Franklin Restorative Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Franklin, Minnesota.
- Location
- 900 3rd Street South, Franklin, Minnesota 55333
- CMS Provider Number
- 245273
- Inspections on file
- 29
- Latest survey
- May 28, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Franklin Restorative Care Center during CMS and state inspections, most recent first.
The facility did not ensure RN coverage for at least eight consecutive hours daily, as required. Staffing reports and timecard logs confirmed the absence of RN coverage on certain days, and interviews with administration acknowledged ongoing scheduling challenges. This deficiency had the potential to affect all residents in the facility.
The facility did not consistently include all required information on daily nurse staffing postings, with missing elements such as facility name, date, census, and staff details on multiple occasions. This was confirmed by administrative staff, and no policy for staff posting was available when requested.
Surveyors found that the facility did not ensure the dishwasher reached the required rinse temperature for proper sanitization, with staff failing to notice or document the issue during routine checks. Additionally, temperature logs for all kitchen refrigerators and freezers were inconsistently completed, with many missed entries and some logs missing entirely, contrary to facility policy and expectations.
The facility did not maintain effective QAPI monitoring, resulting in a repeat deficiency for failing to offer or provide the pneumococcal vaccine series to several residents as recommended by the CDC. QAA committee meeting minutes lacked ongoing data or monitoring related to this issue.
The facility did not obtain or document informed consent, including discussion of risks and benefits, before administering psychotropic medications to several residents with cognitive and psychiatric conditions. Medical records lacked evidence of completed consent forms or documentation that residents or their representatives were informed, despite facility policy and staff expectations requiring this process.
The facility did not maintain an effective system for tracking and monitoring stored narcotics, as staff no longer used the narcotic record index pages and relied on memory to identify which controlled substances should be present. During narcotic counts, nurses matched medication cards to the narcotic book but lacked a comprehensive list or updated index, and a handwritten list of controlled medications did not include necessary details for tracking. The DON confirmed that no refined system was in place to prevent diversion of controlled substances.
The facility did not act on pharmacist consultant recommendations for five residents, including requests for lab work, medication order clarifications, and clinical rationales for continued medication use. Despite repeated monthly recommendations, there was no evidence that staff communicated these findings to providers or updated medical records, as confirmed by both the consulting pharmacist and DON.
Surveyors found that a shared resident refrigerator contained open, undated food items and a freezer with melted popsicles and sticky residue, with no recent cleaning documented. The medication refrigerator had water inside insulin storage containers due to ice buildup and leaking, and temperature logs for both refrigerators were incomplete for several months. The CDM, LPN, DON, and administrator confirmed these unsanitary conditions and lapses in required monitoring.
A resident with multiple chronic conditions was found with an Advair inhaler at bedside without a completed self-administration of medications (SAM) assessment or physician order authorizing this. Staff discovered the inhaler was not stored in the medication cart and confirmed that only certain items were approved for bedside use per the SAM assessment. The DON acknowledged the oversight, noting that only medications deemed safe after nurse evaluation should be left at bedside.
A resident was not given the required SNFABN (CMS-10055) notice at least 48 hours before Medicare Part A services ended. Instead, the notice was provided on the same day services ended, contrary to facility policy and federal requirements. Staff interviews confirmed the lapse in timely notification.
The facility did not control persistent, loud noise from the call light system, which repeatedly sounded for extended periods in resident areas. Cognitively intact residents with various psychiatric and medical diagnoses reported the noise was irritating and disrupted sleep, while staff described difficulty concentrating and increased frustration. Despite staff raising concerns, the outdated call light system continued to negatively affect both residents and staff, contrary to facility policies on maintaining a comfortable and quiet environment.
Two residents were prescribed PRN psychotropic medications beyond the required 14-day period without documented clinical rationale or evidence of gradual dose reduction, despite repeated requests from the consulting pharmacist. The facility did not respond to pharmacy recommendations, and the DON confirmed missing documentation and uncertainty about responsibility for pharmacy reviews.
A resident with multiple diagnoses, including malnutrition and osteoporosis, had a care plan that was not updated to reflect the discontinuation of a nutritional supplement intended for wound healing. The supplement order was discontinued, but the care plan continued to list it as an active intervention. Staff interviews confirmed that care plan updates were not completed in a timely manner, and the facility could not provide a policy on care plan updates.
A resident with multiple medical conditions, including malnutrition and paraplegia, did not have weekly weights monitored as ordered by the physician. Despite an active order and care plan instructions, no weights were documented for several months. Staff interviews confirmed the lapse, and facility policy required regular weight monitoring to ensure nutritional status.
A vial of Lorazepam Oral Concentrate, a Schedule IV controlled substance, was found stored in the refrigerator door outside of the double lock box, which was not permanently affixed and had its key left in the lock. An LPN confirmed this storage practice had been ongoing, and the DON verified that the medication was not properly double locked as required. Both the consultant pharmacist and DON stated that controlled substances should be stored double locked in a permanently affixed compartment, in accordance with facility policy.
Three residents with multiple chronic conditions were not offered or provided the recommended pneumococcal vaccine series as outlined by CDC guidelines, despite having signed consents and facility policy requiring immunizations. The DON confirmed that the required vaccines were not administered or offered as appropriate.
A resident with cognitive and cardiovascular conditions consented to receive the COVID-19 vaccine, but facility records showed the vaccine was not administered and there was no documentation of vaccination, as confirmed by the DON.
The facility did not consistently follow physician orders for pressure ulcer wound care, as evidenced by multiple instances where dressing changes for several residents with stage III and IV pressure ulcers were not completed or documented. Residents and staff confirmed that wound care was missed on several occasions, and staff reported these lapses to the DON. The facility's policy required adherence to provider orders, but this was not maintained.
During wound care for two residents requiring extensive assistance, an infection preventionist did not remove gloves and perform hand hygiene after cleansing wounds and before applying new dressings, contrary to facility policy and expectations. Both the IP and interim DON confirmed that hand hygiene should have been performed at these points during the dressing change process.
Two residents with significant cognitive and physical impairments experienced multiple falls, including one resulting in a rib fracture, due to the facility's failure to investigate falls, update care plans, and implement or communicate fall prevention interventions. Staff were unaware of current interventions, required signage and appropriate footwear were not consistently provided, and documentation lacked evidence of IDT review or root cause analysis after each fall.
The facility failed to ensure RN coverage for 8 consecutive hours a day, 7 days a week, as required. A review of the nursing schedule identified 8 days without RN coverage on weekends. The administrator acknowledged the issue and mentioned efforts to stagger hours and utilize an RN from a sister facility. The facility was actively advertising for full-time RN positions to achieve compliance.
The facility failed to submit accurate direct care staffing information to CMS for Quarter 1 of 2024. The PBJ Report identified dates with no licensed nurse coverage for 24 hours, but staffing schedules and timecards showed otherwise. The administrator noted that an offsite person enters the PBJ data, but no further information or policy was provided.
The facility failed to ensure proper documentation and analysis of data submitted to the QAPI committee, lacking benchmarks, action plans, and data analysis. The administrator acknowledged the issue, noting a format change about a year ago that led to these deficiencies.
The facility failed to have a formal Performance Improvement Project (PIP) focusing on high-risk or problem-prone areas, affecting all 34 residents. Interviews revealed that each department handled issues independently, and staff were not informed about QAPI activities. No policy related to QAPI or a PIP was provided by the end of the survey.
The facility failed to provide mandatory training on its specific QAPI Program. Staff interviews revealed a lack of specific training and awareness about the QAPI plan and their roles within it. The administrator confirmed that only general training was provided, and no policy related to QAPI training was available.
The facility failed to offer and administer the most recent CDC-recommended pneumococcal vaccines to two residents. One resident with multiple health conditions did not receive the PCV-20 vaccine at least five years after receiving the PPSV-23 vaccine. Another resident with various diagnoses did not receive the PCV-20 vaccine at least five years after the last pneumococcal vaccine dose. The facility's records lacked evidence of physician consultation or resident education about the updated vaccine.
The facility failed to notify the county's designated State Mental Health Authority (SMHA) when a resident exhibited a new onset of mental illness, including PTSD and Paranoid Personality Disorder. The social service designee did not review the Pre-Admission Screening for accuracy or refer it to the SMHA.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was scheduled for at least eight consecutive hours a day, seven days a week, as required. Review of the Payroll-Based Journal (PBJ) Staffing report for the first quarter of 2025 revealed several staffing concerns, including a one-star staffing rating, excessively low weekend staffing, and no RN hours reported. Examination of the licensed staff schedule and daily timecard logs confirmed that there was no consecutive eight-hour RN coverage on specific dates, and there was no RN coverage at all on two identified days. Interviews with the administrator and health unit coordinator (HUC) revealed that both were responsible for scheduling and acknowledged difficulties in maintaining RN coverage due to call-ins and scheduling challenges. They confirmed that on the days in question, there was no RN coverage, and also stated that having RN coverage is a requirement for skilled nursing. Additionally, when requested, the facility was unable to provide a staffing policy. This deficiency had the potential to affect all 35 residents residing in the facility.
Incomplete Daily Nurse Staffing Information Posting
Penalty
Summary
The facility failed to ensure that all required data were included on the daily nurse staffing information postings. Record review of the PBJ Staffing report and staff schedule documentation revealed that, on multiple dates from October 2024 through May 2025, the postings were missing one or more of the following required elements: facility name, current date, facility census, total number and actual hours worked by licensed staff, and total number of licensed staff with their designation or title. This omission was identified through review of posted schedules and confirmed by both the administrator and the health unit coordinator (HUC), who acknowledged that the postings were incomplete on the specified dates. Additionally, the facility's PBJ Staffing report indicated concerns such as a one-star staffing rating, excessively low weekend staffing, and no RN hours. During interviews, the administrator and HUC explained that the HUC prepared the staff posting and night nurses were responsible for updating and posting it in the morning. They confirmed their understanding of the posting requirements but acknowledged the deficiencies in the posted information. No staff posting policy was provided when requested.
Failure to Maintain Dishwasher and Cold Storage Temperatures
Penalty
Summary
Surveyors observed that the facility failed to ensure the dishwasher reached the manufacturer's required minimum rinse temperature of 180 degrees Fahrenheit during multiple cycles, with actual rinse temperatures recorded between 160 and 170 degrees Fahrenheit. The nursing assistant responsible for monitoring the dishwasher temperatures did not notice the low rinse temperatures until pointed out by the surveyor, despite being responsible for checking the machine at each mealtime or at least three times daily. The certified dietary manager confirmed the dishwasher was not reaching the required temperatures and that maintenance had been notified. Additionally, the facility failed to consistently monitor and document temperatures for all kitchen refrigerators and freezers. Review of temperature logs for two freezers and four refrigerators revealed numerous missed opportunities for documentation over several months, with some logs missing entirely for certain periods. The certified dietary manager and administrator both confirmed that temperature logs were incomplete and that staff were expected to record temperatures twice daily to ensure food safety.
Repeat Deficiency in Immunization Compliance Due to Ineffective QAPI Monitoring
Penalty
Summary
The facility failed to ensure its Quality Assurance and Performance Improvement (QAPI) program effectively maintained ongoing compliance regarding immunization requirements, resulting in a repeat citation for influenza and pneumococcal immunizations. Specifically, review of records showed that three out of five residents reviewed for immunizations were not offered or provided the pneumococcal vaccine series as recommended by the CDC. Additionally, the Quality Assessment and Assurance (QAA) committee meeting minutes from April 2024 through May 2025 did not include ongoing data or monitoring related to this repeat citation, despite the facility's policy stating that performance improvement activities should be monitored for effectiveness and sustainability.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain and document informed consent, including discussion of risks and benefits, for the use of psychotropic medications for four residents reviewed. For each of these residents, medical records showed prescriptions for various psychotropic drugs such as antidepressants, antipsychotics, and benzodiazepines, but lacked evidence that informed consent was obtained prior to administration. The records did not contain completed consent forms or documentation that residents or their representatives were informed about the risks, benefits, or alternatives to these medications, as required by facility policy. Interviews with facility staff, including the regional director of nursing, consulting pharmacist, and director of nursing, confirmed that consents for psychotropic medications had not been completed and that it was an expectation for such consents to be obtained. The facility's own policy required that residents, families, or representatives be informed of the benefits, risks, and alternatives to psychotropic medications before initiation or dose increases, and that this information be documented. Despite this, the review found no such documentation for the residents in question, all of whom had significant medical and psychiatric diagnoses and were prescribed multiple psychotropic medications.
Failure to Maintain System for Monitoring and Tracking Stored Narcotics
Penalty
Summary
The facility failed to implement an effective system to monitor and track stored narcotics, which had the potential to affect all 16 residents prescribed Schedule II-V medications. Observations and interviews revealed that the narcotic record index pages in both the West and East medication carts were not updated beyond page 55, despite the narcotic books containing documentation through page 127. Staff confirmed that the index pages were no longer used to log new medications or to guide shift change narcotic counts. Instead, staff relied on memory and routine to identify which medications should be present, without a formal list or tracking method. During a medication cart narcotic count, nurses verified the number of doses by matching the medication card with the narcotic book, but did not reference an updated index or comprehensive list. The DON acknowledged that there was no refined system or alternative method in place to account for every narcotic in the facility. Additionally, a handwritten document listing controlled medications did not include corresponding narcotic book page numbers, further limiting the ability to accurately track and monitor controlled substances. The facility's policy required safeguards to prevent diversion, but these were not effectively implemented.
Failure to Act on Pharmacist Medication Review Recommendations
Penalty
Summary
The facility failed to ensure that pharmacist consultant recommendations were acted upon for all five residents reviewed for unnecessary medications. Each resident's monthly pharmacy reconciliation included specific recommendations from the consulting pharmacist, such as requests for laboratory workups, order clarifications, clinical rationales for continued medication use, and suggestions for medication adjustments or discontinuations. Despite these recommendations, there was no evidence in the medical records that the facility responded to or updated the physicians regarding the pharmacist's findings for any of the residents involved. For example, one resident with multiple diagnoses including hypertension, dementia, and depression had recommendations for a laboratory workup for an antipsychotic and clarification of an antidepressant order, but no follow-up was documented. Another resident with heart failure, renal insufficiency, and anxiety had repeated requests from the pharmacist for clinical rationales for continued use of certain medications, which were not addressed. Additional residents had recommendations related to medication schedule changes, laboratory monitoring, and dose reductions, none of which were documented as having been communicated to the prescribing providers. Interviews with the consulting pharmacist and the DON confirmed that the facility was expected to resolve medication review recommendations prior to the next monthly pharmacist visit, but this was not done. The facility's own policy required staff to act upon all pharmacist recommendations according to established procedures, yet records showed a consistent lack of follow-through, leaving the recommendations unaddressed for multiple residents over several months.
Failure to Maintain Sanitary and Temperature-Controlled Storage for Food and Medications
Penalty
Summary
The facility failed to maintain sanitary conditions and proper temperature monitoring for both a shared resident refrigerator and a medication refrigerator. Surveyors observed the shared resident refrigerator containing multiple open and undated bottles and containers, including milk and beverages, as well as a freezer section with melted popsicles and a sticky orange substance affixing a Tupperware container to the freezer floor. The certified dietary manager was unable to confirm when the refrigerator was last cleaned, and temperature logs for the refrigerator were missing significant entries for the month reviewed. The cleaning schedule also lacked documentation of the last cleaning date, and the administrator confirmed there was no evidence of recent cleaning. Additionally, the medication refrigerator was found to have water inside the containers and bags storing insulin pens, with a freezer compartment covered in ice and leaking into the storage area. Temperature logs for the medication refrigerator were incomplete for several months, with numerous shifts lacking recorded temperatures. Both the LPN and DON confirmed that water should not be present in medication storage and that the refrigerator required defrosting. The facility's policies required daily temperature checks and documentation, which were not followed, and the pharmacist emphasized the importance of proper storage conditions for medication effectiveness.
Failure to Complete Self-Administration Assessment for Bedside Medication
Penalty
Summary
The facility failed to ensure that a self-administration of medications (SAM) assessment was completed and appropriate orders were obtained for all medications kept at bedside for a resident. Specifically, a resident with diagnoses including diabetes, heart failure, and COPD was observed with an Advair inhaler at their bedside, which had not been documented as safe for self-administration in the resident's SAM assessment. The assessment only indicated that Bio Freeze and nicotine gum were approved for bedside self-administration, not the Advair inhaler. During medication administration, staff were unable to locate the resident's Advair inhaler in the medication cart and subsequently found it on the resident's bedside table, accessible to the resident. The director of nursing confirmed that the SAM assessment did not authorize the resident to keep Advair at bedside and stated that only medications identified as safe in the SAM assessment should be left at bedside. The facility's policy required that resident choices regarding medication administration be evaluated for safety, but this process was not followed for the Advair inhaler.
Failure to Provide Timely Medicare Coverage Termination Notice
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN-CMS-10055) to a resident within the mandated timeframe. Specifically, the resident was admitted and later discharged, with their Medicare Part A services ending on a specified date. The SNFABN, which informs residents of the end of Medicare coverage and their potential financial responsibility, was given to the resident on the same day that services ended, rather than at least 48 hours in advance as required by both facility policy and federal guidelines. Interviews with the office manager and administrator confirmed that the notice was not provided within the required timeframe. The office manager acknowledged responsibility for completing the SNFABN forms and stated that they typically rely on notifications from therapy or the MDS nurse regarding the end of services. Both the office manager and administrator recognized the importance of timely notification to allow residents to make informed decisions about their care and financial obligations. Review of facility policy further confirmed the expectation that such notices be provided at least two days before the end of Medicare coverage.
Failure to Control Excessive Call Light Noise in Resident Areas
Penalty
Summary
The facility failed to maintain a safe, comfortable, and homelike environment by not controlling excessive and persistent noise from the call light system in resident living areas. Observations revealed that the call light alarm, located at the nurses' station in a central area, produced a continuous, loud, high-pitched noise that could be heard throughout the resident hallways and common areas. The alarm frequently sounded for extended periods, with documented instances ranging from 8 to 34 minutes at a time, occurring multiple times over several days. Residents who were cognitively intact and had diagnoses such as schizophrenia, anxiety disorder, major depressive disorder, bipolar disorder, delusional disorders, mood affective disorder, diabetes, and chronic tension-type headache reported that the noise was irritating and disruptive, with one resident specifically stating it affected their sleep. Staff, including a TMA, RN, LPN, DON, and the administrator, acknowledged the negative impact of the persistent noise on both residents and staff. Staff reported difficulty concentrating and increased frustration, while residents expressed their annoyance and distress, sometimes resulting in negative behaviors. The DON and administrator recognized that the loud environment could trigger challenging behaviors and negatively affect quality of life, especially for residents with dementia. Despite staff reporting concerns about the noise, they were told that nothing could be done due to the age and design of the call light system, which continued to ring until manually turned off. Facility policies indicated a commitment to providing a quiet, comfortable environment, but these were not upheld in practice.
Failure to Document Rationale and Gradual Dose Reduction for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that as-needed (PRN) antipsychotic medications were limited to a 14-day period and that clinical rationale was documented for continuation beyond this timeframe. For two residents, there was no evidence in the medical records to support the ongoing use of PRN psychotropic medications past 14 days, nor was there documentation of a gradual dose reduction (GDR) or appropriate indication for use. Pharmacy reconciliation reports repeatedly requested clinical rationale and GDRs, but the facility did not respond or provide the required documentation. One resident, who was moderately cognitively impaired and had multiple diagnoses including anemia, heart failure, renal insufficiency, diabetes, hyperlipidemia, and anxiety, was prescribed alprazolam PRN with no documented rationale for use beyond 14 days. Another resident, who was severely cognitively impaired with diagnoses including peripheral vascular disease, arthritis, Alzheimer's, and anxiety, was prescribed multiple psychotropic medications, including haloperidol and olanzapine, with no clinical rationale for their continued use past 14 days. Additionally, there was no evidence of a GDR for the resident's antidepressant, and morphine was prescribed with an inappropriate indication of dementia. The consulting pharmacist confirmed that the required clinical rationales and GDRs were missing from the medical records and that multiple requests for this information had gone unanswered. The DON also confirmed the lack of documentation and was unsure who was responsible for completing pharmacy reviews, as the previous DON had left unexpectedly. Facility policy required documentation of rationale for extended psychotropic use and GDRs, but these requirements were not met for the residents reviewed.
Failure to Update Care Plan Following Discontinued Pressure Ulcer Intervention
Penalty
Summary
The facility failed to update the care plan for a resident with pressure ulcer interventions after a significant change in condition. The resident, who was cognitively intact and had diagnoses including osteoporosis, thyroid disorder, malnutrition, and depression, had an order for Arginaid Oral Packet to aid with wound healing, which was discontinued in August 2024. However, the care plan, last reviewed in April 2025, still listed the discontinued supplement as an active intervention. Interviews with staff revealed that care plan updates were typically done the same day or as soon as possible after changes, but there was no set schedule. The director of nursing confirmed that care plans should be updated at least quarterly and with any change of condition, and acknowledged that the care plan should have been updated when the order was discontinued. The facility was unable to provide a policy regarding care plan updates.
Failure to Follow Physician Orders for Weekly Weight Monitoring
Penalty
Summary
The facility failed to implement physician orders for weekly weight monitoring for a resident who was cognitively intact and had diagnoses including neurogenic bladder, paraplegia, malnutrition, and depression. The physician order, active since late December, required weekly weights and vitals to be taken on bath day. The resident's care plan also identified a risk for nutrition and hydration problems, specifying that weights should be monitored per medical orders or facility policy. However, a review of the electronic medical and treatment administration records showed that the last documented weight for the resident was in December, with no further weights recorded through May. Interviews with facility staff confirmed that the responsibility for obtaining weights fell to the nurse on duty or could be delegated to a CNA, and that the process was tracked through the MAR, TAR, or by requests from dietary staff. The LPN confirmed no weights had been charted since December and was unsure of the reason. The DON also confirmed the lack of documented weights and emphasized the importance of following physician orders as part of the nurse's scope of practice and the resident's care plan. Facility policy required monitoring of residents' weights to maintain acceptable nutritional status.
Improper Storage of Controlled Substance in Medication Room Refrigerator
Penalty
Summary
A vial of Lorazepam Oral Concentrate USP 2 mg/ml, a Schedule IV controlled substance, was found stored in the door of the medication room refrigerator, outside of the designated double lock box. The lock box intended for controlled substances was not permanently affixed to the refrigerator and had a key left in the lock. An LPN, who was agency staff, confirmed that the lock box had been unaffixed and the key left in place since they began working at the facility. The LPN also confirmed that the Ativan should have been stored and locked in the lock box, and that the key should not have been left in the box. The medication count for Ativan was verified as correct in the narcotic box. The DON confirmed that the Ativan was inappropriately stored and not double locked as required, and that the key should have been kept with the charge nurse rather than left in the box. Both the consultant pharmacist and the DON stated that the expectation was for Lorazepam Oral Concentrate to be stored double locked in a permanently affixed compartment within the refrigerator. The facility's medication policy indicated that Schedule II drugs and backup stock of Schedule III, IV, and V medications are to be stored under double lock and key, with Schedule II medications specifically requiring storage in a separately locked, permanently affixed compartment when stored with other medications.
Failure to Offer and Administer Pneumococcal Vaccines per CDC Guidelines
Penalty
Summary
The facility failed to ensure that three out of five residents reviewed for immunizations were offered and/or provided the recommended pneumococcal vaccine series according to CDC guidelines. Specifically, one resident with diagnoses including dementia, diabetes, rheumatoid arthritis, and epilepsy had received PPSV23 and PCV13 in previous years and had a signed consent for further pneumococcal vaccination, but there was no evidence that the PCV20 or PCV21 vaccine was administered. Another resident with Alzheimer's disease, anxiety disorder, and peripheral vascular disease had received PCV15 and had a signed consent for additional pneumococcal vaccination, but there was no documentation of receiving PPSV23, PCV20, or PCV21. A third resident with adult failure to thrive, depression, and osteoporosis had not received any pneumococcal vaccinations, nor was there evidence that the vaccine was offered. The director of nursing confirmed that the facility did not administer the requested or consented pneumococcal vaccinations to two residents and failed to offer the vaccine to a third resident. The facility's policy stated that immunizations should be offered in accordance with current CDC guidelines, but documentation and interviews revealed that this was not consistently followed for the residents reviewed.
Failure to Administer COVID-19 Vaccine After Consent
Penalty
Summary
The facility failed to ensure that a resident with diagnoses including mild cognitive impairment, transient ischemic attack, cerebral infarction, and aortic valve stenosis was provided the COVID-19 vaccine after consenting to receive it. Documentation showed that the resident had not received any COVID-19 vaccinations as of the date reviewed, despite having signed a consent form to receive the vaccine. The resident's clinical record lacked evidence that the vaccine was administered, and this was confirmed by the DON, who acknowledged the absence of documentation and stated that staff are expected to review and offer immunizations upon admission and at quarterly care conferences.
Failure to Follow Physician Orders for Pressure Ulcer Wound Care
Penalty
Summary
The facility failed to ensure physician orders for pressure ulcer wound care were followed for three residents with documented pressure ulcers. Each resident had specific wound care orders, including cleansing, application of wound care products, and dressing changes at prescribed intervals. However, treatment administration records showed multiple dates where there was no documentation that the required dressing changes were completed for various wounds, including stage III and IV pressure ulcers on the sacrum, heel, gluteal area, ischial tuberosity, and elbow. Residents involved had significant medical histories, such as paraplegia, protein-calorie malnutrition, adult failure to thrive, muscle weakness, and type 2 diabetes mellitus. Their care plans and provider orders detailed the necessary wound care interventions, but the records indicated repeated lapses in performing or documenting these treatments. Interviews with the residents confirmed that there were several occasions when their dressings were not changed as ordered, though they could not specify exact dates or reasons. Staff interviews revealed that LPNs and the infection preventionist acknowledged there were times when dressing changes were not completed and that these instances were reported to the DON. Staff consistently stated that if a dressing change was not documented, it was not done. The interim DON confirmed that staff were expected to follow provider orders for wound care. The facility's wound treatment management policy required treatments to be completed according to physician orders, but this was not consistently followed.
Failure to Perform Proper Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to ensure proper hand hygiene was performed during wound care for two residents who required extensive assistance with bed mobility and personal hygiene. For both residents, the infection preventionist (IP) did not remove gloves and perform hand hygiene after cleansing wounds and before applying new dressings, as observed during dressing changes. The IP initially sanitized or washed hands and donned appropriate personal protective equipment before starting the procedures, but did not follow hand hygiene protocols between the removal of soiled dressings, cleansing of wounds, and application of clean dressings. Interviews with the IP and the interim director of nursing confirmed that facility policy and expectations required staff to perform hand hygiene before and after handling dressings, and specifically after removing soiled dressings and cleansing wounds. The facility's hand hygiene policy, reviewed in February 2025, also indicated that hand hygiene should be completed before and after handling clean or soiled dressings and when moving from a contaminated to a clean body site. The IP acknowledged not following these procedures during the observed wound care for both residents.
Failure to Investigate Falls and Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to thoroughly investigate falls, implement adequate fall prevention interventions, and follow care planned fall interventions for two residents identified as high risk for falls. One resident with hemiplegia, dementia, disorientation, and muscle weakness experienced multiple falls, including both witnessed and unwitnessed incidents, with documentation repeatedly lacking identification or implementation of new interventions. After several falls, the resident suffered a fractured rib following an unwitnessed fall while attempting to use the bathroom, and the care plan and care sheets did not reflect any updated fall interventions. Another resident with Alzheimer's disease, dementia, and muscle weakness, also assessed as high risk for falls, experienced several falls, including one with a suspected head injury. Documentation for these incidents similarly lacked identification or implementation of new interventions, and the resident's care sheet did not include any fall interventions. In both cases, there was no evidence of interdisciplinary team (IDT) review, root cause analysis, or appropriate updates to the care plan after each fall. Observations revealed that required signage and appropriate footwear were not consistently provided, and staff interviews indicated a lack of awareness regarding current fall interventions for these residents. Staff were unclear about who was responsible for updating care plans with fall interventions, and the facility's fall prevention policy, which required review and update of care plans after a fall, was not followed.
Failure to Ensure RN Coverage 8 Hours a Day, 7 Days a Week
Penalty
Summary
The facility failed to ensure registered nurse (RN) coverage for 8 consecutive hours a day, 7 days a week, as required by CFR 483.35 (b)(1). A review of the nursing schedule from 10/1/2023 through 3/15/2024 identified 8 days where no RN was scheduled on Saturdays or Sundays. During an interview on 3/28/2024, the administrator acknowledged the lack of coverage and mentioned efforts to stagger hours and utilize an RN from a sister facility to meet the requirement. The facility was actively advertising for full-time RN positions to achieve compliance.
Inaccurate Staffing Data Submission to CMS
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to CMS for Quarter 1 of 2024. Specifically, the Payroll Based Journal (PBJ) Report identified several dates where there was a failure to have licensed nurse coverage for 24 hours per day. However, a review of staffing schedules and staff timecards showed that there were licensed nursing staff present on those dates, indicating that the data submitted was inaccurate. During an interview, the administrator mentioned that an offsite person enters the PBJ data, but no further information or policy was provided by the end of the survey.
Failure to Document and Analyze QAPI Data
Penalty
Summary
The facility failed to ensure that data submitted to the Quality Assurance and Performance Improvement (QAPI) committee was properly analyzed and documented. This deficiency was identified through a review of the monthly QAPI meeting minutes from June 2023 through March 2024, which showed that while department heads brought data on various topics such as infection control, falls, grievance reports, and incident reports, there were no documented benchmarks for goals, analysis of the data, or action plans to achieve these goals. An interview with the administrator revealed that the facility had changed their QAPI meeting format about a year ago, resulting in a lack of documentation for goals, action plans, and data analysis. The administrator acknowledged that the previous format, which included a table for goals, action plans, and analysis results, was more effective. The March 2020 QAPI Program indicated that the committee should oversee areas for improvement, develop action plans, and analyze the results, but this was not being followed.
Lack of Formal Performance Improvement Project
Penalty
Summary
The facility failed to have evidence of a Performance Improvement Project (PIP) that focused on high-risk or problem-prone areas identified through appropriate data collection, analysis, and evaluation during Quality Assurance and Performance Improvement (QAPI). This deficiency had the potential to affect all 34 residents. Interviews with the Director of Nursing, a trained medication aide, and the administrator revealed that the facility did not have a formal PIP in place. Each department was handling issues independently, and staff were not informed about the QAPI committee's activities. Additionally, there was no policy related to QAPI or a PIP provided by the end of the survey.
Failure to Provide Specific QAPI Training
Penalty
Summary
The facility failed to provide mandatory training on its specific Quality Assurance Performance Improvement (QAPI) Program. During interviews, a dietary aide and a trained medication aide (TMA) revealed they had either no training or only general training on QAPI, and were unaware of how to communicate concerns to the QAPI committee or what issues the facility was addressing. The administrator confirmed that staff had only received general online training through Relias and brief mentions during stand-up meetings, but not specific training on the facility's QAPI plan or their roles within it. There was no policy related to QAPI training provided by the end of the survey.
Failure to Administer CDC-Recommended Pneumococcal Vaccines
Penalty
Summary
The facility failed to offer and/or administer the most recent CDC-recommended pneumococcal vaccine for two residents reviewed for immunizations. Specifically, the facility did not provide the PCV-20 vaccine to residents who had previously received the PPSV-23 vaccine, as required by CDC guidelines. Resident 22, who had a history of stroke, hyperlipidemia, spinal stenosis, iron deficiency anemia, hypotension, bipolar disorder, and major depressive disorder, received the PPSV-23 vaccine in 2017 but was not offered the PCV-20 vaccine at least five years later. Similarly, Resident 32, with diagnoses including type 2 diabetes mellitus, cirrhosis of the liver, chronic viral hepatitis C, traumatic brain injury, muscle weakness, peripheral vascular disease, and major depressive disorder, received the PCV-13 vaccine in 2019 and the PPSV-23 vaccine in 2000 but was not offered the PCV-20 vaccine at least five years after the last pneumococcal vaccine dose, as per CDC guidelines. The medical records for both residents lacked evidence of physician consultation or documentation that the residents or their representatives were educated about the need for the updated vaccine. An interview with the Director of Nursing confirmed that the facility had not been offering the PCV-15 or PCV-20 vaccines but planned to do so in the future. The facility's October 2019 Pneumococcal Vaccine policy stated that all residents would be offered pneumococcal vaccines in accordance with current CDC recommendations, but this was not followed in practice.
Failure to Notify SMHA of New Mental Illness Diagnosis
Penalty
Summary
The facility failed to notify the county's designated State Mental Health Authority (SMHA) when a resident (R15) exhibited a new onset of mental illness. R15 required law enforcement and emergency medical services to transport him to a local hospital for behavioral issues, and he was later moved to a mental health inpatient facility. Upon re-entering the facility, R15 had new diagnoses of Post Traumatic Stress Disorder (PTSD) and Paranoid Personality Disorder, which were not identified in the Pre-Admission Screening (PAS) conducted on 6/21/23. The social service designee (SSD) admitted to not reviewing R15's PAS for accuracy or referring it to the SMHA for review. No policy was provided by the facility by the end of the survey.
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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