Edenbrook Of Rochester
Inspection history, citations, penalties and survey trends for this long-term care facility in Rochester, Minnesota.
- Location
- 1875 19th Street Northwest, Rochester, Minnesota 55901
- CMS Provider Number
- 245409
- Inspections on file
- 36
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Edenbrook Of Rochester during CMS and state inspections, most recent first.
Surveyors found that staff repeatedly left medication carts unlocked and unattended, allowing unsupervised access by residents and guests. Multiple medications on the carts were missing required open dates, and expired medications were not removed or destroyed as required. Controlled substances belonging to a deceased resident remained in the cart beyond the expected timeframe for removal. Facility leadership confirmed these practices did not meet policy expectations.
Staff did not clean a mechanical transfer lift after using it with a resident who required substantial assistance, and the same uncleaned equipment was subsequently used with another resident. Staff interviews confirmed knowledge of standard precautions and facility policy requiring cleaning of reusable equipment after each use, but the expectation was not followed in these instances.
A resident with multiple diagnoses was allowed to self-administer prescribed eye drops without a completed self-administration of medication (SAM) assessment or a provider order. An LPN left the medication at the bedside, and staff confirmed that facility policy requires both an assessment and a physician order before permitting self-administration, neither of which were present in this case.
A resident with quadriplegia and dysphagia was observed with dried, chewed food accumulating on his electric wheelchair, which he could not clean himself, and staff were unclear about cleaning responsibilities or frequency. Another resident experienced ongoing discomfort due to a roommate's consistently loud TV, with staff and social services aware of the issue but no effective interventions or policies in place to address sound levels or roommate incompatibility.
Two residents with complex medical needs did not receive care as ordered, including daily weights and application of compression wraps. Staff did not consistently notify providers when residents refused care or when weight thresholds were exceeded, and documentation was lacking. Observations and interviews confirmed that individualized care plans were not followed as required.
The QAPI committee failed to properly identify, investigate, and analyze medication errors, with meeting minutes lacking dates, attendee lists, and specific action plans. Multiple residents experienced missed or incorrectly administered medications, and the facility underreported the true number of errors by not counting each omitted dose. Medication error reports did not include causal analysis or preventive measures, and there was no evidence of staff retraining or accountability.
The facility's assessment did not identify a resident with a liver transplant or address the specific care, monitoring, or staff training required for organ transplant recipients. Interviews with staff, including an LPN, nurse manager, DON, and nurse practitioner, revealed a lack of education and awareness regarding organ rejection monitoring and absence of contact with the resident's transplant team. The facility also could not provide a policy for facility assessment.
A resident with a Foley catheter did not receive care in accordance with enhanced barrier precautions (EBP), as staff failed to use gowns, gloves, and proper hand hygiene during high-contact activities, despite posted signage and policy. The care plan did not clearly specify EBP requirements for catheter care, and the catheter bag was observed on the floor multiple times, with staff handling it without following EBP protocols.
A resident at risk for choking and with a history of aspiration pneumonia was not provided the correct physician-ordered Level 5 minced and moist diet upon returning from the hospital. Instead, the resident received a regular diet due to a failure in the facility's system for updating and communicating dietary orders. The care plan and Kardex were not updated, and the kitchen staff did not receive the new diet orders, leading to the resident receiving the wrong diet for several days.
A resident with a history of diabetes and vascular disease was admitted with bruises that were not properly assessed or documented by the LTC facility. Despite directives to hold aspirin due to a GI bleed, it was administered, potentially worsening the bruising. Staff interviews revealed inconsistencies in procedures for monitoring and documenting bruises, contributing to the deficiency.
A resident with a recent right below-knee amputation experienced a fall that led to wound dehiscence. The facility failed to assess, monitor, and report the wound changes, delaying necessary surgical intervention. Despite the resident's reports of bleeding, the staff did not conduct a comprehensive assessment or notify the physician, resulting in a prolonged healing process and emotional distress for the resident.
Three residents reported being treated without dignity and respect by a nursing assistant (NA-B). One resident, who required maximal assistance due to hemiplegia, felt threatened by rough handling and disrespectful comments. Another resident, dependent on staff for toileting, experienced improper care and derogatory remarks during incontinence episodes. A third resident, needing assistance due to a back fracture, reported dismissive and gruff responses to her needs. Staff interviews confirmed that such behavior violates residents' rights to dignity and respect.
A facility failed to notify physicians of critical incidents involving two residents. One resident fell from a wheelchair, causing a wound dehiscence on a recently healed amputation site, but the surgical team was not informed, leading to delayed treatment. Another resident with elevated potassium levels did not receive prescribed medication due to unavailability, and the physician was not notified, resulting in an emergency room visit. Staff interviews revealed communication gaps and a lack of urgency in addressing these issues.
A resident's privacy was compromised when a facility's video monitoring device captured footage inside their room without consent. The resident, requiring assistance due to hemiplegia, was recorded in a state of undress. The facility's policy prohibited such surveillance, but the camera's placement allowed for this breach, which was unknown to the administrator until the survey.
A resident with diabetes and hemiplegia was not provided routine nail care, despite being dependent on staff for such care. Observations revealed long, soiled fingernails, and interviews with staff confirmed the resident's need for assistance. The care plan required nail care on bath days, but there was no documentation of it being offered or completed.
The facility failed to administer critical medications to three residents, including a resident with hyperkalemia who did not receive Lokelma, a resident with diarrhea who missed Saccharomyces boulardii doses, and a resident with chronic pain who did not receive Pregabalin. The facility did not have a system to identify, record, and report these omissions as medication errors, nor did they notify physicians or follow emergency procedures.
A facility failed to maintain accurate medical records for two residents, leading to care deficiencies. One resident with high potassium levels did not receive critical medication due to poor communication and documentation. Another resident was transferred to the hospital without proper documentation of the transfer. Staff interviews revealed gaps in communication and access to information, impacting care quality.
A resident's privacy was violated during a skin assessment when an LPN conducted a check without permission, exposing the resident in front of a male PT. The resident, who had psychosocial well-being issues, felt embarrassed and moved to another facility.
A resident with severe sleep apnea and heart problems was discharged from an LTC facility to a hotel without a plan for obtaining necessary supplemental oxygen, despite needing it with a Bi-PAP machine. The discharge summary lacked equipment details, and the facility's social service note did not mention a referral for oxygen DME. The DON confirmed the resident was discharged with medications and Bi-PAP supplies but without secured oxygen delivery, contrary to facility policy requiring safe discharge preparation.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Surveyors observed multiple failures in medication storage and labeling practices. On several occasions, staff left medication carts unlocked and unattended in hallways, allowing residents and guests to pass by without supervision. Staff members, including those not wearing name badges, repeatedly walked away from the unlocked carts, and even a nurse manager passed by without securing the cart. During medication administration, an LPN also left the cart unlocked while entering a resident's room. These actions left medications accessible and unsecured for extended periods. Further review of the medication carts revealed several medications that were not properly labeled with open dates, including saline nasal gel, Vitamin C, liquid Haloperidol, Prednisolone eye drops, Lantoprost eye drops, Dorzolamide eye drops, Deep-Sea nasal spray, and Flonase nasal spray. An expired bottle of Vitamin C was found, and the LPN acknowledged it should have been removed and destroyed. Additionally, controlled substances belonging to a resident who had expired the previous day were still present in the narcotic box and had not been removed or destroyed as required. The DON confirmed that multi-dose medications should be dated when opened and that medications for expired residents should be removed and destroyed promptly, in accordance with facility policy.
Failure to Clean Mechanical Lift Between Resident Uses
Penalty
Summary
Staff failed to clean a mechanical transfer lift (EZ stand) after use with a resident who was cognitively intact, dependent on staff for toileting, and required substantial assistance with transfers. The EZ stand, which had visible debris, was used by two nursing assistants to transfer the resident from bed to commode. After the transfer, the equipment was placed in the hallway without being cleaned. Later, another nursing assistant used the same EZ stand with a different resident without cleaning it before or after use. Interviews with staff, including a nursing assistant, an LPN, and the DON, confirmed that standard precautions and facility policy require cleaning and disinfecting reusable equipment after each use. Staff acknowledged the expectation to clean equipment and confirmed that infection control training is provided at hire and annually.
Failure to Complete Assessment and Obtain Order for Self-Administration of Medication
Penalty
Summary
A resident with intact cognition and diagnoses including atrial fibrillation, heart failure, respiratory failure, cataracts, and glaucoma was observed to have prescribed eye drop medications left at their bedside for self-administration. The resident's medical record did not contain evidence that a self-administration of medication (SAM) assessment had been completed, nor was there a provider order authorizing the resident to self-administer medications. During medication administration, an LPN left one of the resident's prescribed eye drops on the bedside table and later confirmed that the resident did not have an order to self-administer medications. Interviews with staff, including the DON, confirmed that facility policy requires a SAM assessment and a physician order before residents are permitted to self-administer medications. The DON acknowledged that these steps had not been completed for the resident in question, and that medications should not be left at the bedside without proper assessment and orders. Facility policy also specifies that the ability to self-administer medications must be care planned with interventions specific to the individual resident.
Failure to Maintain Clean Equipment and Address Excessive Noise Levels
Penalty
Summary
The facility failed to maintain resident equipment in a clean and sanitary condition and did not ensure a comfortable environment regarding sound levels for two residents. One resident, who is nonverbal, has quadriplegia, dysphagia, and requires an electric wheelchair for mobility, was observed with a significant accumulation of dried, chewed, and spilled food on various parts of the wheelchair. The resident communicated that he is unable to clean the wheelchair due to his disabilities and does not like the presence of dried food. Staff interviews revealed uncertainty about who is responsible for cleaning wheelchairs and how often this should occur. The director of nursing acknowledged awareness of the issue and confirmed that the wheelchair often appears unsightly after meals, but there were no care plan interventions to protect the wheelchair during meals, and cleaning frequency was not documented. Another resident, who is cognitively intact and requires assistance with mobility and personal care, reported ongoing discomfort due to the loud volume of her roommate's television. The resident stated she had made multiple complaints about the noise, which affected her sleep and comfort, but no effective interventions were implemented. Staff confirmed the roommate's TV is frequently loud, and although they sometimes lower the volume when the roommate is absent, they do not consistently monitor or address the issue. The social services staff was aware of the complaint and had only asked staff to lower the volume when possible, with no further interventions or plans to address the incompatibility or sound levels. The facility lacked clear policies regarding the cleaning frequency of resident equipment and did not have a policy addressing roommate incompatibility or appropriate sound levels in resident rooms. Documentation and staff interviews confirmed that these deficiencies were ongoing and not addressed through care planning or facility policy.
Failure to Implement and Document Resident-Centered Care Plans
Penalty
Summary
The facility failed to implement and follow individualized care plans for two residents with complex medical needs. For one resident with a history of liver transplant, chronic kidney disease, and major depressive disorder, daily weights were ordered to monitor for signs of liver rejection and kidney function changes. However, the resident was not weighed daily as ordered, and when weights were obtained, they were not performed consistently in the same manner or at the same time of day. Documentation showed that the resident refused weights on 17 days, but there was no evidence that the provider or transplant coordinator was notified of these refusals, as required by the care plan and facility policy. Multiple staff interviews confirmed that provider notification was expected after repeated refusals, but this did not occur. For another resident with congestive heart failure (CHF) and atrial fibrillation, the care plan included daily weights and the application of compression garments to manage fluid retention and monitor for CHF exacerbation. The resident's medical record indicated that weights frequently exceeded the threshold requiring provider notification, but there was no documentation that the provider was informed. Observations revealed that compression wraps were not consistently applied in the morning as ordered, and the resident was often seen with swollen feet and without the prescribed wraps. Staff interviews confirmed knowledge of the care plan requirements but acknowledged that time constraints and other factors led to inconsistent implementation. Facility policy required timely provider notification and documentation of significant weight changes or refusals of care. Despite this, both residents' records lacked evidence of appropriate provider notification and consistent implementation of ordered interventions. The deficiency was identified through observation, record review, and staff interviews, all of which demonstrated a failure to follow individualized care plans and provider orders for residents with significant health risks.
Failure to Identify, Analyze, and Respond to Medication Errors in QAPI Process
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to properly identify, investigate, analyze, and respond to medication errors, as evidenced by a review of committee minutes and medication error reports from December 2024 to February 2025. The QAPI meeting minutes were often undated, did not list attendees, and lacked documentation of specific action plans or goals related to medication errors. Medication error reports were inconsistently analyzed, with no causal analysis or preventive measures documented, and the committee did not consistently track each omitted medication dose as a separate error. Multiple medication errors were identified during this period, including missed or incorrectly administered doses for several residents. Examples include a resident receiving Tamiflu at the wrong frequency, another missing multiple doses of Sevelamer Carbonate due to pharmacy and insurance issues, and a resident missing several doses of Muro eye drops because of supply delays. Additional errors involved missed doses of Advair and Erythromycin Ophthalmic ointment following a readmission, and a resident missing multiple doses of Heparin due to a transcription error. In each case, the reports lacked causal analysis, identification of responsible staff, and documentation of retraining or preventive steps. The facility's method of tracking medication errors was inconsistent, as they counted multiple missed doses for a single resident as one error rather than accounting for each omitted dose. This led to significant underreporting of medication errors in QAPI meetings compared to the actual number identified in medication error reports. Interviews with the DON and a nurse practitioner confirmed that the facility did not have an effective process for analyzing medication errors or implementing action plans to prevent recurrence, and that the QAPI committee did not address the full scope of medication errors occurring in the facility.
Facility Assessment Lacked Organ Transplant Recipient Care and Staff Training
Penalty
Summary
The facility failed to ensure its Facility Assessment (FA) included the identification of organ transplant recipients and the specific care or practices necessary to meet their needs. The FA, last revised on 9/18/24, did not document the presence of a resident with a liver transplant and end stage kidney disease, nor did it address the required monitoring for organ rejection or the necessary staff training and competencies for such care. Staff interviews revealed that neither the LPN responsible for the resident's care nor the nurse manager had received education on organ transplant recipient care, and both were unaware of the signs and symptoms of organ rejection. The facility also lacked information and contact with the resident's liver transplant team, and this information was not present in the resident's medical records. Further interviews with the DON, regional nurse manager, and nurse practitioner confirmed that the FA did not address organ transplant recipient care or related education. The liver transplant care coordinator, when contacted, emphasized the importance of monitoring for liver rejection, administering anti-rejection medications, and conducting routine lab and ultrasound monitoring, none of which were documented in the facility's assessment or care practices. Additionally, the facility was unable to provide a policy for facility assessment when requested.
Failure to Implement Enhanced Barrier Precautions for Catheter Care
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for a resident with an indwelling Foley catheter, as required to reduce the risk of infection transmission. The resident had diagnoses of obstructive and reflux uropathy and required assistance with personal care. The care plan included interventions for catheter care and monitoring for signs of infection but did not specify the need for EBP during catheter-related activities. Although a sign indicating EBP requirements was posted outside the resident's room, the care plan did not clearly identify which care activities necessitated EBP, nor did it link EBP to the Foley catheter. Observations revealed that the resident's catheter bag was repeatedly found lying on the floor, and staff, including an LPN and a nursing assistant, handled the catheter bag without following EBP protocols or proper hand hygiene, despite signage and policy requirements. The LPN was observed entering the room, handling the catheter bag without donning gown and gloves, and failing to wash hands before and after resident contact. The DON confirmed that EBP should have been used for catheter care and that staff were expected to follow posted precautions and hand hygiene protocols. The facility did not provide a requested handwashing policy.
Failure to Provide Correct Textured Diet to Resident
Penalty
Summary
The facility failed to ensure that a resident, who was at risk for choking and had a history of aspiration pneumonia, received the correct physician-ordered textured diet. The resident returned from the hospital with new diet texture orders for a Level 5 minced and moist diet but was instead provided with a regular textured diet from January 3 to January 9. This discrepancy was due to a failure in the facility's system for updating and communicating dietary orders, as the care plan and Kardex were not updated to reflect the new diet requirements. The resident's care plan initially identified a regular liberalized renal diet, but after hospitalization for acute respiratory failure and aspiration pneumonia, the discharge orders specified a Level 5 minced and moist diet. Despite this, the resident continued to receive a regular diet, which was not suitable given their condition and increased risk of aspiration. Interviews with staff revealed that the dietary communication process was flawed, as the kitchen staff did not receive the updated diet orders, and the meal tickets continued to reflect the incorrect diet. Observations and interviews with nursing and dietary staff highlighted a lack of communication and verification processes to ensure diet accuracy. Nursing assistants and nurses relied on meal tickets rather than care plans to verify diet orders, and there was confusion about who was responsible for notifying the kitchen of diet changes. The culinary director confirmed that the meal ticket system was not updated due to a lack of communication from nursing staff, resulting in the resident receiving the wrong diet for several days.
Removal Plan
- Reviewed and revised policies and procedures related to serving resident meals and ensuring residents receive correct textured meals.
- Educated to procedures as appropriate.
- Educated all nursing staff to utilize diet communication form and give to kitchen staff and on updating the care plan for diet orders.
- Educated dietary and all staff who serve resident food to recognize each specific diet type/textured meal.
- Educated dietary staff related to the importance of ensuring the meal ticket is updated.
- Educated all staff who serve resident food items on the importance of checking the diet slip, ensure the resident is getting the correct textured food, and then delivering the correct diet order to the resident.
- Developed and implemented a plan to complete all training before each staff worked their next shift.
Failure to Monitor and Document Bruises
Penalty
Summary
The facility failed to adequately assess and monitor non-pressure related skin injuries, specifically bruises, for a resident identified as R1. Upon admission, R1 was noted to have a hematoma on the forehead and bruising on the upper extremities and abdomen, but the skin assessment lacked details such as bruising color, characteristics, measurements, and pain. Despite R1's intact cognition and medical conditions including diabetes, obesity, and peripheral vascular disease, the care plan did not address the risk of bleeding or bruising, nor did it include interventions to protect R1's skin from further injury. R1 was hospitalized and upon readmission, the bruises were still not properly assessed or documented. The readmission screener and subsequent weekly skin checks continued to lack comprehensive details about the bruises. Furthermore, R1's medication administration record showed that aspirin was administered despite a directive to hold it due to a gastrointestinal bleed, which could have contributed to the bruising. The facility's staff, including nursing assistants and LPNs, failed to document and investigate the bruises adequately, and there was no daily monitoring of the bruises as expected. Interviews with staff revealed a lack of clarity and consistency in the facility's procedures for assessing and documenting bruises. The facility did not have a specific policy for non-pressure skin care, and staff were unsure about when to measure bruises or how to document them properly. The director of nursing and regional nurse manager acknowledged the gaps in the facility's approach to monitoring and documenting bruises, which contributed to the deficiency in providing appropriate care for R1.
Failure to Monitor and Report Surgical Wound Changes
Penalty
Summary
The facility failed to properly assess, monitor, and communicate changes in a surgical wound for a resident who had undergone a right below-knee amputation. The resident, who was admitted with a history of orthopedic aftercare following surgical amputation and type 2 diabetes mellitus, experienced a fall that resulted in the dehiscence of her surgical wound. Despite the presence of bleeding and the resident's report of the incident, the facility did not conduct a comprehensive assessment of the wound or notify the physician, leading to a delay in necessary surgical intervention. The resident's care plan included interventions to monitor and document the status of her surgical wound weekly, but these were not adequately followed. After the fall, the incident report and subsequent assessments failed to document the condition of the wound accurately. The resident's medical records did not reflect a thorough evaluation of the injury, and the surgical team was not informed of the fall and the resulting wound complications. This lack of communication and documentation contributed to the resident's wound dehiscence going unnoticed until a follow-up appointment with a physician, who then arranged for the necessary surgical revision. Interviews with facility staff revealed that there was an awareness of the bleeding from the wound, but the response was insufficient. The staff did not implement a protocol for ongoing monitoring or notify the surgical team, which was a critical oversight. The facility's policies on post-fall monitoring and wound care management were not adhered to, resulting in the resident's prolonged healing process and emotional distress. The deficiency highlights a significant lapse in the facility's duty to provide appropriate care and communication regarding the resident's surgical wound condition.
Failure to Treat Residents with Dignity and Respect
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect, as evidenced by the experiences of three residents who required assistance with activities of daily living (ADLs). Resident R2, who had diagnoses including hemiplegia following a stroke and required maximal assistance with transfers and bed mobility, reported being handled roughly by a nursing assistant (NA-B). R2 described an incident where the NA changed his sheets without asking, causing him to feel like he was going to fall out of bed, and noted that the NA sometimes hit his legs and spoke to him disrespectfully. Resident R3, who had undergone knee joint prosthesis surgery and was dependent on staff for toileting hygiene, reported that NA-B placed a bedpan incorrectly, leading to an episode of incontinence. R3 stated that the NA responded with frustration and left her to sleep on a soaker pad instead of changing her. R3 also recounted instances where the NA made derogatory comments about her incontinence, making her feel harassed and disrespected. Resident R4, who had a fractured lower back and required assistance with toileting, reported that NA-B responded to her call light with a gruff attitude and made comments about her frequent need to use the restroom. R4 felt that the NA's behavior was dismissive and made her feel like a burden. Interviews with other staff members, including a trained medication aide and another nursing assistant, confirmed that such behavior would make residents feel neglected and disrespected, violating their right to dignity and respect.
Failure to Notify Physicians of Critical Incidents
Penalty
Summary
The facility failed to notify the physician of an injury after a fall for a resident who fell from a wheelchair, landing on a freshly healed below-knee amputation site, causing bleeding and dehiscence. The resident, who had been admitted to the facility with a recent surgical amputation, experienced a fall on 7/9/24. Despite the bleeding and pain reported by the resident, the licensed practical nurse (LPN) only faxed an SBAR report to the primary provider, MD-C, and did not receive a response. The surgical or physical medicine and rehabilitation teams were not notified, which led to a delay in addressing the wound dehiscence. The resident was later admitted to the hospital for revision surgery after the wound was discovered to be open during a follow-up clinic visit. In another incident, the facility failed to notify the physician of the inability to procure and administer an emergent medication for a resident with elevated potassium levels. The resident, who had a history of type 1 diabetes, kidney transplants, and hyperkalemia, was ordered to receive Lokelma to manage high potassium levels. However, the medication was not administered as it was not available, and the facility did not inform the physician of this issue. The resident's potassium levels remained elevated, leading to an emergency room visit for treatment. The lack of communication and failure to obtain the necessary medication in a timely manner contributed to the resident's condition requiring emergency intervention. Interviews with staff revealed a lack of understanding and communication regarding the urgency of the situations. The LPN involved in the fall incident assumed no further action was needed when no response was received from the faxed SBAR report. Similarly, the staff involved in the medication incident did not recognize the importance of the ordered medication and failed to notify the director of nursing (DON) or the physician about the unavailability of Lokelma. These deficiencies highlight significant communication gaps and procedural failures in the facility's handling of critical resident care situations.
Privacy Breach Due to Improper Camera Placement
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of a resident, identified as R2, by having a video monitoring device that captured footage inside the resident's room without their knowledge or consent. R2, who was admitted with diagnoses including hemiplegia following a cerebral infarction, required maximal assistance with personal hygiene and transfers. The facility's electronic health record did not contain a consent form for video surveillance in R2's room. During a review of video footage, it was confirmed that the camera captured R2 in a state of undress while receiving care from a nursing assistant, which was visible from the mid-torso up. The facility administrator acknowledged that the camera, named North Medroom Camera, was positioned in such a way that it could view inside R2's room when the door was open. The administrator was unaware of this issue prior to the survey and confirmed that the camera's view did not protect R2's privacy. The administrator and the environmental services director had access to the footage, which was not displayed on any monitors within the facility. The environmental services director, who installed the cameras, stated that they were intended for monitoring common areas and not resident rooms, as this would violate privacy regulations. Interviews with the social services director and R2 revealed that the resident was informed about the footage and did not express significant concern or distress. The facility's policy on video surveillance explicitly stated that cameras should not allow for viewing inside resident rooms. Despite this policy, the camera's placement allowed for a breach of privacy, as it captured footage of R2 without consent. The facility's failure to adhere to its own policy and ensure the privacy of its residents resulted in this deficiency.
Failure to Provide Routine Nail Care for Dependent Resident
Penalty
Summary
The facility failed to provide routine grooming and personal hygiene care, specifically nail care, for a resident who was dependent on staff for such care. The resident, who had intact cognition and required maximal assistance due to conditions including diabetes mellitus and hemiplegia following a stroke, was observed with long fingernails and a brown substance underneath them. Despite the care plan indicating that nail care should be checked and performed on bath days, there was no evidence in the resident's task charting or electronic health record that nail care was offered or completed. Interviews with staff, including a Licensed Practical Nurse (LPN) and a Nursing Assistant (NA), confirmed that the resident needed assistance with hygiene and nail care, particularly because of his diabetes and hemiparesis. The Director of Nursing (DON) acknowledged that nail care should be performed by aides during baths and by nurses for diabetic residents, but there was no documentation of when the resident's nails were last cut. The facility's policy on Activities of Daily Living (ADLs) emphasized the importance of providing care based on the resident's individualized plan and preferences, which was not adhered to in this case.
Failure to Administer Critical Medications and Report Errors
Penalty
Summary
The facility failed to provide and administer medications and lacked a system to identify, record, and report omitted medications as medication errors for three residents. Resident 1, who had a history of type 1 diabetes, kidney transplants, and hyperkalemia, was not administered the prescribed medication Lokelma to lower critically high potassium levels. The medication was not available at the scheduled times, and there was no indication that the pharmacy was contacted or that the physician was notified of the missed doses. Consequently, Resident 1 was sent to the emergency department with elevated potassium levels. Resident 2, diagnosed with hemiplegia, depression, and diarrhea, did not receive the prescribed medication Saccharomyces boulardii for diarrhea from July 1 to July 15, 2024, due to the medication not being available from the pharmacy. There was no documentation of physician notification or a plan to administer the medication, nor was there monitoring for symptoms resulting from the medication not being administered. The facility's medication error reports did not recognize these missed doses as medication errors. Resident 3, who had undergone knee joint prosthesis surgery and suffered from chronic pain, did not receive the prescribed pain medication Pregabalin on two occasions due to the medication not being available at the facility. The facility's emergency medication procedure was not followed, and the pharmacy was not contacted to request the medication STAT. The facility's medication error reports did not identify these missed doses as medication errors, and there was no appropriate follow-up to the errors completed per policy.
Deficiencies in Medical Record Accuracy and Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, leading to deficiencies in care. For the first resident, who had a complex medical history including type 1 diabetes, kidney transplants, and critically high potassium levels, the facility did not document a critical lab value in the electronic health record. The medication Lokelma, prescribed to manage the resident's potassium levels, was not administered as ordered due to a lack of awareness and access to necessary information by the nursing staff. The medication was not available at the scheduled time, and the critical nature of the medication was not communicated effectively among the staff, resulting in the resident being sent to the emergency department for further treatment. The second resident, who had type two diabetes with a foot ulcer and peripheral vascular disease, was transferred to the hospital due to exacerbation of necrosis and pain in the toes. However, the facility failed to document the transfer appropriately in the resident's medical record. There were no progress notes from the time of the transfer, and the record did not include necessary details such as the reason for the transfer, the resident's condition at the time, or notifications made to relevant parties. The lack of documentation did not align with the facility's policy on acute care transfers, which requires detailed records of such events. Interviews with facility staff revealed gaps in communication and documentation processes. Licensed practical nurses reported not having access to lab results or understanding the critical nature of certain medications. The director of nursing acknowledged the absence of required documentation in the second resident's record and expressed expectations for timely and comprehensive progress notes. These deficiencies highlight a failure to adhere to professional standards for maintaining medical records, impacting the quality of care provided to the residents.
Violation of Resident Privacy During Skin Assessment
Penalty
Summary
The facility failed to protect a resident's right to privacy during a routine skin observation, which led to a resident feeling their personal privacy was violated. The incident involved a resident, identified as R2, who was admitted to the facility and had an unplanned discharge to home. During a physical therapy session, an LPN entered the room and conducted a skin check on R2's back and buttocks without asking for permission, exposing R2's bare skin in the presence of a male physical therapist. This action caused R2 to feel embarrassed and violated, as she was not expecting such an examination in front of the therapist. R2's care plan indicated she had potential psychosocial well-being issues related to her recent hospitalization and admission to the skilled nursing facility, including depression, anxiety, and loss of independence. Interviews with R2, the physical therapist, and LPN-A confirmed the sequence of events, with R2 expressing that the experience was shocking and led her to move to a different facility. The facility's policy on resident rights and dignity emphasized the importance of treating residents with respect and ensuring their privacy, which was not upheld in this instance.
Failure to Provide Supplemental Oxygen for Discharged Resident
Penalty
Summary
The facility failed to safely discharge a resident who required supplemental oxygen and a Bi-level Positive Airway Pressure (Bi-PAP) machine for obstructive sleep apnea. The resident, who was cognitively intact and had diagnoses including heart failure, end-stage renal disease, diabetes, obstructive sleep apnea, and morbid obesity, was discharged to a hotel without a plan to obtain the necessary supplemental oxygen. The discharge summary did not list any equipment needed, despite the resident's physician order indicating the need for Bi-PAP with oxygen supplementation for lifetime use. The facility's social service progress note indicated that the resident decided to discharge to a hotel to avoid private pay costs, but it lacked any mention of a referral for oxygen durable medical equipment (DME). The Director of Nursing (DON) confirmed that the resident was discharged with medications and Bi-PAP supplies but without secured oxygen delivery. The facility's policy requires sufficient preparation and orientation for safe discharge, which was not met in this case, as the resident had to independently arrange for oxygen the day after discharge.
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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