Edenbrook Of Edina
Inspection history, citations, penalties and survey trends for this long-term care facility in Minneapolis, Minnesota.
- Location
- 6200 Xerxes Avenue South, Minneapolis, Minnesota 55423
- CMS Provider Number
- 245275
- Inspections on file
- 41
- Latest survey
- January 22, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Edenbrook Of Edina during CMS and state inspections, most recent first.
The facility failed to implement and maintain an effective fall management program for multiple high-risk residents, including those with hemiplegia, Parkinson’s disease, stroke, dizziness, and cognitive impairment. One resident with chronic dizziness and severe cognitive deficits had multiple unwitnessed falls and self-transfers despite documented high fall risk, incomplete orthostatic BP monitoring, and inconsistent environmental interventions such as missing no-skid tape near the bed. Another resident with Parkinson’s disease and dizziness was identified as a moderate fall risk at admission but had no fall-prevention care plan initiated before experiencing an unwitnessed fall while walking to the bathroom unassisted, resulting in a spinal fracture and hospitalization. A third resident with stroke-related deficits and visual impairment had repeated unwitnessed falls linked to self-transfers, call light access, and shoe use, while incident reports and IDT reviews lacked comprehensive causal analysis and timely care plan revisions. Staff interviews showed that NAs and LPNs were often unaware of residents’ transfer status and specific fall interventions, and baseline or updated care plans were delayed or incomplete, contributing to repeated falls and serious injuries.
The facility failed to operate its QAPI committee in accordance with its written plan by not identifying falls as a high-risk, problem-prone area, not initiating Performance Improvement Projects, and not conducting root cause analyses despite repeated elevations in fall rates and internal metric triggers for falls with major injury. Over multiple months, fall rates per 1,000 resident days exceeded the facility’s goal, with many unwitnessed falls occurring primarily in resident rooms and bathrooms, yet Quality Review minutes showed only data tracking without analysis of causal factors or development of system-wide corrective actions. Several residents experienced multiple unwitnessed falls, including two who sustained major injuries (a left tibial fracture and a spinal fracture) requiring hospitalization, and one major injury event was not accurately reflected in quality meeting minutes. Interviews with the DON, regional clinical leader, and medical director confirmed that concerns about increased falls were not brought forward to the QAPI committee and that the medical director was not informed of the rise in falls.
Two residents with significant neurological and mobility-related diagnoses experienced unwitnessed falls that resulted in serious injuries, including a T12 compression fracture and a comminuted tibial plateau fracture. In both cases, staff documentation identified the falls as explainable events, incident reports lacked comprehensive fall investigations and analysis of causal factors, and one resident’s baseline care plan and toileting plan were not in place before the falls. An LPN could not describe required transfer methods or fall-prevention interventions for one resident, and prior episodes of dizziness for the other resident were not followed by thorough assessment or individualized fall-prevention strategies. Despite hospital findings of major injuries and MDS coding of a fall with major injury, the administrator did not report either serious-injury fall to the State Agency, stating they were not viewed as allegations of abuse, contrary to facility policy requiring reporting of events resulting in serious bodily injury.
The facility failed to timely revise care plans for two residents after changes in fall risk interventions and transfer status. One resident with multiple comorbidities and high fall risk had a care plan intervention for brightly colored tape on wheelchair brakes added after a self-reported fall, but later the wheelchair had anti-roll bars instead of tape and the care plan was never updated to reflect this change. Another resident with hemiplegia, epilepsy, Charcot’s foot, severe cognitive impairment, and prior falls, including a fall with fracture, continued to have a care plan requiring a total mechanical lift for transfers even though therapy had changed the resident’s transfer status to independent and the resident was self-transferring. Nursing leadership and therapy staff confirmed that the care plans were not revised in a timely manner to match current interventions and transfer recommendations.
Two residents experienced deficiencies in their living conditions at the facility. One resident, with moderate cognitive impairment, reported that staff did not respond promptly to her call light, resulting in her urinating in her brief and soiling her bed, which was not promptly addressed. Another resident, who is totally dependent on staff, had a cluttered room with supplies and personal items scattered, making it difficult for family visits. The facility lacked a policy for maintaining a homelike environment, and staff were unaware of the cleanliness status of items in the room.
A resident with a leg prosthetic did not have a comprehensive care plan addressing the prosthetic's placement and use, leading to inadequate care. The care plan lacked specific instructions, and the Kardex did not document the prosthetic, leaving staff without guidance. Interviews revealed that staff were not specifically trained on the resident's prosthetic, resulting in discomfort and improper placement. The director of physical therapy noted the need for the prosthetic during transfers, but this was not included in the care plan.
A resident with a below-the-knee prosthesis was unable to use his preferred toileting method due to staff delays in applying the prosthesis, leading to the use of incontinent briefs. Despite being aware of his bowel movements, the resident often soiled himself before staff could assist. The facility did not document attempts to provide alternative toileting measures, and staff were unaware of the resident's preferences.
The facility failed to ensure proper procedures for self-administration of medications (SAM) for three residents. One resident self-administered insulin without a SAM assessment or physician's order, another was left with medications unattended in the dining room without proper documentation, and a third had an over-the-counter pain relief roll-on in their room without a SAM assessment or order. The facility's policy required assessments and orders for SAM, which were not followed in these cases.
A resident with a feeding tube was found to have an unclean tube feeding pole in their room, with smudged areas and a tannish substance on the pole and floor. Staff interviews revealed inconsistencies in cleaning routines, with no documentation or clear protocol, leading to concerns about infection control and resident dignity.
The facility failed to provide proper wound care for a resident with a skin tear, as documented care was not administered. Additionally, false documentation of wound care was noted for two residents whose wounds had healed. Observations and interviews confirmed discrepancies in care and documentation, with staff lacking clarity on discontinuing wound care orders. The medical director expressed concern over these deficiencies, indicating a systemic issue in wound care management.
The facility failed to implement enhanced barrier precautions and proper hand hygiene during care for two residents. A resident with a history of MRSA did not receive care with the required personal protective equipment, as an LPN did not don a gown despite EBP signage. Another LPN performed wound care with improper hand hygiene, using double gloves and not sanitizing hands between glove changes, contrary to facility policy.
A resident with cognitive impairments reported rough handling by staff, leading to an abuse investigation. Despite implementing a 'Cares in Pairs' intervention requiring two staff members during care, this was not consistently followed. The facility's investigation was ongoing, and there was uncertainty about when the intervention was implemented. The facility's policy emphasized resident safety during investigations, which was not adequately followed.
A resident with post-surgical needs called 911 for assistance after being neglected by staff who were found sleeping during their shift. The resident required pain management and toileting assistance, which were not provided, leading to the involvement of police. Facility policy mandates a safe environment free from neglect, which was not upheld in this instance.
The facility did not assign a designated charge nurse for each shift, as required. An LPN reported that on a specific night, no charge nurse was assigned, and all nurses were considered in charge. The administrator confirmed that the nurses were in charge, with the DON on call for clinical concerns. The DON acknowledged the lack of a designated charge nurse, and the facility could not provide a policy on this matter.
A facility failed to report an alleged abuse incident involving a resident to the State Agency within the required timeframe. Law enforcement visited the facility to investigate claims of staff being physically rough with the resident, who has a history of PTSD and other conditions. Despite the visit, the facility did not document or report the allegations, relying on the resident's verbal assurance of having no concerns. The facility's policy requires immediate reporting and investigation, which was not followed.
A resident with a history of PTSD and renal dialysis dependence reported being mishandled by staff, prompting a police visit. Despite the facility's policy requiring investigation of abuse allegations, the DON did not initiate an investigation, citing frequent false reports by the resident's family. Interviews revealed that neither the DON, ADON, nor the administrator conducted a formal investigation or documented the incident, failing to adhere to the facility's abuse prevention policy.
Failure to Implement Effective Fall Management and Care Planning for High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement an effective fall management program, including accurate assessment, care planning, and follow-through on fall-related interventions for multiple residents at high risk for falls. For one resident with hemiplegia, epilepsy, Charcot foot, dizziness, severe cognitive impairment, and dependence in most ADLs, the record showed repeated unwitnessed falls associated with dizziness and self-transfers. Although the care plan labeled the resident as high risk for falls and listed various interventions such as low bed, therapy screens, anti-skid tape, and medication review, the facility did not complete ordered orthostatic blood pressures after falls, did not revise the care plan to address ongoing dizziness and self-transfers, and did not conduct a comprehensive assessment of the cause of the dizziness. Post-fall reviews repeatedly identified dizziness and self-transfers as root causes, but there was no evidence of a thorough root cause analysis or effective modification of interventions, and the resident’s environment lacked consistent no-skid surfaces near the bed despite independent transfers. Another resident with Parkinson’s disease, CHF, atrial flutter, diabetes, dizziness, and dyskinetic movements was identified as a moderate fall risk on a Morse Fall Scale at admission and had a PT evaluation noting unsteadiness and fear of falling. However, no fall prevention care plan was initiated after admission despite the identified risk. The resident experienced an unwitnessed fall while attempting to walk to the bathroom unassisted, after which she was found on the floor with pain in multiple areas and later diagnosed in the ED with an acute T12 compression fracture requiring hospitalization. The facility’s records showed that the baseline care plan, including fall interventions, was not initiated until after the resident had already been transferred to the hospital and did not return. Interviews with staff and the ADON confirmed that the baseline care plan had not been completed over the weekend, that there was no investigation into the fall because the resident did not return, and that the absence of a care plan increased the resident’s risk of falls. A third resident with stroke, diabetes, visual impairment, epilepsy, hemiplegia, and foot drop was assessed as high risk for falls and required substantial assistance with transfers and ADLs. The fall care plan initially identified the resident as a moderate fall risk and included general interventions such as medication review, pain evaluation, snacks, therapy, and clutter-free environment, but did not address specific, evolving fall patterns. Over a series of unwitnessed falls, the resident repeatedly attempted self-transfers, tried to retrieve a fallen call light, ambulated without assistance, and fell while trying to put on shoes. Incident reports frequently left predisposing environmental and physiological factors blank, and post-fall reviews documented root causes such as new admission, self-transfers, and balance issues but lacked comprehensive causal analysis. Care plan revisions were delayed or incomplete, with some interventions (e.g., wheelchair placement by bed, gripper socks, removal of shoes as visual cues) added days to weeks after falls, and staff interviews revealed unawareness of key fall-prevention interventions such as wheelchair placement and specific monitoring expectations. Across these residents, the facility did not consistently ensure that staff knew residents’ transfer status or fall interventions, as multiple NAs and LPNs reported needing to check the EHR or being unable to articulate current fall-prevention measures. One nurse aide caring for the resident with hemiplegia and dizziness was unaware of the resident’s transfer status and falls until checking the Kardex, which showed a total mechanical lift order that was not being followed, while the resident was observed independently transferring without no-skid tape at the bedside. Another LPN caring for the same resident acknowledged daily reports of dizziness but could not identify any fall-prevention interventions in place. For the resident with Parkinson’s disease, the LPN who found her on the floor could not describe how the resident was supposed to transfer or what fall interventions should have been used. These documented inactions and gaps in assessment, care planning, and staff awareness contributed to multiple unwitnessed falls, including two residents who sustained major injuries (a tibial plateau fracture and a spinal fracture) requiring hospitalization. The facility’s fall incident documentation and IDT post-fall reviews repeatedly lacked complete information on environmental, physiological, and situational predisposing factors, and often recorded generic immediate actions such as encouragement to call for help, without detailed analysis of why residents continued to self-transfer or how dizziness, balance, cognition, and environmental setup contributed to the falls. Orders and recommendations for orthostatic blood pressure monitoring for the dizzy resident were not carried out or documented, and there was no evidence that the results were evaluated or used to adjust care. Residents reported not being involved in care plan development or being asked about symptoms such as dizziness, and one resident’s family member reported that a requested fall mat was never provided. Collectively, these actions and omissions demonstrate that the facility failed to maintain an environment free from accident hazards and did not provide adequate supervision and individualized fall-prevention interventions for residents at known risk for falls.
Failure of QAPI Committee to Analyze and Address Increased Falls and Falls With Major Injury
Penalty
Summary
The deficiency involves the facility’s failure to implement its Quality Assurance and Performance Improvement (QAPI) program in accordance with its written plan, specifically related to identifying, analyzing, and responding to increased resident falls and falls with major injury. The facility’s QAPI Plan requires the QAA committee to review data monthly, identify high-risk and problem-prone areas, initiate Performance Improvement Projects (PIPs), conduct root cause analyses, and develop system-level corrective actions. Facility records, Quality Review minutes, QAPI documentation, and incident reports showed that falls, including falls with major injury, triggered internal quality measures in multiple quarters, but the QAPI documentation did not show initiation of sustained PIPs, completion of comprehensive root cause analyses, or implementation and monitoring of system-wide corrective actions related to falls. Quality Review documentation over several months showed that the facility tracked fall rates per 1,000 resident days with a stated goal of 5, and repeatedly recorded fall rates above this goal. For example, fall rates and counts included: March (4.2; 9 falls), April (15.1; 31 falls), May (5.9; 12 falls), June (9.0; 17 falls), July (3.1; 6 falls), August (8.5; 17 falls), September (8.3; 16 falls), October (6.1; 13 falls), and November (5.7; 12 falls month-to-date in mid-November, with 23 total falls for the month). The documentation consistently included data tables and graphs showing cumulative fall totals, with a high proportion of unwitnessed falls and a concentration of falls in resident rooms and bathrooms. Despite increases in cumulative falls between reporting periods and repeated exceedance of the facility’s fall rate goal, the Quality Review minutes did not reflect discussion of underlying or contributing factors, completion of comprehensive root cause analyses, initiation of PIPs, or development and monitoring of system-wide corrective actions related to fall prevention. The deficiency is further supported by specific fall events and harm identified in a related fall management citation (F689), which documented that the facility failed to implement a fall management program including care plans, comprehensive fall analysis, and appropriate interventions for five residents at risk for falls. These residents experienced multiple unwitnessed falls, including one resident with four unwitnessed falls and a left tibial fracture requiring hospitalization, and another resident with an unwitnessed fall resulting in a spinal fracture and hospitalization. Quality Review documentation identified at least two residents with falls resulting in major injury, but one major injury was not reflected in the November Quality Review minutes because the facility became aware of it after the report was generated, and it was still not accounted for in the subsequent quality meeting minutes. Interviews with the DON, regional director of clinical services, and medical director confirmed that, despite recognition of high fall rates and metric triggers, concerns about increased falls were not brought to the QAPI committee, and the medical director was not informed of any concern with an increase in falls.
Failure to Report Serious-Injury Falls and Inadequate Fall Investigation for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to timely report to the State Agency falls with serious injury for two residents and to conduct adequate fall investigations and care planning. One resident with Parkinson’s disease, congestive heart failure, atrial flutter, and diabetes was assessed as a moderate fall risk and required substantial assistance with transfers, toileting, and some ADLs, but the admission assessment lacked a cognitive assessment and a baseline care plan was not initiated until after the resident had already been transferred to the hospital. The resident experienced an unwitnessed fall in the early morning, was found on the floor with her head on a pillow, and was documented as having no injury, with neuro checks and vital signs completed. The incident report did not include a comprehensive fall investigation or analysis of causal factors, including the absence of care plan interventions to direct staff on the level of assistance needed for ADLs. Hospital emergency department records later showed that this resident sustained an acute superior endplate compression fracture of T12 with burst-type morphology and slight bony retropulsion, requiring pain management, a spinal brace, and physical therapy. The resident’s family member reported that the resident stated she had been on the floor for several hours before being found, and that the family member called 911 to transfer the resident to the hospital, where the spinal fracture was discovered. The LPN who found the resident on the floor was unable to state when the resident was last checked and could not articulate how the resident was supposed to transfer or what fall-prevention interventions were to be used. The administrator later stated that this fall was not reported to the State Agency because it was considered explainable and not an allegation of abuse, and the administrator was unaware that the resident’s MDS had been coded as a fall with major injury based on hospital information. The second resident had diagnoses including hemiplegia and hemiparesis following stroke, epilepsy, Charcot joint of the left ankle and foot, and dizziness, and had severe cognitive impairment and dependence in most ADLs. This resident had multiple prior falls where dizziness was repeatedly identified as a causal factor, but records lacked monitoring of dizziness and comprehensive assessments to identify individualized fall-prevention strategies. The resident then had an unwitnessed, self-reported fall in the bathroom during a self-transfer after toileting, resulting in left knee swelling and significant pain; an x-ray later showed a comminuted fracture of the left tibial plateau, and the resident was hospitalized for worsening leg/knee pain with displaced and impacted intra-articular fractures. The administrator stated that this fall also was not reported to the State Agency after knowledge of the serious injury because it was considered explainable and not an allegation of abuse, despite facility policy directing that events resulting in serious bodily injury must be reported to the State Agency.
Failure to Revise Care Plans After Changes in Fall Risk and Transfer Status
Penalty
Summary
The deficiency involves the facility’s failure to timely revise and accurately maintain comprehensive care plans for residents at risk for falls and accidents. One resident with multiple diagnoses including acute respiratory failure with hypoxia, seizures, bipolar disorder, heart failure, reduced mobility, and a history of pulmonary embolism had a fall-focused care plan identifying high fall risk and interventions such as reviewing medications, managing pain, monitoring for acute changes, using gripper socks, and keeping the environment free of clutter. After the resident self-reported an unwitnessed fall while transferring from bed to wheelchair when a wheelchair brake was not locked, the care plan was updated to include brightly colored tape on the wheelchair brakes as a reminder and discussion of risks versus benefits of self-transfers. Later observation showed the wheelchair did not have the colored tape on the brakes but instead had anti-roll bars on both wheels, and the DON confirmed that the care plan had not been revised to remove the tape intervention or add the anti-roll bars despite this change having occurred “a while back.” Another resident with hemiplegia and hemiparesis following stroke affecting the right side, epilepsy, Charcot’s joint of the left ankle and foot, dizziness, severe cognitive impairment, and dependence in most ADLs had a mobility care plan indicating limited physical mobility and an intervention requiring assist of two with a total mechanical lift for transfers. A significant change MDS indicated this resident had falls in the past six months, including a fall with fracture, but the MDS section stated no falls in the last six months and no falls with fracture. A NA reported that the resident had been self-transferring to the wheelchair multiple times during a shift and, upon reviewing the care plan, saw that it still required a total mechanical lift, prompting the NA to seek clarification. The therapy director and OT stated that the resident’s transfer status had been changed to independent on a specific date, and that therapy recommendations are provided to nursing so the care plan can be updated. The ADON acknowledged that the care plan had not been revised to reflect the change in transfer status after therapy’s recommendation, leaving the written care plan inconsistent with the resident’s current transfer abilities and practice.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for two residents, R1 and R3. R1, who has moderate cognitive impairment and is frequently incontinent, reported that staff did not respond promptly to her call light at night, resulting in her urinating in her brief and soiling her bed. On one occasion, R1's bed was made over a urine-soiled bath blanket, which was confirmed by a surveyor and staff. Despite R1's complaints, the bedding was not changed promptly, and the room had a noticeable urine odor. R3, who has no cognitive impairment but is totally dependent on staff for personal care, had a cluttered room with facility supplies covering furniture and clean supplies on the floor. His room was observed to have various items scattered, including wound care supplies, clothing, and personal items, making it difficult for his family to visit comfortably. R3 expressed a desire for his room to be organized, particularly for his wound care supplies to be placed in a bin, but this had not been addressed by the facility. The Director of Nursing acknowledged that beds should not be made if they are soiled and that residents have the right to have their rooms arranged as they wish. However, the facility did not have a policy regarding maintaining a homelike environment, and the Assistant Director of Nursing was unaware of the cleanliness status of items in R3's room. The facility's failure to maintain a clean and homelike environment for these residents was evident in the observations and interviews conducted.
Inadequate Care Plan for Resident with Leg Prosthetic
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with a leg prosthetic, leading to inadequate care and services. The resident, who had a significant change MDS indicating no cognitive impairment, was dependent on staff for various activities of daily living and had multiple diagnoses, including the absence of a right leg below the knee. Despite these needs, the resident's care plan lacked specific, person-centered details regarding the placement and use of the prosthetic. The care plan did not specify when the prosthetic should be used, how it should be placed, or if it was required during transfers with the EZ-stand. Additionally, the resident's Kardex did not document the prosthetic, leaving staff without guidance on its use. Interviews with the resident and staff revealed further deficiencies. The resident expressed discomfort and irritation from the prosthetic due to improper placement by floor staff, who lacked specific training. The assistant director of nursing and nursing assistants were uncertain about the training and care plan details for the prosthetic. The director of physical therapy acknowledged the need for the prosthetic during transfers due to the resident's balancing concerns but noted that this was not reflected in the care plan. The director of nursing confirmed the omission of the prosthetic from the Kardex and believed that general prosthetic care training was sufficient, despite the lack of specific instructions for the resident's needs.
Failure to Accommodate Resident's Toileting Preferences
Penalty
Summary
The facility failed to meet a resident's needs and choices for performing activities of daily living, specifically toileting, for a resident with a below-the-knee leg prosthesis. The resident was unable to use his preferred method of toileting due to staff not being able to apply the prosthesis in a timely manner, which was necessary for transferring the resident to the toilet or commode chair as indicated in his care plan. The resident expressed feeling like a baby because he was made to wear an incontinent brief, despite being aware of his need to defecate. However, by the time staff arrived to assist him, he had often already soiled himself. The resident's medical history included chronic congestive heart failure, acute respiratory failure, type II diabetes, morbid obesity, and amputations of the right leg below the knee and left foot. Despite these conditions, the resident had no cognitive impairment and was aware of his bowel movements. The care plan indicated that the resident was to have incontinence care after each episode and was encouraged to sit on the toilet to evacuate bowels if possible. However, the facility did not document any attempts at alternative measures to allow the resident to be free from wearing an incontinent brief. Interviews with staff revealed a lack of awareness and training regarding the resident's preferences and needs. The Assistant Director of Nursing believed the resident wanted to wear briefs, while the Director of Nursing was unaware of the resident's wishes to not wear an incontinence pad. The nursing assistant stated he did not ask the resident if he wanted to use the commode or toilet, assuming it was not the resident's wish. The facility's plan was for the resident to use the toilet or commode, but due to the resident's refusal to wear the prosthetic, he was required to wear an incontinence pad. The facility did not provide a policy regarding activities of daily living when requested.
Failure to Ensure Proper Self-Administration of Medications
Penalty
Summary
The facility failed to ensure proper procedures for self-administration of medications (SAM) were followed for three residents. For one resident, who was admitted with a history of managing their own diabetes and insulin, the facility did not complete a SAM assessment or obtain a physician's order before allowing the resident to self-administer insulin. The resident had been managing their diabetes for many years and brought their own insulin and syringes from home. Despite the resident's ability to communicate and understand staff, the facility did not involve the interdisciplinary team or document the resident's clinical appropriateness for SAM. The resident's blood sugar levels were not recorded on the day of admission, and there was a discrepancy between the resident's self-administered insulin dosage and the physician's orders. Another resident, who was cognitively intact and varied in their need for assistance with activities of daily living, was observed with medications left unattended in the dining room. The resident typically took their medications after breakfast without licensed staff supervision, which was against the facility's policy requiring an order and care plan for SAM. The resident expressed discomfort with staff watching them take medications, and the staff confirmed that the resident had been left with medications routinely. However, there was no documentation of a SAM assessment, physician's order, or care plan for this resident. A third resident, who had intact cognition and physical limitations requiring assistance with self-care, was found with an over-the-counter pain relief roll-on in their room. The resident occasionally requested staff assistance to apply the medication, but there was no SAM assessment or physician's order for self-administration. The facility's policy required a SAM assessment and provider's order for any medication, including over-the-counter products, to be left with a resident. Staff were expected to remove any medications found in a resident's room and bring them to the nurse, but this procedure was not followed in this case.
Unclean Tube Feeding Pole in Resident's Room
Penalty
Summary
The facility failed to provide a homelike environment for a resident who was dependent on staff for all activities of daily living and had a feeding tube through which they received more than 50% of their nutrition. During an observation, the tube feeding pole in the resident's room was found to be unclean, with smudged areas and a tannish colored substance covering parts of the pole and base. The floor also had drops of the same substance. This was confirmed by a registered nurse who acknowledged the need for cleaning and expressed concerns about infection. Interviews with staff revealed inconsistencies in the cleaning routine for tube feeding poles. A registered nurse stated that cleaning was done when dirt was noticed but was not documented. A licensed practical nurse admitted to not knowing the routine and mentioned that different shifts handled different tasks. The director of nursing expected staff to clean the poles, but the lack of a clear protocol led to the deficiency in maintaining a clean and homelike environment for the resident.
Deficiencies in Wound Care Management and Documentation
Penalty
Summary
The facility failed to provide appropriate wound care treatment for a resident, R3, who had a skin tear on the right lower leg. Despite physician orders directing daily wound care, the treatment was not administered as documented. Observations revealed that the dressing had not been changed since 10/10/24, contradicting the treatment administration record (TAR) entries by nursing staff. Interviews with R3 and nursing staff confirmed discrepancies in wound care documentation and actual care provided. The director of nursing verified the dressing date and acknowledged the lapse in care. Additionally, the facility falsely documented wound care for two other residents, R4 and R5, whose wounds had already healed. R4's wound care was documented as ongoing despite the surgical incision being healed, as verified by the director of nursing. Similarly, R5's TAR indicated continued wound care for skin tears that had resolved, as confirmed by both the resident and the director of nursing. The staff appeared to lack clarity on discontinuing wound care orders once wounds were resolved. The medical director expressed concern over the failure to follow wound care orders and the false documentation of care for resolved wounds. The facility's policy on wound care management was not adhered to, resulting in inaccurate records and potential neglect of resident care needs. The report highlights a systemic issue with wound care management and documentation within the facility.
Failure to Implement Enhanced Barrier Precautions and Proper Hand Hygiene
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for two residents during personal care and wound care treatments. One resident, who had a history of methicillin-resistant Staphylococcus aureus (MRSA) and required EBP, was observed receiving care without the proper use of personal protective equipment. An LPN entered the resident's room to administer a suppository and reposition the resident without donning a gown, despite a sign indicating the need for EBP. The LPN stated she only wore a gown if a resident had an active infection, indicating a misunderstanding of the EBP requirements. Additionally, another LPN was observed performing wound care for the same resident using improper hand hygiene practices. The LPN used double gloves and failed to perform hand hygiene between glove changes, which was against the facility's policy. The Director of Nursing and the Medical Director confirmed that double gloving was not acceptable and that hand hygiene should be performed before and after wound care, as well as during glove changes. The facility's policies on EBP and wound care management were not followed, contributing to the deficiency.
Failure to Protect Resident During Abuse Investigation
Penalty
Summary
The facility failed to protect a resident during an ongoing investigation of an abuse allegation. The resident, who was moderately cognitively impaired and required assistance for daily activities, reported that staff were rough with him, specifically mentioning being lifted by his shirt, which caused pain. The resident's power of attorney corroborated the resident's account, stating that a staff member had yanked the resident by the arm while he was asleep. Despite the resident's inability to identify the alleged perpetrator from staff photos, the facility implemented a 'Cares in Pairs' intervention, which required two staff members to be present during care. However, this intervention was not consistently followed, as observed when a nursing assistant assisted the resident without a second staff member present. The facility's investigation into the abuse allegation was still ongoing at the time of the report. The Director of Nursing and the Administrator were unsure about the exact timing of the implementation of the 'Cares in Pairs' intervention. The Director of Nursing indicated that the intervention was intended to protect staff from false allegations rather than to ensure the resident's safety. The facility's policy on abuse and neglect prevention emphasized the importance of ensuring the safety and well-being of vulnerable adults during investigations, but this was not adequately adhered to in this case.
Resident Neglect Due to Staff Sleeping on Duty
Penalty
Summary
The facility failed to provide adequate supervision and care for a resident during the overnight shift, leading to the resident calling 911 for assistance. The resident, who had undergone surgery for colon cancer and had an ileostomy, required assistance for pain management and toileting due to reduced mobility. The care plan specified that two staff members were needed to assist the resident to the toilet and to provide incontinence care. However, on the night in question, the resident was left unattended, resulting in the resident experiencing pain and needing to use the bathroom without assistance. The incident was discovered when police responded to the resident's 911 call, finding staff members asleep on duty. The police bodycam footage showed officers waking staff members who were sleeping in a dark dining room and an office. The resident expressed distress to the officers, stating that the staff did not take care of her needs. The facility's policy on abuse and neglect prevention emphasizes providing a safe environment free from harm, but the actions of the staff on duty failed to meet these standards, resulting in neglect of the resident's care needs.
Failure to Assign Designated Charge Nurse for Each Shift
Penalty
Summary
The facility failed to have a designated charge nurse for each shift, as required. On the night of June 14, 2024, a Licensed Practical Nurse (LPN) stated that there was no charge nurse assigned, and that every nurse was considered to be in charge. The facility administrator confirmed via email that the nurses in the building were in charge, and that the Director of Nursing (DON) was on call 24/7 for any clinical concerns. The DON also stated that there was not a designated charge nurse for each shift. When requested, the facility did not provide a policy regarding the assignment of a designated charge nurse for each shift.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to report an alleged violation of abuse involving a resident, identified as R1, to the State Agency within the required timeframe. The incident came to light when law enforcement visited the facility to investigate allegations that nursing staff had been physically rough with R1. Despite the police visit, the facility did not document any progress notes on the day of the incident, nor did they report the allegations to the State Agency as required by their policy. R1, who has a history of post-traumatic stress disorder, dependence on renal dialysis, and major depressive disorder with severe psychotic symptoms, was reportedly grabbed and jerked around by staff. Although R1 was cognitively intact, as indicated by a BIMS score of 14, she expressed fear of reporting the abuse due to potential retaliation. The DON and ADON did not initiate an investigation, citing that R1's family member frequently made allegations and that R1 had no concerns when asked. The facility's policy mandates immediate reporting of abuse allegations to the State Agency, but this was not followed. The DON and administrator both failed to report the incident, relying instead on R1's verbal assurance that she had no concerns, despite the serious nature of the allegations. The facility's policy requires an investigation and reporting within two hours if abuse is alleged, but this protocol was not adhered to in this case.
Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to investigate a report of abuse involving a resident who was visited by law enforcement due to allegations of being grabbed and jerked around by nursing staff. The resident, who has a history of post-traumatic stress disorder, renal dialysis dependence, and major depressive disorder with severe psychotic symptoms, was reported to be cognitively intact. Despite the police report indicating the need for an investigation, the Director of Nursing (DON) did not initiate one, citing that the resident's family member frequently makes such allegations and that the resident appeared fine according to law enforcement. Interviews with the DON, Assistant Director of Nursing (ADON), and the administrator revealed that none of them conducted a formal investigation or documented the incident in the resident's progress notes. The facility's policy requires immediate reporting and investigation of abuse allegations, but this protocol was not followed. The DON and ADON both stated that the resident expressed no concerns when asked, but they did not specifically inquire about abuse. The administrator also failed to ask directly about abuse, neglect, or mistreatment, despite the facility's policy mandating such actions.
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A resident with dry eye syndrome and degenerative eye disease had orders for cyclosporine ophthalmic emulsion and Refresh Tears, both scheduled at the same time. Medication records and direct observation showed a TMA instilled cyclosporine drops in both eyes and immediately followed with Refresh Tears in both eyes without waiting between medications. This practice conflicted with referenced professional guidance recommending several minutes between multiple eye drops and with the medical provider’s recommendation to wait fifteen minutes between the two ophthalmic medications. No facility policy on ophthalmic medication administration was provided when requested.
A resident with severe cognitive impairment, impaired mobility, and high fall risk was care planned to have wheelchair footrests in place at all times, with staff ensuring proper positioning and monitoring for leaning during transport. A NA transported the resident in a manual wheelchair from the shower without the footrests, and while going through the doorway the wheelchair struck the door frame, causing the resident, who was leaning forward, to fall out. The resident sustained a T12 fracture, head injury with concussion, abrasions and contusions, and multiple right-hand lacerations requiring sutures, and the DON confirmed the care plan had not been followed.
A high‑risk, immobile resident with MS and prior heel DTI developed an avoidable unstageable coccygeal pressure ulcer after staff failed to consistently assess and document skin status, did not transfer or timely provide ordered pressure‑relieving mattresses, and did not reliably perform q2h repositioning. The resident was repeatedly left on a bedpan for prolonged periods despite early reports of this issue, and the toileting care plan was not revised to a bedside commode until after the coccygeal wound had significantly worsened. Wound assessments lacked complete measurements and staging, changes in wound size and color were not promptly recognized as deterioration or reported to providers, and recommended interventions from a wound NP (including an air mattress and offloading) were not promptly implemented. As a result, the coccygeal ulcer rapidly progressed to a large, necrotic, malodorous wound requiring hospital transfer and surgical debridement.
A resident with 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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