Crest View Lutheran Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Columbia Heights, Minnesota.
- Location
- 4444 Reservoir Boulevard Northeast, Columbia Heights, Minnesota 55421
- CMS Provider Number
- 245018
- Inspections on file
- 29
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 29
Citation history
Health deficiencies cited at Crest View Lutheran Home during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of loud vocalizations was assaulted in a TV room by another ambulatory resident with dementia and moderate cognitive impairment, resulting in facial injuries including a nasal fracture and hematoma. Staff had repeatedly observed that the aggressive resident became visibly agitated, spoke in Spanish, and directed anger toward others when exposed to loud environments and the victim’s frequent calling out, and they informally redirected or separated him at times. However, these behaviors and triggers were not documented, a prior psych recommendation to track behavioral dysregulation and develop a behavior support plan was not implemented, and the care plan lacked specific behavioral interventions or supervision strategies. Nursing and NA staff reported awareness of agitation and a prior altercation but were unsure where to document behaviors and were unaware of any behavior support plan, resulting in inadequate protection of a resident’s right to be free from physical abuse.
A resident with significant mobility deficits and on hospice care was left on a bare air mattress without a draw sheet during a bed bath. Staff failed to follow the care plan requiring two-person assistance and proper use of a draw sheet, and did not ensure bed brakes were engaged. During repositioning, excessive force was used, causing the resident to slide off the bed and sustain a femur fracture requiring surgery.
A nurse failed to perform proper hand hygiene and did not disinfect a glucometer after use during blood glucose monitoring and insulin administration for a resident. Additionally, soiled laundry was not consistently bagged before transport, and clean linens were stored improperly, including on the floor and near contaminated areas. These actions did not follow facility infection control policies.
Handrails in several hallway locations, including between rooms and near the dining area, were found to be loose and not securely attached. Staff interviews revealed that maintenance relied on staff to report issues using forms, but no work orders for handrail repairs were found in the reviewed period. No facility policy or procedure on handrails was available when requested.
Drugs and biologicals were not labeled according to professional standards, and medications, including controlled drugs, were not stored in locked or separately locked compartments as required.
Surveyors found that food and drink served to residents was not consistently palatable, attractive, or at a safe and appetizing temperature, failing to meet required standards for meal service.
Nutritional supplements were found stored directly on the floor in two medication rooms, with staff unaware of proper storage requirements despite available shelf and cupboard space. Additionally, the ice machine door in the kitchen was damaged, exposing insulation and making it impossible to clean or disinfect properly, with no maintenance records or policy provided for its upkeep.
Surveyors observed that the kitchen floor in the dishwashing area had missing tile chunks, missing grout, and a green substance on the subfloor. The dietary director acknowledged these issues and identified them as a cleaning concern, but no maintenance work orders or relevant cleaning and maintenance policies were found.
Surveyors found that several rooms had broken window blinds, compromising resident privacy, and multiple shower rooms were observed with mold, cracked or missing tiles, and unclean surfaces. Staff interviews revealed inconsistent cleaning practices and lack of clarity about responsibilities. Additionally, a resident with significant medical needs reported numerous missing personal items over several months, with staff failing to adequately track or resolve the losses as required by facility policy.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact circumstances or individuals involved.
A resident was subjected to physical restraints without a documented medical need, in violation of requirements that ensure restraints are only used for medical treatment.
A resident with moderate cognitive impairment and multiple complex medical conditions was hospitalized twice, but the facility did not include these transfers in its required monthly notifications to the Ombudsman. The social service assistant confirmed the omissions, and no relevant policy was provided during the survey.
A resident with a diagnosis of PTSD and a history of complex trauma did not have PTSD triggers or interventions included in their care plan, despite clinical recommendations and facility policy. Multiple staff members, including nursing and social services, were unaware of the resident's PTSD history or specific needs, and trauma assessments were not completed or incorporated into the care plan.
A resident with multiple complex medical conditions and moderate cognitive impairment was receiving oxygen therapy, but the care plan did not specify the reason for oxygen use, the flow rate, or the route of administration. Facility staff confirmed that the care plan lacked necessary resident-specific details, contrary to facility policy requiring individualized and comprehensive care plans.
A resident lost the ability to perform ADLs without a documented medical reason, as the facility did not ensure maintenance of the resident's highest practicable level of functioning or provide evidence that the decline was clinically unavoidable.
Three residents with varying cognitive and physical impairments did not have their individualized activity needs and preferences consistently met, as evidenced by missing or inadequate activity supplies, limited participation in preferred activities, insufficient documentation of one-to-one interactions, and a lack of updates to care plans despite ongoing assessments and staff awareness of their preferences.
A resident dependent on staff for mobility was repeatedly observed in a wheelchair without footrests, leaving her heels unsupported and contrary to her care plan, which lacked specific wheelchair positioning instructions. Another resident with a care plan intervention for eyeglass padding to protect skin integrity was observed multiple times without the required padding, resulting in skin discoloration and indentations. Staff interviews confirmed the lack of intervention implementation and monitoring, and facility policies did not provide adequate guidance for these care needs.
A resident with severe cognitive impairment and significant hearing loss was not consistently provided with hearing assistive devices as required by their care plan. Staff observations and interviews revealed the resident frequently did not have access to or use a pocket talker or hearing aids, resulting in ongoing difficulty communicating with staff and peers. Staff were unclear about the location of the resident's hearing aids and did not consistently ensure the use of available assistive devices.
A resident with multiple diagnoses, including COPD and nicotine dependence, was not provided with a thorough and current smoking assessment as required by facility policy. The resident's care plan indicated the need for a smoking apron while smoking, but the most recent assessment did not address this, and staff were inconsistent in ensuring its use. Staff interviews revealed confusion about assessment frequency and apron use, and the facility's policy for regular smoking assessments and safety equipment was not followed.
A resident did not receive safe and appropriate respiratory care when needed, as required by their condition.
A resident with a history of PTSD and past trauma did not receive a comprehensive trauma assessment or individualized trauma-informed interventions. Staff were unaware of the resident's diagnosis and triggers, and the care plan lacked necessary information, despite facility policy requiring such assessments and care planning.
The facility did not ensure that results of complaint investigations, including surveyor reports and facility responses, were available for review by residents, families, or staff. Only recertification survey results were posted, and the administrator was unaware of the requirement to include all investigation results.
The facility's policy for reporting abuse, neglect, and misappropriation of property contained conflicting timelines and was not fully consistent with federal requirements. The administrator confirmed that staff were expected to report sexual abuse within two hours and other types of abuse within 24 hours, which did not align with the federal mandate that all abuse or serious bodily injury allegations be reported within two hours. This inconsistency had the potential to affect all residents.
A resident in a LTC facility, with diagnoses including anxiety and depression, was not provided with adequate clothing and shoes, impacting her ability to socialize and use her prosthetic limb. Despite multiple assessments and staff awareness, the facility failed to address her needs, resulting in her isolation and feelings of loneliness and depression.
Two residents at risk for pressure ulcers did not receive the necessary interventions as outlined in their care plans. One resident's wheelchair lacked a required cushion, and another resident did not have lamb's wool or dressings applied to her toes as directed. Staff confirmed the care plans were not followed, and the DON acknowledged the oversight, which placed the residents at risk.
A resident with moderate cognitive impairment was not provided with individualized activities that matched her preferences, such as crocheting and card games. Despite her expressed interests, the facility's care plans and life enrichment assessments did not reflect her specific needs, leading to minimal engagement in activities. Interviews revealed that staff did not offer meaningful one-to-one activities, and the resident expressed dissatisfaction with the lack of personalized options.
A resident with a cervical fracture was not provided the required assistance from two licensed staff members when applying a cervical collar, as per physician orders. Instead, a family member was involved, contrary to facility policy. The resident expressed discomfort due to improper application. Interviews with staff confirmed the failure to adhere to the protocol, despite training and policy requirements.
A facility failed to follow a care plan for a resident with a history of trauma, requiring two female staff for care and transfers. Despite the care plan's directives, a nursing assistant was observed providing care alone. The resident had moderate cognitive impairment and was dependent on staff for transfers, with a care plan in place due to past trauma and recent allegations of sexual assault.
The facility failed to ensure food was labeled, dated, and stored properly, and did not maintain proper sanitization levels for dishware. Additionally, vents over clean dishes were not adequately cleaned, posing a risk of contamination.
The facility failed to implement transmission-based precautions for a resident with emesis and loose stools during an outbreak, did not place a resident with MRSA on TBP, and neglected enhanced barrier precautions for two residents with indwelling catheters and wounds. Additionally, proper handling of linens was not ensured, compromising infection control efforts.
The facility failed to provide a resident with a written discharge notice and the basis for discharge, and did not notify the Ombudsman Office for Long-Term Care (OOLTC) of the transfer or discharge. The resident, who was on parole due to a felony history, was discharged without proper documentation or notification. The social worker was unaware of the requirement to notify the OOLTC, and the facility's policies were not followed.
A facility failed to complete a comprehensive MDS assessment for a resident with anxiety, depression, and schizoaffective disorder. The responsible social worker was not on campus during the assessment period, and no other staff were authorized to complete the MDS, resulting in unassessed cognitive and mood sections. Staff interviews confirmed the importance of these assessments for appropriate care and mental health referrals.
The facility failed to ensure that physical devices were assessed and reassessed for continued appropriateness for a resident who had perimeter mattresses placed on their bed as a fall intervention. Despite being identified as a high fall risk, the facility did not assess or reassess the perimeter mattress. Observations and interviews revealed that the resident had not attempted to get out of bed independently and required total assistance with bed mobility. The perimeter mattress was eventually removed, and the bed was positioned in the lowest position to the floor.
The facility failed to ensure a resident's preferred activities, such as listening to country music and playing with dolls, were consistently provided. Despite these preferences being documented in the care plan, staff did not adhere to it, leaving the resident often without music or dolls. Observations and interviews revealed a lack of awareness and implementation of the care plan, leading to the deficiency.
A resident with COPD, CHF, and CKD was observed adjusting their own oxygen settings without a physician's order, despite a SAM assessment indicating they required assistance with medications. Staff confirmed that residents should not adjust their own oxygen settings and need a SAM assessment and physician's order for self-administration of medications.
A facility failed to ensure a call light was accessible for a resident who was moderately cognitively impaired and dependent on staff for turning in bed. The call light cord was found on the floor, out of reach, and despite the resident calling for help multiple times, no staff responded. The DON briefly looked into the room but did not notice the call light or respond to the resident's calls.
A resident was discharged from the facility without a documented medical reason after the facility was informed of the resident's felony history. The discharge was initiated by the administrator, and the physician provided discharge orders without documenting the reason. The resident's family had to arrange alternative accommodation, and the facility's policy for discharges was not properly followed.
Failure to Assess, Document, and Care Plan Behavioral Triggers Leading to Resident‑to‑Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident. One resident (R1) had diagnoses including primary hypertension, traumatic subdural hemorrhage with loss of consciousness, and non‑Alzheimer’s dementia, with a comprehensive MDS indicating severe cognitive impairment and no documented behaviors. R1’s care plan identified her as a categorically vulnerable adult who required substantial/maximal assistance with transfers and toileting, and directed staff to monitor for emotional distress or mood/behavior changes and to provide a safe, consistent environment with supervision as needed. On the evening of 3/15/26, while R1 was seated in the TV room, another resident (R2) struck her in the face, causing her to fall from her chair. Staff were present and witnessed the event, which was described as unprovoked based on staff accounts. R1 sustained swelling to the eyebrow, a lip laceration, and was transferred to the ED, where imaging showed a large left forehead hematoma with associated swelling, a lip laceration, and a closed nasal bone fracture. Interviews with family confirmed that R1 had been sitting in the TV area with other residents when R2, seated behind her, suddenly punched her, resulting in a broken nose and forehead hematoma. Multiple nursing assistants reported that R1 frequently spoke loudly to the television or called out to staff, and that R2 became agitated or angry in response to these loud vocalizations. Staff described that when R2 was agitated, he would show facial expression changes and speak in Spanish, and that they would sometimes separate him from other residents or redirect him to his room during these episodes. However, these observations and known triggers were not documented in the medical record. R2 had diagnoses including disorientation, dementia, and behavioral symptoms, with an MDS indicating moderate cognitive impairment and no behaviors identified, and was independent with transfers and ambulation. R2’s ADL care plan directed staff to monitor for emotional distress or mood and behavior changes, including agitation/aggression, but did not identify specific agitative or aggressive behaviors or triggers. A psychiatric assessment recommended that the care team track and monitor R2’s behavioral dysregulation to identify triggers and beneficial interventions, and advised the IDT to review findings and develop a behavior support plan if agitation persisted, with emphasis on maintaining appropriate supervision, reinforcing boundaries, and objectively monitoring behaviors. Record review from 3/11/26 through 3/15/26 showed no evidence that these recommendations were implemented: there was no tracking or monitoring of behavioral dysregulation, no identification of triggers, no documentation of interventions attempted, and no behavior support plan developed. Staff interviews revealed that nurses and aides were aware of R2’s agitation, prior altercations, and specific triggers related to loud environments and R1’s vocalizations, but they were unsure where to document behaviors, were unaware of any behavioral support plan, and did not report that the IDT had reviewed or addressed these behaviors. This lack of assessment, documentation, and care planning for R2’s known behavioral issues and triggers led to the failure to protect R1’s right to be free from physical abuse.
Failure to Prevent Accident During Bed Bath Results in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to provide care consistent with a resident's needs and care plan during a bed bath, resulting in an accident. The resident involved had multiple diagnoses, including low back pain, chronic congestive heart failure, a prior left femur fracture, generalized weakness, and was on hospice care. The care plan required two staff to assist with bed mobility and directed the use of a draw sheet to prevent shearing and sliding. During the incident, the resident was left on a bare air mattress without a draw sheet after the soiled linen was removed, and one staff member left the room to retrieve a clean draw sheet, leaving the other staff member alone with the resident. While repositioning the resident for care, staff did not use a draw sheet and applied excessive force, causing the resident to slide off the bed and fall to the floor. The bed brakes were not engaged on both sides, and the resident was undressed at the time of the fall. The staff involved did not review the care plan prior to providing care, and one of the staff members was unfamiliar with the resident and the hallway. There were inconsistencies in staff accounts regarding their presence and actions during the incident, and it was unclear whether proper procedures were followed. As a result of the fall, the resident sustained a comminuted and displaced fracture of the left femur, which required surgical intervention. The incident was witnessed by other staff who responded after hearing a noise and finding the resident on the floor. The facility's policy required protection from harm and adherence to care plans, but these were not followed during the incident, directly leading to the resident's injury.
Infection Control Deficiencies in Hand Hygiene, Glucometer Cleaning, and Laundry Handling
Penalty
Summary
Surveyors observed that a registered nurse failed to consistently perform hand hygiene during blood glucose monitoring and insulin administration for a resident on the memory care unit. The nurse applied gloves before retrieving the glucometer, performed the blood glucose test, and then returned the glucometer to the medication cart without cleaning or disinfecting it. The nurse also failed to perform hand hygiene after removing gloves and before donning new gloves for insulin administration, as well as after completing the insulin injection. The nurse acknowledged that hand hygiene should have been performed at multiple points and that the glucometer should have been disinfected after each use, but stated that cleaning was sometimes delayed due to competing responsibilities. Additionally, the facility did not ensure proper handling and containment of soiled personal laundry and linens. In the main laundry washroom, soiled clothing was transported unbagged across areas where clean clothing was stored, and clean clothing and bedding were placed in garbage bags or boxes directly on the floor. In the upstairs laundry unit, soiled laundry was placed on the floor before sorting, and clean clothing was placed on countertops near sinks, which were identified as highly contaminated areas. Mechanical lift slings were also stored in baskets and boxes on the floor. The housekeeper responsible for laundry acknowledged that soiled items were not always bagged prior to transport and that clean items should not be stored on the floor. Facility policies required that glucometers be disinfected after every use and that hand hygiene be performed before and after resident care, after glove removal, and after contact with potentially contaminated items. Policies also specified that soiled laundry should be bagged at the point of use and that clean linens should be handled and stored to prevent contamination. However, these procedures were not consistently followed, as confirmed by staff interviews and direct observation.
Handrails Not Firmly Secured in Facility Hallways
Penalty
Summary
Surveyors observed that handrails in multiple areas of the facility, including between resident rooms and outside the dining room by the men's restroom, were loose and not securely attached to the wall. Specifically, one handrail was not attached to the second bracket, and others were generally loose. During interviews, the Environmental Service Director (ESD) explained that staff were expected to report maintenance concerns using designated forms, which were then placed in specific boxes for follow-up. The ESD also stated that maintenance staff were attentive to needed repairs, but emphasized that identifying issues was a joint effort among all staff. A review of maintenance and housekeeping work order forms over a period of several months revealed no documented work orders related to handrail repairs. Additionally, the facility was unable to provide a policy or procedure regarding handrails when requested.
Failure to Properly Label and Securely Store Drugs and Biologicals
Penalty
Summary
Drugs and biologicals in the facility were not labeled in accordance with currently accepted professional principles. Additionally, all drugs and biologicals were not stored in locked compartments, and controlled drugs were not kept in separately locked compartments as required. These actions constitute a failure to follow proper procedures for the labeling and secure storage of medications and biologicals within the facility.
Failure to Provide Palatable and Properly Tempered Food and Drink
Penalty
Summary
The facility failed to ensure that food and drink provided to residents was palatable, attractive, and served at a safe and appetizing temperature. This deficiency was identified through surveyor observation and review, indicating that the food and beverages did not consistently meet standards for taste, appearance, or temperature at the time of service.
Improper Storage of Nutritional Supplements and Damaged Ice Machine Door
Penalty
Summary
Surveyors observed that nutritional supplements were being stored directly on the floor in two medication rooms, including the memory care unit and the transitional care unit (TCU). Multiple open and unopened cases of supplements such as Breeze, Boost, and Ensure Plus were found on the floor. Staff, including registered nurses and the clinical coordinator, stated that the supplements were placed on the floor upon delivery and were unaware that this was not an acceptable storage practice. It was also noted that there was available space in cupboards and on shelves that could have been used for proper storage. No facility policy regarding the storage of nutritional supplements was provided upon request. Additionally, the facility failed to maintain the ice machine in good repair. During a kitchen tour, the ice machine was found to have two areas on the door where the black plastic surface was missing, exposing yellow insulation that was worn and had a brown, yellow substance along the broken edge. The dietary director acknowledged that the damaged areas could not be properly cleaned or disinfected, raising concerns about infection control. No maintenance or housekeeping work orders related to the ice machine door were found in the facility's records, and no policy for ice machine maintenance was provided.
Unsanitary Kitchen Floor with Missing Tiles and Grout
Penalty
Summary
The facility failed to maintain the kitchen in a clean, sanitary, and good state of repair, as evidenced by multiple observations of missing tile chunks, missing grout, and the presence of a green substance on the subfloor in the dishwashing area. The dietary director acknowledged the missing tiles, grout, and green substance, and demonstrated that water could fill the damaged areas, noting this as a cleaning concern with potential for bacterial growth. Despite regular mopping, the damaged floor condition persisted on subsequent observation. A review of maintenance and housekeeping work order forms over a ten-month period revealed no documentation of any requests to repair the kitchen floor. Additionally, when asked, the facility was unable to provide a policy or procedure regarding kitchen cleaning and maintenance.
Deficiencies in Resident Privacy, Cleanliness, and Personal Property Management
Penalty
Summary
Multiple rooms on the Evergreen unit were observed to have large windows with white plastic blinds that were missing several slats, allowing visibility into the rooms from outside even when the blinds were closed. Maintenance and housekeeping work order records reviewed over a ten-month period did not show any requests for repair or replacement of these blinds. Staff interviews confirmed that many blinds throughout the building were broken, creating privacy concerns for residents, especially during personal care activities. Facility policy required broken blinds to be repaired or replaced and for audits to be conducted, but these actions were not documented for the affected rooms. Shower rooms throughout the facility were found to be in poor condition, with observations of mold-like black substances, cracked and missing tiles, slimy and discolored surfaces, and unclean fixtures. In several shower rooms, tiles were missing or cracked, exposing bare walls to water, and various colored substances were present on floors, walls, and fixtures. Staff interviews revealed inconsistent knowledge and practices regarding cleaning responsibilities and frequencies, with some staff unsure about the presence of mold or the adequacy of cleaning. The facility's cleaning policy did not specifically address shower rooms, and the Environmental Service Director acknowledged the need for tile replacement and ongoing issues with mold. A resident with multiple chronic health conditions, including alcoholic cirrhosis, hypertension, renal failure, hepatic encephalopathy, and fibromyalgia, reported numerous personal items missing over a period of approximately nine months. The missing items included clothing, jewelry, and personal care products. Interviews with staff indicated that missing item reports were completed and distributed, but there was a lack of follow-up, tracking, or resolution regarding the recovery of the resident's belongings. The facility's policy required thorough investigation, documentation, and follow-up for missing items, but staff were unaware of the need to track or resolve these reports, and the resident had not received updates about her missing possessions.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved.
Use of Physical Restraints Without Medical Necessity
Penalty
Summary
A deficiency was identified regarding the use of physical restraints on residents. The report notes that residents were not consistently free from the use of physical restraints, except when required for medical treatment. This indicates that physical restraints were used in situations where they were not medically necessary, contrary to regulatory requirements.
Failure to Notify Ombudsman of Resident Transfers and Discharges
Penalty
Summary
The facility failed to notify the Ombudsman of transfers and discharges for one resident who was hospitalized on two separate occasions. The resident, who had moderate cognitive impairment and required assistance with all activities of daily living, had multiple diagnoses including atrial fibrillation, heart failure, hypertension, cerebrovascular accident, depression, ADHD, and aortic aneurysm and dissection. Medical records showed that the resident was discharged to the hospital with return anticipated on two occasions, and hospital discharge summaries indicated hospitalizations for acute metabolic encephalopathy and acute on chronic hypoxemic hypercapnic respiratory failure. Review of the facility's monthly notices to the Ombudsman for the relevant months did not include this resident's transfers or discharges. During an interview, the social service assistant confirmed that the resident's hospitalizations were not reported to the Ombudsman as required. No policy regarding the notification process was provided by the facility during the survey.
Failure to Develop and Implement PTSD Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan addressing post-traumatic stress disorder (PTSD) triggers and interventions for a resident with a documented diagnosis of PTSD. The resident, who had intact cognition and required assistance with all activities of daily living, had a history of complex trauma and abuse, as well as other significant medical conditions including alcoholic cirrhosis, renal failure, hepatic encephalopathy, and fibromyalgia. Clinical notes from a psychology provider indicated the resident experienced re-experiencing of trauma, mistrust of authority, and anxiety about dependency on others, and recommended specific memory care approaches and coping tools. Despite this, the resident's care plan did not include PTSD triggers or interventions. Interviews with facility staff, including nursing assistants, registered nurses, the clinical coordinator, social worker, and assistant director of nursing, revealed that none were aware of the resident's PTSD history or specific triggers. Staff confirmed that trauma assessments and related care planning were not completed or included for this resident, despite facility policy requiring trauma-informed care assessments and individualized care plans for residents with a history of trauma or PTSD. The absence of this information in the care plan meant staff were not equipped with the necessary knowledge or strategies to appropriately respond to the resident's needs related to PTSD.
Failure to Individualize Care Plan for Oxygen Therapy
Penalty
Summary
The facility failed to update and individualize the care plan for a resident who was receiving respiratory care, specifically oxygen therapy. The resident, who had moderate cognitive impairment and required assistance with all activities of daily living, had multiple diagnoses including atrial fibrillation, heart failure, hypertension, cerebrovascular accident, depression, ADHD, and aortic aneurysm and dissection. The Minimum Data Set (MDS) indicated that the resident was receiving oxygen therapy. However, upon review, the care plan only noted the use of oxygen without specifying the reason for its use, the prescribed oxygen flow rate, or the route of administration. Interviews with facility staff, including an LPN clinical coordinator and the assistant director of nursing, confirmed that the care plan lacked resident-specific information regarding oxygen therapy. Both staff members acknowledged that the care plan should include detailed instructions so that staff are aware of when, how, and at what liter flow oxygen should be administered. The facility's care planning policy requires that care plans be comprehensive, individualized, and include measurable goals and specific interventions, but these requirements were not met in this case.
Failure to Prevent Unjustified Decline in ADL Abilities
Penalty
Summary
Residents experienced a loss in their ability to perform activities of daily living (ADLs) without a documented medical reason. The facility failed to ensure that residents maintained their highest practicable level of functioning in ADLs, as required, unless a decline was clinically unavoidable due to a medical condition. This deficiency was identified through surveyor observation and review of resident records, which did not provide evidence of a medical justification for the decline in ADL performance.
Failure to Meet Residents' Individualized Activity Needs and Preferences
Penalty
Summary
The facility failed to consistently meet the identified needs and preferences for activities for three of four residents reviewed. For one resident, assessments indicated a strong preference for listening to music and engaging in independent activities such as coloring. However, the resident's CD player was missing for three weeks, preventing access to preferred music, and there was no evidence that staff updated the care plan or provided alternative means to meet these preferences. Activity calendars showed minimal participation, and documentation of one-to-one interactions was lacking in narrative notes, with no subsequent changes to interventions. Another resident, who required assistance with all activities of daily living and had multiple diagnoses including dementia and depression, expressed preferences for music, being around animals, and going outside. Despite these preferences, the resident participated in a limited number of scheduled activities and received few one-to-one visits, with narrative notes lacking documentation of these interactions. Staff interviews revealed that the resident often refused activities and preferred to roam the hallway, but there was no evidence of updated care plan interventions to address these behaviors or preferences. A third resident with severe cognitive impairment and significant hearing loss also had specific activity preferences, including group activities and being around animals. This resident attended very few scheduled activities and received minimal one-to-one attention, with poor documentation of these visits. Staff acknowledged the resident's hearing difficulties and inconsistent participation, but there were no updates to the care plan to better address the resident's needs. The facility's policy required individualized activity programming and documentation of one-to-one visits, but the frequency and focus of these visits were not specified, and the policy was not consistently followed.
Failure to Provide Positioning Assistance and Implement Vision-Related Interventions
Penalty
Summary
The facility failed to provide appropriate positioning assistance for a resident with impaired cognition, dementia, and physical limitations who was dependent on staff for activities of daily living and used a wheelchair. Observations over several days revealed that the resident was repeatedly seated in a wheelchair without footrests, resulting in her heels being elevated off the ground and only the tips of her slippers touching the floor. Staff interviews confirmed that footrests were not in use, and staff were unaware of their absence. The care plan directed staff to assist with repositioning and transfers but lacked specific instructions for wheelchair positioning, and the facility policy did not provide guidance on wheelchair positioning assistance. Additionally, the facility failed to implement a care plan intervention for another resident who required eyeglasses and had a history of skin integrity issues on the bridge of the nose. The care plan specified that a band-aid should be applied to the metal nose piece of the glasses for extra padding. Multiple observations showed the resident wearing glasses without the required padding, resulting in an indent and purple discoloration of the skin under the metal nose piece. Staff interviews confirmed awareness of the skin issue but revealed that the intervention was not being followed, and there was no documentation or monitoring of the resident's skin condition as required by the care plan. The facility's policies on activities of daily living required services to maintain mobility and nutrition and called for documentation and evaluation of interventions, but did not provide specific direction for wheelchair positioning or eyeglass-related skin protection. The lack of adherence to care plan interventions and absence of clear policy guidance contributed to the deficiencies observed in the care and treatment of both residents.
Failure to Ensure Consistent Access to Hearing Assistive Devices
Penalty
Summary
The facility failed to ensure that a resident with severe cognitive impairment and significant hearing loss consistently had access to and used hearing assistive devices as required to meet their communication needs. The resident, who had diagnoses including non-traumatic brain dysfunction, Alzheimer's disease, diabetes mellitus, anxiety disorder, and depression, was care planned to wear bilateral hearing aids daily. Multiple observations over several days showed the resident was not wearing any hearing assistive devices and had difficulty hearing staff and other residents. Staff were observed speaking loudly and directly into the resident's ear, and on one occasion, a pocket talker was retrieved and placed on the resident, but the resident continued to have difficulty hearing. Interviews with nursing assistants and nurses confirmed the resident was extremely hard of hearing and should use a pocket talker at all times when awake, but it was only provided upon request or not at all. Staff were unsure about the whereabouts of the resident's hearing aids, and there was inconsistency in ensuring the resident had access to or used the pocket talker. The facility was unable to provide a policy regarding the provision of hearing assistive devices when requested.
Failure to Complete and Document Smoking Assessment and Safety Measures
Penalty
Summary
The facility failed to ensure a thorough and up-to-date smoking assessment was completed for a resident who wished to smoke. The resident, who had intact cognition but required assistance with all activities of daily living, had multiple diagnoses including COPD, non-Alzheimer's dementia, anxiety disorder, depression, schizophrenia, and nicotine dependence. The resident's care plan indicated she was an independent smoker and required the use of a smoking apron when smoking, in accordance with facility policy. However, the most recent smoking assessment did not document the use or assessment of the smoking apron, and there was no evidence that the assessment had been updated as required. Observations showed staff inconsistently reminded the resident to use the apron, and interviews with staff revealed confusion and inconsistency regarding the resident's use of the smoking apron and the frequency of required smoking assessments. Further review of facility policy indicated that residents identified as smokers should be assessed upon admission, quarterly, annually, and as needed for significant changes or incidents. The policy also required that residents needing a smoking apron, as determined by the assessment, must always wear one while smoking. Despite this, the last documented smoking assessment was not current, and it did not address the use of the smoking apron. Multiple staff interviews confirmed that the required assessments were not completed as per policy, and the use of the smoking apron was not consistently enforced or documented.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate respiratory care for a resident when needed. The report indicates that the facility failed to ensure that a resident received necessary respiratory care in accordance with their needs. Specific details about the actions or inactions of staff, the resident's medical history, or the circumstances at the time of the deficiency are not provided in the report excerpt.
Failure to Assess and Implement Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to comprehensively assess and implement trauma-informed care for a resident with a known history of post-traumatic stress disorder (PTSD) and past traumatic experiences. The resident, who had intact cognition and required assistance with all activities of daily living, reported a long history of verbal, physical, and sexual abuse, and continued to experience distressing symptoms such as seeing demon-like shadows and feeling triggered by staff interactions. Despite the resident's disclosure of PTSD and ongoing trauma-related symptoms, there was no evidence in the electronic health record (EHR) of a trauma assessment being completed, nor were individualized trauma-informed interventions or identification of triggers included in the care plan. Interviews with facility staff, including nursing assistants, registered nurses, the clinical coordinator, and the social worker, revealed that none were aware of the resident's PTSD diagnosis or specific triggers. The social worker and assistant director of nursing confirmed that a trauma assessment had not been completed and the PTSD diagnosis was not documented in the EHR or care plan. The facility's own policy required trauma-informed care assessments upon admission and as needed, with care plans reflecting identified triggers and interventions, but this was not followed for the resident in question.
Failure to Make Complaint Investigation Results Available for Review
Penalty
Summary
The facility failed to make the results of complaint investigations available for review by residents, families, visitors, and staff. During an observation, survey results were found in a binder labeled Annual Survey Results, which included only the past three recertification survey results and did not contain the 2567 forms or reports related to complaint investigations. Review of the Aspen Central Office system confirmed that several complaint investigations had been completed, some with citations, but these were not included in the posted or available survey results. The administrator stated she was unaware that posting the corresponding letters from all investigations was required, and no facility policy for posting survey results was available.
Deficient Abuse Reporting Policy with Conflicting Timelines
Penalty
Summary
The facility failed to develop and implement a policy for reporting allegations of abuse that was consistent with federal requirements and free of conflicting information. The Resident Protection Plan policy, last revised in February 2023, stated that reports of mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of property, are to be promptly and thoroughly investigated and reported immediately. However, the policy contained conflicting timelines, indicating that if the events involved abuse or resulted in serious bodily injury, the report must be made immediately and no later than two hours after the allegation, but for other events, the report could be made within 24 hours. Additionally, the policy stated that certain findings, such as unexplainable injuries or substantiated abuse, must be reported to the Office of Health Facility Complaints immediately, not to exceed 24 hours, which is inconsistent with the federal requirement for reporting within two hours if abuse or serious bodily injury is involved. During interviews, the administrator confirmed that the current policy was in use and stated that staff were expected to report allegations of abuse immediately to her, with reports of sexual abuse to be made within two hours and all other reports within 24 hours. The administrator also stated that verbal abuse would need to be reported within 24 hours of being made aware of the incident. These statements and the policy itself were not fully aligned with the federal regulation, which requires all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, to be reported immediately, but not later than two hours if the events involve abuse or result in serious bodily injury. This inconsistency had the potential to affect all residents in the facility.
Failure to Provide Adequate Clothing and Shoes
Penalty
Summary
The facility failed to provide medically related social services, specifically clothing and shoes, to a resident, resulting in harm. The resident, who had diagnoses including anxiety disorder, depression, and an acquired absence of the left leg below the knee, expressed a need for proper clothing and shoes to participate in social activities and leave her room. Despite multiple assessments and progress notes indicating the resident's feelings of loneliness, depression, and isolation, the facility did not adequately address her need for clothing and shoes. The resident's records showed that she had limited finances and lacked proper clothing and shoes, which affected her ability to use her prosthetic limb and participate in social activities. Interviews with staff revealed that the resident was often seen wearing an oversized shirt over a hospital gown and a single gripper sock, and she expressed a desire to eat in the dining room and attend activities if she had appropriate attire. Staff acknowledged the resident's lack of clothing but failed to provide a long-term solution, relying instead on temporary fixes such as donated clothes from the laundry. The facility's social services and life enrichment staff were aware of the resident's needs but did not take sufficient action to address them. The Director of Social Services and other staff members recognized the impact of inadequate clothing on the resident's dignity, mental health, and socialization but did not follow through with a comprehensive plan to meet her needs. The resident's primary care provider and psychology provider also noted the potential negative psychosocial impact of her isolation and lack of proper clothing, yet the facility did not implement effective measures to resolve the issue.
Failure to Implement Pressure Ulcer Prevention Care Plans
Penalty
Summary
The facility failed to implement the comprehensive care plan for two residents, R1 and R2, who were at risk for pressure ulcers. R1, who had moderate cognitive impairment and was frequently incontinent, required a pressure-reducing cushion in her wheelchair as per her care plan. However, observations and interviews revealed that R1's wheelchair did not have any cushion, and staff confirmed that the care plan was not being followed. The Director of Nursing (DON) acknowledged that R1 was at risk for skin integrity issues and expected the interventions to be in place. R2, who had mild cognitive impairment and a history of skin diseases, was also at risk for pressure ulcers. Her care plan included placing lamb's wool around her toes and ensuring a dressing was present if she wore specific shoes. However, during observations, it was found that these interventions were not being implemented. Staff interviews confirmed that the care plan directives were not being followed, and the DON noted that the absence of these interventions placed R2 at risk of developing new skin issues. The facility's policies on skin and pressure ulcer prevention and care planning emphasized the importance of implementing prevention protocols and ensuring care plans are followed. Despite these policies, the facility did not adhere to the care plans for R1 and R2, leading to a deficiency in providing the necessary care to prevent pressure ulcers.
Failure to Provide Individualized Activities for Resident
Penalty
Summary
The facility failed to provide individualized activities for a resident, identified as R1, who was reviewed for activities. R1's admission Minimum Data Set (MDS) assessment indicated moderate cognitive impairment and a preference for certain activities such as going outside, participating in religious services, and listening to music. Despite these preferences, the facility's life enrichment assessments and care plans did not reflect R1's specific interests or provide individualized activities. R1's care plan noted she was independent in making activity choices, but interventions were limited to providing activity invites and a monthly calendar, without addressing her specific interests. R1's activity attendance records from June to October 2024 showed limited engagement in activities, with several refusals and minimal one-to-one visits. Interviews with life enrichment aides revealed that R1 often declined group activities, and there was no clear strategy to offer her individualized activities during one-to-one visits. The aides admitted to not offering activities related to R1's interests, such as crafts or card games, during these visits. R1 expressed dissatisfaction with the activities offered, stating that she had not been provided with meaningful activities that matched her preferences, such as crocheting or playing cards. The director of life enrichment and the director of nursing both acknowledged that R1's care plan was not individualized and did not include her specific interests. The facility's policies required activities to be based on comprehensive assessments and tailored to residents' interests, but these were not followed in R1's case. The lack of individualized activities and failure to address R1's clothing concerns contributed to her non-participation in group activities, highlighting a deficiency in meeting her needs.
Failure to Follow Physician Orders for Cervical Collar Application
Penalty
Summary
The facility failed to adhere to physician orders for a resident requiring a cervical collar, leading to a deficiency in care. The resident, who had a history of transient ischemic attack, cerebral infarction, and a cervical fracture, was observed not receiving the required assistance from two licensed staff members when applying the cervical collar. Instead, a family member was involved in the process, which is against the facility's policy and physician's orders. The resident expressed discomfort when the collar was initially applied too tightly, indicating improper application by the staff. The resident's medical records indicated a need for the cervical collar to be worn continuously, including during bathing, and required the assistance of two people for any movement involving the collar. Despite this, during an observation, only one licensed practical nurse (LPN) assisted the resident, with the family member providing additional support. Interviews with the family member and staff confirmed that the facility's policy of using two trained staff members was not followed, and the family member was inappropriately relied upon for assistance. Interviews with various staff members, including the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Registered Nurses (RNs), revealed a lack of adherence to the established protocol for handling the resident's cervical collar. The staff acknowledged the requirement for two trained personnel to assist with the collar, yet this was not consistently practiced. The facility's policy and training materials emphasized the importance of two staff members for the safe application and removal of the cervical collar, but this was not implemented in practice, leading to the deficiency.
Failure to Follow Care Plan for Resident with Past Trauma
Penalty
Summary
The facility failed to adhere to the care plan for a resident who was reviewed for abuse. The resident, who had diagnoses of anxiety, depression, psychotic disorder, and a history of falls, was assessed to have moderate cognitive impairment and was dependent on staff for transfers. Her care plan, dated 5/21/24, specified that two female staff members were required for all personal care and transfers due to a history of past trauma. Despite this, a nursing assistant was observed transferring the resident and providing personal care without the assistance of another staff member, contrary to the care plan directives. The incident occurred after the resident had returned from the hospital following an allegation of sexual assault. The facility's policy required that the care plan and Kardex, which provided a brief overview of the resident's care plan, be followed. Both the nursing assistant and the director of nursing acknowledged the requirement for two female staff members for the resident's care and transfers. However, the care plan was not followed, as evidenced by the nursing assistant's actions, which were observed and confirmed by the facility's staff.
Failure to Properly Label, Store, and Sanitize Food and Dishware
Penalty
Summary
The facility failed to ensure food was labeled, dated, and stored properly to prevent foodborne illness. During an observation, it was noted that the refrigerator contained undated items such as a sandwich, a Styrofoam container of soup, an opened container of cucumber salad, and a bag of lettuce. The Director of Dining Services (CD) confirmed that these items were undated and from over the weekend. Additionally, a resident's salmon was found in the kitchen's refrigerator without a date, which was against the facility's policy. The CD admitted that leftovers and opened items should be dated and that the weekend staff were not as organized. The facility also failed to ensure that dishware was cleaned and sanitized properly. During an observation, a dietary aide (DA-B) was seen testing the dish machine with test strips that did not change color, indicating improper sanitization levels. The cook confirmed that the sanitizer level was between 10 and 50 ppm, which was below the required level. The cook admitted that the dishes were not properly sanitized and that prep dishes and utensils used for cooking were still being used despite the low sanitizer levels. The facility's Dishmachine/PPM Temperature Log showed inconsistencies in recording the sanitizer levels, and expired test strips were found in use. Additionally, the facility failed to maintain clean vents over clean dishes. During an observation, a vent above the clean silverware was noted to have gray and whitish fuzzy particles hanging from it. The Culinary Supervisor (CS) confirmed that the smaller vents above the clean dish area were not regularly cleaned and that there was no documentation of cleaning tasks. The CS admitted that the vent looked dusty enough to be concerned about dust falling onto the clean dishes. The facility's policies and procedures did not adequately address the dating of opened items or leftovers, and there was a lack of proper documentation for cleaning tasks.
Failure to Implement Transmission-Based and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement transmission-based precautions (TBP) for a resident who had emesis and loose stools during an outbreak of confirmed rotavirus and norovirus cases. The resident was observed vomiting in their bathroom, and the nursing assistant assisting them did not wear a protective gown. Additionally, there was no personal protective equipment (PPE) cart or signage on the resident's door indicating TBP. The bathroom remained soiled with bodily fluids for an extended period, and the resident's roommate, who used the same bathroom, was not provided with adequate precautions to prevent cross-contamination. The infection preventionist (IP) and director of nursing (DON) acknowledged the oversight and the need for proper cleaning and isolation measures but failed to ensure timely implementation. Another resident with a history of MRSA was not placed on TBP despite having an indwelling foley catheter and a recent history of severe sepsis and recurrent urinary tract infections. The resident's room lacked TBP signs and PPE supplies, and staff were observed providing catheter care without wearing protective gowns. The infection preventionist admitted that the resident should have been on contact precautions to prevent the spread of MRSA but had not yet implemented the necessary measures. Two additional residents with indwelling catheters and wounds were not placed on enhanced barrier precautions as required. Staff were observed providing catheter care without wearing protective gowns, and the infection preventionist confirmed that the facility had not yet educated staff or developed policies for enhanced barrier precautions. The director of nursing acknowledged the need for enhanced barrier precautions and the importance of proper infection control practices but had not yet taken action to address the deficiencies. Additionally, the facility failed to ensure proper handling of linens, with clean personal items being delivered uncovered and placed on doorknobs outside rooms with contact and droplet precautions, further compromising infection control efforts.
Failure to Provide Discharge Notice and Notify Ombudsman
Penalty
Summary
The facility failed to provide a resident with a written discharge notice and the basis for discharge, and did not notify the Ombudsman Office for Long-Term Care (OOLTC) of the transfer or discharge. The resident, who had intact cognition and required supervision with bed mobility, transfers, and toileting, was discharged without proper documentation or notification. The resident was on parole due to a felony history, which the facility cited as the reason for discharge, but no formal notice or appeal rights were provided to the resident or their family member. The family member was only given a medication list via email and had to arrange temporary accommodation for the resident. The facility's social worker was unaware of the requirement to notify the OOLTC of resident discharges and had not been completing this task. The facility's policies indicated that the resident, family, and OOLTC should be notified within 72 hours of a transfer or discharge, but this was not followed. The facility's discharge and transfer notice form was also found to be incomplete, lacking the reason for discharge and information regarding the resident's rights to appeal.
Failure to Complete Comprehensive MDS Assessment
Penalty
Summary
The facility failed to complete a comprehensive Minimum Data Set (MDS) assessment for a resident, specifically neglecting to evaluate cognitive and mood needs. The resident, who was admitted with anxiety disorder, depression, and schizoaffective disorder, had an incomplete MDS assessment. Sections C (Cognitive Patterns) and D (Mood) were marked as not assessed, indicating that the Brief Interview for Mental Status (BIMS) and the Resident Mood Interview were not conducted. This failure was attributed to the social worker responsible for these sections not being on campus during the assessment period and no other staff being authorized to complete the MDS in her absence. The social worker admitted to marking the sections as not assessed if she could not complete them by the due date and stated that the MDS process was new to her. Interviews with other staff members, including a registered nurse and the director of nursing, confirmed the importance of completing these sections to assess the resident's cognitive abilities and mood status. The registered nurse emphasized that any nurse could complete the assessment and that it was crucial to know the resident's status, especially given their mental health conditions. The director of nursing also highlighted the necessity of completing the MDS sections to ensure the resident received appropriate care and mental health referrals if needed. The facility did not have a specific policy for completing the MDS but followed the Resident Assessment Instrument (RAI) manual guidelines. The director of nursing confirmed that assessments were expected to be completed before the assessment range date (ARD). The failure to complete the MDS assessment as required led to a deficiency in evaluating and addressing the resident's cognitive and mood needs, which are critical for individualized care planning and appropriate mental health interventions.
Failure to Assess and Reassess Physical Devices for Resident
Penalty
Summary
The facility failed to ensure that physical devices were assessed and reassessed for continued appropriateness for a resident (R66) who had perimeter mattresses placed on their bed as a fall intervention. R66, who had Alzheimer's disease and was on hospice, required extensive assistance with transfers and bed mobility. Despite being identified as a high fall risk, the facility did not assess or reassess the perimeter mattress placed on R66's bed. The perimeter mattress was initially placed after R66 fell from bed without injury, but subsequent assessments and progress notes did not evaluate the continued need for the device. Observations and interviews with staff revealed that R66 had not attempted to get out of bed independently and required total assistance with bed mobility. The perimeter mattress was eventually removed, and R66's bed was positioned in the lowest position to the floor. The facility's policy required physical devices to be assessed on admission, re-admission, significant change of condition, and annually, but this was not followed in R66's case.
Failure to Provide Resident's Preferred Activities
Penalty
Summary
The facility failed to ensure a resident's preferred activities were available, as evidenced by multiple observations and interviews. The resident, who had Alzheimer's disease, anxiety, and a psychotic disorder, had specific preferences for activities such as listening to country music, playing with dolls, and attending religious services. Despite these preferences being documented in the resident's care plan, staff did not consistently provide these activities. Observations showed the resident often left without music or dolls, and staff were unaware of the resident's radio or did not use it to play music during care routines. The resident's activity attendance records indicated limited participation in preferred activities, especially during a lockdown period. The resident's care plan and life enrichment assessments highlighted the importance of music and other activities, but these were not consistently offered. Interviews with nursing assistants and the director of life enrichment revealed a lack of awareness and adherence to the care plan, with staff not playing music or providing dolls as required. The resident was often observed moaning and facing the wall without engagement in preferred activities. The director of nursing and other staff acknowledged the deficiencies, noting the importance of providing activities, especially during lockdowns. The facility's policy emphasized the responsibility of all staff to ensure residents could participate in life enrichment programs, but this was not effectively implemented. The failure to follow the care plan and provide the resident's preferred activities led to the deficiency identified in the report.
Failure to Complete SAM Assessment and Monitor Oxygen Settings
Penalty
Summary
The facility failed to ensure a self-administration of medications (SAM) assessment was completed for a resident (R19) who was observed with medications at bedside. R19, who had intact cognition and diagnoses of COPD, CHF, and CKD, was receiving oxygen therapy. Despite the physician's order for 2.5 liters per minute (lpm) of oxygen, R19 was observed receiving 4 lpm and admitted to adjusting the oxygen settings independently. The SAM assessment indicated that R19 did not want to administer her own medications and required assistance, and there was no physician's order allowing R19 to self-administer medications. Multiple staff members, including a registered nurse (RN), a trained medication assistant (TMA), and the director of nursing (DON), confirmed that residents should not adjust their own oxygen settings and that a SAM assessment and physician's order are required for self-administration of medications. The DON emphasized that nurses should intervene immediately if a resident is found adjusting their oxygen settings, educate the resident, discuss the risks and benefits, and update the care plan. The facility's policy on SAM requires a nurse to complete an assessment and obtain a physician's order for residents to self-administer their medications.
Failure to Ensure Call Light Accessibility
Penalty
Summary
The facility failed to ensure a call light was accessible for a resident (R385) who was moderately cognitively impaired, had diagnoses of malnutrition and depression, and was dependent on staff for turning in bed. During an observation, the call light cord was found clipped to the fitted sheet with approximately four feet of cord hanging down onto the floor, making it inaccessible to the resident. Despite the resident calling out for help multiple times, no staff entered the room to assist. The Director of Nursing (DON) briefly looked into the room but did not notice the call light on the floor or respond to the resident's calls for help. When staff eventually entered the room, they confirmed that the call light was out of reach and the resident expressed a desire to be repositioned to face the window and lie on their side to alleviate pain. The facility's policy and procedure on call lights, dated June 2022, indicated that call lights should always be within the resident's reach and never on the floor. The DON acknowledged that call lights should be accessible and that staff should respond to residents' needs in a timely manner.
Failure to Document Basis for Resident Discharge
Penalty
Summary
The facility failed to include a physician-documented basis for the discharge of a resident (R82). R82 was admitted for short-term rehabilitation after a hospitalization for a bladder infection and required supervision with bed mobility, transfers, and toileting. Despite having intact cognition and no behaviors or rejection of care, R82 was discharged from the facility without a documented medical reason. The discharge was initiated after the facility was informed of R82's felony history by his parole officer. The physician provided discharge orders but did not document the reason for the discharge in the medical record. Interviews revealed that the facility's staff, including the PT, DON, and administrator, were aware of the discharge but did not ensure proper documentation. The administrator stated that the discharge was in accordance with the facility's Resident Protection Plan, but the required documentation was missing. R82's family member had to arrange alternative accommodation, as the facility did not provide a clear basis for the discharge. The facility's policy or procedure for facility-initiated discharges was requested but only a blank example of a discharge and transfer notice form was provided, which included a section for the reason for transfer or discharge and information regarding resident rights to appeal.
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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 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 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 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 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 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 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 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 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 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 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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