Ecumen North Branch
Inspection history, citations, penalties and survey trends for this long-term care facility in North Branch, Minnesota.
- Location
- 5379 -383rd Street, North Branch, Minnesota 55056
- CMS Provider Number
- 245370
- Inspections on file
- 18
- Latest survey
- July 24, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Ecumen North Branch during CMS and state inspections, most recent first.
A stack of steam table pans, labeled as clean and ready for use, was found stored with visible moisture on several pans. The director of culinary services confirmed these items should have been fully air dried and inspected for dryness before storage, in accordance with facility policy, but this process was not followed.
Laundry staff routinely left damp resident clothing, mop heads, and cleaning cloths in washing machines overnight, with the expectation that morning staff would transfer them to the dryer. This practice was confirmed by interviews with the DON, infection prevention nurse, and environmental services manager, and was not specifically addressed in the facility's laundry policy, despite written instructions prohibiting leaving damp linen in machines overnight.
The facility did not make the most recent survey results available for residents and visitors to review, as only outdated survey results were present in the binder at the front desk. The administrator confirmed that more recent recertification and complaint survey results were missing.
The facility failed to follow CDC guidelines during a COVID-19 outbreak, resulting in improper cohorting of residents and inconsistent PPE use by staff. Residents with positive and negative COVID-19 tests shared rooms, and staff did not consistently wear required PPE. Additionally, the facility did not conduct broad-based testing for staff, despite some working on multiple units.
A facility failed to assess a resident for self-administration of medications, despite the resident having severely impaired cognition and a history of respiratory issues. The resident was observed using a nebulizer without an assessment or order for self-administration. Staff confirmed the absence of a SAM order and stated that the nurse should be within eyesight during nebulizer use for safety. The facility's policy required an assessment for SAM, which was not conducted.
A resident admitted with acute on chronic diastolic congestive heart failure and requiring oxygen did not have a baseline care plan developed within 48 hours as required. The care plan was found blank a week after admission, lacking critical care information. Both an RN and the DON confirmed the oversight, and a policy on baseline care plans was not provided.
A facility failed to update a care plan for a resident with pressure ulcers, despite frequent refusals to wear prescribed Prevalon boots. The resident, with severe cognitive impairment and multiple health issues, was observed without the boots, and staff confirmed the refusals were not consistently documented. The facility's policy required care plan revisions with significant changes, which was not followed, leading to a deficiency.
A facility failed to follow provider orders for a resident with severe cognitive impairment and multiple health conditions. The resident did not receive prescribed PRN doses of furosemide for significant weight gain, and there were lapses in weekly skin assessments. The ADON acknowledged these deficiencies, citing staffing issues but emphasizing that it was not an excuse.
A facility failed to document and review a PRN opioid medication for a resident with paraplegia, anxiety, and depression. Despite being on a scheduled pain regimen, the resident had not used the PRN Oxycodone, and pain scores were frequently zero. Staff interviews revealed no clinical justification for the medication, and the pharmacy consultant recommended discontinuation due to non-use and potential risks. However, the provider denied the request, and the medication order remained active without proper documentation.
The facility failed to properly store and label resident food, as observed in unit refrigerators where items were found without proper labeling or dating. The culinary director admitted to not checking the fridges due to absence, and the administrator confirmed that staff should ensure food safety by checking dates. The facility's policy requires labeling and timely disposal of food to prevent food-borne illness.
A resident with impaired cognition and a history of falls was admitted without a comprehensive care plan addressing fall risks and interventions. Despite being identified as high risk for falls, the care plan and nursing assistant care sheet lacked necessary documentation. Interviews with facility staff confirmed the absence of required fall interventions, contrary to the facility's policy on managing falls.
Improper Storage of Food Preparation Items Due to Incomplete Drying
Penalty
Summary
During a kitchen tour with the director of culinary services, a stack of nine large steam table pans was observed on a storage rack, designated as clean and ready for food preparation. Upon inspection, five of the nine pans were found to have visible moisture, despite the facility's policy requiring all dishes to be completely air dried and inspected for dryness before storage. The director of culinary services acknowledged that the pans were not fully dry and confirmed that all dishes should be checked for dryness prior to being put away. The facility's Ware Washing policy, dated August 2023, specifies that dishes must be air dried and inspected for dryness before storage, a procedure that was not followed in this instance.
Damp Laundry Left Overnight in Washing Machines
Penalty
Summary
The facility failed to ensure that damp laundry, specifically resident clothing, mop heads, and cleaning cloths, was not left in washing machines overnight, contrary to facility policy. Laundry staff reported that it was routine practice to start a load of mop heads and cleaning rags in the washing machine at the end of their shift, leaving the items for the morning staff to transfer to the dryer the next day. Interviews with the Director of Nursing and the infection prevention nurse confirmed that the facility's laundry policy did not specifically address cleaning supplies, and both acknowledged the potential for bacterial growth when items are left damp for extended periods. The environmental services manager and administrator also confirmed this practice and indicated it could be changed if it was an infection prevention concern. The facility's written policy instructed that damp linen should not be left in washing machines overnight and that washing machine doors should be left open when not in use.
Survey Results Not Accessible to Residents and Visitors
Penalty
Summary
The facility failed to ensure that the previous year's survey results were available for residents and visitors to review. During an observation, it was noted that the survey results binder at the front desk only contained results from a survey conducted in the prior year, with no additional or more recent survey results included. Document review confirmed that the last recertification survey and two complaint surveys had been conducted after the date of the survey results present in the binder, but these were not available for review. In an interview, the administrator, who was responsible for maintaining the survey results binder, acknowledged that the most recent survey results were missing from the binder.
Inadequate COVID-19 Cohorting and PPE Compliance
Penalty
Summary
The facility failed to adhere to CDC recommendations for testing and cohorting during a COVID-19 outbreak, affecting several residents and staff. Specifically, the facility did not ensure proper cohorting of residents with confirmed COVID-19 infections, as evidenced by residents with positive and negative COVID-19 tests sharing rooms. For instance, Resident 7, who tested positive, shared a room with Resident 31, who tested negative. Similarly, Resident 39, who tested positive, shared a room with Resident 36, who tested negative. This improper cohorting was confirmed by the Director of Nursing (DON), who acknowledged that residents were more than six feet apart but did not move COVID-negative residents to separate rooms due to room availability. Additionally, the facility did not ensure that staff followed posted transmission-based precaution signs. Observations revealed that staff members, including nursing assistants and housekeepers, did not consistently wear the required personal protective equipment (PPE) when entering rooms with enhanced respiratory precautions. For example, a nursing assistant was observed wearing only a surgical mask instead of the required N95 respirator, gown, and gloves when exiting Resident 7's room. Similarly, a housekeeper entered and exited Resident 7's room wearing only a surgical mask, under the mistaken belief that PPE was only necessary for close-contact care. The facility also failed to conduct broad-based testing for staff during the outbreak, despite some staff working on multiple units and residents intermingling during group activities. The DON confirmed that staff were only tested if they exhibited symptoms or had a high-risk exposure, defined as being within six feet of a COVID-positive individual for more than 15 minutes. This approach was inconsistent with the CDC's guidance for managing a COVID-19 outbreak, which contributed to the potential spread of the virus within the facility.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to comprehensively assess a resident for self-administration of medications (SAM), which is a requirement for ensuring the safety and appropriateness of medication management. The resident in question, identified as having severely impaired cognition and a history of respiratory failure, hemiplegia, and hemiparesis following a cerebral vascular accident, was observed using a nebulizer without a proper assessment or order for self-administration. The resident's care plan and medical records lacked documentation of an assessment for SAM, and there was no order permitting the resident to self-administer medications. Observations and interviews revealed that the resident was left alone with a nebulizer mask on, which was considered a form of self-administration by the facility's staff. The LPNs and the assistant director of nursing confirmed that the resident did not have an order for SAM and that the nurse should remain within eyesight of the resident during nebulizer treatments for safety reasons. The facility's policy required an interdisciplinary team to assess each resident's cognitive and physical abilities to determine the safety and appropriateness of self-administering medications, which was not done in this case.
Failure to Implement Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident who was admitted with acute on chronic diastolic congestive heart failure and required two liters of oxygen via nasal cannula. The resident's admission orders were dated 7/31/24, but as of 8/7/24, the baseline care plan was found to be blank, lacking essential information such as transfer status, activities of daily living performance, assistive device use, impairments, or special treatments like oxygen use. During interviews, both a registered nurse and the director of nursing confirmed that the baseline care plan had not been completed within the required timeframe, acknowledging the importance of timely care plan development to ensure proper resident care. A policy on baseline care plans was requested but not provided.
Failure to Revise Care Plan for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to review and revise the care plan for a resident with pressure ulcers, leading to a deficiency in care. The resident, identified as having severely impaired cognition and multiple diagnoses including hypertension, chronic kidney disease, dementia, respiratory failure with hypoxia, peripheral vascular disease, and hemiplegia following a cerebral vascular accident, was dependent on staff for assistance with mobility and hygiene. The care plan included interventions such as offloading and repositioning every two hours, weekly skin inspections, and the use of Prevalon boots to prevent pressure ulcers. However, observations revealed that the resident was often not wearing the Prevalon boots as prescribed, and staff interviews confirmed that the resident frequently refused to wear them. Despite the resident's refusals, the facility did not update the care plan to reflect these challenges or document the refusals consistently. The assistant director of nursing acknowledged the importance of real-time updates to care plans to ensure appropriate care but noted that the resident's increased mobility made the boots cumbersome. The facility's policy required care plans to be reviewed and revised with significant changes in the resident's condition or when desired outcomes were not met, but this was not adequately done in this case, resulting in a deficiency.
Failure to Follow Provider Orders for Medication and Skin Assessments
Penalty
Summary
The facility failed to adhere to provider orders for a resident with severe cognitive impairment and multiple health conditions, including hypertensive heart disease, chronic kidney disease, and pressure ulcers. The orders included administering furosemide as needed for significant weight gain and conducting weekly skin assessments. However, the facility did not administer the prescribed PRN doses of furosemide on occasions when the resident experienced weight gains exceeding two pounds. Additionally, there were multiple lapses in performing the required weekly skin assessments over several months. The assistant director of nursing acknowledged these deficiencies, attributing them to the high use of licensed agency staff and a trained medication aid, although she emphasized that this was not an excuse. The facility's failure to follow the orders was confirmed during an interview, and the relevant policies were requested but not provided. The resident's care plan included interventions for monitoring weight and skin condition, but these were not consistently implemented, leading to the identified deficiencies.
Lack of Documentation for PRN Opioid Medication
Penalty
Summary
The facility failed to provide appropriate documentation and physician review for a PRN opioid medication ordered for a resident, identified as R11, who was cognitively intact and diagnosed with paraplegia, anxiety, and depression. Despite being on a scheduled pain medication regimen, R11 had not received any PRN pain medication or non-medication interventions for pain. The provider visit notes from February 2024 lacked documentation justifying the need for PRN Oxycodone for severe pain, and there were no notes available for a visit on February 23, 2024. The order for Oxycodone 5 mg by mouth twice daily as needed for severe pain was placed on February 23, 2024, and remained active despite R11's pain scores frequently being rated at zero, with occasional ratings between 1 and 4. The electronic medication administration record indicated that R11 had not taken the PRN Oxycodone since the order was placed. Interviews with staff revealed that the medication lists were monitored for unnecessary medications, including PRN pain medications like Oxycodone. However, there was no clinical documentation supporting the need for the PRN medication, and the nursing staff had not discussed the medication with the provider. The pharmacy consultant recommended reviewing and discontinuing the Oxycodone in July 2024, as it was not being utilized, but the request was denied by the provider. The pharmacy consultant noted the lack of documentation for the need of the medication and expressed concerns about the increased risk of addiction and diversion by keeping the medication order active. The assistant director of nursing stated that if a resident wanted to keep a medication active without utilizing it, the staff and provider needed to justify the medication or find a different intervention for the resident's comfort.
Failure to Properly Store and Label Resident Food
Penalty
Summary
The facility failed to ensure proper food storage practices in accordance with regulations for food safety, as observed during a survey. Specifically, the facility did not label and date resident food items and failed to remove expired food from unit refrigerators. During observations, a resident meal was found in the [NAME] unit refrigerator with a label and date, and in the Wild River unit refrigerator, a plastic container of blueberries with initials but no open date, and a hard plastic container of leftover green beans with a resident name and date were found. The culinary director (CD) acknowledged these issues, noting that leftover food should be discarded after three days to prevent food-borne illness, but admitted that he had been absent from work for a week and no one else checked the unit fridges in his absence. The facility's policy, as stated by the administrator, requires labeling food with the resident's initials and the date of opening, and the CD is responsible for checking unit fridges for expired food. However, the administrator also stated that staff should check food dates even when the CD is not present. The facility's 'Food from Outside Sources' policy mandates that personal food items be labeled with the resident's name and date, placed in an impervious container with a lid, and disposed of per the manufacturer's date or three days after marking. The policy also states that improperly packaged, labeled, or dated personal items will be discarded to maintain food safety and minimize the risk of food-borne illness.
Failure to Develop and Maintain Comprehensive Fall Care Plan
Penalty
Summary
The facility failed to ensure a comprehensive care plan was developed and maintained for a resident identified as being at high risk for falls. The resident, who had impaired cognition and a history of falling, was admitted with a Minimum Data Set indicating these risks. However, the resident's care plan, dated June 10, 2024, lacked any information related to fall risk and fall interventions. Additionally, the nursing assistant care sheet, which was undated, indicated the resident was at high risk for falls but did not include any specific fall interventions. Interviews with facility staff, including a nurse practitioner, licensed practical nurses, registered nurses, and the assistant director of nursing, revealed that all residents should have documented fall interventions, especially those with a history of falls. The staff confirmed that the resident's care plan did not include necessary fall risk assessments or interventions, and there was a lack of documentation on the nursing assistant care sheet. The facility's policy on managing falls directed staff to implement a resident-centered fall prevention plan, which was not followed in this case, leading to the deficiency.
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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