Cura Of Le Sueur
Inspection history, citations, penalties and survey trends for this long-term care facility in Le Sueur, Minnesota.
- Location
- 621 South 4th Street, Le Sueur, Minnesota 56058
- CMS Provider Number
- 245416
- Inspections on file
- 24
- Latest survey
- February 24, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Cura Of Le Sueur during CMS and state inspections, most recent first.
A resident with a recent diagnosis of invasive ductal carcinoma of the right breast experienced severe pain and visible changes to the affected area, but staff failed to perform comprehensive skin assessments or ongoing monitoring. Despite care plan references to skin integrity and comfort, there were no specific treatment orders or documentation addressing the breast cancer site. The lack of assessment and documentation persisted until the resident required emergency care for an abscess, revealing a significant gap in care and monitoring.
The facility failed to provide adequate staffing, resulting in delayed assistance with meals, personal hygiene, and health monitoring for residents. Observations and interviews revealed that residents waited excessively for help, and necessary health assessments were not conducted. The facility's staffing plan was not adhered to, leading to missed baths and delayed care, impacting residents' quality of life.
During an influenza A outbreak, the facility failed to implement effective infection control measures. Observations showed a lack of droplet precaution signage for residents with symptoms or positive tests, and improper PPE use by staff, including wearing the same mask from room to room. The infection preventionist was unable to focus on outbreak management due to staffing shortages, leading to delayed implementation of necessary precautions.
The facility did not complete annual performance reviews for four nursing assistants, citing leadership turnover as the reason. Personnel records for these staff members lacked evidence of completed reviews, and the administrator acknowledged the oversight. A policy on performance reviews was requested but not provided.
The facility failed to conduct annual performance reviews for four nursing assistants, resulting in a lack of individualized training based on identified weaknesses. Interviews revealed that the nursing assistants only completed standard annual computer training, with no additional training provided. The facility administrator and a registered nurse were unaware of any performance-based training processes, and a policy on performance reviews was not provided.
The facility failed to maintain two tub/shower rooms on the Prairie unit in good repair and sanitary conditions, affecting 15 residents. Observations revealed issues such as a heavily laden furnace filter, crumbling wall material, dusty vents, and worn shower floors. The maintenance director and administrator were unaware of most issues, despite a policy requiring regular maintenance.
A resident with a history of falls and moderate cognitive impairment experienced multiple falls without the care plan being updated to include new interventions. Despite assessments and expectations from the facility's administration, the care plan did not reflect necessary changes to prevent further incidents. Interviews revealed a lack of communication and responsibility among staff regarding updating the care plan.
The facility failed to provide necessary meal assistance to three residents, leading to deficiencies in care. A resident with moderate cognitive impairment struggled to open food containers without help, while another resident with dysphagia was left to eat in bed without staff assistance. A third resident with severe cognitive impairment was unable to remove straw wrappers or open a banana, and staff did not provide the expected meal setup assistance.
The facility failed to monitor weights as ordered for three residents, leading to deficiencies in care. A resident with severe cognitive impairment and multiple diagnoses had missing weight documentation despite a provider order for daily monitoring. Another resident with heart failure had inconsistent weight recordings, and a third resident with a stroke history was not weighed as required. Staff interviews revealed communication issues and non-functioning scales, contributing to the deficiencies.
A facility failed to act on a consulting pharmacist's recommendation for a resident with severe cognitive impairment and multiple diagnoses, including Parkinson's disease, who was taking quetiapine fumarate. The pharmacist recommended monthly blood pressure monitoring, but the order was entered incorrectly and not maintained, resulting in a lack of current monitoring. The regional nurse specialist confirmed the error, and the consulting pharmacist emphasized the need for monitoring to check for side effects.
The facility failed to serve meals at appropriate temperatures, affecting two residents and potentially all 25 residents. A resident with ALS and another with a pressure ulcer reported receiving cold meals, impacting their nutritional intake. Observations showed meal trays left in hallways, leading to delays and cold food. The facility's policy to ensure proper food temperatures was not followed, resulting in meals being served below optimal temperatures.
The facility did not hold QAPI meetings quarterly as required, with no documentation of meetings between July and December. The administrator, new to the facility, confirmed the lack of records for this period, despite the policy mandating quarterly meetings.
A facility failed to accurately code the MDS for a resident with pressure ulcers. The resident was admitted with an unstageable heel pressure ulcer and osteomyelitis, but the MDS did not reflect this condition. Medical staff confirmed the presence of the ulcer, and both the MDS coordinator and the nurse responsible for the MDS acknowledged the error. The facility's policy required accurate completion and transmission of MDS assessments.
The facility failed to perform weekly comprehensive skin assessments for two residents, leading to undetected and untreated pressure ulcers. One resident developed pressure injuries on the heel and coccyx without prior documentation or treatment, while another resident's heel ulcers were not measured weekly as required. Staffing shortages and poor communication contributed to these deficiencies.
Two residents in a LTC facility did not receive adequate restorative services to maintain their range of motion. One resident, recovering from heart surgery, was not walked as prescribed due to a lack of documentation and follow-through by staff. Another resident with ALS did not consistently receive ROM exercises due to short staffing and confusion over instructions. The facility's failure to adhere to restorative programs was compounded by poor communication and documentation practices.
A resident with moderate cognitive impairment and a history of falls experienced multiple falls without comprehensive reassessment or updated interventions. Despite discussions with the family for increased supervision, the resident was often found in their room rather than near the nursing station. Staff interviews revealed a lack of awareness and communication regarding the resident's fall risk and necessary interventions, leading to a failure in preventing further falls.
A staff member in an LTC facility diverted medications by signing them out of the narcotic logbook without documenting their administration in the MAR. This affected 12 residents who required pain management for various conditions. The issue was discovered when residents reported not receiving their medications, leading to an investigation that confirmed the diversion of 121 oxycodone tablets, one tramadol tablet, and two doses of liquid lorazepam. Despite the diversion, no negative outcomes were reported.
The facility failed to properly destroy and document narcotic and controlled substances, leading to potential risks of diversion or theft. Discrepancies were found in the documentation of destroyed medications, and discontinued medications were not promptly removed from the medication cart. Interviews with staff revealed lapses in handling and securing the med safe liner, which was not picked up in a timely manner, contrary to facility policies.
A resident with a right hip fracture, requiring two-person assistance for transfers, was allegedly mishandled by a nursing assistant who was unaware of the care plan requirements. The facility's investigation did not review the care plan or ensure staff compliance, concluding no abuse occurred despite the resident sustaining a skin tear.
A resident with a hip fracture was transferred by a single staff member without a transfer belt, contrary to the care plan requiring a two-person assist. Staff were unaware of the care plan requirements, and the facility's policy for reviewing care plans was not effectively implemented, leading to a deficiency.
The facility failed to submit accurate and complete direct care staffing information to CMS for Quarter 1, 2024. The PBJ Staffing Data report indicated missing RN hours and a lack of licensed nursing coverage 24 hours a day on several dates. It was revealed that salaried nursing leadership staff did not punch a timecard, leading to their hours not being reflected in the PBJ data.
Staff failed to disinfect mechanical transfer lifts after use for two residents, despite facility policy requiring cleaning before and after each use to prevent infection spread. Observations and interviews revealed a lack of adherence to the policy, leading to a deficiency in infection control practices.
The facility failed to assess and document the use of weighted blankets for two residents, who were using them without proper physician orders, nursing assessments, or care plan inclusion. The DON confirmed that the facility's policy on weighted blankets was not followed.
Failure to Assess and Monitor Skin Integrity in Resident with Breast Cancer
Penalty
Summary
A deficiency occurred when the facility failed to complete a comprehensive skin assessment and ongoing monitoring for a resident with a known diagnosis of invasive ductal carcinoma of the right breast. Upon admission from the hospital, the resident's discharge summary and care plan identified breast cancer and associated pain, but the initial skin evaluation and risk audit did not document any impairments or specific observations of the right breast. Despite the resident experiencing significant pain and visible changes to the breast, including redness and tenderness, there was no comprehensive assessment or documentation of the breast's condition in the medical record. Throughout the resident's stay, multiple progress notes indicated ongoing and severe pain in the right breast, with repeated requests for pain medication. However, there were no detailed assessments or updates regarding the breast's appearance or any changes in its condition. Nursing staff interviews revealed a lack of awareness about the breast cancer diagnosis and an absence of treatment orders or monitoring instructions for the affected area. The care plan interventions focused on general skin integrity and comfort but did not address the specific needs related to the breast cancer site. The situation escalated when the resident's pain became unmanageable, leading to a transfer to the emergency department, where an abscess requiring surgical intervention was identified. The facility's documentation lacked admission photos and failed to provide a baseline or ongoing assessment of the breast cancer site. The director of nursing acknowledged that the admission and skin assessments did not reflect the condition of the right breast, despite being aware of the cancer diagnosis. Facility policies required care plans to address identified problem areas and risk factors, but these were not implemented for the resident's breast cancer site.
Staffing Shortages Lead to Deficiencies in Resident Care
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of its residents, resulting in several deficiencies. Observations and interviews revealed that residents were not receiving timely assistance with meals, personal hygiene, and other daily activities. For instance, residents requiring assistance with meals were left waiting, and call lights indicating the need for help were not answered promptly. One resident reported waiting over an hour to use the urinal, leading to discomfort and incontinence. Staff interviews confirmed that the facility was understaffed, with only two nursing assistants available for the entire building, which was insufficient to meet the residents' needs. The facility also failed to conduct necessary health monitoring and care for its residents. Residents with specific health conditions, such as edema and pressure ulcers, did not receive the required monitoring and assessments. For example, one resident's weight was not monitored as per the physician's order, and comprehensive skin assessments for pressure ulcers were not completed for two residents. Additionally, the facility did not provide services to maintain and prevent the loss of range of motion for residents requiring restorative services. Furthermore, the facility did not adhere to its own staffing plan, which was based on the resident population's acuity and needs. The nursing schedules showed numerous instances where the required number of nursing assistants and nurses were not present, leading to missed baths and delayed assistance. Staff interviews revealed that the facility resorted to using agency staff and offering overtime to address the staffing shortages, but these measures were not consistently implemented. The facility's failure to maintain adequate staffing levels and provide necessary care and assistance resulted in significant deficiencies affecting the residents' quality of life.
Inadequate Infection Control During Influenza Outbreak
Penalty
Summary
The facility failed to implement an effective infection prevention and control program during an influenza A outbreak. Observations revealed that the facility did not post appropriate droplet precaution signage for residents who exhibited symptoms or tested positive for influenza A. This lack of signage was noted for 11 residents, which included individuals with various medical conditions such as heart failure, Parkinson's disease, and type 2 diabetes mellitus. The absence of proper signage meant that staff, residents, and visitors were not adequately informed about the necessary precautions to prevent the spread of the virus. Additionally, the facility did not ensure the correct use of personal protective equipment (PPE). Staff members were observed wearing the same mask from room to room, contrary to infection control guidelines. Nursing assistants and licensed practical nurses were seen disposing of soiled gowns in a hallway garbage bin instead of in the resident's room, further increasing the risk of cross-contamination. Interviews with staff revealed a lack of awareness and training regarding the proper donning and doffing of PPE, as well as the specific precautions required for residents with influenza A. The infection preventionist, who was also the assistant director of nursing, was unable to focus on infection control duties due to staffing shortages and was required to work as a floor nurse. This contributed to the delay in implementing necessary infection control measures, such as posting precaution signs and ensuring the availability of PPE. The facility's administrator acknowledged the oversight and confirmed that the infection preventionist was not given designated time to address the outbreak effectively. This deficiency in infection control practices had the potential to affect all residents in the facility.
Failure to Conduct Annual Performance Reviews for Nursing Assistants
Penalty
Summary
The facility failed to conduct annual performance reviews for four nursing assistants (NA-A, NA-F, NA-B, NA-E) whose personnel records were reviewed. NA-A, hired on June 14, 2023, and NA-F, hired on November 7, 2023, both lacked evidence of any completed annual performance reviews. NA-B, hired on July 16, 2018, did not have a current annual performance review on file. NA-E, hired on June 7, 2021, also lacked evidence of any completed annual performance review. During interviews, administrative support and the administrator acknowledged the absence of performance reviews, attributing it to leadership turnover and stating that reviews had not been conducted. A policy on performance reviews was requested but not provided.
Failure to Conduct Annual Performance Reviews and Individualized Training
Penalty
Summary
The facility failed to conduct annual performance reviews for four nursing assistants, identified as NA-A, NA-F, NA-B, and NA-E. This deficiency was discovered through interviews and document reviews, which revealed that none of these nursing assistants had evidence of completed annual performance reviews in their personnel records. NA-A and NA-F, who were hired in 2023, along with NA-B and NA-E, hired in 2018 and 2021 respectively, all lacked documentation of such reviews. This failure to conduct performance reviews also meant that the facility did not provide individualized training based on any identified areas of weakness from these reviews. Interviews with the nursing assistants and a registered nurse further confirmed the lack of awareness and implementation of performance-based training. NA-B, NA-E, and NA-A all reported only completing the standard annual computer training required for all employees, with no additional individualized training. The registered nurse, RN-A, also stated he was unaware of any training based on performance reviews. The facility administrator, who was new, admitted to not being aware of any completed performance reviews or specific training processes. Additionally, a policy on performance reviews and training was requested but not provided, indicating a possible lack of established procedures in this area.
Deficiencies in Tub/Shower Room Maintenance and Sanitation
Penalty
Summary
The facility failed to maintain two of the three tub/shower rooms on the Prairie unit in good repair and sanitary conditions, affecting 15 residents who utilized these areas. During an observation, the east Prairie unit's tub/shower room was found to have a heavily laden furnace filter with gray fuzzy material partially under a wall-mounted heater, and the heater's grates were covered with dust and webs. Additionally, a section of the wall had missing sheetrock, exposing crumbling, discolored material. The ceiling vent was also covered with gray debris, and the shower floor appeared worn and stained, with the shower head secured by black zip ties. In the north Prairie unit's tub/shower room, the shower floor was similarly worn and stained, with black marks that could not be removed. During an interview, the maintenance director acknowledged the poor condition of the filter but was unaware of the other issues, while the administrator was only aware of the filter problem. The facility's policy on maintenance and cleanliness was reviewed, indicating that filters should be cleaned or discarded monthly during the summer, and air vents cleared annually, but these practices were not followed in the observed areas.
Failure to Update Care Plan for Resident with Fall Risk
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan to address falls for a resident with a history of falls and moderate cognitive impairment. The resident, who had diagnoses including a left femur fracture, dementia, and anxiety, experienced multiple falls without the care plan being updated to include new interventions. Despite the resident's history of falls and the family's expressed concerns, the care plan did not reflect necessary changes to prevent further incidents. The resident experienced two falls within a short period, with the first incident involving the resident crawling out of a recliner and the second fall occurring while the resident was seated on the floor. In both cases, immediate assessments were conducted, and no injuries were reported. However, the care plan was not updated with new interventions following these incidents, despite expectations from the facility's administration and policies. Interviews with facility staff revealed a lack of communication and responsibility regarding updating the care plan. The Director of Nursing was expected to ensure comprehensive reassessments and new interventions, but these were not consistently implemented. Staff members, including the Assistant Director of Nursing and nursing assistants, were either unaware of the resident's fall risk or not informed of new interventions, highlighting a breakdown in the facility's fall management procedures.
Failure to Provide Meal Assistance to Residents
Penalty
Summary
The facility failed to ensure that residents received necessary assistance with meals, leading to deficiencies in care for three residents who required staff assistance or supervision during dining. Resident 1, with moderate cognitive impairment and a self-care deficit related to dementia, was observed struggling to open a container of ice cream and remove lids from drinking glasses without assistance. Despite the expectation that staff delivering meal trays would provide necessary setup assistance, Resident 1 was left without help until prompted by a surveyor. Similarly, Resident 2, who was cognitively intact but required supervision due to conditions like dysphagia, was left to eat in bed without staff assistance, with drinking glasses placed out of reach and lids not removed. Resident 10, with severe cognitive impairment and multiple diagnoses including dementia and Parkinson's disease, was also observed without adequate meal setup assistance. The resident was unable to remove straw wrappers or open a banana, and these tasks were not completed by the staff delivering the meal tray. Staff members, including a housekeeping aide and a nursing assistant, acknowledged the oversight and confirmed that meal setup assistance was expected but not provided. The facility's policy required staff to follow the care plan and assist residents with meal setup, but this was not adhered to, resulting in the observed deficiencies.
Failure to Monitor Resident Weights as Ordered
Penalty
Summary
The facility failed to monitor weights as ordered for three residents, leading to deficiencies in care. Resident R10, who had severe cognitive impairment and multiple diagnoses including coronary artery disease and Parkinson's disease, had a provider order for daily weights with specific instructions to update the provider if there was a significant weight gain. However, there were no documented weights for several days, and the resident experienced a weight gain that was not reported as required. Interviews with staff revealed an expectation to follow provider orders, but the documentation was lacking. Resident R20, who was cognitively intact and had a history of coronary artery bypass surgery and heart failure, also had a physician order for daily weights to monitor his cardiac status. Despite this, only 13 out of 40 opportunities for daily weights were recorded. The resident expressed concerns about food choices and was unaware of his weight status due to inconsistent weight monitoring. Interviews with staff indicated that the process for communicating weight orders was not effectively followed, and there were issues with the scales not working properly. Resident R23, who had severe cognitive impairment and a history of stroke, was supposed to be weighed twice a week according to physician orders. However, only six out of 13 opportunities for weight measurement were recorded. Staff interviews highlighted a lack of awareness and communication regarding weight orders, and there were no documented refusals for weight measurement. The facility's policies on weight monitoring and refusal of care were not adhered to, contributing to the deficiencies observed.
Failure to Address Pharmacist Recommendations for Resident on Antipsychotic
Penalty
Summary
The facility failed to ensure that consulting pharmacist recommendations were addressed or acted upon for a resident reviewed for unnecessary medications. The resident, who had severe cognitive impairment and multiple diagnoses including dementia, Parkinson's disease, anxiety, depression, and a psychotic disorder, was taking an antipsychotic medication, quetiapine fumarate. The resident's care plan indicated a potential for drug interactions and adverse effects related to polypharmacy, with interventions including a monthly medication regimen review by a pharmacy consultant and forwarding recommendations to the medical doctor for review. The consulting pharmacist recommended adding an order for monthly blood pressures or documenting why this could not be completed. Although a registered nurse indicated that the order was placed, the resident's treatment administration record showed that the order for monthly orthostatic blood pressures was entered incorrectly and subsequently fell off. The last documented orthostatic blood pressure was dated over two months prior, and there was no current order for monthly orthostatic blood pressures. The regional nurse specialist confirmed the error, and the consulting pharmacist stated the expectation for monthly orthostatic blood pressures to monitor for side effects in residents on Seroquel.
Failure to Serve Meals at Appropriate Temperatures
Penalty
Summary
The facility failed to ensure that meals were served at a warm and palatable temperature, affecting the quality of life and nutritional intake for two residents, R22 and R16, and potentially impacting all 25 residents in the facility. R22, diagnosed with amyotrophic lateral sclerosis (ALS), required total assistance with meals and reported consistently receiving cold food, particularly breakfast. Observations confirmed that meal trays were left in the hallway on an open-sided cart, leading to delays in delivery and cold meals. R22's breakfast was observed to be cold, and the resident expressed dissatisfaction with the meal temperature. R16, who had an unstageable pressure ulcer and osteomyelitis, also reported receiving cold meals, which affected their ability to eat. Observations showed that meal trays were left on a cart in the hallway for extended periods before being delivered to residents' rooms. R16's meal was delivered late, and the resident stated that the food was cold and uneaten. The facility's policy required staff to ensure hot foods were hot and cold foods were cold, but this was not adhered to, resulting in meals being served at suboptimal temperatures. During the survey, it was noted that the facility was experiencing an influenza outbreak, and all residents were receiving meals in their rooms. Despite this, there was a lack of coordination among staff to ensure timely delivery of meals. The dietary manager and cook acknowledged the issue and stated that they would revert to using regular dishes and warmers to maintain food temperature. However, during the survey, the deficiency in meal service was evident, with food temperatures measured below the acceptable range, and staff not assisting promptly with meal delivery.
Failure to Conduct Quarterly QAPI Meetings
Penalty
Summary
The facility failed to ensure that Quality Assurance Performance Improvement (QAPI) meetings were held on a quarterly basis as required. A review of the QAPI meeting minutes and agenda revealed that meetings were conducted on 12/19/24, 7/11/24, and 4/11/24. However, there was no documentation of any QAPI meetings occurring between 7/11/24 and 12/19/24. During an interview on 1/16/25, the administrator, who had been at the facility for approximately four weeks, stated she was unaware of any QAPI meetings held during that period and confirmed the absence of documentation for such meetings. The facility's QAPI policy, dated 2/2024, mandates that the QAA committee meet quarterly, with activities and outcomes shared with staff, residents, and family members, and reported to the board of directors.
Inaccurate MDS Coding for Pressure Ulcers
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was accurately coded for a resident with pressure ulcers. The resident, identified as R16, was admitted with an unstageable pressure ulcer on the right heel and osteomyelitis. The admission MDS assessment did not reflect the presence of the heel pressure ulcer, despite the resident's care plan indicating a self-care deficit related to morbid obesity and decreased functional ability due to bilateral heel pressure injuries. The care plan included interventions such as administering treatments, floating heels while in bed, and using a wound vac on the right heel. Interviews and observations revealed discrepancies in the MDS coding. On separate occasions, medical staff, including a medical doctor and registered nurses, confirmed the presence of the heel pressure ulcer, which was not documented in the MDS. The MDS coordinator and the nurse who completed the MDS both acknowledged the inaccuracy. The facility's policy required all MDS assessments to be completed and transmitted accurately, which was not adhered to in this case.
Failure to Conduct Weekly Skin Assessments and Document Pressure Ulcers
Penalty
Summary
The facility failed to conduct weekly comprehensive skin assessments, including measurements, for two residents, R16 and R20, who were at risk for pressure ulcers. R20, who had a history of coronary artery bypass surgery, heart failure, diabetes, and chronic kidney disease, was admitted with no pressure ulcers and was considered low risk. However, over an eight-week period, skin checks were only completed five times, and a pressure injury to the right heel and coccyx was discovered without prior documentation or treatment orders. The lack of communication and documentation among staff led to a delay in addressing R20's pressure injuries. R16 was admitted with unstageable pressure ulcers on both heels and required weekly wound assessments with measurements. Despite this, the last documented wound check with measurements was on 12/16/24, and subsequent assessments failed to include necessary measurements. R16's care plan included interventions for pressure ulcer management, but the facility's staffing shortages and lack of a dedicated wound nurse contributed to the failure to perform comprehensive wound assessments as required. Interviews with facility staff revealed a lack of awareness and communication regarding the residents' conditions. Staff members, including nurses and nurse practitioners, were not informed of the presence of pressure wounds, and there was no documentation in the electronic medical records. The facility's policies required adherence to physician orders and comprehensive documentation of wound care, but these were not followed, leading to deficiencies in the care provided to R16 and R20.
Failure to Provide Adequate Restorative Services for Residents
Penalty
Summary
The facility failed to provide adequate restorative services to maintain and prevent the loss of range of motion (ROM) for two residents, R20 and R22. R20, who had undergone coronary artery bypass surgery and was recovering from a recent hospitalization, was supposed to be on a walking program as per the rehabilitation instructions. However, the walking program was not documented in the electronic medical record (EMR) TASK tab, which nursing assistants used to determine care tasks. Interviews revealed that R20 was not being walked as prescribed, and there was a lack of communication and follow-through from the nursing staff regarding the walking program. R22, diagnosed with amyotrophic lateral sclerosis (ALS), required ROM exercises to maintain muscle function. Despite having instructions for ROM exercises posted in his room and documented in the EMR, the exercises were inconsistently performed. The nursing assistants frequently cited short staffing as a reason for not completing the ROM exercises. Additionally, there was confusion among staff about the specific ROM instructions, as the instructions in the EMR differed from those posted in R22's room and from the occupational therapy recommendations. The facility's failure to adhere to the prescribed restorative programs for R20 and R22 was compounded by inadequate communication and documentation practices. Nursing staff were not consistently informed or aware of the residents' restorative needs, and there was a lack of oversight to ensure that the prescribed care was being delivered. This deficiency highlights a systemic issue in the facility's management of restorative nursing services, impacting the residents' ability to maintain or improve their physical function.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to conduct a comprehensive reassessment after falls to identify the root cause and ensure new interventions were implemented to prevent further falls for a resident with a history of falls. The resident, who had moderate cognitive impairment and was dependent on staff for various activities, experienced multiple falls without a comprehensive assessment or updated care plan to address the risks. The resident's care plan included interventions such as keeping the bed at an appropriate height and encouraging the use of appropriate footwear, but these were not updated following the falls. The resident experienced falls on two separate occasions, with incident reports failing to indicate new interventions or predisposing factors. The facility's interdisciplinary team (IDT) met to discuss the falls, but no new interventions were implemented, and the care plan was not updated. The administrator and other staff members acknowledged the gap in implementing interventions and completing comprehensive assessments post-falls. Despite discussions with the resident's family about increased supervision, the resident was often found in their room rather than near the nursing station as agreed. Staff interviews revealed a lack of awareness and communication regarding the resident's fall risk and necessary interventions. Some staff members were not informed about the resident's fall risk or the interventions required, and agency staff did not have access to the electronic medical record to review care plans. The facility's fall management policy required a fall risk evaluation and analysis, but these were not consistently followed, leading to a failure in preventing further falls for the resident.
Medication Diversion by Staff Member in LTC Facility
Penalty
Summary
The facility failed to protect residents from the wrongful use of their medications, resulting in drug diversion by a staff member. A trained medication aide (TMA-A) was found to have signed out controlled medications from the narcotic logbook without documenting their administration in the Medication Administration Record (MAR). This discrepancy was discovered when residents reported not receiving their prescribed medications, and an internal investigation revealed that 121 oxycodone tablets, one tramadol tablet, and two doses of liquid lorazepam were diverted. The issue came to light when a registered nurse (RN-A) was informed by residents that they had not received their as-needed medications. Upon reviewing the narcotic logbook and electronic medical records, RN-A found that TMA-A had been signing out medications but not documenting their administration. This led to the discovery of discrepancies in the records of 12 residents, who had various medical conditions requiring pain management, such as fractures, chronic pain syndrome, and anxiety. Despite the diversion, the records indicated that no negative outcomes occurred from the residents not receiving their medications. Interviews with staff and residents further highlighted the issue. Residents reported inconsistencies in their medication administration, and staff members noted that TMA-A had been signing out medications without proper documentation. TMA-A admitted to forgetting to document the administration of medications in the MAR, citing laziness and dissatisfaction with the job as reasons. The facility's director of nursing (DON) was notified, and an investigation was launched, confirming the diversion of medications by TMA-A.
Removal Plan
- Staff education was initiated which included the following topics: Medication Administration by Unlicensed Personnel and Controlled Substances training including: Ensuring the meds are secure at all times, Every dose given must be documented in the narcotic record and the electronic medication administration record, At the time of follow up for a PRN medication, if a resident denies receiving the medication, immediately report it to the nursing supervisor for review.
- AP was immediately suspended and then was terminated concluding investigation.
- Management conducted audits on all residents with prescribed controlled medications to confirm medications were not diverted.
Failure to Properly Destroy and Document Controlled Substances
Penalty
Summary
The facility failed to ensure the proper destruction of narcotic and controlled substances, as required by their policies and procedures, to mitigate the risk of diversion or theft. On October 2, 2024, a review of narcotic books and related documentation revealed discrepancies, including 123 tablets of Oxycodone, 175 tablets of lorazepam, 30 tablets of temazepam, 36 tablets of pregabalin, 44 tablets of tramadol, and 14.5 ml of morphine that were signed out as destroyed but not documented on the required forms. Additionally, medications that had been discontinued were found in the medication cart, indicating a failure to remove them promptly, which was acknowledged as a potential error or diversion risk by an LPN. Interviews with staff, including an LPN, RN, scheduler, business office personnel, pharmacy consultant, and the DON, highlighted lapses in the handling and documentation of controlled substances. The med safe liner, which should have been securely stored and promptly picked up, was left in the DON's office for an undetermined period and was not picked up in a timely manner. The facility's policies required immediate disposal of controlled substances and proper documentation, which were not adhered to, raising concerns about the security and accountability of these medications.
Failure to Investigate Alleged Abuse and Ensure Care Plan Compliance
Penalty
Summary
The facility failed to conduct a thorough investigation following an allegation of staff-to-resident abuse involving a resident who was reportedly mishandled during a transfer. The incident involved a nursing assistant (NA-B) who allegedly picked up the resident from a wheelchair and threw them into bed, resulting in a skin tear on the resident's elbow. The resident, who had a history of a right hip fracture and was non-weight bearing on the right leg, required assistance from two staff members for transfers according to their care plan. However, NA-B was unaware of this requirement and had been transferring the resident alone, contrary to the care plan. The facility's investigation concluded that no abuse occurred, but it did not include a review of the resident's care plan to ensure proper transfer procedures were followed. The assistant director of nursing (ADON) confirmed that there was no re-education or competency testing for NA-B or other staff regarding adherence to care plans or safe transfer practices, only education on abuse. The director of nursing (DON) believed the care plan was followed, but could not confirm the presence of a second staff member during the transfer. This oversight in the investigation process and failure to ensure compliance with the care plan put the resident at risk for future incidents.
Failure to Implement Care Plan for Resident Transfers
Penalty
Summary
The facility failed to implement the Self Care plan interventions for a resident, identified as R1, which put R1 at risk for falls during the provision of care. R1's significant change Minimum Data Set (MDS) indicated that R1 was dependent on assistance for transfers and was non-weight bearing on the right leg due to a hip fracture. Despite this, observations and interviews revealed that R1 was transferred by a single staff member, NA-B, without the use of a transfer belt, contrary to the care plan which required a two-person assist for transfers. NA-B was unaware of the care plan requirements and had always transferred R1 alone, indicating a lack of communication and training regarding care plan updates. Further interviews with other staff, including NA-A and the Director of Nursing (DON), revealed inconsistencies in the understanding and implementation of R1's care plan. NA-A confirmed that R1 was never transferred with two people and often refused the use of a transfer belt. The DON stated that staff were expected to review care plan updates on IPADs before each shift, but was unaware that this practice was not being followed. The facility's policy required care plans to be used in developing daily care routines and available to staff, but this was not effectively implemented, leading to the deficiency.
Failure to Submit Accurate Staffing Data to CMS
Penalty
Summary
The facility failed to submit accurate and complete direct care staffing information to CMS for Quarter 1, 2024. The PBJ Staffing Data report indicated missing RN hours on specific dates and a lack of licensed nursing coverage 24 hours a day on several other dates. During interviews, it was revealed that the nursing staff scheduler and the administrator were unaware of how the data was pulled for the report. The administrator noted that salaried nursing leadership staff, who did not punch a timecard, worked the shifts identified but their hours might not be reflected in the PBJ data. Verifiable information such as EMR log in/log out times was requested to confirm the shifts worked by these salaried staff members. Upon review of the provided documents, it was confirmed that RN coverage and licensed nursing staff coverage were indeed present on the dates identified in the PBJ report. The facility's policy on PBJ Reporting, revised in May 2022, indicated that the facility would electronically submit complete and accurate direct care staffing information based on payroll and other verifiable and auditable data. However, the failure to include the hours worked by salaried nursing leadership staff in the PBJ data led to the deficiency noted in the report.
Failure to Disinfect Mechanical Lifts After Resident Use
Penalty
Summary
Staff failed to ensure mechanical transfer lifts were cleaned after resident use for two residents. One resident, who was cognitively intact and dependent on staff for toileting and transfers, had a care plan indicating the use of a mechanical lift. Another resident, who was rarely/never understood and dependent on staff for toileting, dressing, and transfers, also required the use of a mechanical lift. Observations revealed that staff did not disinfect the mechanical lifts after use with these residents, despite facility policy requiring cleaning before and after each use to prevent infection spread. Multiple staff members, including nursing assistants and a trained medication aide, were observed not disinfecting the mechanical lifts after use. Interviews with these staff members revealed a lack of awareness or adherence to the facility's policy on disinfecting mechanical lifts. The Director of Nursing confirmed that the expectation was for staff to clean the lifts after each use, and disinfectant wipes were available for this purpose. However, staff practices did not align with this policy, leading to a deficiency in infection control practices.
Failure to Assess and Document Use of Weighted Blankets
Penalty
Summary
The facility failed to assess the use of weighted blankets for two residents, R12 and R20, who were using them without proper documentation and evaluation. R12, who had hemiplegia following a stroke, was observed using a weighted blanket without a physician's order, nursing assessment, or inclusion in her care plan. Staff members, including nursing assistants and a licensed practical nurse, were aware of the blanket but did not follow any guidelines for its use. The Director of Nursing (DON) confirmed that the necessary assessments and documentation were missing, and the facility's policy on weighted blankets was not followed. Similarly, R20, who had multiple diagnoses including autism, cerebral palsy, and severe cognitive impairment, was also using a weighted blanket without a physician's order, nursing assessment, or care plan inclusion. The DON acknowledged that the facility had not adhered to their weighted blanket policy, which required a physician's order, a physical device assessment to ensure the resident could remove the blanket independently, and care plan documentation. The facility's policy indicated that weighted blankets should be used as a therapeutic modality and required specific procedures to ensure resident safety, none of which were followed for R12 and R20.
Latest citations in Minnesota
A resident with dry eye syndrome and degenerative eye disease had orders for cyclosporine ophthalmic emulsion and Refresh Tears, both scheduled at the same time. Medication records and direct observation showed a TMA instilled cyclosporine drops in both eyes and immediately followed with Refresh Tears in both eyes without waiting between medications. This practice conflicted with referenced professional guidance recommending several minutes between multiple eye drops and with the medical provider’s recommendation to wait fifteen minutes between the two ophthalmic medications. No facility policy on ophthalmic medication administration was provided when requested.
A resident with severe cognitive impairment, impaired mobility, and high fall risk was care planned to have wheelchair footrests in place at all times, with staff ensuring proper positioning and monitoring for leaning during transport. A NA transported the resident in a manual wheelchair from the shower without the footrests, and while going through the doorway the wheelchair struck the door frame, causing the resident, who was leaning forward, to fall out. The resident sustained a T12 fracture, head injury with concussion, abrasions and contusions, and multiple right-hand lacerations requiring sutures, and the DON confirmed the care plan had not been followed.
A high‑risk, immobile resident with MS and prior heel DTI developed an avoidable unstageable coccygeal pressure ulcer after staff failed to consistently assess and document skin status, did not transfer or timely provide ordered pressure‑relieving mattresses, and did not reliably perform q2h repositioning. The resident was repeatedly left on a bedpan for prolonged periods despite early reports of this issue, and the toileting care plan was not revised to a bedside commode until after the coccygeal wound had significantly worsened. Wound assessments lacked complete measurements and staging, changes in wound size and color were not promptly recognized as deterioration or reported to providers, and recommended interventions from a wound NP (including an air mattress and offloading) were not promptly implemented. As a result, the coccygeal ulcer rapidly progressed to a large, necrotic, malodorous wound requiring hospital transfer and surgical debridement.
A resident with spastic hemiplegia, muscle weakness, and moderate cognitive impairment was observed using bilateral bed grab bars for bed mobility and transfers, but the care plan did not address grab bar or side rail use. Review of the EMR showed no completed bed mobility device or side rail assessment to determine the necessity or safety of the grab bars, and no documentation that risks and benefits were discussed or that informed consent was obtained. An LPN and the ADON stated that a bed mobility device assessment is required before grab bars are installed and confirmed that no such assessment existed for this resident.
A resident with bilateral heel pressure ulcers and multiple comorbidities received wound care during which an RN removed dressings from both heels, cleansed both wounds, and wiped each heel without changing gloves or performing hand hygiene between wounds or after disposing of soiled dressings. This practice conflicted with the facility’s written wound care procedure, which requires glove removal and hand hygiene after dressing removal and after wound cleansing. In interviews, the RN, NP, and DON/IP acknowledged that hand hygiene and glove changes are expected between dirty and clean tasks and between separate wounds to prevent infection.
A resident with MS, neurogenic bladder, mobility limitations, and existing pressure injuries was identified as dependent for toileting hygiene and at risk for pressure ulcers, yet the care plan lacked an individualized toileting/incontinence plan and a defined repositioning schedule. Despite a new coccyx pressure ulcer and documentation that interventions such as increased repositioning and incontinent care were needed, the care plan was not revised for a period of time to reflect these changes. During this time, the resident sometimes fell asleep on a bedpan and remained on it until staff removed it, and staff were not initially informed that the bedpan should no longer be used. The DON later acknowledged that the care plan revisions for turning, repositioning, and toileting were delayed until after the resident’s coccyx ulcer had significantly worsened.
A resident with diabetes, Crohn’s disease, bowel incontinence, and a history of MASD on the right gluteus developed an open, painful lesion on the right gluteal area that was documented over time without complete wound characteristics, clear etiology, or timely provider notification. Wound care orders were written for a stage 3 pressure ulcer on the left buttocks, while staff reported the wound was only on the right side and applied the left‑sided orders to the right gluteal wound in the absence of specific right‑side treatment orders. The DON acknowledged discomfort with staging the wound, lack of early physician notification, and confusion over wound classification, despite a facility policy requiring comprehensive wound assessment, consistent measurement, and provider notification when treatment orders are absent.
A resident with diabetes, chronic leg ulcer, kidney transplant, and a documented gluteal wound was care-planned for Enhanced Barrier Precautions (EBP), with posted instructions requiring gown and gloves for high-contact care such as transfers and wound care. During a telehealth wound assessment, the DON donned a gown and initially performed hand hygiene but then applied gloves without hand hygiene, removed a soiled dressing from the resident’s gluteal area, discarded it, removed gloves, and applied new gloves again without performing hand hygiene between glove changes. On another occasion, during use of a sit-to-stand lift, an NA wore gown and gloves, but the DON handled the lift harness, the resident’s clothing, and assisted with the transfer and repositioning while wearing a gown but no gloves, despite EBP requirements for transfers. The DON stated EBP was only needed for catheter or wound care and not for transfers, contradicting the posted EBP instructions and facility policy.
A resident with severe dementia, psychiatric disorders, and high dependence for ADLs was verbally abused during evening care when a NA, frustrated with the resident’s crying and resistance, loudly ridiculed her as acting like a two-year-old, threatened to hit her back if struck, told her she would be sent to a locked unit, and questioned who would want to care for her when she cried like a baby. Multiple staff witnessed the loud, stern, and intimidating tone and reported it to an LPN, who recognized it as verbal abuse but did not immediately remove the NA from duty or promptly report the allegation per policy, allowing the NA to continue working on the unit. Following this incident, the resident demonstrated increased crying, combativeness, resistance to care, wandering, self-isolation, and refusal of food, fluids, and medications above baseline, with documentation of significant emotional distress and subsequent ED evaluation for aggressive behaviors and poor intake.
A resident with dementia, bilateral above‑knee amputations, vascular disease, and severe protein‑calorie malnutrition developed a wound on an amputation stump that had a dressing dated several days before any documentation or treatment orders appeared in the record. Although bath audits and nursing notes initially reported no skin issues, a later assessment described a full‑thickness stage 4 ulcer/diabetic ulcer on the stump with exposed bone, erythema/edema, slough, and moderate serosanguineous drainage. Nursing staff interviews showed no one could identify who first discovered the wound or applied the initial dressing, and there was no evidence that the wound was assessed, the provider notified, or standing orders implemented when it was first present, despite facility expectations that new wounds be promptly evaluated and reported.
Failure to Follow Professional Standards for Ophthalmic Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice for administering ophthalmic medications to a resident with dry eye syndrome and degenerative eye disease. The resident was cognitively intact, required assistance with ADLs, and had physician orders for cyclosporine ophthalmic emulsion 0.05% one drop in both eyes twice daily and Refresh Tears ophthalmic solution one drop in both eyes four times daily for dry eyes. The administration summary showed that both eye medications were scheduled for the same time and were documented as being given at the same time on multiple dates. During a medication pass observation, a trained medication aide administered the ordered oral medications, then applied gloves and instilled one drop of cyclosporine in each eye, immediately followed by one drop of Refresh Tears in each eye, without any waiting period between the two medications. The surveyors referenced guidance from the American Academy of Allergy, Asthma, and Immunology stating that when more than one eye drop is ordered, three to four minutes should be allowed between drops in the same eye, and five to fifteen minutes should be allowed between different eye medications to prevent dilution. Interviews with the DON, pharmacy consultant, and medical provider confirmed that best practice and the provider’s recommendation were to wait between administration of cyclosporine and Refresh Tears, with the medical provider specifying a fifteen-minute interval. The facility did not provide a policy on ophthalmic medications when requested. The observed practice and documented administration times demonstrated that staff did not follow these professional standards or the medical provider’s recommended interval between the two eye medications.
Failure to Follow Wheelchair Transport Care Plan Leads to Fall With Injuries
Penalty
Summary
The deficiency involves the facility’s failure to implement care-planned fall prevention interventions for a resident at high risk for falls, resulting in a fall with injury. The resident had diagnoses including aphasia, dysphagia, muscle weakness, traumatic brain injury, and impaired mobility, with severe cognitive impairment documented on the MDS and dependence on staff for transfers and wheelchair transport. A care plan addressing wheelchair transport safety and positioning directed staff to ensure the resident was fully positioned and supported in the wheelchair prior to transport, verify footrests were in place prior to transport, and monitor for leaning, sliding, or unsafe positioning. An additional care-planned approach required wheelchair pedals to be on at all times. On the date of the incident, a nursing assistant transported the resident in a manual wheelchair from the shower room to the resident’s room without the foot pedals in place, contrary to the care plan. While being wheeled through the doorway, the wheelchair struck the door frame, causing the chair to stop and the resident, who had begun leaning forward, to fall out of the wheelchair onto the floor. Progress notes and ED documentation identified that the resident sustained a T12 vertebral fracture, a head injury with concussion, an abrasion and contusion to the head, a bruise to the left knee, and multiple lacerations to the right hand requiring sutures. The nursing assistant later acknowledged awareness that the foot pedals should have been on but did not apply them because the transport was only from the shower to the room. The DON confirmed that the resident’s care plan had not been followed when the fall occurred.
Failure to Implement and Update Pressure Ulcer Prevention and Treatment Led to Avoidable Unstageable Coccygeal Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, monitor, and implement individualized pressure ulcer prevention and treatment interventions for multiple high‑risk residents, resulting in an avoidable, unstageable coccygeal pressure ulcer for one resident that required surgical debridement and hospitalization. The resident had primary progressive multiple sclerosis, hereditary spastic paraplegia, obesity, and pre‑existing pressure‑related deep tissue injury to the left heel, and was identified as high risk for pressure ulcers on the Braden Scale due to constant moisture, chairfast status, very limited mobility, inadequate nutrition, and friction/shear risk. Hospital records on readmission documented irritant contact dermatitis of the bilateral gluteal cleft with specific cleansing and barrier cream orders, and facility documentation showed the resident could not reposition in bed or chair and required assist of two and a full‑body mechanical lift for transfers. Despite this, the admission/readmission skin assessment and weekly skin checks lacked measurements and detailed wound characteristics for the heel ulcer and gluteal dermatitis, and the care plan did not include comprehensive, individualized interventions beyond generic repositioning and wound care orders. After a new coccyx pressure ulcer was identified and documented as a stage 2 lesion, the facility failed to promptly and accurately update the care plan and implement recommended pressure‑relieving interventions. The wound nurse practitioner on 3/5 ordered coccyx wound care, an air mattress, pressure offloading, and a dietician consult, but the care plan was not revised and there was no evidence that an air mattress was placed on the bed for nearly two weeks. The environmental services director later confirmed that when the resident was moved to a new room, the gel mattress was not transferred, and the air mattress requested on 3/17 was not actually placed until the following day, despite being marked as completed. During this period, TAR documentation showed gaps in the every‑2‑hour repositioning order, and staff interviews revealed that CNAs were unaware of which residents were on repositioning programs, were not consistently repositioning residents, and had not received recent education on pressure ulcer prevention. The DON and RN case manager acknowledged that the coccyx wound increased in size and changed color between assessments, that the bed lacked the ordered gel mattress, and that the physician was not notified of the wound’s deterioration at that time. The facility also failed to timely modify toileting and incontinence care practices despite knowledge that the resident was being left on a bedpan for extended periods. The DON reported hearing before an IDT meeting that the resident had fallen asleep on a bedpan for an undetermined amount of time, but the care plan was not revised to discontinue bedpan use and implement a bedside commode until after the coccyx wound had significantly worsened. CNAs confirmed that the resident sometimes fell asleep on the bedpan and that they were not informed she should no longer use it until after the sore had worsened. Subsequent wound assessments documented rapid progression of the coccyx wound from a small stage 2 ulcer to a large, malodorous, necrotic wound with eschar, slough, erythema, and purulent drainage, ultimately classified as an unstageable pressure ulcer. The DON, NP, PA, and medical director all indicated that the lack of a pressure‑relieving mattress, failure to adjust pressure‑reducing interventions, and prolonged time on a bedpan likely contributed to the development and deterioration of the resident’s pressure ulcer, which was determined to be avoidable and resulted in hospitalization and surgical debridement. Additional documentation and interviews showed systemic assessment and communication failures related to pressure ulcer management. Weekly skin checks and wound assessments often omitted complete measurements, staging, and wound characteristics, and changes in wound size and appearance were not consistently recognized as deterioration or communicated to providers. The DON acknowledged that a 3/12 assessment showing increased wound size and purple discoloration should have been identified as a deep tissue injury and reported to the physician, but this did not occur. When nursing later documented foul odor, increased pain, and expanding necrotic tissue, telemedicine and PA responses deferred in‑person evaluation and ED transfer despite earlier recommendations that the resident be sent to the ED if an in‑person provider could not assess the wound. The NP ultimately found a large, malodorous, purulent wound with expanding eschar and ordered transfer to the hospital, where imaging and surgical findings confirmed a large necrotic sacral wound requiring extensive debridement. Throughout this sequence, the facility did not consistently follow its own pressure ulcer protocols, did not ensure ordered pressure‑relieving equipment was in place, and did not promptly revise care plans or interventions in response to known risk factors and documented wound changes. The report also notes that other residents reviewed for pressure ulcers were affected by similar failures in monitoring and individualized intervention, though detailed narratives focus primarily on this resident. Staff interviews revealed that CNAs relied on paper care guides that did not clearly identify residents on repositioning programs or at risk for skin breakdown, and that they were unaware of some residents’ special mattress orders or toileting restrictions. The DON and medical director stated that residents at risk for pressure ulcers should have immediate pressure‑relieving interventions and that existing ulcers require ongoing evaluation to prevent deterioration, but the documented practices for this resident did not align with those expectations. These combined actions and inactions—insufficient assessment detail, delayed or missing care plan revisions, failure to implement ordered support surfaces and repositioning, and delayed response to wound deterioration—constituted the deficiency in providing appropriate pressure ulcer care and preventing new ulcers from developing.
Failure to Assess, Care Plan, and Obtain Consent for Bed Grab Bar Use
Penalty
Summary
The deficiency involves the facility’s failure to follow required procedures before installing and using bed grab bars for a resident. The resident had diagnoses including spastic hemiplegia affecting the left side and muscle weakness, and an admission MDS indicating moderate cognitive impairment. During observation, the resident was seen in a power chair with bilateral grab bars on the bed and reported using them to roll in bed and for transfers. The resident’s care plan, dated 1/23/26, documented a need for assistance with bed mobility and independence with transfers but did not mention or address the use of grab bars or side rails. Review of the electronic medical record showed no completed grab bar/side rail or bed mobility device assessment to determine the necessity of the grab bars or whether the resident could safely use them. There was also no evidence that the resident or the resident’s representative had been educated on the risks of having a grab bar on the bed or that informed consent had been obtained. In interviews, an LPN and the ADON both stated that a bed mobility device assessment was required to determine need and safety prior to installing grab bars, and both confirmed that no such assessment was present in the resident’s record.
Failure to Perform Hand Hygiene and Change Gloves During Wound Care
Penalty
Summary
Surveyors observed that a registered nurse (RN) and a nurse practitioner (NP) did not follow the facility’s established infection control practices during wound care for one resident. During a wound treatment, the RN wore gloves while removing the dressing from the resident’s left heel, then removed the dressing from the right heel, sprayed both wounds with wound cleanser, wiped the left heel with gauze, and then used a clean gauze pad to wipe the right heel. The RN did not remove her gloves or perform hand hygiene after disposing of the soiled dressings or between cleaning the left and right heel wounds, contrary to the facility’s written wound care procedure, which requires glove removal and hand hygiene after removing the previous dressing and again after cleaning the wound. The resident’s admission MDS documented diagnoses including multiple rib fractures, heart failure, dementia, anxiety, and the presence of a pressure ulcer, and indicated the resident was cognitively intact and required staff assistance with care and transfers. The resident’s care plan identified pressure ulcers on both heels requiring wound care. In interviews, the RN, NP, and the DON/infection prevention nurse each stated that gloves should be changed when moving from dirty to clean areas and that hand hygiene is expected after glove removal and between wounds to prevent infection, confirming that the observed practice did not align with facility policy or expected infection control standards.
Failure to Timely Revise Care Plan for Toileting and Skin Integrity
Penalty
Summary
The deficiency involves the facility’s failure to timely revise and individualize a resident’s care plan to address toileting and incontinence needs in relation to impaired skin integrity. The resident had diagnoses including primary progressive multiple sclerosis, hereditary spastic paraplegia, obesity, and a pressure-induced deep tissue injury to the left heel. A Significant Change MDS identified the resident as dependent for toileting hygiene, with lower extremity range-of-motion limitations, wheelchair use, dependence for transfers, occasional urinary incontinence, intact cognition, and at risk for pressure ulcers with existing unhealed pressure injuries and MASD. The resident’s skin-focused care plan, revised on various dates, included skin inspections, wound care orders, weekly skin checks, pressure ulcer care to the left heel, nutritional supplements, and a gel mattress, but did not include an individualized toileting or incontinence plan. On a weekly skin check dated 3/3/26, nursing staff identified a new Stage 2 pressure ulcer on the coccyx and contact dermatitis on both gluteal folds. An IDT Final Post Review Follow Up dated 3/10/26 (signed 3/23/26) documented that a new skin issue had occurred and that interventions after the incident included wound care treatment orders, increased repositioning, and increased incontinent care. However, the resident’s care plan from 3/3/26 through 3/16/26 did not show revisions reflecting increased incontinence care or a repositioning schedule, and the care plan was not updated to include these elements until 3/17/26. During this period, the care plan still lacked an individualized toileting plan despite the resident’s identified incontinence and new coccyx pressure ulcer. Progress notes on 3/17/26 documented that the resident’s coccyx wound had declined, with an evaluation describing a deteriorating wound characterized as a Kennedy terminal ulcer/End of Life, staged as a Stage 4 pressure ulcer, in-house acquired, with increased size, exudate, odor, pain, and surrounding erythema. On that same date, the skin focus care plan was revised to include prompt incontinence care and keeping the skin clean and dry, and the elimination focus care plan was revised to address incontinence due to neurogenic bladder with use of a bedside commode offered every 2–3 hours. A nursing assistant reported that when working with the resident, the resident would sometimes fall asleep on the bedpan and forget to ask staff to remove it, and that she was not aware the resident was not supposed to use the bedpan until after the sore had worsened. The DON stated that the resident’s care plan had not been revised earlier to include a turning and repositioning schedule or toileting changes, and that it should have been revised as soon as staff learned the resident was falling asleep on the bedpan, rather than waiting until after the pressure ulcer worsened.
Failure to Assess and Notify Provider for Right Gluteal Wound
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess and appropriately manage a non‑pressure skin issue on a resident’s right gluteal area, and to notify the physician in a timely manner. The resident had diagnoses including diabetes, Crohn’s disease, and a kidney transplant, and the MDS indicated occasional bowel incontinence, no pressure ulcers, and no moisture‑associated skin damage at that time. Earlier documentation identified a resolved MASD to the right gluteus, and a progress note later described a sacral wound with creams applied, noting that sores were still open and painful during application, but without any measurements, wound characteristics, or evidence of physician notification. Subsequent wound assessments documented an open lesion on the right gluteus with specific measurements on multiple dates, but did not identify the wound type or other characteristics, and the record did not show physician notification or treatment orders for the right gluteal lesion. Provider orders in place initially addressed cleansing the buttocks and applying barrier cream, and later included a detailed wound care order for a stage 3 pressure ulcer documented on the left buttocks. However, the resident’s record did not contain a specific treatment order for the right gluteal wound, despite the ongoing documentation of an open lesion in that area. Interviews revealed confusion and inconsistency in wound identification and classification. The DON stated that the right gluteal wound was documented as an open lesion because she did not feel comfortable determining the wound type, and acknowledged that the physician should have been notified when the wound was first identified. The DON was unaware that the NP had documented the wound as being on the left buttocks and as a stage 3 pressure ulcer, while the RN reported that the wound had never been on the left buttocks and that she had been applying the left‑sided wound orders to the right gluteal area because there was no open area on the left. The resident reported a recurring painful area on the right buttocks and chronic stool leakage since prior anal fistula surgery. The facility’s own wound treatment policy required comprehensive assessment of wound etiology and characteristics, consistent measurement and documentation, and provider notification in the absence of treatment orders, which were not followed for this resident’s right gluteal wound. The deficiency centers on the lack of a comprehensive wound assessment for the right gluteal lesion, incomplete documentation of wound characteristics, failure to clearly determine and document the wound etiology, and failure to notify the physician and obtain appropriate treatment orders when the wound was identified and remained open. These actions and inactions resulted in a discrepancy between the documented wound location and type and the actual clinical presentation, as well as a period during which the right gluteal wound had no specific, clearly ordered treatment despite being open and painful.
Failure to Perform Hand Hygiene and Implement Enhanced Barrier Precautions During Wound Care and Transfers
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper hand hygiene during wound care and to consistently implement Enhanced Barrier Precautions (EBP) for a resident requiring such measures. The resident had diagnoses including diabetes, a non-pressure chronic ulcer of the right lower leg, and a kidney transplant, and a wound assessment documented an open lesion on the right gluteal area. The resident’s care plan and a sign posted outside the room specified that EBP, including gown and gloves, were required for high-contact care activities such as dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, catheter care, and wound care. During one observation, the DON performed hand hygiene and donned a gown before entering the resident’s room for a telehealth wound assessment. Inside the room, the DON went into the bathroom, applied gloves without performing hand hygiene, removed the resident’s brief, and removed a foam dressing from the right gluteal area that had stool on one corner. After discarding the soiled dressing, the DON removed gloves and then applied new gloves without performing hand hygiene between glove changes. When questioned, the DON stated that hand hygiene should be done when hands or gloves are visibly soiled and before and after removing or applying gloves, and acknowledged that hand hygiene had not been performed each time gloves were removed and reapplied. In a separate observation, the resident was transferred using a sit-to-stand mechanical lift while EBP requirements were not fully followed. An NA entered the room wearing a gown and gloves with the lift, and the DON applied the lift harness under the resident’s arms and cinched the waist strap, encountering the resident’s clothing, while not wearing gloves. After the transfer to bed, the DON pulled down the resident’s pants and removed the harness while touching the resident’s clothes. Following wound care by a CNP-WOC, the DON again assisted the resident by sitting the resident on the edge of the bed, applying the lift harness, and adjusting the resident’s pants and shirt while wearing a gown but no gloves. The DON stated that EBP was only needed for catheter or wound care and not for transfers, and only upon reading the posted EBP sign acknowledged that EBP was required for all high-contact resident care activities, including transfers.
Failure to Protect Resident From Verbal Abuse and Delay in Removing Alleged Perpetrator
Penalty
Summary
The deficiency involves the facility’s failure to protect a vulnerable resident from mental abuse and to respond appropriately to an allegation of abuse. The resident had severe cognitive impairment, Alzheimer’s disease, dementia, anxiety, depression, psychotic disorder, and significant functional dependence, including frequent incontinence and the need for extensive assistance with ADLs and transfers. Her care plan identified behavioral and mood issues such as wandering, yelling, combative behavior, and calling staff names, with interventions including calm approaches, emotional support, redirection, and monitoring for emotional distress and mood/behavior changes. She was identified as a vulnerable adult, with instructions to monitor for signs of emotional distress and to follow the facility’s abuse reporting policy. On the evening in question, while the resident was crying on the phone with her son and expressing a desire to leave, NA-A and NA-B entered to provide evening care using an EZ stand lift. After the resident ended the phone call, multiple staff reported that NA-A spoke to the resident in a loud, stern, and frustrated tone, telling her to stop crying and that she was acting like a two-year-old. When the resident swatted at NA-A, NA-A stated, “If you hit me, I’m going to hit you back,” and later told the resident she was “in trouble now.” Staff reported that NA-A told the resident she would be sent to a locked unit so she could not get out, and questioned who would want to care for her when she cried like a baby, and that nobody would want to keep working with her. NA-C described NA-A yelling commands such as “HOLD ON!” and “Stop crying! Where would you be if you were not here? Probably lying on the floor,” and felt NA-A was obviously upset and overwhelmed. These statements were made in the presence of the resident while she was already distressed and crying. Following this interaction, the resident exhibited crying, yelling, combativeness, resistance to care, wandering into other residents’ rooms, self-isolation, and refusal of food, fluids, and medications above her prior baseline, as documented in behavior charts, target behavior monitoring, and nursing progress notes. Staff documented that she cried most of the morning, was very restless, difficult to redirect, hit and pinched staff, called staff names, and refused care and meals. She required repeated redirection, 1:1 attention, and non-pharmacological interventions, and was ultimately sent to the ED for evaluation of combativeness and emotional distress, where she was treated for dementia with aggressive behavior and hypoglycemia related to poor intake. The report identifies that the resident’s actual response and the reasonable person concept showed serious psychosocial harm, including increased crying and combative behavior above baseline, fear/anxiety manifested as combativeness, resistance to care and social interaction, and self-isolation. The facility also failed to immediately remove the alleged perpetrator from resident care and to promptly report and investigate the allegation in accordance with its abuse policy. After NA-B and NA-C reported to LPN-A that NA-A had yelled at and threatened the resident, LPN-A acknowledged it as verbal abuse but did not initiate immediate protective measures or timely reporting. LPN-A stated she believed she had 24 hours to report because there was no injury, despite facility policy requiring reporting within two hours. NA-A remained on the unit and continued working until the end of her shift, including after staff had clearly communicated their concerns to LPN-A. TMA and NA staff described uncertainty about their authority to remove NA-A and reliance on the nurse to act, while the DON later informed LPN-A that NA-A should have been removed from the floor to prevent further danger to residents. The Immediate Jeopardy was determined to have begun when NA-A’s derogatory, intimidating, and threatening statements were made and continued while she remained on duty with access to the resident and other vulnerable residents.
Failure to Timely Assess and Treat Newly Discovered Stump Wound
Penalty
Summary
The deficiency involves the facility’s failure to provide timely treatment and care for a newly discovered wound on a resident’s above‑knee amputation stump. The resident was admitted with diagnoses including unspecified dementia with behavioral disturbances, vascular dementia, bilateral above‑knee amputations, vascular disease, reduced mobility, and severe protein‑calorie malnutrition, and had no documented ulcers or skin problems on admission or on the most recent MDS. A weekly bath audit on 3/17/26 documented only non‑tender lymph nodes on the right upper hip and did not identify any open areas. However, when the wound was later assessed, the dressing on the stump was dated 3/16/26, indicating that a wound and dressing existed at that time, even though no corresponding assessment, provider notification, or treatment orders were documented. On 3/23/26, nursing staff documented a new skin issue above the resident’s knee at the amputation site, describing a stage 4 pressure ulcer/injury with full‑thickness skin and tissue loss, exposed bone, erythema/edema, and moderate serosanguineous exudate. The wound measured 1.56 cm by 1.64 cm, with 20–29% granulation tissue and 80% slough. A progress note and skin issues assessment on that date confirmed the wound characteristics and staging, and the NP, after reviewing a picture, determined the wound to be a diabetic ulcer with peripheral vascular disease and severe protein‑calorie malnutrition as contributing factors. On that same date, the NP was notified, antibiotic therapy (doxycycline) was ordered for possible cellulitis, and specific wound care orders were initiated, with documentation on the MAR that these treatments were carried out beginning 3/23/26. Multiple interviews with nursing staff revealed that no one could identify who discovered the wound or who applied the initial dressing dated 3/16/26, and there was no documentation of a wound assessment, provider notification, or interim treatment between 3/16/26 and 3/22/26. Several RNs and LPNs who worked shifts from 3/16/26 through 3/20/26 stated they did not notice a wound on the stump and that, per their usual practice, they would have contacted the provider and initiated treatment if they had found one. One LPN recalled seeing a band‑aid with a date on the stump but could not recall the date, and another LPN stated she did not see the wound because she was not looking for one. The facility’s standing orders required staff to assess all wounds daily, change dressings every three days and as needed, treat with normal saline or non‑cytotoxic cleanser and appropriate dressings, and notify the provider the next business day when a new wound or injury was found. Despite these expectations, the wound identified by the dated dressing on 3/16/26 was not assessed, reported, or treated according to orders and facility policy until 3/23/26.
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