Episcopal Church Home Of Minnesota
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Paul, Minnesota.
- Location
- 1879 Feronia Avenue, Saint Paul, Minnesota 55104
- CMS Provider Number
- 245452
- Inspections on file
- 27
- Latest survey
- December 18, 2025
- Citations (last 12 mo.)
- 6 (1 serious)
Citation history
Health deficiencies cited at Episcopal Church Home Of Minnesota during CMS and state inspections, most recent first.
Two residents with cognitive and mobility impairments experienced alleged verbal, mental, and physical abuse, as well as neglect of care, by nursing assistants. Facility staff failed to promptly investigate, report to the State Agency, or implement resident protections, and did not suspend the alleged perpetrators or conduct thorough interviews with other staff or residents. Documentation and communication gaps were identified among the administrator, DON, and other staff, resulting in incomplete investigations and lack of timely action.
Annual performance reviews were not completed or documented for four nursing assistants as required by facility policy, with some reviews overdue and one lacking any record. The administrator confirmed that these reviews should be conducted annually and documentation was missing, potentially affecting all residents receiving care from these staff.
Three residents experienced undignified and disrespectful care, including rough handling, inappropriate language, being left in public areas in soiled clothing, and being denied timely assistance with incontinence care. Staff interviews confirmed that communication and actions did not align with the facility's dignity policy.
The facility did not report allegations of physical and verbal abuse to the State Agency within the required two-hour window for three residents, despite family members and residents reporting incidents involving inappropriate staff conduct, rough handling, and punitive language. Documentation showed that facility leadership was notified, but reporting to the SA was delayed or not completed, and staff involved were not consistently suspended pending investigation. Interviews revealed confusion among staff and administrators regarding what constituted reportable abuse and the required reporting process.
Three nursing assistants did not complete the required 12 hours of annual in-service training, with one completing only 8.6 hours, another four hours, and a third none. Staff development confirmed these individuals had not been assigned the necessary online training after missing in-person sessions, contrary to facility policy.
Two residents diagnosed with UTIs were not consistently monitored or assessed for changes in urinary symptoms or adverse reactions to antibiotics. Documentation was lacking regarding the presence or resolution of UTI symptoms, effectiveness of antibiotic treatment, and monitoring for side effects, despite facility policy and staff expectations requiring such documentation after a change in condition.
The facility failed to properly store frozen food items in two unit kitchenettes, leading to potential cross-contamination. Observations revealed opened and unsealed bags of pre-cooked bacon and sausage links, as well as pancakes with ice crystals. Staff were expected to remove outdated items and ensure all food was sealed, but this was not consistently done, violating the facility's food storage policy.
A resident with a history of kidney failure, diabetes, and vascular disease experienced a delay in provider notification after a blackened, malodorous toe was identified. Despite the toe's worsening condition, the provider was not notified until days later, resulting in a hospital visit and toe amputation. Additionally, changes to the resident's surgical incision were not documented or communicated to the provider, contrary to facility policy.
A facility failed to assess and document a resident's gangrenous toe, leading to a necessary partial foot amputation. Additionally, the facility did not ensure proper coordination of care for a hospice patient experiencing seizures, resulting in a lack of communication between hospice and primary care providers. These deficiencies highlight issues in documentation and communication within the facility.
The facility failed to provide a safe smoking environment for two residents, leading to a deficiency. One resident was observed smoking without a proper disposal receptacle, extinguishing cigarettes on the ground, and not wearing a smoking apron as required. Another resident, despite being on smoking restrictions, disposed of cigarette butts improperly due to the absence of a receptacle. The facility's smoking policy was not effectively enforced, and maintenance checks were not documented, contributing to the unsafe conditions.
A facility failed to maintain a dialysis fistula site according to professional standards for a resident requiring dialysis. The resident's care plan lacked specific instructions regarding blood pressure restrictions on the arm with the fistula. A TMA took the resident's blood pressure on the same arm as the fistula, unaware of any restrictions. Interviews revealed a lack of communication and documentation about the resident's dialysis care needs, and the facility's policy did not address standards of care for dialysis residents.
Two residents were prescribed antifungal medications without proper monitoring or evaluation for continued use. One resident received clotrimazole cream for over a year without reassessment, while another used nystatin powder for nearly three years without review. The facility failed to adhere to its policy on unnecessary medications, leading to prolonged use without documented need.
The facility failed to ensure proper hand hygiene and adherence to transmission-based precautions, leading to deficiencies in infection prevention and control. A resident with a history of MRSA had inadequate precautions, with staff unsure of required PPE and failing to don appropriate gear. Another resident experienced lapses in infection control during personal care, with staff not changing gloves or performing hand hygiene before touching clean items. Facility policies on hand hygiene and precautions were not adequately followed.
Two residents were not offered or provided updated pneumococcal vaccinations, and one resident was not offered an updated influenza vaccination, despite being at higher risk due to medical conditions. The facility lacked documentation of discussions, signed declinations, and risk/benefit information, and failed to provide their vaccination policy upon request.
A resident with heart failure and hypertension was not provided a timely COVID-19 vaccination despite requesting it. The resident's immunization report lacked documentation, and there was no signed consent or declination form in the medical record. The DON confirmed the absence of a Minnesota Immunization Information Connection report and that the resident had not received the vaccination, contrary to facility policy.
A resident with cognitive impairment and multiple health issues developed severe skin ulcerations due to the facility's failure to provide timely treatment and communication. The resident's care plan lacked focus on skin integrity, and there was inadequate documentation and notification to the primary care provider. The wounds worsened, requiring hospitalization and surgical intervention, highlighting significant communication and coordination issues among the facility's staff.
A resident developed three pressure ulcers due to inadequate monitoring and care in a facility. Despite being at risk, the resident's care plan lacked focus on skin integrity, and staff failed to report or treat changes in the resident's skin condition. The ulcers were only identified during a hospital admission, indicating a significant lapse in care.
A facility failed to notify a resident's representative of a health change when a new medication and treatment were ordered for a wound. The resident, who was cognitively impaired, had a wound on the right leg, and the facility initiated treatment without informing the power of attorney. The representative only learned of the wound during a care conference, raising concerns about the lack of timely communication.
A resident with cognitive impairment and multiple health conditions was admitted to the hospital with severe necrotic wounds requiring surgical intervention. The facility failed to report the incident to the State Agency as required. Despite awareness of the situation, facility staff did not perceive the wounds as neglect and did not have a reporting policy available.
A facility failed to update a care plan for a resident with cognitive impairment and multiple health conditions, who developed a wound. The care plan lacked interventions for skin integrity and inaccurately stated transfer needs, despite the resident using a mechanical lift and wheelchair. Staff were aware of the resident's needs, but these were not reflected in the care plan, and the family was not informed until a care conference.
Failure to Timely Investigate and Protect Residents After Abuse Allegations
Penalty
Summary
The facility failed to immediately respond, investigate in a timely manner, and implement resident protections following allegations of verbal, mental, and physical abuse, as well as neglect of care, for two residents. In the first case, a resident with dementia and impaired mobility required staff assistance for repositioning. The resident and a family member reported that a nursing assistant used inappropriate language and physically handled the resident in a rough manner, including throwing the resident's legs against the wall. The incident was reported to the social worker, and both the administrator and DON were notified. However, the investigation lacked interviews with other staff or residents, and there was no documentation of protective measures taken during the investigation. Progress notes did not mention the incident, and the staff member involved was not immediately suspended. In the second case, a resident with moderate cognitive impairment and limited mobility required assistance with activities of daily living and was at risk for pressure injuries. The resident's family member reported overhearing a nursing assistant refuse to provide timely incontinence care, make threatening statements about using the call light, and remove the resident from her room while she was wet and in her nightgown, placing her in a public area without her phone. The investigation documentation lacked interviews with other staff or residents, and the staff member was only removed from caring for the resident but continued to work with other vulnerable residents. The incident was not reported to the State Agency as required, and the investigation was not thorough. Interviews with facility staff, including the social worker, LPN, RN, and administrator, revealed inconsistencies and gaps in the investigation process. Staff acknowledged that best practices, such as suspending the alleged perpetrator and interviewing all relevant parties, were not followed. Facility policy required prompt reporting, suspension of the alleged perpetrator, and comprehensive investigation, but these steps were not consistently implemented. The administrator and DON did not ensure timely communication with families or complete documentation, and there was a lack of clarity regarding which incidents were reportable and how investigations should be conducted.
Removal Plan
- Reviewed and revised policies and procedures related to abuse reporting, protections, and investigating allegations of abuse.
- Educated all staff and leadership on the above policies and procedures with competency. Training included conducting thorough investigations.
- Assessed all residents for abuse who had contact with implicated staff.
- Care plans for R2 and other affected residents were updated to include specific protections and interventions.
- Staff involved in the allegations were removed from the schedule to eliminate access to resident pending completion of the investigations.
- Thorough investigations were completed for the incidents and were reported to the State Agency.
Failure to Complete Annual Performance Reviews for Nursing Assistants
Penalty
Summary
The facility failed to ensure that annual performance reviews were completed for four out of five nursing assistants whose personnel files were reviewed. Specifically, one nursing assistant had not received a performance review since October 2022, another since February 2023, a third since July 2023, and for the fourth, no documentation of any performance review could be provided. The administrator confirmed that annual performance reviews should be conducted by nurse managers and overseen by the DON, but acknowledged that documentation for recent reviews was missing for these staff members. The employee handbook states that annual reviews are to be provided on or around each employee's anniversary date of employment. This deficiency had the potential to affect all residents who could receive care from these staff members.
Failure to Promote Resident Dignity During Care Interactions
Penalty
Summary
The facility failed to promote dignity and respect for three residents requiring assistance with activities of daily living. One cognitively intact resident reported being handled roughly by a nursing assistant, including having his legs thrown against the wall and being spoken to in a disrespectful manner. The resident's family member overheard the incident via phone, including staff using inappropriate language and physically spinning the resident in bed, which led to the resident requesting not to work with that staff member again. Another resident with moderate cognitive impairment and limited mobility was left sitting in a public area by the nurses' station in a wet brief and nightgown after requesting assistance for incontinence care. The nursing assistant told the resident that staff no longer provided toileting on demand and made the resident wait for rounds. The resident was also denied access to her phone during this time. Staff interviews confirmed that the resident was left in a public space in inappropriate attire and that the communication used by the nursing assistant was not appropriate and could be perceived as punitive or degrading. A third resident with moderate cognitive impairment and impaired mobility reported being struck on the legs by a nursing assistant while being awakened for dinner. The resident expressed distress about being handled roughly. Staff interviews confirmed that striking a resident to awaken them was not appropriate and that alternative, respectful methods should be used. The facility's own dignity policy requires all residents to be treated with dignity and respect at all times, which was not upheld in these incidents.
Failure to Timely Report Alleged Abuse and Neglect to State Agency
Penalty
Summary
The facility failed to immediately report allegations of physical and verbal abuse to the State Agency (SA) within the required two-hour window for three residents after family members or the residents themselves reported the alleged abuse. In one case, a resident with dementia and impaired mobility, who required staff assistance for repositioning, and his family member reported that a nursing assistant used inappropriate language and physically handled the resident in a rough manner. The incident was documented by the social worker, and both the administrator and DON were notified, but the required report to the SA was not filed in a timely manner. The resident later expressed reluctance to return to the facility due to the abuse. Another incident involved a resident with moderate cognitive impairment and limited mobility, who was dependent on staff for toileting and transfers. The resident's family member overheard a nursing assistant making punitive statements and denying the resident timely toileting assistance, resulting in the resident being left in a wet brief and nightgown in a public area. The incident was reported to facility leadership, but the SA was not notified within the mandated timeframe. Interviews with staff confirmed that the actions and communication by the nursing assistant could be considered abusive and should have been reported immediately. A third case involved a resident with moderate cognitive impairment who reported being struck on the legs by a nursing assistant when being awakened for dinner. The incident was reported to the SA, but not within the required two-hour window. Facility policy required immediate reporting and suspension of the alleged perpetrator pending investigation, but in these cases, the facility either delayed reporting or did not report at all, and did not consistently suspend the staff involved. Interviews with facility staff and administrators revealed uncertainty and inconsistency in the reporting process, with some incidents being classified as customer service issues rather than abuse, leading to failures in timely reporting as required by regulation.
Failure to Ensure Completion of Required Annual In-Service Training for Nurse Aides
Penalty
Summary
The facility failed to ensure that three out of five nursing assistants reviewed for annual training completed the required 12 hours of in-service education within the last 12 months. Personnel file reviews showed that one nursing assistant had completed only 8.6 hours, another had completed four hours, and a third had completed zero hours of the required training. The facility used a computer-based education system (Relias) to track training hours, and these deficiencies were identified through document review. Interviews with staff development and the administrator revealed that annual education was expected to be completed in person during each staff member's anniversary month, with online training assigned if in-person sessions were missed. However, the staff development department confirmed that the three nursing assistants had not completed the required training and had not been assigned the necessary online modules. The facility's policy required a minimum of 12 hours of annual in-service training, with completion documented in personnel files, but this process was not followed for the identified staff.
Failure to Monitor and Document UTI Symptoms and Antibiotic Effectiveness
Penalty
Summary
The facility failed to adequately monitor and assess for signs and symptoms of urinary tract infections (UTIs) and to document the effectiveness and potential adverse reactions to antibiotics for two residents who experienced a change in condition. For one resident with impaired cognition, frequent incontinence, and a history of lumbar fracture and encephalopathy, there was an order for a urinalysis and culture, but the resident's family opted for outside testing. Upon return with a UTI diagnosis and an order for oral antibiotics, the resident's records lacked evidence of consistent monitoring for UTI symptoms beyond vital signs, such as changes in incontinence, burning, odor, or frequency, and did not consistently document monitoring for antibiotic side effects. Another resident, with diagnoses including congestive heart failure and depression, was also identified as frequently incontinent of bladder. After being diagnosed with a UTI and prescribed a five-day course of oral antibiotics, the resident's documentation did not indicate what UTI symptoms were present or provide consistent notes on the presence, increase, or decrease of symptoms, nor on any side effects from the antibiotic. There was no clear documentation to determine if the resident's urinary symptoms had resolved or if the antibiotic was effective after the treatment course. Interviews with nursing staff and the DON confirmed that facility policy requires documentation of UTI symptoms, vital signs, and any adverse reactions to antibiotics every shift following a UTI diagnosis. However, the records for both residents lacked this required documentation, including initial symptoms, provider notifications, and follow-up monitoring. The facility's own policies on change in condition and UTI management were not followed, as assessments, interventions, and resident responses were not consistently recorded in the medical record.
Improper Storage of Frozen Food Items
Penalty
Summary
The facility failed to ensure that frozen food items were stored properly to prevent cross-contamination in two of the three unit kitchenettes reviewed. During an observation of the second-floor kitchenette, an opened plastic bag of frozen, pre-cooked bacon was found unsealed and dated 3/3. Additionally, a resealable gallon-sized bag of frozen, pre-cooked sausage links was also dated 3/3. A sealed plastic bag of frozen, pre-cooked pancakes was found with a thick layer of white ice crystals inside. Nursing assistant (NA)-J confirmed the dates and stated that the unit typically went through the food items in three days per policy. However, the opened bags of bacon and sausage links were not removed by the main kitchen staff, who were expected to check and remove undated and old food items each morning. Further observation of the first-floor kitchenette revealed an opened and unsealed bag of frozen, pre-cooked bacon dated 3/4, which was not resealed in its original packaging, leaving it exposed to air in the freezer. The culinary supervisor (CS) confirmed that kitchen staff were expected to remove outdated or bad-looking food items and that everything in the fridge and freezer should be covered or sealed. The culinary manager (CM) verified the opened food packages and stated that both kitchen and nursing staff were expected to remove outdated and opened items. The facility's policy required all food products not in their original containers to be placed in approved, seamless, tightly sealed containers to prevent freezer burn and spoilage. The administrator also expected food to be labeled and sealed appropriately to prevent cross-contamination.
Failure to Notify Provider of Skin Alteration
Penalty
Summary
The facility failed to ensure timely provider notification when a skin alteration was identified for a resident, R24, who was at risk for skin breakdown due to conditions such as kidney failure, diabetes, and vascular disease. On 2/8/25, a nurse noted R24's right little toe was blackened and malodorous, but there was no indication that the provider or family was notified. The situation worsened by 2/9/25, with the toe appearing gangrenous, yet again, there was no documentation of provider or family notification. It was not until 2/10/25 that the nurse practitioner assessed the toe and sent R24 to the hospital for surgery, resulting in a toe amputation. Further deficiencies were noted in the follow-up care of R24's surgical incision. From 2/28/25 to 3/5/25, there was no documentation of changes to the surgical incision or notification to the provider or surgical team. Interviews with staff revealed a lack of communication and documentation regarding the resident's condition. The facility's policy required prompt notification of the provider for changes in condition, which was not adhered to in this case, leading to a delay in appropriate medical intervention.
Deficiencies in Wound Care and Hospice Coordination
Penalty
Summary
The facility failed to comprehensively assess and document a new skin alteration and changes in a surgical incision for a resident who developed a gangrenous toe requiring surgical treatment. The resident, who was cognitively intact and had diagnoses including kidney failure, diabetes, and vascular disease, was at risk for skin breakdown. Despite the care plan directing staff to monitor and report skin changes, the facility did not notify the family or provider when the blackened, malodorous toe was first observed. The lack of comprehensive assessment and documentation continued until the resident was sent to the emergency room, where a partial foot amputation was deemed necessary. Additionally, the facility failed to ensure proper coordination of care for a hospice patient with a change in condition. The hospice patient, who had severe cognitive impairment and was on hospice care for a terminal illness, experienced multiple seizures. Despite documented seizure activity, the primary provider was not updated, leading to a discrepancy in the provider's notes, which stated no seizures had occurred since a previous date. The hospice case manager and consultant pharmacist were unaware of the ongoing seizure activity, indicating a lack of communication between the facility, hospice, and primary care providers. Interviews with facility staff, including registered nurses and the Director of Nursing, revealed expectations for documentation and communication that were not met. The facility's policy required collaboration and communication between hospice and facility staff, but this was not effectively implemented. The Director of Nursing acknowledged potential issues with communication due to nurse managers' availability, and the medical doctor confirmed a lack of updates regarding the hospice patient's condition. The facility's failure to adhere to its policies and ensure timely communication and documentation contributed to the deficiencies identified in the report.
Unsafe Smoking Environment and Lack of Disposal Receptacles
Penalty
Summary
The facility failed to ensure a safe smoking environment for two residents, leading to a deficiency in maintaining a hazard-free area. One resident, identified as R50, was observed smoking without a proper disposal receptacle for cigarette butts, resulting in him extinguishing cigarettes on the ground. His care plan indicated he was independent with smoking and used a smoking apron, but there was no description of safe disposal of smoking materials. During observations, R50 was seen without his smoking apron, and staff did not remind him to wear it, despite acknowledging its necessity to prevent burns. The designated smoking area lacked an ashtray or container for safe disposal, and maintenance staff confirmed this was an ongoing issue due to theft of the receptacles. Another resident, R55, also faced issues with the lack of a smoking receptacle. Despite being on smoking restrictions due to dental surgery, R55 admitted to not always following them and disposed of cigarette butts on the sidewalk or trash can. The facility's smoking policy required smoking waste to be cleaned up and kept out of sight, but observations showed this was not adhered to. Interviews with staff revealed that maintenance checks were not documented, and the facility's policy was not effectively enforced, contributing to the unsafe smoking environment.
Failure to Maintain Dialysis Fistula Site According to Standards
Penalty
Summary
The facility failed to maintain a dialysis fistula site according to professional standards of care for a resident requiring dialysis. The resident, who was cognitively intact and had diagnoses of kidney failure, diabetes, and vascular disease, required dialysis three times a week. However, the resident's provider and nursing orders did not specify the location of the fistula or any restrictions for taking blood pressure on the left arm. During an observation, a trained medication assistant (TMA) took the resident's blood pressure on the left arm, which was the same arm as the dialysis fistula site. The TMA was unaware of any restrictions regarding blood pressure measurements on the arm with the fistula and needed to verify with the nurse. Interviews with staff revealed a lack of communication and documentation regarding the resident's dialysis care needs. The registered nurse confirmed that blood pressure should not have been taken on the left arm and noted that the resident was wearing a sweatshirt, which may have obscured the fistula site. The Director of Nursing expected staff to take blood pressures on the opposite arm of the fistula, and this information should have been included in the orders and communicated to the nursing assistants. The facility's policy on dialysis did not address standards of care for dialysis residents, contributing to the oversight.
Failure to Monitor and Evaluate Antifungal Medication Use
Penalty
Summary
The facility failed to ensure that antifungal medications prescribed to two residents were monitored and evaluated for the appropriateness of continued use. Resident R17 was prescribed clotrimazole cream for a fungal infection, which was applied twice daily for over a year without an end date or reassessment of its necessity. Despite the absence of any documented skin issues or candidiasis in R17's records, the medication continued to be administered. The primary care provider's notes lacked any review of the continued use of clotrimazole, and the medication was not reconciled with the provider's list, indicating a lack of communication and oversight. Similarly, Resident R27 was prescribed nystatin powder and later Zeasorb-AF powder for skin conditions, with orders lacking end dates. The nystatin powder was used for nearly three years without reassessment, and the addition of Zeasorb-AF was not accompanied by discontinuation of the nystatin, despite its ineffectiveness. The resident's care plan and medical records did not document any ongoing fungal infections, and the primary care provider's notes did not address the continued use of antifungal medications. The hospice RN case manager later identified that the nystatin should have been discontinued when Zeasorb-AF was started. The facility's policy on unnecessary medications requires regular review of each resident's medication regimen to prevent excessive durations and ensure appropriate indications for use. However, the facility did not adhere to this policy, as evidenced by the prolonged use of antifungal medications without proper evaluation or documentation of need. Interviews with staff revealed a lack of consistent practice in reviewing and updating medication orders, particularly for topical antifungals, contributing to the deficiency.
Infection Control Deficiencies in Hand Hygiene and Precautions
Penalty
Summary
The facility failed to ensure proper hand hygiene and adherence to transmission-based precautions (TBP) for residents, leading to deficiencies in infection prevention and control. Resident R24, who was cognitively intact and had a history of MRSA, was observed to have inadequate TBP measures in place. Despite the presence of signs indicating Enteric Contact Precautions, staff members, including a trained medication assistant and a registered nurse, were unsure of the specific precautions required and failed to don appropriate personal protective equipment (PPE) when entering R24's room. Additionally, during personal care, a nursing assistant did not perform hand hygiene after glove removal and reused washcloths inappropriately, further compromising infection control. Resident R84, who had severe cognitive impairment and was dependent on staff for personal care, also experienced lapses in infection control practices. During a brief change, nursing assistants failed to change gloves and perform hand hygiene before touching clean items such as blankets and bed controls. This was acknowledged by the staff involved, who admitted to not following proper hand hygiene protocols as outlined in the facility's policy. The facility's policies on hand hygiene and Enhanced Barrier Precautions were not adequately followed, as evidenced by the staff's actions and statements. The Director of Nursing expected staff to adhere to TBP and perform hand hygiene after glove removal, but these expectations were not met. The lack of clear communication and understanding of the required precautions contributed to the deficiencies observed during the survey.
Failure to Provide Updated Vaccinations
Penalty
Summary
The facility failed to ensure that two residents, R59 and R211, were offered and/or provided updated vaccinations for pneumococcal disease, and one resident, R59, was not offered an updated influenza vaccination in accordance with CDC guidelines. R59, who was admitted with a diagnosis of diabetes, had not been offered the necessary pneumococcal vaccinations despite being at higher risk for pneumococcal diseases. His medical record lacked documentation of a discussion regarding additional pneumococcal vaccines, a signed declination, or documentation of risks and benefits. Although R59 received a pneumococcal conjugate vaccine in 2017 and an influenza vaccine in 2023, the facility did not ensure his vaccinations were up to date. R211, who had diagnoses of heart failure and hypertension, also did not have up-to-date influenza and pneumococcal vaccinations. His immunization report lacked documentation of any vaccinations, a signed declination, or information regarding risks and benefits. The Director of Nursing (DON) stated that the health unit coordinator was responsible for entering vaccine information into the computer system, and the nurse was responsible for offering and administering the vaccines. However, the facility did not have a Minnesota Immunization Information Connection (MIIC) report for R211, and the facility's policy on influenza and pneumococcal vaccinations was not provided upon request.
Failure to Provide Timely COVID-19 Vaccination
Penalty
Summary
The facility failed to provide a timely COVID-19 vaccination to a resident, identified as R211, who had requested it. R211 was admitted with intact cognition and diagnoses of heart failure and hypertension. The resident's immunization report lacked documentation of a COVID-19 vaccination, and there was no signed consent or declination form with the risks and benefits for the COVID-19 vaccination in the medical record. During an interview, R211 stated he had not been vaccinated in years and had inquired about receiving various vaccinations, including COVID-19, but was told they could only be administered at the care center, which had not occurred. The Director of Nursing/Infection Preventionist confirmed that the facility did not have a Minnesota Immunization Information Connection report for R211 and that the resident had not received the COVID-19 vaccination. The facility's policy required documentation of vaccine administration or declination, which was not followed in this case.
Failure to Provide Timely Wound Care and Communication
Penalty
Summary
The facility failed to provide appropriate treatment, monitoring, and care for a resident (R1) who developed skin ulcerations. R1's primary physician was not immediately notified when the first wound was discovered or when the wound had a significant change. R1 was admitted to the hospital with wounds on both legs requiring surgical interventions, but the facility was only aware of the wound on R1's right leg. The care plan for R1 did not include any focus, goals, or interventions for potential skin integrity concerns, and there was a lack of documentation and communication regarding the wounds. R1's nursing assistant skin monitoring documentation indicated multiple instances of skin tears and open areas, but the audit did not provide detailed information. The facility's records showed that R1 had a cognitive impairment and required assistance with daily activities. Despite being at risk for pressure ulcers, R1's care plan did not address these concerns. The facility's weekly skin body audits were incomplete, and there was a delay in notifying the wound care team and the primary care provider about the worsening condition of R1's wounds. Interviews with staff revealed a lack of communication and coordination in addressing R1's wounds. Nursing staff did not consistently report changes in R1's condition to the primary care provider or the wound care team. The facility's medical director acknowledged communication issues and the need for more consistent staff on the dementia unit. The facility's policy on skin care was not followed, leading to a delay in treatment and the progression of R1's wounds to a critical state requiring hospitalization.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to prevent the development of three pressure ulcers in a resident, identified as R1, who was cognitively impaired and required assistance with daily activities. Despite being at risk for pressure ulcers, R1's care plan did not address potential or actual skin integrity concerns. The resident's condition was not adequately monitored, as evidenced by the absence of documentation for a weekly skin body audit on one occasion and the lack of noted pressure ulcers in subsequent audits. Staff interviews revealed that nursing assistants and registered nurses were aware of changes in R1's skin condition, including redness and missing skin layers, but failed to report these findings or implement a treatment plan. The resident's decline in mobility and increased time spent in bed were noted by staff, yet no adjustments were made to R1's care plan to address these changes. The facility's protocol for wound care, which required daily skin inspections and physician notification for identified wounds, was not followed. The pressure ulcers were only discovered when R1 was admitted to the hospital for wound care, where they were assessed as serious, with one being unstageable and another at Stage III. The hospital's assessment indicated that these pressure injuries were acquired at the nursing facility, highlighting a significant lapse in care and monitoring by the facility staff.
Failure to Notify Resident's Representative of Health Change
Penalty
Summary
The facility failed to notify a resident's representative of a change in the resident's health condition when a new medication and treatment were ordered. The resident, identified as R1, was cognitively impaired and required assistance with daily activities. R1 was diagnosed with several conditions, including chronic atrial fibrillation, hypertension, renal failure, and dementia. On a specific date, the facility noted a wound on R1's right leg and contacted the primary care physician, who prescribed an antibiotic and a dressing change. However, the facility did not inform R1's representative, who was the power of attorney, about the wound or the new treatment until a care conference was held several days later. The family member, FM-A, who was the power of attorney, only became aware of the wound during the care conference and expressed concern that earlier notification might have prevented the resident's hospitalization. The assistant director of nursing confirmed that there was no documentation of notification to the resident's representative before the care conference. The facility's policy required prompt notification of changes in a resident's condition to the attending medical doctor and the resident's power of attorney, which was not followed in this case.
Failure to Report Neglect of Resident with Severe Wounds
Penalty
Summary
The facility failed to report an allegation of neglect immediately, as required, to the State Agency for a resident who was admitted to the hospital for wound care. The resident, who was cognitively impaired and required assistance with daily activities, was found to have three pressure ulcers upon hospital admission. The resident's medical history included chronic atrial fibrillation, anemia, hypertension, renal failure, diabetes type II, and dementia, among other conditions. The facility's records indicated that the resident was at risk for pressure ulcers but did not have any documented wounds prior to the hospital admission. The resident's physician had ordered treatment for blisters on the right leg, but the situation escalated when the nurse practitioner recommended hospital evaluation due to the severity of the wounds. The hospital's assessment revealed extensive necrotic wounds on the resident's lower extremities, requiring surgical intervention. Despite the severity of the wounds and the hospital's involvement, the facility did not report the incident to the State Agency as required. Interviews with facility staff revealed a lack of immediate action in reporting the incident. The social worker acknowledged awareness of the situation through communication with the hospital and family, but the facility did not report the incident. The assistant director of nursing deferred questions to the director of nursing, who was on vacation, and the administrator confirmed awareness of the hospital update but did not perceive the wounds as neglect. The facility did not have a policy on reporting available during the survey.
Failure to Update Care Plan for Skin Integrity and Transfer Needs
Penalty
Summary
The facility failed to develop a care plan addressing a significant change in a resident's skin integrity and wound treatment interventions. The resident, who was cognitively impaired and had multiple health conditions including chronic atrial fibrillation, anemia, hypertension, renal failure, diabetes type II, and dementia, was at risk for pressure ulcers. Despite this risk, the care plan did not include any focus, goals, or interventions for skin integrity concerns or wound treatment when a wound was discovered. Additionally, the care plan inaccurately indicated that the resident required assistance from one staff member for transfers, while in reality, the resident was using a mechanical lift and a wheelchair for ambulation. Interviews and record reviews revealed that the resident's wound was first noticed on 5/1/24, but the care plan was not updated to include wound care interventions. The resident's family member was not informed of the wound until a care conference on 5/14/24, and the care plan lacked directions for staff regarding the use of a mechanical lift. Nursing staff were aware of the resident's need for daily dressing changes and the use of a mechanical lift, but these were not reflected in the care plan. The Assistant Director of Nursing (ADON) confirmed that skin integrity concerns and the use of the EZ-stand were not included in the care plan, despite facility policy requiring such issues to be addressed in the care plan.
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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