Cura Of Melrose
Inspection history, citations, penalties and survey trends for this long-term care facility in Melrose, Minnesota.
- Location
- 101 5th Avenue Nw, Melrose, Minnesota 56352
- CMS Provider Number
- 245396
- Inspections on file
- 24
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Cura Of Melrose during CMS and state inspections, most recent first.
A resident with dementia, osteoporosis, and a history of falls had a care plan and Kardex directing that her electric lift recliner remain unplugged and be used only as a stationary chair, with additional interventions such as signage, grip strips, and appropriate non-slip footwear. Despite this, staff and possibly family intermittently plugged in the recliner, staff did not consistently check whether it was plugged in, and the resident was twice found face down on the floor in front of the recliner when it was in the highest position, sustaining a large frontal hematoma, skin tear, and pain requiring ED evaluation. Observations also showed the resident wearing regular nylon socks instead of anti-slip footwear, and staff interviews confirmed that the care-planned interventions for the recliner and footwear were not reliably implemented, contrary to facility policy that staff follow the care plan and Kardex.
A resident with parkinsonism, dementia, and other conditions had a care plan and hot liquid safety evaluation requiring use of covered mugs for hot beverages outside the dining room after prior coffee spills and documented thigh burns from a coffee spill. Despite this, the resident was later observed in her room with a hot coffee cup without a lid, and she reported that staff had not been providing the required cover. A NA-C, an RN, and the interim DON all acknowledged that the resident was supposed to have covered cups per the care plan, but this intervention was not consistently implemented.
A resident with dementia and impaired mobility, requiring a full body mechanical lift and two staff for transfers, was instead pivot-transferred by a nursing assistant who did not consult the care plan or use a gait belt. The resident fell, later developed pain and swelling, and was diagnosed with a fractured fibula. Staff interviews confirmed the care plan was not followed and facility policy was not adhered to.
A resident with dementia and impaired mobility, who required transfer with a mechanical lift, was instead pivot transferred by a staff member, resulting in a fall and a fractured ankle. The facility's report to the SA omitted the fact that the care plan was not followed, and the DON did not provide full details about the incident or the root cause, despite being aware of the deviation from the care plan.
A resident did not receive appropriate care for existing pressure ulcers, and the facility did not implement adequate measures to prevent new ulcers from developing.
Staff did not promptly inform a resident, their physician, and a family member about important events such as injury, decline, or room changes, resulting in a breakdown of required communication.
Staff failed to follow enhanced barrier precautions and proper hand hygiene while providing care to a resident with a suprapubic catheter, open wound, and UTI. Despite clear signage and available PPE, staff did not consistently wear gowns or perform hand hygiene during high-contact care activities, including catheter and wound care, as confirmed by staff interviews and direct observation.
The facility failed to provide timely call light responses for four residents, leading to incidents of incontinence and frustration. Device activity reports showed response times exceeding two hours. Staff felt rushed, contributing to delays, and the DON acknowledged the issue, with expected response times not being met.
The facility failed to implement necessary interventions for two residents to prevent further decline in range of motion and mobility. One resident with a history of stroke and hemiplegia had inconsistent completion of passive range of motion exercises, while another cognitively impaired resident's program was rarely completed. Staff cited time constraints as a reason for not performing the exercises, and documentation often lacked rationale for non-completion.
Failure to Follow Care Plan for Lift Recliner and Fall-Prevention Interventions
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow care-planned safety interventions for a resident with a history of falls and use of an electric lift recliner, resulting in an avoidable accident with actual harm. The resident had dementia, depression, overactive bladder, and osteoporosis, and the MDS showed intact cognition but a need for substantial to maximal assistance with transfers and toileting. The care plan, revised in December, identified risk for injury related to falls and specifically to electric recliner use, with interventions including keeping the electric lift recliner unplugged so it functioned only as a stationary chair, use of appropriate footwear, grip strips in the room, and signage. The Kardex also instructed staff, per therapy, to keep the recliner unplugged to promote safety. Despite these documented interventions, the resident experienced multiple falls associated with the recliner. An incident report from late May documented the resident being found face down on the floor in front of the recliner, which was in the highest position, suggesting an attempted self-transfer; the post-fall investigation concluded the resident appeared to have attempted to self-transfer and directed that the recliner remain unplugged. A subsequent incident in mid-December again found the resident face down on the floor with pooling blood, a large frontal hematoma, a skin tear, and complaints of hip, elbow, and neck pain, with the recliner again in the highest position. The post-fall investigation and ED provider note both indicated the resident attempted to get out of the lift chair after it had been plugged in, despite the care plan stating the chair was to remain unplugged. Staff interviews confirmed that the care plan intervention to keep the recliner unplugged was not consistently followed. Nursing staff and NAs acknowledged awareness that the recliner was not supposed to be plugged in due to prior falls but reported they did not routinely check whether it was plugged in, sometimes assuming no one would have plugged it in. Staff and a family member stated that both staff and family had plugged in the chair at times, and the family member reported the resident would not have been able to plug it in herself. Observations also showed the resident seated in a wheelchair with regular nylon socks rather than anti-slip footwear, even though appropriate footwear was a listed intervention in the care plan. The facility’s own policy stated that the care plan is to guide daily care and that the Kardex is comprised of care plan interventions, and that health care personnel are responsible for following the care plan, yet the interventions related to the recliner and footwear were not implemented as written.
Failure to Follow Care Plan for Hot Liquid Burn Prevention
Penalty
Summary
The deficiency involves the facility’s failure to implement care-planned interventions to reduce a resident’s risk for burns from hot liquids. The resident had diagnoses including parkinsonism, depression, anxiety, and dementia, but was care planned as having intact cognition and able to eat independently. Her care plan, dated 12/11/25, identified a risk for altered nutritional status and directed staff to provide covered mugs for hot liquids when she was outside the dining room. A Hot Liquid Safety Evaluation dated 9/19/25 documented that hot liquid temperatures were not to exceed 180 degrees and noted an isolated coffee spill event on 9/16/25, with follow-up completed on 9/17/25. Progress notes from 9/17/25 recorded that the resident reported spilling coffee in her lap while watching television and stated the coffee was “luke warm at best,” and the event was considered isolated. On 12/10/25, progress notes documented pink/red areas on the resident’s left inner thigh (10 cm x 6 cm) and right inner thigh (13 cm x 3 cm), warm to touch and tender, with the cause identified as the resident spilling coffee in her lap. Staff were then directed to put covers on hot liquids when she took them outside the dining room, and an interdisciplinary team review on 12/11/25 confirmed that she had spilled coffee while attending a movie activity and that the care plan was updated to require covered mugs for hot beverages outside the dining room. However, during an observation on 1/14/26, the resident was seen in her room with a hot coffee cup without a lid and stated she was supposed to have a lid but staff had not given her one. A NA-C and RN both indicated the resident was supposed to have covered cups when not in the dining room, and the interim DON stated the resident should have a cover on her cup as directed in the care plan. Facility policy stated that the care plan is to be used to develop residents’ daily care routines and that health care personnel are responsible for following the care plan, but this was not followed for this resident’s hot liquid precautions.
Failure to Follow Care Plan During Transfer Results in Resident Fracture
Penalty
Summary
A deficiency occurred when staff failed to follow a resident's care plan during a staff-assisted transfer, resulting in a fall and subsequent fracture. The resident, who had diagnoses including Alzheimer's disease, vascular dementia, and osteoporosis, was non-ambulatory and had a care plan requiring the use of a full body mechanical lift (EZ lift) with assistance from two staff members for transfers due to being non-weight bearing on the right lower extremity. Despite this, a nursing assistant attempted a pivot transfer without a gait belt, believing the resident could stand independently, and did not consult the resident's Kardex or care plan prior to the transfer. During the transfer, the resident's legs became weak, and the staff member assisted her to the floor. Initially, no injuries were noted, but the resident later developed pain, swelling, and bruising in the right foot. An x-ray confirmed a slightly displaced fracture of the distal fibula. The resident reported significant pain following the incident, and her family was notified. Interviews revealed that the nursing assistant had not worked regularly at the facility and did not review the care plan or use a gait belt as required by facility policy. Other staff members confirmed that the resident's transfer status had recently changed and that staff were expected to review each resident's Kardex before providing assistance. The facility's policy required verification of transfer status and the use of appropriate equipment, such as a gait belt or mechanical lift, based on the resident's care plan. The failure to follow these protocols directly led to the resident's fall and injury.
Failure to Accurately Report Incident and Care Plan Deviation to State Agency
Penalty
Summary
The facility failed to submit a report to the State Agency (SA) with sufficient and accurate information regarding an incident involving a resident with Alzheimer's disease, vascular dementia, and impaired mobility. The resident, who was non-ambulatory and required transfer assistance using an EZ mechanical stand with one staff member, experienced a staff-assisted fall when a nursing assistant attempted a pivot transfer instead of using the required mechanical lift. This deviation from the care plan resulted in the resident being lowered to the floor, and subsequent imaging revealed a slightly displaced fracture of the distal fibula. The incident report submitted to the SA did not include the critical detail that the resident was transferred by pivot with one staff member rather than with the mechanical lift as required by the care plan. Further review of communications and interviews revealed that the Director of Nursing (DON) did not provide complete information to the SA regarding the root cause of the fall or the failure to follow the resident's care plan, despite being aware of these facts from internal reports and staff communications. The DON confirmed that the report was submitted after the fracture was identified but was unsure why the report omitted the details about the improper transfer method. Additionally, the facility had not conducted a full investigation or interviewed the involved staff or resident before submitting the report, even though the incident report and verbal communications indicated the care plan was not followed.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not take adequate measures to prevent the development of new ulcers. This deficiency indicates that the necessary interventions and monitoring to manage existing pressure ulcers and prevent additional ones were not implemented as required.
Failure to Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors as a deficiency in the facility's process for keeping relevant parties informed about significant events impacting the resident's care or condition.
Failure to Implement Enhanced Barrier Precautions and Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to implement adequate infection prevention and control practices for a resident requiring enhanced barrier precautions (EBP) due to the presence of an indwelling suprapubic catheter, an open stage three pressure ulcer, and a current urinary tract infection (UTI). The resident had multiple diagnoses, including neurogenic bladder, dementia, Parkinson's disease, and osteoporosis, and required substantial assistance with activities of daily living. The care plan directed staff to monitor the catheter and wound but did not include EBP instructions. During direct care, staff entered the resident's room without donning required personal protective equipment (PPE), specifically gowns and gloves, despite clear EBP signage and available supplies outside the room. Staff assisted the resident with transferring, catheter care, wound care, and personal hygiene without consistently using gowns, and at times failed to perform hand hygiene between glove changes. Observations included staff handling soiled items, performing dressing changes, and providing peri care without proper PPE or hand hygiene, even after exposure to urine and wound sites. Interviews with the involved nursing assistants and LPN confirmed awareness of the EBP requirements and acknowledged lapses in following protocol, attributing failures to forgetfulness or unexpected care needs. The director of nursing also confirmed that staff were expected to follow EBP signage and that sitting on the floor during care was not recommended due to infection control concerns. Facility policy and posted signage clearly outlined the need for gown and glove use during high-contact care activities for residents on EBP, which was not followed in this instance.
Excessive Call Light Response Times in LTC Facility
Penalty
Summary
The facility failed to provide a reasonable call light response time for four residents, all of whom were cognitively intact and had various medical conditions such as anemia, hypertension, depression, and post-traumatic stress disorder. The device activity reports indicated numerous instances of excessive call light response times, with some exceeding two hours. These delays resulted in residents being unable to reach the restroom in time, leading to incidents of incontinence and feelings of frustration and anger among the residents. Interviews with staff, including a nursing assistant and an LPN, revealed that they felt rushed and unable to spend adequate time with residents, contributing to the long response times. The director of nursing acknowledged the issue, confirming that the facility's call light logs reflected excessively long wait times. The expected response time was stated to be 15 minutes, but this standard was not met, as evidenced by the residents' experiences and the device activity reports.
Failure to Implement Range of Motion Interventions
Penalty
Summary
The facility failed to implement necessary interventions to prevent further decline in range of motion and mobility for two residents. One resident, who had a history of stroke, arthritis, and hemiplegia, was observed with limited range of motion in his upper body. Despite having a care plan that included passive range of motion exercises, documentation showed inconsistent completion of these exercises, with numerous instances of missing documentation or the task being marked as not applicable. Interviews with staff revealed that the exercises were often not performed due to time constraints, and the importance of these exercises was emphasized by the director of therapy. Another resident, who was severely cognitively impaired and had multiple diagnoses including dementia and malnutrition, was also on a restorative nursing program for passive range of motion. However, documentation indicated that the program was rarely completed, with many days marked as not applicable. Interviews with staff and family members confirmed that the exercises were only performed when staff had time, and there was no rationale documented for the lack of completion. The director of nursing acknowledged the importance of completing these exercises to maintain the residents' current health status.
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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