Fair Oaks Lodge
Inspection history, citations, penalties and survey trends for this long-term care facility in Wadena, Minnesota.
- Location
- 201 Shady Lane Drive, Wadena, Minnesota 56482
- CMS Provider Number
- 245581
- Inspections on file
- 34
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 8 (1 serious)
Citation history
Health deficiencies cited at Fair Oaks Lodge during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and mobility dependence was transported in a facility van without a seatbelt due to the transport driver's inability to secure it and misunderstanding of safety requirements. During the trip, the resident slid out of the wheelchair and sustained fractures to both tibias and the left femur. The transport driver had not received specific training on safe transport procedures, and facility policy requiring all residents to be safely secured was not followed.
Two residents in a memory care unit with known wandering behaviors managed to leave the facility unnoticed due to inadequate supervision and monitoring. One resident, who required 24-hour supervision, tailgated a staff member through an exit door, while the other resident, dependent on a wheelchair, followed. Both were found outside the facility, highlighting a lapse in monitoring and supervision.
The facility failed to ensure safe patient handling during mechanical lift-assisted transfers for three residents, leading to potential accident hazards. A resident with quadriplegia was transferred using an incorrect sling size, while another resident had to frequently remind staff about proper sling usage. Interviews revealed staff guessed sling sizes due to a lack of resources, and the facility's policy did not specify how to identify the appropriate sling size.
The facility failed to provide sufficient staffing to meet residents' needs, resulting in significant delays in care, particularly for toileting assistance. Residents and family members reported long wait times for call light responses, with some instances exceeding two hours. Staff interviews confirmed frequent short-staffing, especially on weekends, leading to delays in care and unmet resident needs. The facility's staffing policy was not adhered to, compromising resident care.
The facility failed to provide follow-up responses to concerns raised by the resident council, affecting all 49 residents. During a meeting, residents expressed that they did not receive answers after voicing concerns. Records showed that while concerns were marked as resolved, follow-up information was not communicated back. Interviews confirmed the lack of documentation and follow-up, despite facility policy requiring grievances to be addressed and follow-up recorded.
The facility failed to update care plans for several residents, affecting discharge planning and activity engagement. One resident's care plan did not reflect the spouse's wishes for discharge closer to family, while another resident's plan lacked updates for 24/7 assistance needs. Additionally, a resident receiving hospice services had a care plan that did not include the spouse's requests for additional activities. Staff interviews confirmed care plans were not consistently updated, contrary to facility policy.
The facility failed to ensure appropriate discharge planning for four residents, leading to a deficiency in the continuation of care. One resident, severely cognitively impaired, had undecided discharge plans despite a spouse's request to move closer to family. Another resident, with mild cognitive impairment, had plans to return to an assisted living facility, but lacked discharge planning documentation. A third resident, cognitively intact, expressed a desire to move closer to family, but the medical record lacked follow-up documentation. The facility's director of nursing acknowledged the lack of documentation as a concern.
The facility failed to maintain a clean and sanitary environment, with soiled commode buckets and bedpans left out, and ADL supplies improperly stored. Standing lifts were also found dirty, with staff unclear on cleaning responsibilities. The Director of Nursing noted that all staff should ensure equipment is cleaned between uses.
The facility failed to maintain sanitary conditions for mechanical lifts and implement proper hand hygiene practices. Nursing assistants did not sanitize lifts or their hands between resident transfers. A nursing assistant also failed to change gloves or sanitize hands during personal care tasks, risking cross-contamination. Additionally, dietary aides handled drinkware improperly, and a resident on enhanced barrier precautions lacked proper signage and PPE initially.
A resident with severe cognitive impairment and Parkinson's disease did not receive a comprehensive assessment for their ankle-foot orthosis (AFO) brace. The care plan and electronic health record lacked necessary information, and there were no physician orders or treatment plans for the brace. Observations showed improper application of the brace, and interviews revealed staff were not trained on its use. The DON confirmed the absence of a care plan and assessment for the AFO brace.
A resident's MDS was inaccurately coded, with Section C left blank and Section H incorrectly indicating the absence of a catheter. Interviews with staff confirmed these errors, which contradicted the resident's care plan and progress notes. The facility's policy mandates accurate MDS completion, which was not adhered to in this case.
A resident with moderate hearing difficulty and a history of heart failure and depression did not receive necessary assistance from staff to maintain her hearing aids. Despite informing multiple staff members about the need for repair, no action was taken, and the resident's care plan lacked interventions for hearing aid use. The LSW and DON were unaware of the issue until later, highlighting a communication breakdown in addressing the resident's needs.
A resident with intact cognition and multiple diagnoses did not receive Myrbetriq and Psyllium as ordered due to unavailability for several days. The facility failed to notify the provider or follow the usual process of contacting the pharmacy, resulting in seven missed doses. Interviews revealed that staff did not adhere to the policy requiring physician notification after missing three consecutive doses.
A resident with hypertension, neurogenic bladder, and constipation did not receive prescribed medications Myrbetriq and Psyllium due to unavailability. The RN responsible was unaware of the shortage and did not contact the pharmacy or provider. Interviews revealed the facility failed to follow protocol for handling medication shortages, leading to a 6.25% medication error rate.
The facility failed to offer or administer pneumococcal vaccinations to three residents as per CDC guidelines. Despite the facility's policy requiring adherence to CDC recommendations, the residents' medical records lacked evidence of being offered the PCV20 or PCV21 vaccines. Interviews with the infection preventionist and DON confirmed the oversight, and the facility did not have the most current CDC recommendations.
A resident with an indwelling catheter due to urinary retention had their dignity compromised when their catheter bag was repeatedly left uncovered and visible to others, contrary to the care plan and facility policy. Observations confirmed the uncovered bag, and interviews with staff and the resident highlighted the expectation and preference for the bag to be covered.
A resident with severe cognitive impairment and multiple diagnoses was not provided care according to their comprehensive care plan. The plan required the resident to be fed in a wheelchair in the dining room, but observations showed the resident was fed in bed. Staff were unaware of the care plan requirements, and the plan was not updated to reflect the resident's current preferences, resulting in a deficiency.
A resident who required assistance with hygiene did not receive necessary oral care, as staff failed to perform oral care despite the resident's dependency and care plan requirements. The resident reported never being asked to wash her mouth out, and staff interviews confirmed a lack of awareness and adherence to oral care procedures. The facility's policy lacked specific instructions for oral care, contributing to the deficiency.
A facility failed to provide meaningful activities for a resident with severe cognitive impairment and dementia, despite a care plan emphasizing engagement in leisure activities. Observations showed the resident was often left in their room without being offered activities. Staff interviews revealed that activities were seldom conducted due to staffing issues, and there was a lack of documentation on resident participation. The facility's policy on supporting residents' well-being through activities was not effectively implemented.
The facility failed to ensure that all survey results from the past three years were accessible to residents and visitors. The last survey results in the binder were from a survey dated 8/16/24, missing results from surveys completed on 10/21/24 and 1/14/25. The DON confirmed the oversight and acknowledged the need for transparency, but no policy was provided.
A resident, dependent on staff for personal hygiene, was found with unwanted facial hair that she expressed bothered her. Despite her care plan indicating the need for assistance, staff did not offer to remove the facial hair until it was pointed out during an observation. Interviews revealed a lack of awareness and resources among staff regarding the issue, highlighting a failure to maintain the resident's dignity.
A resident with severe cognitive impairment was involved in an incident where a TMA allegedly responded to the resident's actions with a potentially abusive remark. The incident was reported internally but not to the State agency within the required timeframe, violating the facility's policy on abuse reporting.
The facility failed to submit the results of an abuse investigation to the State Agency within the required timeframe. A resident with severe cognitive impairment was involved in an incident where a staff member allegedly responded in a verbally abusive manner. The investigation was documented, but the report was not submitted as per the facility's policy, leading to a deficiency.
A resident with limited mobility and chronic pain was found without access to her call light, which was clipped to the wall out of reach. This led to the resident being unable to call for assistance, causing distress and a delay in care. Staff interviews confirmed that the call light was improperly placed by the night shift, contrary to facility policy requiring call lights to be within easy access.
A resident with a choking risk was left unsupervised while eating, despite care plan requirements for supervision. The resident, on a Level 6 Soft and Bite-Sized diet, was observed eating independently without staff present due to being moved for behavioral reasons. Staff interviews confirmed the need for supervision, but the facility's policy lacked guidance on supervision requirements.
A resident with specific dietary needs was served an incorrect meal, receiving regular corn instead of the prescribed Level 6 Soft and Bite-Sized texture diet. The dietary aide admitted to an oversight, and the LPN did not correct the error despite observing the resident eating the wrong food. Facility policies on diet verification were not followed, resulting in the dietary error.
A resident requiring assistance for toileting due to medical conditions was not provided with proper hand hygiene care by nursing assistants. One assistant failed to change gloves and perform hand hygiene after assisting with toileting, despite facility policies and expectations. The Director of Nursing confirmed the expected procedures for glove use and hand hygiene.
A resident with a history of neurological and bleeding disorders fell from her bed, resulting in head injuries. Despite being discharged from the ED with instructions for monitoring, the LTC facility failed to document consistent neurological checks and bruising assessments for 72 hours post-fall, as required by their policy. Staff interviews confirmed the lack of adherence to monitoring protocols.
A resident with complex medical needs fell from her bed and sustained head injuries after a nursing assistant failed to follow the care plan requiring two-person assistance for bed mobility. Despite staff awareness of the care plan, the resident was left unattended, leading to the accident. The incident highlighted a lack of immediate comprehensive staff education on care plan adherence.
A facility failed to follow enhanced barrier precautions for a resident with ESBL resistance. Despite signage indicating the need for PPE during high-contact care, nursing assistants provided care without gloves or gowns, mistakenly believing precautions were only for residents with wounds, infections, or catheters. The DON confirmed the need for precautions, as outlined in the facility's policy.
The facility failed to properly label and discard food, maintain correct dishwashing temperatures, and ensure staff wore appropriate hair restraints. Observations revealed expired and unlabeled food items, inadequate dishwashing practices, and staff handling drink glasses improperly. The dietary manager confirmed these practices were against facility policies.
The facility failed to provide mandatory training on its QAPI program, as revealed through interviews and document reviews. Staff, including NAs, LPNs, and TMAs, were unaware of QAPI, and the DON was surprised by this lack of training. The facility's training materials lacked documentation on QAPI, and a training policy was not provided.
A facility failed to maintain cleanliness and sanitation of a resident's tube feeding and suctioning supplies after the resident was hospitalized. The supplies were left in the room, contrary to facility policy. Additionally, standing lifts used by residents were found with dried substances, and staff were unclear about cleaning responsibilities. The DON confirmed expectations for cleanliness were not met.
A resident with moderate cognitive impairment and a history of respiratory issues was observed self-administering a nebulizer without a completed SAM assessment or physician's order. The resident's care plan lacked interventions for self-medication, and staff failed to supervise the nebulizer treatment as required by facility policy. Interviews confirmed the absence of a SAM assessment and the expectation for staff to remain with the resident during nebulizer administration.
A resident with moderate cognitive impairment was left unsupervised while smoking, despite a care plan requiring direct supervision and a smoking apron. Observations showed the resident was unsupervised multiple times, with the apron improperly secured, leading to ashes on clothing and the wheelchair. Staff interviews confirmed a lack of supervision and awareness of safety monitoring, and the LPN admitted the smoking assessment was inaccurate. The DON and regional nurse did not update the assessment, failing to ensure resident safety during smoking.
A resident with cancer and diabetes required continuous tube feeding, but the facility failed to administer it according to physician's orders. Nursing staff stopped the feedings during the day without proper documentation or notifying medical personnel, despite the resident's reports of vomiting and inconsistent feeding. The DON was unaware of these actions, and the facility's policy on verifying physician orders was not followed.
A resident with COPD and respiratory failure did not receive continuous oxygen therapy as ordered, resulting in critically low oxygen saturation levels. The resident was observed in the dining room without oxygen, despite having a portable tank available. The RN was delayed in addressing the issue due to other duties, and the resident's oxygen saturation was found to be 79% before oxygen was administered.
The facility failed to prevent contamination risk by improperly handling linens. A nursing assistant carried soiled bed linen with bare hands against her clothing, and a nurse manager carried a clean hoyer sling over her shoulder after providing care. Both actions were against the facility's policy, which requires soiled linen to be bagged and clean linen to be carried away from the body.
The facility did not notify the State agency when the current DON was appointed, as required. During a survey, both the administrator and the DON confirmed the lack of notification, with the administrator believing it was no longer necessary. A review of the DON's job description, signed in October 2023, provided no additional information.
The facility failed to ensure residents received prescribed diets as ordered, affecting three residents. One resident received inappropriate food items and liquids, another received a pureed diet instead of a minced and moist texture, and a third resident received uncut food items. The dietary manager and director of nursing confirmed these discrepancies.
The facility failed to ensure non-pressure related wounds were monitored for signs and symptoms of infection and healing until resolved for three residents. One resident had a surgical wound that was not properly monitored, leading to an infection diagnosed after discharge. Another resident had surgical wounds with staples, but the treatment administration record lacked evidence of a nursing order to monitor for signs of infection or healing. A third resident had a skin tear, open areas on the coccyx, and stitches on the left knee, but the care plan failed to identify the actual skin impairment of the left knee with stitches, and staff were unaware of the stitches.
Failure to Secure Resident During Van Transport Results in Multiple Fractures
Penalty
Summary
A deficiency occurred when a transport driver (TD) failed to ensure the safe transport of a resident with severe cognitive impairment, morbid obesity, and muscle weakness. The resident, who was dependent on staff for all activities of daily living and wheelchair mobility, was transported in a facility van without a seatbelt. The TD was unable to secure the seatbelt due to the resident's size and, based on previous guidance from a former administrator, believed that securing only the wheelchair was sufficient for safety. During the transport, the resident slid out of the wheelchair and ended up on the floor of the van. Following the incident, the resident was initially evaluated at a clinic where only a hip x-ray was performed and no injuries were identified. However, over the next several days, the resident experienced increasing pain in both legs and hips, as well as visible bruising. The resident was eventually sent to the emergency department, where closed fractures of both tibias and the left femur were diagnosed. The resident required pain management and immobilization of both legs as a result of these injuries. Interviews with facility staff revealed that the TD had not received specific training on the transport of residents or the use of restraints in the facility van. The human resources director confirmed that no policies, procedures, or training related to resident transport had been provided. Facility policy required that all residents and wheelchairs be safely secured during transport, but this was not followed in the incident, leading to the resident's injuries.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to implement adequate interventions and supervision for two residents residing in a memory care unit, both identified with wandering and elopement behaviors. Resident 1, who had a history of wandering and was at risk for elopement, left the facility without staff awareness. Despite being identified as needing 24-hour supervision due to cognitive impairments, Resident 1 was able to exit the building by tailgating a staff member who did not ensure the door was securely locked. Resident 1 was later found at a nearby apartment complex, indicating a lapse in monitoring and supervision. Resident 2, also residing in the memory care unit, exhibited purpose-driven wandering and exit-seeking behaviors. Despite being assessed as a low risk for wandering, Resident 2 managed to leave the facility by using the same exit door as Resident 1. The resident, who was dependent on a wheelchair for mobility, was found outside the facility, indicating a failure in monitoring and supervision. Staff were unaware of Resident 2's absence until informed by an activity director who saw the resident outside. The report highlights that the east hallway exit door was not visible from the nurse's station, contributing to the lack of supervision. Staff interviews revealed that residents frequently talked about leaving the facility, and there was an expectation for staff to monitor residents closely, especially those with elopement risks. However, the facility's failure to ensure the door was secure and to maintain adequate supervision allowed both residents to exit the facility unnoticed.
Deficiency in Safe Patient Handling with Mechanical Lifts
Penalty
Summary
The facility failed to ensure safe patient handling during mechanical lift-assisted transfers for three residents, leading to potential accident hazards. Resident 1, who was diagnosed with functional quadriplegia and cognitive impairments, was observed being transferred using a medium sling instead of the prescribed extra-large sling. This discrepancy was noted despite the resident's care plan and Kardex indicating the need for an extra-large sling. Similarly, Resident 2, with diagnoses including polyneuropathy and muscle weakness, was also transferred using a medium sling, which was consistent with her care plan but not with the observed practice of using a large sling. Resident 3, who had polyneuropathy and mobility impairments, experienced issues with the mechanical lift transfer process. During an observed transfer, the resident had to stop the nursing assistants because the leg straps of the sling were not crossed, a mistake that had previously almost led to a fall. The resident reported frequent reminders to staff about proper sling usage and recounted an incident where she was nearly pulled forward in her recliner due to improper handling of the lift straps. Interviews with nursing assistants revealed a lack of consistent knowledge and resources regarding sling sizing. Staff members admitted to guessing sling sizes based on experience, as there was no readily available sizing guide. The Director of Nursing confirmed that residents did not have dedicated slings and that sling sizes were supposed to be listed on the Kardex. However, the facility's policy did not specify how to identify the appropriate sling size, contributing to the observed deficiencies in safe patient handling practices.
Staffing Shortages Lead to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient staffing to meet the needs of residents, particularly in providing routine and assessed needs for toileting. This deficiency was evident in the cases of two residents, one residing on the main level and another in the memory care unit, who experienced significant delays in receiving assistance. Family members also expressed concerns about the inadequate number of staff to provide necessary care, and several residents and staff members voiced similar concerns about the lack of sufficient staffing. The facility's staffing shortages were reported to occur frequently, with staff often being required to float to different areas due to call-ins or open shifts, leading to delays in resident care and extended wait times for call light responses. During a resident council meeting, multiple residents reported that the wait time for staff to answer call lights could be as long as one and a half hours. Staff interviews revealed that the facility often worked short-staffed, particularly on weekends, and that agency staff were sometimes used to fill gaps. The facility's master schedule showed that staffing levels were consistently below recommended levels, with numerous instances of insufficient staffing on both the memory care and second floors. The call light alarm response report further highlighted the issue, with numerous instances of call lights going unanswered for extended periods, including two instances where call lights were on for over two hours. Specific incidents included a resident who was left on a bedpan for four hours due to unanswered call lights, and another resident who was left in the bathroom without assistance, posing a high fall risk. Staff interviews indicated that the lack of sufficient staffing prevented them from completing all required tasks and providing timely care. The facility's policy on sufficient staffing emphasized the need for qualified nursing staff to meet residents' needs safely, but the reported staffing patterns and call light response times indicated a failure to adhere to this policy, resulting in compromised resident care.
Failure to Provide Follow-Up on Resident Council Concerns
Penalty
Summary
The facility failed to provide follow-up responses to concerns raised by the resident council, affecting all 49 residents. During a resident council meeting, four residents expressed that they did not receive any answers after voicing their concerns. The facility's records from July 2024 to January 2025 showed that while concerns were marked as resolved, partially resolved, or not resolved, follow-up information was not communicated back to the residents. Concerns included issues such as the need for more shower stalls, lack of respect from aides, and delays in service, among others. Interviews with the social worker and the director of nursing confirmed the lack of documentation and follow-up on the concerns raised. The social worker acknowledged that previous concerns were not discussed with residents after action forms were completed. The director of nursing stated that the social worker was responsible for resident council meetings and documentation, and expected that concerns would be reviewed and addressed by the appropriate department, with follow-up information provided to residents. The facility's policy required grievances to be addressed and follow-up recorded, but this was not adhered to.
Failure to Update Care Plans for Discharge and Activities
Penalty
Summary
The facility failed to update the care plans for several residents, leading to deficiencies in discharge planning and activity engagement. For one resident, the care plan was not updated to reflect the resident's spouse's wishes for discharge closer to family, despite the resident's significant cognitive impairment and the spouse's expressed desires during a care conference. The care plan conference summary indicated the spouse's wish for the resident to be moved closer to family, but the care plan lacked documentation of discharge planning. Another resident's care plan was not updated to reflect the resident's need for 24/7 assistance and the plan to return to an assisted living facility. The care plan conference summary indicated the resident required extensive assistance, but the progress notes lacked documentation of discharge planning. Additionally, a resident receiving hospice services had a care plan that was not updated to include the spouse's requests for additional activities, despite the activity director's awareness of these requests. A resident who was cognitively intact and had a goal to discharge to the community did not have an updated care plan to include discharge planning for long-term care placement. The resident expressed a desire to move closer to family, but the care plan was not revised to reflect this. Interviews with facility staff, including the licensed social worker and director of nursing, confirmed that care plans were not consistently updated to include current discharge planning interventions and goals, contrary to the facility's policy.
Deficiency in Discharge Planning for Residents
Penalty
Summary
The facility failed to ensure appropriate discharge planning for four residents, leading to a deficiency in the continuation of care. Resident R41, who was severely cognitively impaired and required minimal assistance with ADLs, had undecided discharge plans. Despite the spouse's request to move R41 closer to family, there was no documentation of discharge planning in the progress notes from December 12, 2024, to February 12, 2025. Similarly, Resident R15, with mild cognitive impairment and extensive assistance needs, had plans to return to an assisted living facility, but the progress notes also lacked discharge planning documentation. Resident R42, who was cognitively intact and dependent on staff for ADLs, expressed a desire to move to a facility closer to family. Although there was some initial communication with the Mahnomen nursing home, the medical record lacked follow-up documentation on R42's wishes. The licensed social worker admitted to not documenting the discharge planning progress consistently. Resident R13, with intact cognition and extensive assistance needs, also wished to move closer to family, but the care plan and conference summary lacked documentation on discharge planning. The facility's director of nursing confirmed the lack of documentation regarding discharge planning and acknowledged it as a concern. The facility's policy on charting and documentation emphasized the importance of maintaining a medical record that details services provided and changes in the resident's condition. However, the facility did not provide a specific policy on discharge planning, highlighting a gap in their procedures.
Failure to Maintain Sanitary Environment and Equipment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for its residents, as evidenced by several observations and interviews. In one instance, a visibly soiled commode bucket was found next to a nightstand in a resident's room, and soiled bedpans were left out in a shared bathroom. The commode bucket had a darkened ring and contained debris, while the bedpans had visible spots and were not stored properly. Housekeeping and nursing staff were unclear about their responsibilities regarding the cleaning and storage of these items, leading to their prolonged presence in the residents' living areas. Additionally, the facility did not store activities of daily living (ADL) supplies in a clean and discreet manner. Observations revealed that wash basins and briefs were left on the floor in residents' rooms, visible from the hallway. Staff interviews confirmed that these items should have been stored in nightstand drawers, but this was not done, contributing to the unsanitary conditions. The facility also failed to maintain standing lifts in a clean and sanitary manner. Observations showed that the lifts had a thick accumulation of substances on their plates, and staff interviews revealed confusion about who was responsible for cleaning them. The Director of Nursing (DON) stated that all staff should ensure lifts are wiped between uses, but this expectation was not met, resulting in the continued presence of dirt and debris on the equipment.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain sanitary conditions for mechanical lifts and implement proper hand hygiene practices. During observations, nursing assistants used a mechanical lift to transfer two residents without sanitizing the lift between uses. Additionally, the nursing assistants did not sanitize their hands before or after assisting the residents, despite acknowledging the importance of these practices to prevent infection spread. In another instance, a nursing assistant failed to follow proper hand hygiene and glove-changing protocols while providing personal care to a resident. The assistant did not change gloves or sanitize hands between different care tasks, such as applying lotion and performing perineal care, which could lead to cross-contamination. The assistant admitted to not receiving adequate education on proper hygiene practices and confirmed the oversight during an interview. The facility also failed to ensure safe delivery of beverages during dining service. Dietary aides were observed handling the rims of glasses and cups with bare hands, which could lead to contamination. Furthermore, the facility did not initially provide proper signage or personal protective equipment for a resident on enhanced barrier precautions due to a pressure ulcer, which was later rectified. These deficiencies highlight lapses in infection control practices within the facility.
Failure to Assess and Plan for AFO Brace Use
Penalty
Summary
The facility failed to conduct a complete and comprehensive assessment for a resident's ankle-foot orthosis (AFO) brace. The resident, who had severe cognitive impairment and multiple diagnoses including Parkinson's disease, required extensive assistance with activities of daily living. Despite these needs, the resident's care plan and electronic health record lacked information and a comprehensive assessment regarding the AFO brace. Additionally, there were no physician orders or treatment plans related to the AFO brace, and therapy recommendations to nursing staff did not include information about the brace. Observations revealed inconsistencies in the application of the AFO brace, such as the absence of a sock underneath the brace, which was not addressed in the resident's care plan. Interviews with nursing staff, including a nursing assistant and an LPN, indicated a lack of knowledge and training regarding the use and application of the AFO brace. The physical therapy assistant confirmed that no orders or assessments had been completed for the brace, and there was no communication to nursing staff about its proper use. The director of nursing acknowledged these findings and confirmed that the AFO brace was not care planned, and an assessment should have been conducted.
Inaccurate MDS Coding for Resident Assessment
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for a resident, identified as R26, during a quarterly assessment. The MDS, which is crucial for care planning, had several inaccuracies. Specifically, Section C, which assesses cognitive patterns, was left blank, and Section H, which pertains to health-related appliances, was incorrectly coded. The care plan and progress notes indicated that R26 had a suprapubic catheter, but the MDS inaccurately noted the absence of a catheter and incorrectly identified the presence of an ostomy. Interviews with the MDS Coordinator, social worker, and Director of Nursing (DON) confirmed these discrepancies. The MDS Coordinator acknowledged the incorrect coding of Section H, while the social worker admitted to omitting Section C, which should have documented R26's cognitive status. The DON verified the inaccuracies and stated that the expectation was for the MDS to be completed and coded correctly. The facility's policy requires accurate completion and certification of MDS assessments, highlighting a failure in adherence to this policy.
Failure to Assist Resident with Hearing Aid Maintenance
Penalty
Summary
The facility failed to assist a resident in maintaining their hearing needs by not ensuring the availability and repair of hearing aids. The resident, who was cognitively intact and had a history of heart failure, peripheral vascular disease, and depression, was dependent on staff for various activities of daily living. Despite having moderate difficulty with hearing and requiring hearing aids, the resident's care plan did not include any interventions related to hearing aid use. The resident reported that her hearing aids needed cleaning and repair, and although she had informed multiple staff members about the issue, no action was taken to address her needs. Interviews with the licensed social worker (LSW) and the director of nursing (DON) revealed a lack of communication and follow-up regarding the resident's hearing aids. The LSW was unaware of the issue until informed by the resident, and the DON acknowledged that staff should have reported the problem to ensure timely repair. The hearing aids were left in a nursing cart for some time before being returned to the resident's room, and no policy was provided to guide staff on handling such situations. This inaction potentially affected the resident's ability to hear and communicate effectively.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that medications were available and administered as ordered for a resident, identified as R14, who did not receive their prescribed medications. R14, who had intact cognition and diagnoses including hypertension, neurogenic bladder, and constipation, was observed on February 11, 2025, not receiving Myrbetriq and Psyllium, which had been unavailable for several days. The resident's Electronic Medication Administration Record (EMAR) indicated that seven doses of both medications were missed. Progress notes from February 4 to February 11, 2025, documented repeated instances of the medications being unavailable, but lacked any notification to R14's provider about the unavailability of these medications. Interviews with staff, including RN-A, the pharmacy consultant, and the Director of Nursing (DON), revealed that the usual process of contacting the pharmacy and notifying the provider when medications were unavailable was not followed. The medical director confirmed that he was not contacted regarding the unavailability of R14's medications and expected the facility to have reached out for assistance with obtaining prior authorization or alternative medication. The facility's policy required physician notification when three consecutive doses were missed, which was not adhered to in this case.
Medication Error Due to Unavailable Medications
Penalty
Summary
The facility was found to have a medication error rate of 6.25% for one of the seven residents observed during medication administration. The resident, identified as R14, had intact cognition and was diagnosed with hypertension, neurogenic bladder, and constipation. R14's medication orders included Myrbetriq for overactive bladder and Psyllium for constipation. However, during an observation, it was noted that these medications were not available for administration, and the resident had not received them since February 5th. The registered nurse (RN-A) responsible for administering the medications was unaware of the shortage and had not contacted the pharmacy or the provider to address the issue. Interviews with the pharmacy consultant, director of nursing (DON), and medical director (MD) revealed that the facility failed to follow the expected protocol for handling medication shortages. The pharmacy consultant stated that the facility should have contacted the pharmacy and the physician to determine whether to hold the medication or administer an alternative. The DON confirmed that seven doses of Myrbetriq and Psyllium were missed, and the provider was not notified. The MD indicated that the facility should have contacted his office to assist with obtaining prior authorization or to decide on alternative medication. The facility's policy on administering medications emphasized the importance of administering medications as per provider orders and ensuring their availability, which was not adhered to in this case.
Failure to Administer Pneumococcal Vaccinations per CDC Guidelines
Penalty
Summary
The facility failed to ensure that three residents, aged 68, 78, and 73, were offered or received pneumococcal vaccinations in accordance with the CDC recommendations. The CDC guidelines specify that adults aged 65 years or older who have previously received the PCV13 and PPSV23 vaccines should receive a dose of the PCV20 or PCV21 five years after the most recent dose. However, the medical records of these residents lacked evidence that they had been offered the PCV20 or PCV21 vaccines as required. Interviews with the infection preventionist and the director of nursing confirmed that the residents had not been offered or received the pneumococcal vaccines as per CDC recommendations. The facility's policy, revised in September 2024, stated that all residents should receive vaccines to protect them from pneumonia according to CDC guidelines. However, the facility did not have the most current CDC recommendations, leading to the oversight in offering the necessary vaccinations to the residents.
Failure to Maintain Resident Dignity with Uncovered Catheter Bag
Penalty
Summary
The facility failed to maintain the dignity of a resident who utilized an indwelling catheter. The resident, who had diagnoses including Alzheimer's, neurogenic bladder, and benign prostatic hyperplasia, required extensive assistance with toileting and had an indwelling catheter due to urinary retention. The resident's care plan and facility policy specified that the catheter bag should be covered at all times for dignity. However, during observations, the resident's catheter bag was found uncovered and visible to others on multiple occasions, both when the resident was seated in a recliner and lying in bed. This visibility was confirmed by staff and the director of nursing, who acknowledged that the expectation was for the catheter bag to be covered. Interviews with the resident and a family member revealed that the resident would have preferred the catheter bag to be covered, although the family member was unsure if it would have bothered the resident. The facility's policy on Foley catheter management, revised shortly before the observations, also required that catheter bags be covered at all times. Despite these guidelines, the facility did not ensure the resident's catheter bag was covered, leading to a failure in maintaining the resident's dignity.
Failure to Follow Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to follow the comprehensive care plan for a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease and dementia. The resident required extensive assistance with activities of daily living and was on hospice care. The care plan, revised on 11/15/24, specified that the resident should have soft cut-up foods and pureed foods when needed, and should be supervised while eating in the dining room, sitting upright in a wheelchair. However, observations revealed that the resident was fed breakfast in bed, contrary to the care plan instructions. The nursing assistant was unaware of the requirement for the resident to be in a wheelchair during meals, and the licensed practical nurse confirmed that the care plan was not being followed. Interviews with staff, including the director of nursing, indicated that the resident's care plan had not been updated to reflect the resident's current preferences, such as not wanting to get out of bed for meals. The facility's policy required that care plans be individualized and updated continuously to ensure residents receive the necessary care. Despite this policy, the care plan for the resident was not revised to accommodate the resident's current wishes, leading to a deficiency in the care provided.
Failure to Provide Required Oral Care for Resident
Penalty
Summary
The facility failed to ensure that oral care was performed for a resident who required assistance with hygiene. The resident, who was cognitively intact and had diagnoses including diabetes mellitus, arthritis, anxiety, and depression, was dependent on staff for oral care, hygiene, dressing, and bathing. Despite the care plan indicating that the resident required assistance with personal hygiene and oral care, the resident reported that staff had never asked her to wash her mouth out and did not provide oral care, including offering oral swabs or mouthwash. The resident's dentures were at home, and she expressed a desire for oral care. Observations and interviews revealed that nursing assistants did not perform oral care for the resident as expected. One nursing assistant admitted to only completing oral care for the resident twice since admission and was unaware of the proper procedures for residents with dentures. The Director of Nursing stated that the expectation was for oral care to be completed every morning and at bedtime, with specific procedures for residents with dentures. However, the facility's policy on oral assessment and management did not include instructions for oral care, contributing to the deficiency.
Failure to Provide Engaging Activities for Resident with Dementia
Penalty
Summary
The facility failed to provide meaningful and engaging activities for a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease and dementia, who was receiving hospice services. The resident required extensive assistance with activities of daily living and had a care plan that included engaging in structured leisure activities. Despite the care plan's emphasis on music and other activities, observations revealed that the resident was often left in their room without being offered activities, as noted on the activity schedule. The resident's spouse had requested additional activities and communication efforts, but these were not consistently provided. Interviews with staff, including nursing assistants and the activity director, indicated that activities were seldom conducted on the memory care unit due to staffing issues. The activity director acknowledged the lack of documentation regarding resident participation in activities and the failure to complete scheduled activities. The director of nursing confirmed these findings and expressed expectations for residents to be invited to activities and for activities to be completed as scheduled. The facility's policy emphasized the importance of providing an ongoing program of activities to support residents' well-being, but this was not effectively implemented for the resident in question.
Survey Results Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that all three years of survey results were readily accessible for residents or visitors, which had the potential to affect all 49 residents currently residing in the facility. During an observation, it was noted that the survey results were located in a white binder near the entrance, but the last survey results included were from a standard abbreviated survey dated 8/16/24. The facility lacked the survey results for surveys completed on 10/21/24 and 1/14/25. During an interview, the Director of Nursing (DON) confirmed that the last survey in the binder was from 8/16/24 and acknowledged that other surveys had been completed since then. The DON stated that all surveys should have been included in the binder for transparency, but a policy was requested and not provided.
Failure to Maintain Resident Dignity Due to Unaddressed Facial Hair
Penalty
Summary
The facility failed to maintain the dignity of a resident who was cognitively intact and dependent on staff for personal hygiene, including shaving. The resident, who had a history of hypertension, diabetes mellitus, respiratory failure, and a recent fracture, was observed with unwanted facial hair that she expressed bothered her. Despite the resident's care plan indicating the need for assistance with personal hygiene, staff did not offer to remove the facial hair until it was brought to their attention during an observation and interview. Interviews with staff revealed that the nursing assistant had not attended to the resident for a few days and was unaware of the facial hair issue until it was pointed out. The LPN acknowledged the need for facial hair removal and mentioned that the resident's family was supposed to bring a new razor, but was unsure if the facility had razors available. The Director of Nursing confirmed that the resident was capable of expressing her needs and emphasized the importance of staff assisting residents with personal hygiene to maintain dignity. The facility's policies on ADLs and resident rights highlighted the obligation to provide necessary care and services based on resident preferences and to treat residents with respect and dignity.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to report an allegation of employee-to-resident abuse to the State agency within the required two-hour timeframe. The incident involved a resident with severe cognitive impairment, Alzheimer's disease, anxiety, and depression, who was dependent on staff for daily activities. The resident was reported to have attempted to hit staff during care, and a trained medication aide (TMA) responded by saying, "Do you want me to hit you?" This was reported by a nursing assistant to the human resources director, but the allegation was not reported to the State agency as required. The human resources director vaguely recalled the incident and found a record of the TMA receiving a verbal warning. The director of nursing confirmed that the incident was not reported to the State agency, despite acknowledging that it could be considered abusive. The facility's policy mandates immediate reporting of abuse allegations to the administrator and the State agency, but this protocol was not followed in this case.
Failure to Submit Abuse Investigation Results Timely
Penalty
Summary
The facility failed to submit the results of an investigation into an alleged abuse incident to the State Agency within the required 5 working days. The incident involved a resident with severe cognitive impairment, Alzheimer's disease, anxiety, and depression, who was dependent on staff for daily activities. The resident was reported to have attempted to hit staff during care, and a staff member allegedly responded in a verbally abusive manner. The incident was reported to the human resources director, who vaguely recalled the report but did not ensure the investigation results were submitted to the State Agency. The investigation into the alleged abuse was documented in the employee's file, including a counseling record and a summary of the incident. The facility's policy required immediate notification of the administrator and a thorough investigation, with a report submitted to the department of health within five business days. However, the Director of Nursing confirmed that the investigation report was not submitted as required. The facility's failure to adhere to its policy and regulatory requirements resulted in a deficiency being identified by surveyors.
Resident Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, leading to a deficiency in call light accessibility for one resident. The resident, who was cognitively intact and had a history of anxiety, depression, asthma, chronic pain, and limited mobility, was found lying in bed unable to move and without access to her call light. The call light was clipped to the wall behind the head of the bed, out of the resident's reach. This situation was discovered when the resident called out for help, and a surveyor entered the room to find the resident in distress, unable to breathe properly, and experiencing pain. Staff interviews revealed that the night shift had placed the call light out of reach, and the nursing assistant on duty was unaware of this until it was brought to her attention. The resident reported that this was not an isolated incident, as staff sometimes clipped her call light to the wall, causing her to wait for assistance. The facility's policy required call lights to be within easy access for residents, but this was not adhered to, as confirmed by the director of nursing, who emphasized the importance of call light accessibility for resident safety and dignity.
Failure to Supervise Resident with Choking Risk During Meals
Penalty
Summary
The facility failed to provide adequate supervision for a resident (R2) who required supervision while eating due to a choking risk. R2's care plan indicated the need for a Level 6 Soft and Bite-Sized diet and supervision during meals, yet during an observation, R2 was seen eating independently in a commons area without staff supervision. The staff, including an LPN and a dietary manager, acknowledged that R2 required supervision while eating, but R2 was left unsupervised due to being moved to a different area because of behavioral issues. Interviews with various staff members, including an LPN, a nursing assistant, a registered nurse, and the director of nursing, confirmed that R2 had impaired cognition and required supervision during meals. Despite this, R2 was not within visual sight of the staff during the observed meal. The facility's policy on diet and diet orders did not provide clear guidance on when residents require supervision while eating, contributing to the oversight in R2's care.
Failure to Provide Prescribed Diet to Resident
Penalty
Summary
The facility failed to ensure that a resident received the prescribed diet as ordered, specifically for a mechanically altered diet. The resident, identified as R2, had diagnoses including epilepsy, hemiplegia, and hemiparesis following cerebrovascular disease, and required a Level 6 Soft and Bite-Sized texture diet. Despite this requirement, R2 was observed eating regular corn, which was not consistent with the prescribed diet. The dietary manager confirmed that R2 should have received creamed corn instead of regular corn, indicating a failure in the dietary process. During the observation, R2 was eating independently in a commons area without staff supervision. The LPN present was unsure of R2's specific dietary needs and did not intervene to correct the diet when observing R2 eating the incorrect food. The dietary aide responsible for preparing the meal admitted to an oversight in providing the correct diet, acknowledging that R2's dietary slip was reviewed but the error occurred due to a lapse in attention. The facility's policies on diet orders and meal service were not followed, as evidenced by the incorrect meal being served to R2. The dietary manager and director of nursing both stated that the facility had processes in place to ensure diet accuracy, including tray identification systems and verification by staff. However, these processes were not effectively implemented, leading to the resident receiving an inappropriate diet.
Failure in Hand Hygiene During Toileting Care
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed during toileting care for a resident. The resident, who had a significant change in their Minimal Data Set (MDS) and required assistance for toileting and personal hygiene due to conditions such as fusion of the spine and reflex neuropathic bladder, was being assisted by two nursing assistants. During the care process, one of the nursing assistants, after assisting with toileting hygiene, failed to change gloves and perform hand hygiene before proceeding to touch various items in the room, including the resident's wheelchair, the mechanical lift, the garbage, and the doorknob. The nursing assistant acknowledged the expectation to change gloves and perform hand hygiene between different care tasks, especially when moving from dirty to clean tasks. The Director of Nursing also confirmed that staff are expected to remove soiled gloves, perform hand hygiene, and apply new gloves as needed. The facility's hand hygiene policy, revised earlier in the year, clearly directed staff to perform hand hygiene before applying gloves, after removing gloves, and after contact with body fluids, as well as before moving from a contaminated body site to a clean body site during resident care.
Failure to Monitor Resident Post-Fall
Penalty
Summary
The facility failed to adequately monitor a resident, referred to as R1, who experienced a fall resulting in a scalp hematoma and traumatic hematoma of the forehead. R1, who had a history of obstructive hydrocephalus, epilepsy, and was on anticoagulant therapy, fell from her bed while being assisted by a nursing assistant (NA-A) who left her unattended to retrieve wipes. This incident occurred despite R1's care plan indicating she was at risk for bleeding and excessive bruising due to her medical conditions and medication. Following the fall, R1 was taken to the emergency department where she was diagnosed with a right frontal forehead hematoma and occipital right scalp hematoma. She was discharged back to the facility with instructions to apply ice to the affected areas. However, the facility's progress notes lacked evidence of consistent monitoring of R1's bruising and neurological status for the required 72 hours post-fall, as per the facility's policy. The nursing staff, including RN-A and RN-B, failed to document the necessary neurological checks and monitoring of bruising, which were expected to be recorded every shift until resolved. Interviews with the nursing staff and the director of nursing (DON) revealed that there was a lack of adherence to the facility's post-fall policy. The DON confirmed that no treatment order was added for monitoring R1's facial bruising, and neurological checks were not documented as required. This oversight in monitoring and documentation represents a deficiency in the facility's care for R1 following her fall.
Failure to Follow Care Plan Leads to Resident Fall
Penalty
Summary
The facility failed to adhere to the care plan for a resident, resulting in an accident. The resident, who had a history of obstructive hydrocephalus, epilepsy, morbid obesity, and was on anticoagulant therapy, required assistance from two staff members for bed mobility and incontinence care. Despite this requirement, a nursing assistant (NA-A) attempted to provide care alone, leading to the resident rolling off the bed and sustaining a scalp hematoma and traumatic hematoma of the forehead. The incident occurred when NA-A, who was contracted through an outside staffing agency, was assisting the resident after transferring her to bed using a mechanical lift with the help of a registered nurse (RN-A). After the transfer, RN-A left the room, and NA-A proceeded with incontinence care without the required second staff member. During the process, NA-A left the resident unattended on her side to retrieve wipes, resulting in the resident falling off the bed and hitting her head. Interviews with staff revealed that multiple staff members, including RN-A and NA-B, were aware of the resident's need for two-person assistance but did not intervene or ensure compliance with the care plan. The director of nursing (DON) confirmed that NA-A did not follow the care plan, leading to the fall. Despite the incident, there was no immediate comprehensive education or training provided to all staff regarding adherence to care plans.
Failure to Follow Enhanced Barrier Precautions for Resident with ESBL
Penalty
Summary
The facility failed to adhere to enhanced barrier precautions for a resident diagnosed with extended spectrum beta lactamase (ESBL) resistance, which requires specific infection control measures. The resident's care plan, revised on March 21, 2022, did not include the need for enhanced barrier precautions despite the diagnosis. On July 9, 2024, nursing assistants were observed providing high-contact care to the resident without wearing the necessary personal protective equipment (PPE), such as gloves and gowns, as indicated by the signage outside the resident's room. The nursing assistants incorrectly believed that enhanced barrier precautions were only necessary for residents with wounds, infections, or catheters, which was not the case for this resident. The director of nursing confirmed that the resident was indeed on enhanced barrier precautions due to the ESBL diagnosis, and staff were expected to follow the PPE guidelines. The facility's policy on Enhanced Barrier Precautions, dated March 26, 2024, outlined that such precautions should be implemented during high-contact care activities for residents at risk of acquiring multidrug-resistant organisms (MDROs), including ESBL. The policy also emphasized the importance of clear signage and staff education regarding these precautions, which were not adequately followed in this instance.
Deficiencies in Food Safety and Hygiene Practices
Penalty
Summary
The facility failed to ensure proper labeling, dating, and discarding of food and beverages stored in refrigerators and freezers. During an inspection, it was observed that several items, including buttermilk, poppyseed dressing, ranch dressing, sour cream, and hazelnut creamer, were either expired or lacked proper labeling of open dates. Additionally, a package of waffles in the freezer was not labeled with an open date. The facility also had a cleanliness issue with a thick black/gray wet substance found on and around the edges of one of the three-compartment sink areas. The facility did not maintain proper dishwashing practices, as the dishwasher temperatures were not reaching the required 120 degrees Fahrenheit. A dietary aide was observed washing dishes at a temperature of 113 degrees Fahrenheit and did not apply sanitizer to the dishes afterward. The facility's dishwasher temperature logs showed inconsistent temperatures ranging from 106 to 130 degrees Fahrenheit over the past month. The dietary aide was unaware of the correct procedure when the dishwasher did not reach the required temperature. Staff members were not wearing appropriate hair restraints during food preparation and service. A dietary aide was observed wearing a baseball cap that did not cover his shoulder-length hair and had a beard without a beard net. Another dietary aide was seen handling drink glasses by the top rim with bare hands, which could lead to contamination. The dietary manager confirmed that staff were trained to avoid such practices and that proper hygiene was expected. The facility's policies required all dietary staff to wear approved hair restraints and handle utensils and drinking cups to avoid touching eating surfaces.
Lack of QAPI Training for Staff
Penalty
Summary
The facility failed to provide mandatory training on its Quality Assurance and Performance Improvement (QAPI) program to its staff. The deficiency was identified through interviews and document reviews, which revealed that the facility's New Employee Orientation Guide, Relias Training Essentials, and the Nursing and Rehab Employee Handbook lacked documentation on QAPI training. Several staff members, including nursing assistants, licensed practical nurses, and trained medical aides, were interviewed and confirmed their lack of knowledge about QAPI. They were unaware of what QAPI stood for or how it was implemented in the facility. The Director of Nursing (DON) was also interviewed and expressed surprise that staff were not being trained on QAPI. The DON acknowledged the importance of staff understanding QAPI as it informs them of current quality projects and necessary improvements within the facility. Despite the DON's recognition of the importance of QAPI training, a policy for such training was not provided upon request, indicating a systemic issue in the facility's training program.
Deficiencies in Sanitation of Resident Supplies and Equipment
Penalty
Summary
The facility failed to store tube feeding and suctioning supplies in a clean and sanitary manner for a resident who was hospitalized. The resident, who was mildly cognitively impaired and had multiple diagnoses including depression, COPD, quadriplegia, and epilepsy, was totally dependent on staff for all transfers, ADLs, and personal hygiene. Observations revealed that after the resident was transported to the hospital, tube feeding and suction supplies were left in the resident's room. These included a tube feeding bag with formula, a bag with clear fluid, and a suction machine with a canister containing substances. The registered nurse confirmed that nursing staff should have managed the supplies when the resident was hospitalized, and the DON stated that supplies should be disposed of immediately after a resident leaves for the hospital. Additionally, the facility failed to maintain standing lifts shared by residents in a clean and sanitary manner. Observations showed that three standing lifts in the hallway had dried yellow/brown food-like substances on their lower ends. Both a housekeeper and a nursing assistant confirmed the presence of the substance and were unsure of who was responsible for cleaning the lifts. The DON stated that all staff should ensure lifts are wiped between uses, including the foot plates, and that lifts should be cleaned per policy. The facility's policy required reusable equipment like mechanical lifts to be cleaned and disinfected after use by one resident and before use by another.
Failure to Ensure Safe Nebulizer Administration for Resident
Penalty
Summary
The facility failed to ensure the safe administration of nebulizer medications for a resident who was observed self-administering a nebulizer without being assessed as safe to do so. The resident, identified as having moderate cognitive impairment and a history of acute respiratory failure, COPD, and hypertension, was observed seated in a wheelchair with a nebulizer mask on, without staff supervision. The resident's care plan indicated a dependency on staff for daily living activities due to immobility and weakness, but lacked interventions related to self-medication administration. Additionally, the resident's medical records did not include a self-administration of medication (SAM) assessment or an order to self-administer medication. During interviews, a trained medication aide (TMA) and the nurse manager confirmed that the resident had not undergone a SAM assessment. The TMA admitted to placing the nebulizer on the resident and leaving the room, which was against the facility's policy that required staff to remain with residents during nebulizer treatments if a SAM assessment had not been completed. The director of nursing also confirmed the absence of a SAM assessment and reiterated the expectation for staff to stay with residents during nebulizer administration in such cases. The facility's policy required a licensed nurse to screen residents for safe medication administration and obtain a physician's order for those deemed appropriate to self-administer medications.
Inadequate Supervision and Assessment for Resident Smoking
Penalty
Summary
The facility failed to ensure adequate supervision and accurate assessment for a resident with moderate cognitive impairment who was identified as not safe to smoke unsupervised. The resident's care plan required direct supervision during smoking activities and the use of a smoking apron for safety. However, observations revealed that the resident was left unsupervised while smoking on multiple occasions, with the smoking apron improperly secured, leading to ashes falling on the resident's clothing and wheelchair. Interviews with staff confirmed that the resident was allowed to smoke without supervision, contrary to the care plan's requirements. The nursing assistant and activity aide were unaware of how to monitor the resident's safety while smoking. The Licensed Practical Nurse (LPN) acknowledged that the smoking assessment did not match the care plan and was inaccurate, leading to a lack of proper supervision. The Director of Nursing (DON) and regional nurse were aware of the discrepancies in the smoking assessment but did not update it. The facility's policy required individualized approaches for resident safety during smoking, but these were not effectively communicated or implemented, resulting in the resident being left unsupervised and at risk during smoking activities.
Failure to Administer Tube Feeding as Ordered
Penalty
Summary
The facility failed to administer tube feeding formula according to the physician's orders for a resident identified as R43. R43, who was cognitively intact and had diagnoses including cancer and diabetes, required tube feeding due to swallowing difficulties. The physician's orders specified continuous tube feeding of Peptamen 1.5 at 65 mL per hour for 24 hours. However, observations and interviews revealed that the nursing staff were not adhering to these orders, as they were stopping the tube feedings during the day without proper documentation or notification to the medical provider or dietician. During observations, it was noted that R43 was receiving tube feedings inconsistently, with the pump being turned off during the day and resumed in the evening. R43 reported that this had been occurring for a couple of weeks, and he often vomited before meals. Despite these issues, there was no documentation in the progress notes indicating that R43 was refusing tube feedings or that the staff were stopping them. Interviews with nursing staff confirmed that they were stopping the tube feedings during the day due to R43's refusal, but they failed to document these refusals or notify the appropriate medical personnel. The Director of Nursing (DON) was unaware of the staff's actions and believed that the orders were being followed. The facility's policy required verification of physician orders for tube feeding, but the staff did not comply with this policy. The DON acknowledged the importance of following orders and documenting any refusals or changes in care, but these expectations were not met, leading to the deficiency in care for R43.
Failure to Provide Continuous Oxygen Therapy
Penalty
Summary
The facility failed to provide continuous oxygen therapy as ordered by the physician for a resident with chronic obstructive pulmonary disease (COPD) and respiratory failure. The resident, who was cognitively intact, was observed in the dining room without receiving the prescribed continuous oxygen therapy via nasal cannula at 2 liters per minute. Despite having a portable oxygen tank on the back of her wheelchair, there was no oxygen tubing connected to the tank. The resident expressed feeling short of breath multiple times while in the dining room. The registered nurse (RN) on duty was unable to immediately address the resident's need for oxygen due to being occupied with discharging another resident. The RN eventually checked the resident's oxygen saturation, which was found to be critically low at 79%, and then connected the oxygen tubing to the concentrator, setting it to the prescribed 2 liters. The Director of Nursing confirmed that the resident was supposed to have continuous oxygen therapy to maintain saturation levels above 90% and acknowledged the failure to adhere to the physician's orders.
Improper Handling of Linens Leads to Contamination Risk
Penalty
Summary
The facility failed to ensure proper handling and transportation of personal laundry, leading to a risk of contamination. During an observation, a nursing assistant was seen carrying soiled bed linen with her bare hands against her clothing, which included a pillowcase that was dropped on the floor and picked up without gloves. The nursing assistant admitted to carrying the soiled linen, which contained urine, without wearing gloves and acknowledged that the linen should have been placed in a bag before being transported through the hallway. Additionally, a nurse manager was observed carrying a clean hoyer sling over her shoulder, allowing it to touch her clothing after providing care to other residents. The nurse manager confirmed that the clean hoyer sling should not have been placed against her clothing to prevent the spread of infections. The director of nursing and infection preventionist stated that the expectation was for staff to wear gloves and bag soiled linen before transport and to carry clean linen away from the body, as per the facility's policy on handling linens and laundry.
Failure to Notify State Agency of DON Appointment
Penalty
Summary
The facility failed to notify the State agency (SA) as required when the current Director of Nursing (DON) was appointed to their position. This deficiency was identified during an extended survey conducted on June 27, 2024, when evidence was requested to demonstrate that the SA had been informed of the DON's hiring. During an interview on the same day, both the administrator and the DON confirmed that the SA was not notified of the DON's appointment. The administrator further indicated a belief that notifying the SA was no longer a requirement. The facility's document titled 'DON Job Description,' prepared on April 17, 2012, and signed by the DON on October 9, 2023, was reviewed, but no further information was provided.
Failure to Provide Prescribed Therapeutic Diets
Penalty
Summary
The facility failed to ensure residents received the prescribed diets as ordered for three residents reviewed for therapeutic diets. Resident 1 (R1) had a hospital discharge order for a pureed diet with moderately thick liquids and thickened Ensure plus supplements. However, R1 did not receive breakfast on the morning of 4/13/24 and was served inappropriate food items such as a regular piece of cake, a pulled pork sandwich, and regular consistency liquids. Family members reported these discrepancies, and the dietary manager confirmed the issues, stating she was not aware of the problems until 4/15/24. Resident 4 (R4) had a physician's order for a mechanically altered therapeutic diet of minced and moist texture with thin liquids. However, R4 was observed with a plate of pureed food, which she found unappetizing and did not eat. The dietary manager and director of nursing verified that R4 received the incorrect diet. The cook admitted that the team had decided to lower R4's diet to pureed without proper documentation or a physician's order, based on nursing communication about swallowing difficulties. Resident 7 (R7) had a dietary order for a regular diet with soft and bite-sized texture and thin liquids. However, R7 was observed with uncut roast beef and other food items not prepared according to the prescribed diet. The dietary manager confirmed that R7 received food that was not cut into bite-sized pieces. The registered dietician emphasized the importance of communicating diet changes to the dietary department and documenting them in progress notes to prevent potential risks such as aspiration or choking.
Failure to Monitor and Document Wound Care
Penalty
Summary
The facility failed to ensure non-pressure related wounds were monitored for signs and symptoms of infection and healing until resolved for three residents. Resident 1 (R1) had a displaced comminuted fracture of the right tibia and a surgical wound. Despite orders to monitor and document the status of the wound every shift, R1's medical record lacked evidence of such documentation. Additionally, there were no physician orders for wound treatment following an orthopedic appointment, and the wound was not properly monitored, leading to an infection diagnosed after discharge from the facility. Resident 2 (R2) had surgical wounds with staples on the spine and iliac crest. The care plan directed staff to administer treatments and monitor the wounds weekly, but the treatment administration record lacked evidence of a nursing order to monitor for signs of infection or healing. Observations revealed redness around the incision, but no signs of infection were noted. However, the facility failed to ensure proper monitoring and documentation of the wound's status. Resident 3 (R3) had a skin tear on the right hand, open areas on the coccyx, and stitches on the left knee. The care plan failed to identify the actual skin impairment of the left knee with stitches. The treatment administration record directed staff to monitor wounds every shift, but it lacked specific directions on which wounds to monitor. Observations revealed that staff were unaware of the stitches on R3's left knee, and there were no treatment orders for the wound. The facility failed to ensure proper monitoring and documentation of R3's wounds, leading to inadequate wound care.
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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