder, was prescribed paroxetine for panic disorder and quetiapine for delusional disorders. Documentation showed that target behaviors such as anxiety, agitation, and depression were only monitored for 8 out of 45 shifts in one month, and there was no evidence of target behavior monitoring in the clinical record for several months. Despite multiple monthly reviews by the pharmacist, the absence of consistent target behavior monitoring was not identified or addressed in the MRRs. The pharmacist's notes included recommendations for gradual dose reduction and monitoring for side effects, but did not note the lack of behavior monitoring. Both the pharmacist and the DON confirmed that target behavior monitoring is expected when psychotropic medications are prescribed, and the facility's policy requires the pharmacist to address irregularities during the MRR. However, this expectation was not met for the resident in question.
Failure to Hold QAPI Meetings Quarterly
Penalty
Summary
The facility failed to ensure that Quality Assurance Performance Improvement (QAPI) meetings were held on a quarterly basis as required. Document review showed that QAPI meetings occurred on 4/16/24, 8/27/24, and 1/7/25, which did not meet the minimum frequency of every three months or quarterly. During an interview, the director of nursing, who leads the QAPI meetings, confirmed that the facility had not been meeting the required schedule and acknowledged that an additional meeting should have been held to maintain compliance. The facility's own QAPI plan, effective 1/2025, specifies that the committee is responsible for meeting at least quarterly.
Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
A trained medication aide (TMA) was observed administering medications to multiple residents without performing appropriate hand hygiene before, after, or between resident contacts. The TMA prepared and administered medications to three different residents consecutively, failing to wash or sanitize hands at any point during the process, including after completing all medication administrations. The TMA later acknowledged the failure to perform hand hygiene and recognized its importance in preventing the spread of infection. During the observation, another staff member, an LPN, was present and the TMA requested assistance. The director of nursing (DON) confirmed that facility policy requires staff to perform hand hygiene before and after all medication administrations and between residents. The facility's hand washing/hygiene policy, last revised in February 2024, specifies that hand washing must be completed between resident care and whenever direct physical contact with a resident occurs.
Failure to Follow Antibiotic Stewardship Protocols for UTI Treatment
Penalty
Summary
The facility failed to ensure that prescribed antibiotics met established criteria for use and did not adequately assess the continued need for antibiotics for a resident with a urinary tract infection (UTI). The resident, who was cognitively intact and had an indwelling urinary catheter along with diagnoses of Parkinson's disease, dementia, and obstructive uropathy, was prescribed cefpodoxime after completing a previous course of Macrobid without improvement. The provider ordered a urinalysis and urine culture, with instructions to update the antibiotic based on culture and sensitivity results. However, the urine culture indicated likely contamination, and there was no evidence that the culture and sensitivity results were reviewed by nursing staff or that the provider was notified when sensitivities were not received. The clinical record lacked documentation that antibiotic stewardship guidelines were followed, including the completion of a 72-hour antibiotic time-out and review of the appropriateness of continued antibiotic therapy. The facility's infection preventionist confirmed that these steps were not completed and acknowledged that the antibiotic stewardship policy, which requires regular review of antimicrobial therapy, was not adhered to in this case.
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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