Ebenezer Integrated Care & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Paul, Minnesota.
- Location
- 45 West 10th Street, Saint Paul, Minnesota 55102
- CMS Provider Number
- 245587
- Inspections on file
- 26
- Latest survey
- April 1, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Ebenezer Integrated Care & Rehab during CMS and state inspections, most recent first.
A resident with hemiplegia and multiple chronic conditions was injured after staff failed to follow the prescribed transfer protocol, which required assist of one with a gait belt, walker, and wheelchair positioned behind. During a toileting transfer, a new nursing assistant was unable to fit the wheelchair in the bathroom and attempted to move both the walker and wheelchair while supporting the resident, resulting in a fall and a fractured shoulder. Documentation and interviews confirmed the care plan was not followed, leading to actual harm.
Staff did not consistently follow Enhanced Barrier Precautions or perform proper hand hygiene during high-contact care activities for residents with wounds or other infection risks. Observations showed that staff failed to wear required gowns and gloves, did not always change gloves or sanitize hands between tasks, and handled soiled linens and resident equipment without appropriate PPE, despite facility policies and care plans indicating these measures were necessary.
A resident with a known severe allergy to ginger was served a meal containing the allergen, leading to an anaphylactic reaction. The facility failed to administer epinephrine due to insurance issues and lack of availability in the emergency kit. The resident's allergy was not accurately reflected in the nutrition program, and the meal tray ticket did not list the allergy, resulting in the resident consuming the allergen. Staff interviews revealed communication and procedural failures in managing the resident's dietary needs and emergency preparedness.
The facility failed to ensure that residents were offered and provided updated pneumococcal and influenza vaccinations according to CDC guidelines. Four residents with conditions increasing their risk for pneumococcal diseases lacked documentation of shared decision-making discussions, declinations, or risk-benefit discussions for additional vaccinations. The infection preventionist and DON confirmed the lack of documentation, despite facility policies requiring such records.
A resident with dementia was left exposed and undignified during personal care by two nursing assistants, despite her protests. The staff failed to cover her adequately, leaving her exposed when a registered nurse entered the room. Interviews with staff revealed an expectation to maintain dignity, but the involved staff admitted to not considering it during the care process.
A resident with a history of stroke, aphasia, dementia, and hemiplegia was found with Tums at his bedside without a self-administration assessment or provider order. Nursing staff confirmed the oversight and acknowledged the need for an assessment and order per facility policy, which was not completed, posing potential risks of medication interactions.
A facility failed to notify a physician of a resident's significant weight gain despite orders to do so, and also failed to follow prescribed wound care orders for another resident. The resident with CHF experienced substantial weight gain, but the physician was not informed as required. Additionally, a nurse applied incorrect wound treatment to a resident with MASD, using Medihoney instead of the prescribed Mepilex dressing. These actions were contrary to the facility's policies and care plans.
A resident with cognitive impairment, dementia, stroke, and dysphasia did not receive the necessary adaptive equipment, a nosey cup, during meals. Despite the care plan and meal tickets indicating the need for a nosey cup, observations showed the resident's meal trays lacked this equipment. Staff interviews confirmed the expectation for dietary staff to provide and nursing staff to use the adaptive equipment, but there was a failure in communication and execution.
The facility failed to ensure proper hand hygiene and infection control during care for two residents with cognitive impairments. Nursing assistants did not change gloves or perform hand hygiene after handling soiled items, and inappropriate cleaning methods were used. Interviews confirmed that expected procedures were not followed, and the facility's policies were inadequate.
A resident with known food allergies experienced an anaphylactic reaction after consuming a meal containing ginger, despite being assured by staff that it was not present. The resident's epinephrine was unavailable due to insurance issues, leading to hospitalization. The facility failed to report the incident to the State Agency in a timely manner, as required by policy.
A resident with a known ginger allergy experienced an anaphylactic reaction after consuming a meal containing ginger. The facility failed to have epinephrine available due to insurance issues, and the resident was sent to the hospital. The incident was not investigated or reported to the State Agency in a timely manner, contrary to facility policy.
A resident with dementia and moderate cognitive impairment, who was at risk for falls, slid out of her wheelchair during transportation to an appointment. The facility failed to conduct a post-fall assessment and update interventions to prevent future falls. Staff interviews revealed the resident frequently attempted to slide out of her wheelchair, and a reclining wheelchair was suggested for safer transportation. The director of nursing was not informed of the resident's risk, indicating a communication breakdown.
A resident with impaired cognition and a history of wandering was taken out of the facility by a family member, despite instructions in the EHR to prevent such outings. The resident fainted at a train station and was hospitalized. Staff miscommunication and lack of awareness of the resident's restrictions contributed to the incident.
Two residents in an LTC facility experienced significant medication errors due to transcription issues. One resident did not receive vortioxetine for over a month due to a missed transcription in the EHR. Another resident's Abilify was discontinued prematurely, leading to a resurgence of hallucinations. The facility's transcription process failed to ensure orders were double-checked and properly entered into the system.
A nursing assistant failed to remove gloves and wash hands after changing a resident's brief, performing multiple tasks without proper infection control. Interviews confirmed the lapse, and the facility's policy lacked specific guidelines.
A facility failed to ensure a pressure relief air mattress was properly assessed for safe size in relation to the bed frame and grab bars for a resident, leading to significant gaps and potential entrapment risks. Despite the resident's need for assistance and the use of grab bars, the mattress moved freely, creating unsafe conditions that were not appropriately addressed by staff or the vendor.
A facility failed to coordinate hospice services for a resident with severe cognitive impairment and schizoaffective disorder. The resident's medical record lacked essential hospice documentation, and there were ongoing coordination issues with the hospice agency, including incomplete forms and incorrect contact information. The hospice director acknowledged these deficiencies, and the facility's hospice contract and policy requirements were not met.
Failure to Follow Care Plan for Safe Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to follow the care plan interventions required for safe transfers of a resident with significant physical impairments. The resident had a history of hemiplegia and hemiparesis following a cerebrovascular event, as well as other chronic conditions including heart failure, COPD, diabetes, and atrial fibrillation. The care plan specified that the resident required assistance of one staff member with a gait belt and two-wheeled walker, with a wheelchair to follow during transfers, and contact guard assist. Despite these directives, the resident was ambulated without the required contact guard assist and without the wheelchair positioned behind her. During a toileting transfer, a new nursing assistant, on her first solo day, was unable to fit the wheelchair into the bathroom with the walker. The assistant attempted to manage the transfer by holding the gait belt while moving the walker and then the wheelchair, resulting in the resident needing to take several unsupported steps. The resident became unsteady and fell, sustaining a comminuted fracture of the proximal humerus. Documentation and interviews confirmed that the care plan was not followed during this transfer, and the wheelchair was not positioned as required. The incident was reported by the nursing assistant, and subsequent documentation indicated that the resident's care plan had not been adhered to at the time of the fall. The facility's policies required staff to follow the care plan or Kardex for transfers, and the failure to do so directly led to the resident's fall and injury. The deficiency was identified through interviews, document review, and progress notes, which all confirmed the deviation from the prescribed transfer protocol.
Failure to Implement Enhanced Barrier Precautions and Hand Hygiene
Penalty
Summary
The facility failed to implement proper infection prevention and control practices, specifically regarding Enhanced Barrier Precautions (EBP) and hand hygiene, during direct care for residents identified as requiring these measures. Observations revealed that three staff members, including nursing assistants and a physical therapist, did not consistently wear gowns and gloves as required during high-contact care activities for residents with wounds or other risk factors for multi-drug-resistant organisms. For example, during a transfer and linen change for a resident with cellulitis, lymphedema, and wounds, staff wore gloves but not gowns, and did not always change gloves or perform hand hygiene between tasks. Another resident with wounds and a history of falls was observed during room tidying and linen changes, where staff did not wear gloves or gowns as indicated by EBP signage and care plans. Staff were seen handling soiled linens, resident equipment, and personal items without appropriate PPE or hand hygiene. Interviews with staff revealed inconsistent understanding and application of EBP protocols, with some staff acknowledging lapses or uncertainty about when gowns and gloves were required. The facility's policy and care plans directed the use of EBP, including gowns and gloves, during high-contact activities such as dressing, bathing, transferring, and changing linens. However, documentation and staff interviews indicated that these protocols were not consistently followed, and order sets for residents requiring EBP lacked specific orders. The infection preventionist and nurse manager confirmed the expectations for EBP use, but observations and staff statements demonstrated gaps in adherence to infection control procedures.
Failure to Prevent Allergic Reaction Due to Inadequate Allergy Management
Penalty
Summary
The facility failed to ensure that a resident with a known severe allergy to ginger received a meal that accommodated this allergy. The resident, who was cognitively intact and required setup assistance for eating, was served a meal containing honey ginger chicken, which led to an anaphylactic reaction. Despite having an order for epinephrine to be used in such cases, the resident was not administered the medication because it was on hold due to insurance issues, and the staff did not have it available in the emergency medication kit. The resident's care plan and dietary communication indicated allergies to ginger and bee pollen, but this information was not accurately reflected in the nutrition program used by the dietary staff. The meal tray ticket for the resident did not list any food allergies, and the dietary staff failed to verify the meal contents against the resident's allergy information. This oversight resulted in the resident consuming the allergen and experiencing a severe allergic reaction, necessitating emergency medical intervention. Interviews with facility staff revealed a breakdown in communication and procedure adherence. Dietary staff were expected to enter and verify allergy information in the nutrition program, which should have prevented the ordering of allergenic foods. However, the system did not flag the ginger allergy, and the meal tray ticket did not display this critical information. Additionally, the facility's emergency preparedness was inadequate, as the necessary medication for anaphylaxis was not readily available, highlighting a significant lapse in ensuring resident safety.
Removal Plan
- Conduct a whole house audit by nutrition services to verify all residents' allergies listed in the medical record are accurately listed in the nutrition system and that those allergies accurately print on the residents' meal tray ticket.
- Implement a process to ensure residents receive appropriate food items and not receive identified food allergens.
- Ensure meal service observation identifies staff confirm the meal served matches the meal tray ticket and any food allergies listed on the meal ticket are not served.
- Ensure R23's orders and stocked medication include epinephrine.
- Review E-kit contents to ensure inclusion of epinephrine.
- Start nutrition staff education on allergy information communication and entry into the nutrition system, meal service, meal ticket and allergy review, and tray assembly.
- Start nursing staff education on verification that the meal delivered matches the tray ticket and does not contain any food allergens.
- Include nursing education on E-kit contents, use of epinephrine via a vial, standing house orders, signs and symptoms of anaphylactic reaction, procedure for allergic and anaphylactic reactions, and incident reporting.
- Educate all staff prior to their next shift.
- Continue compliance monitored via meal service audits.
- Review audit results by the quality committee.
Failure to Document Vaccination Offers and Decisions
Penalty
Summary
The facility failed to ensure that four residents were offered and/or provided updated vaccinations for pneumococcal disease, and two residents for influenza, in accordance with CDC guidelines. The residents involved had various medical conditions that increased their risk for pneumococcal diseases, such as diabetes and hepatic encephalopathy. Despite having received previous vaccinations, the facility did not document discussions of shared clinical decision-making regarding additional pneumococcal vaccines, nor did they document declinations or discussions of risks and benefits for these vaccinations. Resident 15, who had diabetes, had received previous pneumococcal vaccines but lacked documentation of further discussions or decisions regarding additional vaccinations. Similarly, Resident 33, also with diabetes, had up-to-date pneumococcal vaccinations but lacked documentation of shared decision-making for further vaccinations and had not received an influenza vaccine since 2020. Resident 54, with a history of intracerebral hemorrhage, also had complete pneumococcal vaccinations but lacked documentation of further discussions or decisions. Resident 110, with moderately impaired cognition and liver conditions, had outdated pneumococcal and influenza vaccinations and lacked documentation of discussions or decisions regarding additional vaccinations. The facility's infection preventionist and director of nursing confirmed the lack of documentation for these residents. The facility's policy required offering vaccinations and documenting refusals and discussions of risks and benefits, but these procedures were not followed. The infection preventionist stated that the process involved printing immunization reports, offering vaccines, and documenting refusals, but this was not consistently done for the residents in question.
Failure to Maintain Resident Dignity During Care
Penalty
Summary
The facility failed to maintain the dignity of a resident, identified as R35, during personal care activities. R35, who has dementia and is dependent on staff for toileting and personal hygiene, was observed during evening care being assisted by two nursing assistants (NA-C and NA-D) using a mechanical body lift. During the process, R35 was left completely nude and exposed on the bed while the nursing assistants attended to her hygiene needs. Despite R35's repeated verbal protests, the staff continued with the care without adequately covering her, leaving her exposed to the open door when a registered nurse (RN-C) entered the room. RN-C attempted to cover R35 with a hospital gown, acknowledging the importance of maintaining dignity by covering residents during care. Interviews with the staff, including NA-C, RN-D, and the Director of Nursing (DON), revealed an expectation to maintain resident dignity by covering them during care and ensuring privacy. However, the staff involved admitted to not considering the resident's dignity during the care process. The facility's policy on dignity was requested but not provided, indicating a potential gap in policy adherence or availability. The incident highlights a deficiency in maintaining resident dignity during personal care, as observed and reported by the surveyors.
Failure to Complete Self-Administration Assessment for Resident
Penalty
Summary
The facility failed to ensure a self-administration of medications assessment was completed for a resident, identified as R44, who was observed with medications at his bedside. R44 had intact cognition but was dependent on staff for personal hygiene and mobility, and required assistance with eating. His medical history included a stroke, aphasia, dementia, and hemiplegia or hemiparesis. Despite these conditions, there was no documentation in his records of an order for self-administration of medications or an assessment to determine his ability to self-administer. Observations over several days noted a bottle of Tums on his bedside table, which was confirmed by nursing staff to have been brought by his family. Interviews with nursing staff, including an RN and an LPN, revealed that the facility's policy required a self-administration assessment and a provider's order for a resident to self-administer medications. However, these steps were not completed for R44. The staff acknowledged the oversight and expressed concerns about the potential risks of medication interactions and the need for provider involvement. The facility's policy also stated that medications should be removed from a resident's room if found without proper authorization, which was not done in this case.
Failure to Notify Physician and Follow Wound Care Orders
Penalty
Summary
The facility failed to notify the physician of a significant change in condition for a resident with congestive heart failure (CHF) who experienced substantial weight gain. The resident's care plan required daily weights and notification to the provider if there was a weight gain of more than 2 pounds in one day or 5 pounds in one week. Despite the resident's weight increasing by 11.4 pounds in one week and 8.8 pounds in one day, there was no documentation indicating that the physician was informed of these changes. Interviews with nursing staff confirmed that the physician should have been notified, and the lack of notification was acknowledged by the director of nursing. Additionally, the facility failed to follow appropriate wound care orders for a resident with moisture-associated skin damage (MASD). The resident's care plan required specific wound care treatments, including cleansing with a wound cleanser and covering with a Mepilex dressing. However, during an observation, a nurse applied Medihoney, which was not part of the prescribed treatment for the resident's buttocks. The nurse was unable to find current wound treatment orders and mistakenly applied the treatment intended for a different wound on the resident's heel. The facility's policies required staff to document weight changes and notify the provider as needed, as well as to verify treatment orders before administering care. The director of nursing confirmed that staff were expected to review treatment orders if unsure and to report any changes in condition to the provider. The failure to adhere to these protocols resulted in deficiencies in both notifying the physician of the resident's weight gain and in following the prescribed wound care orders.
Failure to Provide Adaptive Equipment for Resident with Dysphasia
Penalty
Summary
The facility failed to ensure that adaptive equipment, specifically a nosey cup, was consistently provided and used for a resident with cognitive impairment, dementia, stroke, and dysphasia. The resident required a mechanically altered diet and honey thick liquids, as indicated in their care plan and meal tickets. Observations on two separate occasions revealed that the resident's meal trays did not include the necessary nosey cup, and nursing assistants assisted the resident with a normal cup instead. This was despite the meal tickets clearly indicating the need for a nosey cup. Interviews with staff, including nursing assistants, dietary aides, the kitchen manager, a registered nurse, and the Director of Nursing, confirmed that the adaptive equipment was expected to be provided by the dietary staff and used by the nursing staff. However, there was a lack of communication and follow-through when the nosey cup was not included on the meal tray. The facility's policy on adaptive equipment required staff to ensure residents were provided with the necessary special equipment to reach their highest level of functioning, which was not adhered to in this case.
Inadequate Hand Hygiene and Infection Control Practices
Penalty
Summary
The facility failed to ensure proper hand hygiene and infection control practices during the care of two residents. One resident, who had cognitive impairment and was diagnosed with dementia and heart failure, was observed in a room where a nursing assistant (NA) did not perform hand hygiene or change gloves after handling soiled items and before assisting the resident with personal care tasks. The NA used soapy water from a commode bucket to clean the floor, which was not an appropriate disinfectant, and did not notify environmental services to properly sanitize the area. Another resident, who had cognitive impairment and was diagnosed with dementia, stroke, and dysphagia, was dependent on staff for toileting and bed mobility. During care, a nursing assistant did not change gloves or perform hand hygiene after handling a soiled brief and before assisting with clean tasks. The soiled brief was placed on the floor instead of being disposed of immediately, and hand hygiene was only performed after the care was completed and the garbage was taken to the utility room. Interviews with staff, including the infection preventionist and the Director of Nursing, confirmed that the expected procedures for hand hygiene and glove exchange were not followed. The facility's policy on environmental cleaning did not outline procedures for cleaning bodily fluids, and a policy for hand hygiene was not provided. These lapses in infection control practices were observed and verified by the surveyors, indicating a deficiency in the facility's infection prevention and control program.
Failure to Timely Report Anaphylactic Reaction
Penalty
Summary
The facility failed to report an incident of potential harm to the State Agency within the required timeframe. A resident, who was cognitively intact and had known food allergies to ginger and bee pollen, experienced an anaphylactic reaction after consuming a meal that contained ginger. Despite the resident's inquiries to staff about the presence of ginger in the meal, they were incorrectly informed that it was not present. The resident's epinephrine order was on hold due to insurance issues, and the medication was not available in the emergency kit, leading to the resident being sent to the hospital for treatment. The facility's risk management records lacked evidence of an investigation or safety incident report for the anaphylactic event. Interviews with the Director of Nursing (DON) and the administrator revealed that the incident was not reported to the State Agency until over two months later. Facility policies required immediate reporting of such incidents and initiation of an internal investigation, which did not occur in this case. The failure to report and investigate the incident in a timely manner constitutes a deficiency in the facility's compliance with state and federal regulations.
Failure to Investigate Anaphylactic Reaction Incident
Penalty
Summary
The facility failed to investigate an incident involving a resident who experienced an anaphylactic reaction after consuming a meal that contained ginger, a known allergen for the resident. The resident, who was cognitively intact and required setup assistance for eating, had a documented allergy to ginger and bee pollen. Despite this, the resident was served a meal of Honey Ginger chicken thighs and Asian Stir fry vegetables, which led to the allergic reaction. The resident reported the reaction to staff and requested epinephrine, but was informed that the epinephrine order was on hold due to insurance issues and was not available in the emergency medication kit. Consequently, the resident was sent to the hospital after staff called 911. The facility's risk management records lacked evidence of an investigation or safety incident report following the resident's anaphylactic reaction. Interviews with the Director of Nursing (DON) and the administrator revealed that the event was not reported to the State Agency (SA) until over two months later. The facility's policies required immediate reporting and investigation of such incidents, but these procedures were not followed. The failure to initiate a safety event or risk management entry, as well as the delay in reporting to the SA, contributed to the deficiency identified by the surveyors.
Failure to Prevent Falls During Resident Transportation
Penalty
Summary
The facility failed to determine causal factors and develop new interventions to prevent falls for a resident with a history of falls. The resident, who had dementia, schizophrenia, and moderate cognitive impairment, was using a wheelchair for mobility and was unable to ambulate. Despite being at risk for falls due to deconditioning, balance problems, incontinence, psychoactive drug use, and a history of falls, the facility did not adequately address these risks. The resident's care plan included verbal reminders and offering to lie down when restless, but these measures were insufficient to prevent the incident. The incident occurred when the resident slid out of her wheelchair while being transported to an appointment. The transportation driver reported that the resident could not stay in the wheelchair and was sitting on the floor of the van for 10 minutes before returning to the facility. The facility's documentation lacked a post-fall assessment to identify the cause of the fall and update interventions to prevent future occurrences. Interviews with staff revealed that the resident frequently attempted to slide out of her wheelchair, and it was suggested that a reclining wheelchair would have been safer for transportation. The facility's director of nursing was not informed of the resident's risk of sliding out of her wheelchair, indicating a communication breakdown among staff. The transportation company owner expressed concern about the resident being sent alone with just the driver, suggesting that a staff member or a stretcher should accompany the resident in the future. The facility's policy on fall risk and post-fall investigation was not effectively implemented, leading to the deficiency in preventing falls for this resident.
Inadequate Supervision Leads to Resident's Hospitalization
Penalty
Summary
The facility failed to provide adequate supervision when a family member took a resident, who had impaired cognition and was an elopement and fall risk, into the community where the resident subsequently fell and was hospitalized. The resident's care plan and electronic health record (EHR) included instructions that the resident was not to go on outings or leave of absence with family due to previous incidents involving the family member. Despite these instructions, a nurse mistakenly allowed the family member to take the resident out of the facility, leading to the resident fainting at a train station and being transported to the hospital for a possible stroke. Interviews with staff revealed a lack of awareness and communication regarding the resident's restrictions. A registered nurse and a nursing assistant confirmed that the family member was allowed to take the resident out after verifying the family member's identity, despite previous instructions to the contrary. The director of nursing acknowledged that staff were initially cautious due to warnings from hospital staff about the family member, but the resident's WanderGuard alarm was removed as the resident was not exit-seeking. The facility did not provide a policy on allowing visitors to take residents out of the building when requested.
Medication Errors Affect Two Residents
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, affecting two residents. One resident, with severely impaired cognition and diagnoses of dementia and depression, was admitted with a hospital discharge order for vortioxetine, an antidepressant. However, the medication was not administered for over a month, as it was not transcribed into the electronic health record. This oversight was discovered by the consulting pharmacist, and the facility reported the error to the State Agency. Another resident, with moderately impaired cognition and diagnoses of depression, anxiety, and psychosis, was prescribed Abilify for hallucinations. The medication was initially administered but was discontinued prematurely due to a transcription error. The resident experienced a resurgence of hallucinations, which were distressing and led to physical harm from scratching. The error was identified when the nurse practitioner reviewed the medication list and found that the scheduled Abilify had been discontinued instead of just the PRN order. The facility's transcription process was flawed, as orders were not consistently double-checked, and there was no procedure for following up with providers on time-limited medication orders. The Director of Nursing acknowledged that the transcription errors occurred because the orders were not properly verified and uploaded into the electronic system. The facility's policy required orders to be double-checked and signed off, but this was not adhered to, leading to significant medication errors for the residents involved.
Failure to Ensure Proper Handwashing and Glove Usage
Penalty
Summary
The facility failed to ensure proper handwashing and glove usage during personal care for a resident. During an observation, a nursing assistant (NA) was seen changing a resident's brief and then performing multiple tasks without removing her gloves or washing her hands. These tasks included changing the resident's shirt, adjusting the bed, and handling the bed controller. The NA only removed her gloves and used hand sanitizer after leaving the resident's room and disposing of the soiled shirt in the utility room. Interviews with the NA, the Infection Preventionist (IP), and the Director of Nursing (DON) confirmed that the NA did not follow proper infection control protocols. The IP and DON both stated that staff should always remove gloves and wash or sanitize their hands after providing peri care and before moving on to other tasks. The facility's policy on handwashing and glove usage did not address the specific requirements for changing gloves and washing hands during resident care.
Improper Fit of Air Mattress on Bed Frame
Penalty
Summary
The facility failed to ensure a pressure relief air mattress was assessed for safe size in relation to the bed frame and grab bars for a resident. The resident, who was cognitively intact and had diagnoses including sepsis, muscle weakness, and encephalopathy, required substantial assistance for bed mobility and was at risk for pressure ulcers. The resident's care plan included the use of a pressure-reducing device for their bed, but the air mattress provided did not fit the bed frame properly, creating significant gaps between the mattress and the grab bars, which posed a risk of entrapment and injury. Observations revealed that the air mattress could move freely on the bed frame, resulting in gaps of up to eight inches between the mattress and the grab bars. Despite the resident's use of the grab bars for repositioning, staff often placed pillows in the gaps, which was not a sufficient or safe solution. Interviews with staff confirmed that the mattress and bed frame were incompatible, and the issue had not been identified or addressed appropriately. The facility's policies and manufacturer guidelines clearly indicated that mattresses must fit snugly against the bed frame to prevent entrapment. However, the staff failed to ensure the proper fit of the mattress, and the issue was not communicated or rectified by the vendor who delivered the mattress. This oversight led to a situation where the resident was at risk of entrapment and injury due to the improper fit of the air mattress on the bed frame.
Failure to Coordinate Hospice Services
Penalty
Summary
The facility failed to ensure proper coordination of services between the facility and the hospice agency for a resident with severe cognitive impairment and schizoaffective disorder, bipolar type. The resident's medical record lacked essential hospice documentation, including current contact information for hospice staff, a current medication list, a care plan, goals for care, hospice certification and recertifications, the hospice election form, and hospice orders. Additionally, there was no schedule for hospice visits for March 2024, and the most recent visit note by a hospice nurse was dated over a month prior, on 2/2/24. Interviews with facility staff revealed ongoing coordination issues with the hospice agency, such as unanswered emails, incomplete forms, and incorrect contact information for hospice team members. The social worker and director of nursing both confirmed that the resident's chart should have contained comprehensive hospice documentation and a visit schedule. The hospice director acknowledged the deficiencies, including missing care plans, outdated provider information, and a lack of documented visits by nursing assistants in February. The facility's hospice contract and policy both outlined the need for coordinated care and timely documentation, which were not met in this case.
Latest citations in Minnesota
A resident with dry eye syndrome and degenerative eye disease had orders for cyclosporine ophthalmic emulsion and Refresh Tears, both scheduled at the same time. Medication records and direct observation showed a TMA instilled cyclosporine drops in both eyes and immediately followed with Refresh Tears in both eyes without waiting between medications. This practice conflicted with referenced professional guidance recommending several minutes between multiple eye drops and with the medical provider’s recommendation to wait fifteen minutes between the two ophthalmic medications. No facility policy on ophthalmic medication administration was provided when requested.
A resident with severe cognitive impairment, impaired mobility, and high fall risk was care planned to have wheelchair footrests in place at all times, with staff ensuring proper positioning and monitoring for leaning during transport. A NA transported the resident in a manual wheelchair from the shower without the footrests, and while going through the doorway the wheelchair struck the door frame, causing the resident, who was leaning forward, to fall out. The resident sustained a T12 fracture, head injury with concussion, abrasions and contusions, and multiple right-hand lacerations requiring sutures, and the DON confirmed the care plan had not been followed.
A high‑risk, immobile resident with MS and prior heel DTI developed an avoidable unstageable coccygeal pressure ulcer after staff failed to consistently assess and document skin status, did not transfer or timely provide ordered pressure‑relieving mattresses, and did not reliably perform q2h repositioning. The resident was repeatedly left on a bedpan for prolonged periods despite early reports of this issue, and the toileting care plan was not revised to a bedside commode until after the coccygeal wound had significantly worsened. Wound assessments lacked complete measurements and staging, changes in wound size and color were not promptly recognized as deterioration or reported to providers, and recommended interventions from a wound NP (including an air mattress and offloading) were not promptly implemented. As a result, the coccygeal ulcer rapidly progressed to a large, necrotic, malodorous wound requiring hospital transfer and surgical debridement.
A resident with spastic hemiplegia, muscle weakness, and moderate cognitive impairment was observed using bilateral bed grab bars for bed mobility and transfers, but the care plan did not address grab bar or side rail use. Review of the EMR showed no completed bed mobility device or side rail assessment to determine the necessity or safety of the grab bars, and no documentation that risks and benefits were discussed or that informed consent was obtained. An LPN and the ADON stated that a bed mobility device assessment is required before grab bars are installed and confirmed that no such assessment existed for this resident.
A resident with bilateral heel pressure ulcers and multiple comorbidities received wound care during which an RN removed dressings from both heels, cleansed both wounds, and wiped each heel without changing gloves or performing hand hygiene between wounds or after disposing of soiled dressings. This practice conflicted with the facility’s written wound care procedure, which requires glove removal and hand hygiene after dressing removal and after wound cleansing. In interviews, the RN, NP, and DON/IP acknowledged that hand hygiene and glove changes are expected between dirty and clean tasks and between separate wounds to prevent infection.
A resident with MS, neurogenic bladder, mobility limitations, and existing pressure injuries was identified as dependent for toileting hygiene and at risk for pressure ulcers, yet the care plan lacked an individualized toileting/incontinence plan and a defined repositioning schedule. Despite a new coccyx pressure ulcer and documentation that interventions such as increased repositioning and incontinent care were needed, the care plan was not revised for a period of time to reflect these changes. During this time, the resident sometimes fell asleep on a bedpan and remained on it until staff removed it, and staff were not initially informed that the bedpan should no longer be used. The DON later acknowledged that the care plan revisions for turning, repositioning, and toileting were delayed until after the resident’s coccyx ulcer had significantly worsened.
A resident with diabetes, Crohn’s disease, bowel incontinence, and a history of MASD on the right gluteus developed an open, painful lesion on the right gluteal area that was documented over time without complete wound characteristics, clear etiology, or timely provider notification. Wound care orders were written for a stage 3 pressure ulcer on the left buttocks, while staff reported the wound was only on the right side and applied the left‑sided orders to the right gluteal wound in the absence of specific right‑side treatment orders. The DON acknowledged discomfort with staging the wound, lack of early physician notification, and confusion over wound classification, despite a facility policy requiring comprehensive wound assessment, consistent measurement, and provider notification when treatment orders are absent.
A resident with diabetes, chronic leg ulcer, kidney transplant, and a documented gluteal wound was care-planned for Enhanced Barrier Precautions (EBP), with posted instructions requiring gown and gloves for high-contact care such as transfers and wound care. During a telehealth wound assessment, the DON donned a gown and initially performed hand hygiene but then applied gloves without hand hygiene, removed a soiled dressing from the resident’s gluteal area, discarded it, removed gloves, and applied new gloves again without performing hand hygiene between glove changes. On another occasion, during use of a sit-to-stand lift, an NA wore gown and gloves, but the DON handled the lift harness, the resident’s clothing, and assisted with the transfer and repositioning while wearing a gown but no gloves, despite EBP requirements for transfers. The DON stated EBP was only needed for catheter or wound care and not for transfers, contradicting the posted EBP instructions and facility policy.
A resident with severe dementia, psychiatric disorders, and high dependence for ADLs was verbally abused during evening care when a NA, frustrated with the resident’s crying and resistance, loudly ridiculed her as acting like a two-year-old, threatened to hit her back if struck, told her she would be sent to a locked unit, and questioned who would want to care for her when she cried like a baby. Multiple staff witnessed the loud, stern, and intimidating tone and reported it to an LPN, who recognized it as verbal abuse but did not immediately remove the NA from duty or promptly report the allegation per policy, allowing the NA to continue working on the unit. Following this incident, the resident demonstrated increased crying, combativeness, resistance to care, wandering, self-isolation, and refusal of food, fluids, and medications above baseline, with documentation of significant emotional distress and subsequent ED evaluation for aggressive behaviors and poor intake.
A resident with dementia, bilateral above‑knee amputations, vascular disease, and severe protein‑calorie malnutrition developed a wound on an amputation stump that had a dressing dated several days before any documentation or treatment orders appeared in the record. Although bath audits and nursing notes initially reported no skin issues, a later assessment described a full‑thickness stage 4 ulcer/diabetic ulcer on the stump with exposed bone, erythema/edema, slough, and moderate serosanguineous drainage. Nursing staff interviews showed no one could identify who first discovered the wound or applied the initial dressing, and there was no evidence that the wound was assessed, the provider notified, or standing orders implemented when it was first present, despite facility expectations that new wounds be promptly evaluated and reported.
Failure to Follow Professional Standards for Ophthalmic Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice for administering ophthalmic medications to a resident with dry eye syndrome and degenerative eye disease. The resident was cognitively intact, required assistance with ADLs, and had physician orders for cyclosporine ophthalmic emulsion 0.05% one drop in both eyes twice daily and Refresh Tears ophthalmic solution one drop in both eyes four times daily for dry eyes. The administration summary showed that both eye medications were scheduled for the same time and were documented as being given at the same time on multiple dates. During a medication pass observation, a trained medication aide administered the ordered oral medications, then applied gloves and instilled one drop of cyclosporine in each eye, immediately followed by one drop of Refresh Tears in each eye, without any waiting period between the two medications. The surveyors referenced guidance from the American Academy of Allergy, Asthma, and Immunology stating that when more than one eye drop is ordered, three to four minutes should be allowed between drops in the same eye, and five to fifteen minutes should be allowed between different eye medications to prevent dilution. Interviews with the DON, pharmacy consultant, and medical provider confirmed that best practice and the provider’s recommendation were to wait between administration of cyclosporine and Refresh Tears, with the medical provider specifying a fifteen-minute interval. The facility did not provide a policy on ophthalmic medications when requested. The observed practice and documented administration times demonstrated that staff did not follow these professional standards or the medical provider’s recommended interval between the two eye medications.
Failure to Follow Wheelchair Transport Care Plan Leads to Fall With Injuries
Penalty
Summary
The deficiency involves the facility’s failure to implement care-planned fall prevention interventions for a resident at high risk for falls, resulting in a fall with injury. The resident had diagnoses including aphasia, dysphagia, muscle weakness, traumatic brain injury, and impaired mobility, with severe cognitive impairment documented on the MDS and dependence on staff for transfers and wheelchair transport. A care plan addressing wheelchair transport safety and positioning directed staff to ensure the resident was fully positioned and supported in the wheelchair prior to transport, verify footrests were in place prior to transport, and monitor for leaning, sliding, or unsafe positioning. An additional care-planned approach required wheelchair pedals to be on at all times. On the date of the incident, a nursing assistant transported the resident in a manual wheelchair from the shower room to the resident’s room without the foot pedals in place, contrary to the care plan. While being wheeled through the doorway, the wheelchair struck the door frame, causing the chair to stop and the resident, who had begun leaning forward, to fall out of the wheelchair onto the floor. Progress notes and ED documentation identified that the resident sustained a T12 vertebral fracture, a head injury with concussion, an abrasion and contusion to the head, a bruise to the left knee, and multiple lacerations to the right hand requiring sutures. The nursing assistant later acknowledged awareness that the foot pedals should have been on but did not apply them because the transport was only from the shower to the room. The DON confirmed that the resident’s care plan had not been followed when the fall occurred.
Failure to Implement and Update Pressure Ulcer Prevention and Treatment Led to Avoidable Unstageable Coccygeal Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, monitor, and implement individualized pressure ulcer prevention and treatment interventions for multiple high‑risk residents, resulting in an avoidable, unstageable coccygeal pressure ulcer for one resident that required surgical debridement and hospitalization. The resident had primary progressive multiple sclerosis, hereditary spastic paraplegia, obesity, and pre‑existing pressure‑related deep tissue injury to the left heel, and was identified as high risk for pressure ulcers on the Braden Scale due to constant moisture, chairfast status, very limited mobility, inadequate nutrition, and friction/shear risk. Hospital records on readmission documented irritant contact dermatitis of the bilateral gluteal cleft with specific cleansing and barrier cream orders, and facility documentation showed the resident could not reposition in bed or chair and required assist of two and a full‑body mechanical lift for transfers. Despite this, the admission/readmission skin assessment and weekly skin checks lacked measurements and detailed wound characteristics for the heel ulcer and gluteal dermatitis, and the care plan did not include comprehensive, individualized interventions beyond generic repositioning and wound care orders. After a new coccyx pressure ulcer was identified and documented as a stage 2 lesion, the facility failed to promptly and accurately update the care plan and implement recommended pressure‑relieving interventions. The wound nurse practitioner on 3/5 ordered coccyx wound care, an air mattress, pressure offloading, and a dietician consult, but the care plan was not revised and there was no evidence that an air mattress was placed on the bed for nearly two weeks. The environmental services director later confirmed that when the resident was moved to a new room, the gel mattress was not transferred, and the air mattress requested on 3/17 was not actually placed until the following day, despite being marked as completed. During this period, TAR documentation showed gaps in the every‑2‑hour repositioning order, and staff interviews revealed that CNAs were unaware of which residents were on repositioning programs, were not consistently repositioning residents, and had not received recent education on pressure ulcer prevention. The DON and RN case manager acknowledged that the coccyx wound increased in size and changed color between assessments, that the bed lacked the ordered gel mattress, and that the physician was not notified of the wound’s deterioration at that time. The facility also failed to timely modify toileting and incontinence care practices despite knowledge that the resident was being left on a bedpan for extended periods. The DON reported hearing before an IDT meeting that the resident had fallen asleep on a bedpan for an undetermined amount of time, but the care plan was not revised to discontinue bedpan use and implement a bedside commode until after the coccyx wound had significantly worsened. CNAs confirmed that the resident sometimes fell asleep on the bedpan and that they were not informed she should no longer use it until after the sore had worsened. Subsequent wound assessments documented rapid progression of the coccyx wound from a small stage 2 ulcer to a large, malodorous, necrotic wound with eschar, slough, erythema, and purulent drainage, ultimately classified as an unstageable pressure ulcer. The DON, NP, PA, and medical director all indicated that the lack of a pressure‑relieving mattress, failure to adjust pressure‑reducing interventions, and prolonged time on a bedpan likely contributed to the development and deterioration of the resident’s pressure ulcer, which was determined to be avoidable and resulted in hospitalization and surgical debridement. Additional documentation and interviews showed systemic assessment and communication failures related to pressure ulcer management. Weekly skin checks and wound assessments often omitted complete measurements, staging, and wound characteristics, and changes in wound size and appearance were not consistently recognized as deterioration or communicated to providers. The DON acknowledged that a 3/12 assessment showing increased wound size and purple discoloration should have been identified as a deep tissue injury and reported to the physician, but this did not occur. When nursing later documented foul odor, increased pain, and expanding necrotic tissue, telemedicine and PA responses deferred in‑person evaluation and ED transfer despite earlier recommendations that the resident be sent to the ED if an in‑person provider could not assess the wound. The NP ultimately found a large, malodorous, purulent wound with expanding eschar and ordered transfer to the hospital, where imaging and surgical findings confirmed a large necrotic sacral wound requiring extensive debridement. Throughout this sequence, the facility did not consistently follow its own pressure ulcer protocols, did not ensure ordered pressure‑relieving equipment was in place, and did not promptly revise care plans or interventions in response to known risk factors and documented wound changes. The report also notes that other residents reviewed for pressure ulcers were affected by similar failures in monitoring and individualized intervention, though detailed narratives focus primarily on this resident. Staff interviews revealed that CNAs relied on paper care guides that did not clearly identify residents on repositioning programs or at risk for skin breakdown, and that they were unaware of some residents’ special mattress orders or toileting restrictions. The DON and medical director stated that residents at risk for pressure ulcers should have immediate pressure‑relieving interventions and that existing ulcers require ongoing evaluation to prevent deterioration, but the documented practices for this resident did not align with those expectations. These combined actions and inactions—insufficient assessment detail, delayed or missing care plan revisions, failure to implement ordered support surfaces and repositioning, and delayed response to wound deterioration—constituted the deficiency in providing appropriate pressure ulcer care and preventing new ulcers from developing.
Failure to Assess, Care Plan, and Obtain Consent for Bed Grab Bar Use
Penalty
Summary
The deficiency involves the facility’s failure to follow required procedures before installing and using bed grab bars for a resident. The resident had diagnoses including spastic hemiplegia affecting the left side and muscle weakness, and an admission MDS indicating moderate cognitive impairment. During observation, the resident was seen in a power chair with bilateral grab bars on the bed and reported using them to roll in bed and for transfers. The resident’s care plan, dated 1/23/26, documented a need for assistance with bed mobility and independence with transfers but did not mention or address the use of grab bars or side rails. Review of the electronic medical record showed no completed grab bar/side rail or bed mobility device assessment to determine the necessity of the grab bars or whether the resident could safely use them. There was also no evidence that the resident or the resident’s representative had been educated on the risks of having a grab bar on the bed or that informed consent had been obtained. In interviews, an LPN and the ADON both stated that a bed mobility device assessment was required to determine need and safety prior to installing grab bars, and both confirmed that no such assessment was present in the resident’s record.
Failure to Perform Hand Hygiene and Change Gloves During Wound Care
Penalty
Summary
Surveyors observed that a registered nurse (RN) and a nurse practitioner (NP) did not follow the facility’s established infection control practices during wound care for one resident. During a wound treatment, the RN wore gloves while removing the dressing from the resident’s left heel, then removed the dressing from the right heel, sprayed both wounds with wound cleanser, wiped the left heel with gauze, and then used a clean gauze pad to wipe the right heel. The RN did not remove her gloves or perform hand hygiene after disposing of the soiled dressings or between cleaning the left and right heel wounds, contrary to the facility’s written wound care procedure, which requires glove removal and hand hygiene after removing the previous dressing and again after cleaning the wound. The resident’s admission MDS documented diagnoses including multiple rib fractures, heart failure, dementia, anxiety, and the presence of a pressure ulcer, and indicated the resident was cognitively intact and required staff assistance with care and transfers. The resident’s care plan identified pressure ulcers on both heels requiring wound care. In interviews, the RN, NP, and the DON/infection prevention nurse each stated that gloves should be changed when moving from dirty to clean areas and that hand hygiene is expected after glove removal and between wounds to prevent infection, confirming that the observed practice did not align with facility policy or expected infection control standards.
Failure to Timely Revise Care Plan for Toileting and Skin Integrity
Penalty
Summary
The deficiency involves the facility’s failure to timely revise and individualize a resident’s care plan to address toileting and incontinence needs in relation to impaired skin integrity. The resident had diagnoses including primary progressive multiple sclerosis, hereditary spastic paraplegia, obesity, and a pressure-induced deep tissue injury to the left heel. A Significant Change MDS identified the resident as dependent for toileting hygiene, with lower extremity range-of-motion limitations, wheelchair use, dependence for transfers, occasional urinary incontinence, intact cognition, and at risk for pressure ulcers with existing unhealed pressure injuries and MASD. The resident’s skin-focused care plan, revised on various dates, included skin inspections, wound care orders, weekly skin checks, pressure ulcer care to the left heel, nutritional supplements, and a gel mattress, but did not include an individualized toileting or incontinence plan. On a weekly skin check dated 3/3/26, nursing staff identified a new Stage 2 pressure ulcer on the coccyx and contact dermatitis on both gluteal folds. An IDT Final Post Review Follow Up dated 3/10/26 (signed 3/23/26) documented that a new skin issue had occurred and that interventions after the incident included wound care treatment orders, increased repositioning, and increased incontinent care. However, the resident’s care plan from 3/3/26 through 3/16/26 did not show revisions reflecting increased incontinence care or a repositioning schedule, and the care plan was not updated to include these elements until 3/17/26. During this period, the care plan still lacked an individualized toileting plan despite the resident’s identified incontinence and new coccyx pressure ulcer. Progress notes on 3/17/26 documented that the resident’s coccyx wound had declined, with an evaluation describing a deteriorating wound characterized as a Kennedy terminal ulcer/End of Life, staged as a Stage 4 pressure ulcer, in-house acquired, with increased size, exudate, odor, pain, and surrounding erythema. On that same date, the skin focus care plan was revised to include prompt incontinence care and keeping the skin clean and dry, and the elimination focus care plan was revised to address incontinence due to neurogenic bladder with use of a bedside commode offered every 2–3 hours. A nursing assistant reported that when working with the resident, the resident would sometimes fall asleep on the bedpan and forget to ask staff to remove it, and that she was not aware the resident was not supposed to use the bedpan until after the sore had worsened. The DON stated that the resident’s care plan had not been revised earlier to include a turning and repositioning schedule or toileting changes, and that it should have been revised as soon as staff learned the resident was falling asleep on the bedpan, rather than waiting until after the pressure ulcer worsened.
Failure to Assess and Notify Provider for Right Gluteal Wound
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess and appropriately manage a non‑pressure skin issue on a resident’s right gluteal area, and to notify the physician in a timely manner. The resident had diagnoses including diabetes, Crohn’s disease, and a kidney transplant, and the MDS indicated occasional bowel incontinence, no pressure ulcers, and no moisture‑associated skin damage at that time. Earlier documentation identified a resolved MASD to the right gluteus, and a progress note later described a sacral wound with creams applied, noting that sores were still open and painful during application, but without any measurements, wound characteristics, or evidence of physician notification. Subsequent wound assessments documented an open lesion on the right gluteus with specific measurements on multiple dates, but did not identify the wound type or other characteristics, and the record did not show physician notification or treatment orders for the right gluteal lesion. Provider orders in place initially addressed cleansing the buttocks and applying barrier cream, and later included a detailed wound care order for a stage 3 pressure ulcer documented on the left buttocks. However, the resident’s record did not contain a specific treatment order for the right gluteal wound, despite the ongoing documentation of an open lesion in that area. Interviews revealed confusion and inconsistency in wound identification and classification. The DON stated that the right gluteal wound was documented as an open lesion because she did not feel comfortable determining the wound type, and acknowledged that the physician should have been notified when the wound was first identified. The DON was unaware that the NP had documented the wound as being on the left buttocks and as a stage 3 pressure ulcer, while the RN reported that the wound had never been on the left buttocks and that she had been applying the left‑sided wound orders to the right gluteal area because there was no open area on the left. The resident reported a recurring painful area on the right buttocks and chronic stool leakage since prior anal fistula surgery. The facility’s own wound treatment policy required comprehensive assessment of wound etiology and characteristics, consistent measurement and documentation, and provider notification in the absence of treatment orders, which were not followed for this resident’s right gluteal wound. The deficiency centers on the lack of a comprehensive wound assessment for the right gluteal lesion, incomplete documentation of wound characteristics, failure to clearly determine and document the wound etiology, and failure to notify the physician and obtain appropriate treatment orders when the wound was identified and remained open. These actions and inactions resulted in a discrepancy between the documented wound location and type and the actual clinical presentation, as well as a period during which the right gluteal wound had no specific, clearly ordered treatment despite being open and painful.
Failure to Perform Hand Hygiene and Implement Enhanced Barrier Precautions During Wound Care and Transfers
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper hand hygiene during wound care and to consistently implement Enhanced Barrier Precautions (EBP) for a resident requiring such measures. The resident had diagnoses including diabetes, a non-pressure chronic ulcer of the right lower leg, and a kidney transplant, and a wound assessment documented an open lesion on the right gluteal area. The resident’s care plan and a sign posted outside the room specified that EBP, including gown and gloves, were required for high-contact care activities such as dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, catheter care, and wound care. During one observation, the DON performed hand hygiene and donned a gown before entering the resident’s room for a telehealth wound assessment. Inside the room, the DON went into the bathroom, applied gloves without performing hand hygiene, removed the resident’s brief, and removed a foam dressing from the right gluteal area that had stool on one corner. After discarding the soiled dressing, the DON removed gloves and then applied new gloves without performing hand hygiene between glove changes. When questioned, the DON stated that hand hygiene should be done when hands or gloves are visibly soiled and before and after removing or applying gloves, and acknowledged that hand hygiene had not been performed each time gloves were removed and reapplied. In a separate observation, the resident was transferred using a sit-to-stand mechanical lift while EBP requirements were not fully followed. An NA entered the room wearing a gown and gloves with the lift, and the DON applied the lift harness under the resident’s arms and cinched the waist strap, encountering the resident’s clothing, while not wearing gloves. After the transfer to bed, the DON pulled down the resident’s pants and removed the harness while touching the resident’s clothes. Following wound care by a CNP-WOC, the DON again assisted the resident by sitting the resident on the edge of the bed, applying the lift harness, and adjusting the resident’s pants and shirt while wearing a gown but no gloves. The DON stated that EBP was only needed for catheter or wound care and not for transfers, and only upon reading the posted EBP sign acknowledged that EBP was required for all high-contact resident care activities, including transfers.
Failure to Protect Resident From Verbal Abuse and Delay in Removing Alleged Perpetrator
Penalty
Summary
The deficiency involves the facility’s failure to protect a vulnerable resident from mental abuse and to respond appropriately to an allegation of abuse. The resident had severe cognitive impairment, Alzheimer’s disease, dementia, anxiety, depression, psychotic disorder, and significant functional dependence, including frequent incontinence and the need for extensive assistance with ADLs and transfers. Her care plan identified behavioral and mood issues such as wandering, yelling, combative behavior, and calling staff names, with interventions including calm approaches, emotional support, redirection, and monitoring for emotional distress and mood/behavior changes. She was identified as a vulnerable adult, with instructions to monitor for signs of emotional distress and to follow the facility’s abuse reporting policy. On the evening in question, while the resident was crying on the phone with her son and expressing a desire to leave, NA-A and NA-B entered to provide evening care using an EZ stand lift. After the resident ended the phone call, multiple staff reported that NA-A spoke to the resident in a loud, stern, and frustrated tone, telling her to stop crying and that she was acting like a two-year-old. When the resident swatted at NA-A, NA-A stated, “If you hit me, I’m going to hit you back,” and later told the resident she was “in trouble now.” Staff reported that NA-A told the resident she would be sent to a locked unit so she could not get out, and questioned who would want to care for her when she cried like a baby, and that nobody would want to keep working with her. NA-C described NA-A yelling commands such as “HOLD ON!” and “Stop crying! Where would you be if you were not here? Probably lying on the floor,” and felt NA-A was obviously upset and overwhelmed. These statements were made in the presence of the resident while she was already distressed and crying. Following this interaction, the resident exhibited crying, yelling, combativeness, resistance to care, wandering into other residents’ rooms, self-isolation, and refusal of food, fluids, and medications above her prior baseline, as documented in behavior charts, target behavior monitoring, and nursing progress notes. Staff documented that she cried most of the morning, was very restless, difficult to redirect, hit and pinched staff, called staff names, and refused care and meals. She required repeated redirection, 1:1 attention, and non-pharmacological interventions, and was ultimately sent to the ED for evaluation of combativeness and emotional distress, where she was treated for dementia with aggressive behavior and hypoglycemia related to poor intake. The report identifies that the resident’s actual response and the reasonable person concept showed serious psychosocial harm, including increased crying and combative behavior above baseline, fear/anxiety manifested as combativeness, resistance to care and social interaction, and self-isolation. The facility also failed to immediately remove the alleged perpetrator from resident care and to promptly report and investigate the allegation in accordance with its abuse policy. After NA-B and NA-C reported to LPN-A that NA-A had yelled at and threatened the resident, LPN-A acknowledged it as verbal abuse but did not initiate immediate protective measures or timely reporting. LPN-A stated she believed she had 24 hours to report because there was no injury, despite facility policy requiring reporting within two hours. NA-A remained on the unit and continued working until the end of her shift, including after staff had clearly communicated their concerns to LPN-A. TMA and NA staff described uncertainty about their authority to remove NA-A and reliance on the nurse to act, while the DON later informed LPN-A that NA-A should have been removed from the floor to prevent further danger to residents. The Immediate Jeopardy was determined to have begun when NA-A’s derogatory, intimidating, and threatening statements were made and continued while she remained on duty with access to the resident and other vulnerable residents.
Failure to Timely Assess and Treat Newly Discovered Stump Wound
Penalty
Summary
The deficiency involves the facility’s failure to provide timely treatment and care for a newly discovered wound on a resident’s above‑knee amputation stump. The resident was admitted with diagnoses including unspecified dementia with behavioral disturbances, vascular dementia, bilateral above‑knee amputations, vascular disease, reduced mobility, and severe protein‑calorie malnutrition, and had no documented ulcers or skin problems on admission or on the most recent MDS. A weekly bath audit on 3/17/26 documented only non‑tender lymph nodes on the right upper hip and did not identify any open areas. However, when the wound was later assessed, the dressing on the stump was dated 3/16/26, indicating that a wound and dressing existed at that time, even though no corresponding assessment, provider notification, or treatment orders were documented. On 3/23/26, nursing staff documented a new skin issue above the resident’s knee at the amputation site, describing a stage 4 pressure ulcer/injury with full‑thickness skin and tissue loss, exposed bone, erythema/edema, and moderate serosanguineous exudate. The wound measured 1.56 cm by 1.64 cm, with 20–29% granulation tissue and 80% slough. A progress note and skin issues assessment on that date confirmed the wound characteristics and staging, and the NP, after reviewing a picture, determined the wound to be a diabetic ulcer with peripheral vascular disease and severe protein‑calorie malnutrition as contributing factors. On that same date, the NP was notified, antibiotic therapy (doxycycline) was ordered for possible cellulitis, and specific wound care orders were initiated, with documentation on the MAR that these treatments were carried out beginning 3/23/26. Multiple interviews with nursing staff revealed that no one could identify who discovered the wound or who applied the initial dressing dated 3/16/26, and there was no documentation of a wound assessment, provider notification, or interim treatment between 3/16/26 and 3/22/26. Several RNs and LPNs who worked shifts from 3/16/26 through 3/20/26 stated they did not notice a wound on the stump and that, per their usual practice, they would have contacted the provider and initiated treatment if they had found one. One LPN recalled seeing a band‑aid with a date on the stump but could not recall the date, and another LPN stated she did not see the wound because she was not looking for one. The facility’s standing orders required staff to assess all wounds daily, change dressings every three days and as needed, treat with normal saline or non‑cytotoxic cleanser and appropriate dressings, and notify the provider the next business day when a new wound or injury was found. Despite these expectations, the wound identified by the dated dressing on 3/16/26 was not assessed, reported, or treated according to orders and facility policy until 3/23/26.
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