Episcopal Church Home The Gardens
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Paul, Minnesota.
- Location
- 1860 University Avenue West, Saint Paul, Minnesota 55104
- CMS Provider Number
- 245625
- Inspections on file
- 25
- Latest survey
- April 9, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Episcopal Church Home The Gardens during CMS and state inspections, most recent first.
A deficiency was cited when a resident's right to a dignified existence, self-determination, communication, and the exercise of their rights was not upheld by the facility.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in a deficiency related to resident safety.
A bed rail was used without first attempting alternative interventions, assessing the resident for safety risk, reviewing risks and benefits with the resident or representative, or obtaining informed consent. The facility also failed to ensure the bed rail was correctly installed and maintained.
A resident was not protected from a significant medication error, as required, due to a failure in the medication administration process.
A resident was not provided with hospice services, nor was assistance given to transfer the resident to a facility that could arrange for hospice care, resulting in a deficiency related to the provision of end-of-life services.
The facility did not regularly inspect bed frames, mattresses, and bed rails for safety, and failed to ensure that bed rails and mattresses were safely attached to the bed frame as required.
A resident with significant cognitive and physical impairments reported to multiple staff that she experienced rough handling and yelling from staff, causing her pain and distress. Several staff were aware of these allegations, with some reporting to supervisors and others not reporting at all. One staff member reported the incident to the state agency independently, but not on behalf of the facility. The facility's required immediate reporting and investigation procedures were not followed, and the grievance log contained no record of the complaints.
A resident with Parkinson's disease, dementia, and kidney disease experienced multiple falls, and although new interventions were identified after each incident, these were not consistently added to the care plan or communicated to staff. As a result, important safety measures such as frequent checks and the use of a fall mat were not reliably implemented, leading to gaps in care.
A resident with multiple chronic conditions had a skin tear on the right forearm that was not consistently assessed or treated after initial physician orders were discontinued. Staff interviews and documentation review revealed that the wound was not monitored or addressed according to facility policy, and weekly skin checks were not performed as required.
The facility failed to monitor refrigerator, dishwasher, and breakfast food temperatures across six unit kitchens, leading to undated and potentially unsafe food consumption. Observations revealed missing or incomplete temperature logs, and interviews highlighted confusion among staff about monitoring responsibilities. A resident reported sour-tasting milk, underscoring the issue. The RD acknowledged the need for training nursing assistants on temperature monitoring and the importance of dating opened food containers.
The facility failed to follow proper infection control practices, as observed when a nursing assistant did not change gloves after providing peri-care to a resident and continued to assist with dressing and transfers. Additionally, a standing lift sling shared by residents was not sanitized between uses, contrary to facility policy. These actions were confirmed as infection control issues by an LPN.
A resident with a history of coronary artery disease and skin conditions had a PRN order for Nystatin powder, which was improperly administered by a nursing assistant. The NA applied the medication without authorization, as only nurses are permitted to assess and document PRN medication needs. The facility's policy on medication administration was not provided.
Two residents in a facility were not provided adequate assistance with personal hygiene, specifically shaving, despite their dependence on staff for such care. One resident with severe cognitive impairment was observed with long facial hair, which she disliked, while another resident, who preferred to be clean-shaven, was found with a full-face beard. Staff interviews revealed inconsistencies in offering shaving assistance, contrary to the facility's policy on maintaining cleanliness and grooming.
A resident with severe cognitive impairment and multiple medical conditions was observed leaning to the right in various chairs without staff intervention to reposition her. Despite being dependent on staff for daily activities and having a history of falls, her care plan lacked interventions for positioning. Staff were aware of her tendency to lean but did not take action to address it, contrary to the facility's policy of providing necessary care.
A facility failed to consistently monitor orthostatic blood pressures for a resident on antipsychotic medication, despite physician orders and facility policy requiring monthly checks. The resident, with a history of dementia and bipolar disorder, was at increased risk of falls due to potential side effects of the medication. Staff interviews confirmed the importance of these checks but revealed incomplete documentation without any noted refusals by the resident.
A resident's medication cabinet was found open and unsecured, containing multiple medications and a glucometer, while the resident was not in the room. A nurse admitted to leaving the cabinet open after being distracted, acknowledging the need for it to be locked to prevent unauthorized access. The facility's policy requires medication cabinets to be locked to ensure safe storage and administration.
Two residents at a long-term care facility experienced repeated falls due to the facility's failure to update and implement effective fall prevention strategies. One resident, with severe cognitive impairment and multiple medical conditions, had 20 falls without new interventions being added to her care plan. Another resident, who was independent with mobility, also experienced multiple falls with injuries, but her care plan was only updated once. Staff interviews revealed inconsistencies in applying fall interventions and conducting necessary assessments.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor a resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or observations involving individual residents.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Assess, Obtain Consent, and Properly Install Bed Rail
Penalty
Summary
The facility failed to try alternative approaches before using a bed rail. When a bed rail was determined to be needed, the facility did not assess the resident for safety risk, did not review the risks and benefits with the resident or their representative, and did not obtain informed consent. Additionally, the facility did not ensure the bed rail was correctly installed and maintained.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident experienced a significant medication error, indicating a failure in the medication administration process. Specific details about the actions or inactions leading to the error, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Arrange Hospice Services
Penalty
Summary
The facility failed to arrange for the provision of hospice services for a resident or assist the resident in transferring to a facility that would provide such services. This deficiency indicates that the necessary steps were not taken to ensure the resident received appropriate hospice care as required.
Failure to Ensure Safe Attachment and Inspection of Bed Equipment
Penalty
Summary
The facility failed to regularly inspect all bed frames, mattresses, and bed rails for safety. Additionally, bed rails and mattresses were not ensured to be safely attached to the bed frame as required. This deficiency was identified through direct observation and review of facility practices regarding the maintenance and safety checks of beds and related equipment.
Failure to Immediately Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to ensure that an allegation of abuse involving a resident was reported immediately to the state agency and the facility administrator, as required. The resident, who had significant cognitive and physical impairments including dementia, hypovolemia, cirrhosis, and dependence on staff for daily care, reported to multiple staff members that she experienced rough handling and yelling from staff during care. She described being treated roughly by two nursing assistants, which caused her pain for several days, and stated that one staff member consistently yelled at her. The resident communicated these concerns to various staff members, but was unable to provide specific dates due to her cognitive and physical limitations. Multiple staff interviews revealed that several staff members were aware of the resident's complaints of rough care and verbal abuse. Some staff reported these concerns to their supervisors or nurse managers, while others did not report them, either because they did not witness the incidents firsthand or because they believed the resident frequently complained. One staff member reported the allegations to the state agency independently, but not on behalf of the facility, citing a lack of trust in the facility's willingness to investigate or act on such reports. The facility's grievance log did not contain any entries related to the resident's complaints during the relevant period. The nurse manager and administrator both indicated that they had not received specific reports of abuse or rough care regarding the resident, and the nurse manager admitted to not investigating rumors of possible abuse. The facility's policy required immediate reporting of suspected abuse, neglect, or mistreatment to both the facility and the state agency, but this protocol was not followed in this case. As a result, the required immediate reporting and investigation of the abuse allegation did not occur as mandated.
Failure to Update Care Plan After Multiple Falls
Penalty
Summary
The facility failed to revise and update the care plan for a resident with Parkinson's disease, dementia, and kidney disease who was at high risk for falls. Despite multiple falls and new interventions being identified in incident reports, these interventions—such as frequent visual checks, hourly safety checks, and the use of a fall mat—were not consistently incorporated into the resident's care plan or nursing assistant care sheets. Nursing staff and assistants reported that they were not given specific instructions or documentation regarding the frequency of checks, and unfamiliar staff could miss critical interventions like placing the fall mat, as it was not documented in the care plan. The resident experienced several falls over a period of time, with each incident resulting in new interventions being recommended in incident reports. However, these interventions were not systematically added to the care plan, leading to inconsistent implementation by staff. Interviews with nursing assistants and an LPN confirmed that important safety measures were omitted from the care plan, and the DON acknowledged that new interventions should have been added in a timely manner. The facility's care planning policy was requested but not provided.
Failure to Assess and Monitor Skin Tear
Penalty
Summary
The facility failed to comprehensively assess and monitor a skin tear for a resident with multiple diagnoses, including heart failure, COPD, and peripheral vascular disease. The resident had a documented skin tear on the right forearm upon admission, with an initial physician order for wound care that was discontinued after a period. Following the discontinuation, there were no further treatment orders or consistent monitoring of the wound, as evidenced by gaps in the treatment administration record and weekly skin audits that either omitted the wound or lacked detailed descriptions and measurements. Observations confirmed the presence of an open wound on the resident's right forearm, which was not being treated or monitored according to physician orders or facility policy. Interviews with nursing staff and review of documentation revealed that the wound had been present since the resident's return from the hospital, but no ongoing treatment or comprehensive assessment was in place. Nursing assistants and LPNs acknowledged the lack of treatment and inconsistent skin checks, and the DON stated that weekly skin assessments and prompt reporting of new skin concerns to the physician were expected. The facility's own skin care policy required routine and as-needed assessments and interventions to promote healing and prevent further skin problems, but these procedures were not followed for this resident.
Failure to Monitor Food and Equipment Temperatures
Penalty
Summary
The facility failed to implement a process to monitor temperatures in refrigerators, dishwashers, and breakfast foods across all six unit kitchens. This deficiency was identified through observations and interviews, revealing that temperature logs were either missing or incomplete for industrial and unit refrigerators, as well as dishwashers. The registered dietician (RD) acknowledged the absence of a kitchen manager and the transition of responsibilities from kitchen staff to nursing staff, which contributed to the lack of monitoring. The RD also noted that nursing assistants required training on proper food temperature monitoring. During observations, it was found that several unit refrigerators contained open and undated food and beverage containers, such as milk and liquid eggs, which were not labeled with dates to ensure safe consumption. This issue was highlighted when a resident reported that the milk served to them tasted sour. Interviews with nursing assistants and kitchen staff revealed confusion over who was responsible for monitoring temperatures, with discrepancies in understanding between the staff members. The RD confirmed that the expectation was for nursing assistants to monitor breakfast food temperatures and that all opened food or drink containers should be dated and discarded within seven days. The facility's policy on date marking and labeling, dated March 2016, required all food held for more than 24 hours to be labeled. However, a policy on refrigeration and dishwasher temperature monitoring was requested but not provided, indicating a gap in the facility's procedures to ensure food safety for its residents.
Infection Control Deficiencies in Glove Use and Equipment Sanitization
Penalty
Summary
The facility failed to ensure proper infection control practices during personal care for a resident identified as R35. During an observation, two nursing assistants, NA-H and NA-I, assisted R35 with personal care after the resident used a bedpan. NA-H wore gloves while providing peri-care but did not change them afterward. Instead, she continued to assist R35 with dressing and transferring to a wheelchair using the same gloves, which were potentially contaminated. NA-H acknowledged her failure to change gloves, which was confirmed as an infection control issue by the clinical coordinator, LPN-C. Additionally, the facility did not sanitize a standing lift sling shared by residents, including R35 and R9. After using the standing lift to transfer R35, NA-H cleaned the lift but not the sling, which was then used to transfer R9 without sanitization. NA-H and NA-I confirmed that while the standing lifts were sanitized after each use, the slings were not, and they were only washed weekly by the laundry. LPN-C stated that the slings should be sanitized after every use, and the failure to do so was an infection control concern. The facility's policies on standard precautions and infection control for equipment and care items were not followed. The policies required gloves to be changed after contact with body fluids and for reusable equipment to be sanitized between uses. The failure to adhere to these policies resulted in potential cross-contamination and infection control issues, as observed during the survey.
Unqualified Staff Administered PRN Medication
Penalty
Summary
The facility failed to ensure that unqualified staff did not administer as-needed (PRN) medication for a resident. The resident, who was cognitively intact, had a history of coronary artery disease, peripheral vascular disease, hypertension, and diabetes. The resident's clinical records indicated a diagnosis of local infection of the skin and irritant contact dermatitis due to fecal and urinary incontinence. The resident had a PRN order for Nystatin powder to be applied under the breast every 12 hours for a skin rash. However, the Medication Administration Record for September showed no documentation of the medication being administered. During an observation, a nursing assistant (NA) was seen applying Nystatin powder to the resident's skin, despite not being authorized to administer medicated creams or powders. The NA stated that she was instructed by nurses on how to apply the powder but acknowledged that only nurses could assess and document the need for PRN medications. Interviews with a registered nurse (RN) and a clinical coordinator/licensed practical nurse (LPN) confirmed that nursing assistants were not trained or authorized to perform assessments or administer PRN medications. The facility's policy on medication administration was requested but not provided.
Failure to Provide Personal Hygiene Assistance
Penalty
Summary
The facility failed to provide adequate assistance with personal hygiene for two residents, R6 and R44, who were dependent on staff for activities of daily living. R6, who had severe cognitive impairment and required extensive assistance, was observed with long facial hair, which she expressed a desire to have removed. Despite the care plan indicating the need for assistance with grooming, staff interviews revealed inconsistencies in the provision of care, with some staff acknowledging the expectation to offer shaving but failing to do so consistently. R44, who had moderate cognitive impairment and was dependent on staff for personal hygiene, was observed with a full-face beard despite preferring to be clean-shaven. He reported not receiving help with shaving despite requesting it. Staff interviews indicated that shaving was typically offered on bath days, but R44's preference for being clean-shaven was not consistently respected, leading to a situation where he felt shaving was forced upon him. The facility's policy on elder rights and standard of care emphasized the need for assistance with shaving to maintain cleanliness and grooming. However, the observations and interviews highlighted a failure to adhere to this policy, resulting in neglect of personal hygiene needs for both residents. This neglect was noted as a concern for dignity, particularly for female residents, as stated by the staff.
Failure to Address Resident Positioning Needs
Penalty
Summary
The facility failed to assess and implement interventions for a resident who was unable to maintain proper positioning. The resident, who had severe cognitive impairment, Parkinson's Disease, vascular dementia, and legal blindness, was observed multiple times leaning to the right in various chairs without staff assistance to reposition her. Despite being dependent on staff for activities of daily living and having a history of falls with injury, the resident's care plan lacked interventions to address her positioning needs. During observations, staff members, including a nurse and a nursing assistant, did not attempt to reposition the resident or provide support to help her sit upright. Interviews with staff revealed an awareness of the resident's tendency to lean but no active measures were taken to address it. The nurse manager acknowledged the absence of positioning interventions in the care plan and suggested the possibility of consulting hospice for therapy assistance. The facility's policy indicated that residents should receive necessary care to maintain their wellbeing, but this was not reflected in the care provided to the resident.
Failure to Monitor Orthostatic Blood Pressures for Resident on Antipsychotics
Penalty
Summary
The facility failed to monitor orthostatic blood pressures for a resident (R51) who was prescribed antipsychotic medication, specifically Risperidone, to manage conditions such as schizoaffective disorder and bipolar disorder. The resident's medical history included dementia, bipolar disorder, anxiety, major depression, arthritis, diabetes, heart failure, and a history of falling. Despite the physician's orders for monthly orthostatic blood pressure checks, these were only documented in 5 out of 13 months since the resident's admission. Interviews with facility staff, including LPNs and an RN, revealed that the expectation was for all vital signs, including orthostatic blood pressures, to be documented in the electronic medical record (EMR). The staff acknowledged the importance of these checks due to the potential side effects of antipsychotic medications, which can alter blood pressure and increase fall risk. However, the staff could not provide a reason for the incomplete documentation and confirmed that the resident did not refuse the checks. The facility's policy on psychoactive medication, revised in 2018, required monthly orthostatic blood pressure checks for all residents receiving antipsychotic medication. Despite this policy, the checks were not consistently performed or documented for R51, indicating a failure to adhere to established protocols and potentially compromising the resident's safety.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure medications were safely and securely stored for a resident with moderate cognitive impairment and multiple health conditions, including peripheral vascular disease, diabetes, anxiety, depression, and hyperlipidemia. The resident was dependent on staff for dressing, toileting, bathing, and transfers, but could eat independently. The resident's care plan indicated poor safety awareness and impaired cognitive function. During an observation, the medication cabinet in the resident's room was found open and unsecured, containing 19 cards of medications, about 10 lidocaine patches, and a glucometer, while the resident was not present in the room. A registered nurse admitted to leaving the cabinet open after being distracted by another resident, acknowledging that the cabinet should have been locked to prevent unauthorized access to the medications. A clinical nurse further emphasized the dangers of unsecured medication cabinets, noting that anyone could take the medications, which could be harmful if residents have allergies or difficulty swallowing. The facility's policy on medication storage requires that medication cabinets be kept locked to ensure orderly and effective medication preparation and administration, in line with infection control standards.
Failure to Implement Effective Fall Interventions
Penalty
Summary
The facility failed to implement and update appropriate fall interventions for two residents, R40 and R51, who were at high risk for falls. R40, who had severe cognitive impairment and multiple medical conditions including Parkinson's Disease and vascular dementia, experienced 20 falls since a new care plan intervention was put in place. Despite the high frequency of falls, R40's care plan lacked new interventions since February 2024, and the existing interventions were not effectively preventing falls. Observations and interviews revealed that R40 often did not have her call light within reach, and her fall interventions, such as alarms and walker placement, were inconsistently applied. R51, who had intact cognition and was independent with mobility, also experienced multiple falls with injuries, including a rib injury and a toe fracture. Despite having a history of falls and being on antipsychotic medication, R51's care plan was only updated once following a fall, and the interventions were not consistently revised to address the root causes of the falls. The facility's policy required staff to document falls, update care plans, and implement new interventions, but these actions were not consistently carried out for R51. Interviews with facility staff, including nursing assistants and a nurse manager, indicated a lack of consistent assessment and intervention following falls. Staff acknowledged that R40's fall interventions were outdated and not working, and there was a failure to conduct neuro assessments for falls involving head injuries. The facility's failure to update and implement effective fall prevention strategies for R40 and R51 resulted in repeated falls and injuries, highlighting deficiencies in the facility's fall management practices.
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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