Glenoaks Senior Living Campus
Inspection history, citations, penalties and survey trends for this long-term care facility in New London, Minnesota.
- Location
- 100 Glen Oaks Drive, New London, Minnesota 56273
- CMS Provider Number
- 245360
- Inspections on file
- 28
- Latest survey
- September 12, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Glenoaks Senior Living Campus during CMS and state inspections, most recent first.
A resident with impaired mobility and a history of falls sustained a head laceration after falling from a wheelchair lift during transport. The staff member operating the lift did not follow manufacturer safety guidelines, failed to ensure the resident was properly secured, and left the resident unattended on the lift. Incomplete staff training documentation and lack of adherence to facility policy on wheelchair securement contributed to the incident.
Several residents with varying medical and cognitive conditions reported that a nursing assistant provided care in a rushed, rough, and disrespectful manner, leading to increased anxiety, feelings of worthlessness, and avoidance of care. Staff also observed the nursing assistant intentionally agitating residents and using inappropriate language, with prior warnings documented in her employee file.
Multiple residents reported being treated harshly and roughly by a nursing assistant, including being moved in ways that caused pain and being subjected to demeaning remarks. Despite these allegations, facility leadership did not conduct a thorough investigation, failed to document or follow up on complaints, and allowed the nursing assistant to continue working with residents, contrary to facility policy.
The facility did not conduct required annual performance evaluations for four nursing assistants, with employee records and staff interviews confirming the absence of recent evaluations. The DON reported not performing evaluations during her tenure, and the Administrator stated there was no formal policy in place, despite an expectation that evaluations occur.
A resident without cognitive impairment alleged to a physician that staff were physically abusing them. The administrator was informed of the allegation but did not report it to the State Agency, citing lack of specific details from the resident. Later, the DON received a related grievance about rough care but also did not report it, believing it was not a reportable event. Facility policy requires immediate reporting of all abuse allegations, which was not followed.
The facility did not have a formal QAPI plan or documentation to track and measure performance, establish goals, or implement corrective actions, despite holding quarterly meetings attended by the DON. This deficiency had the potential to affect all residents.
The facility did not ensure its QAPI team developed or revised a quality improvement program to address infection control concerns, as shown by incomplete meeting documentation and lack of program focus, benchmarks, or current PIP initiatives. The administrator was unable to provide program-specific information prior to her arrival, and the facility was only beginning to formalize its QAPI process, potentially affecting all residents.
The facility failed to maintain an effective infection prevention and control program, with incomplete infection surveillance logs, lack of antibiotic stewardship practices, and insufficient tracking of staff illnesses. Staff were observed transporting soiled linens without proper bagging and cleaning a glucometer with an inappropriate product. The infection preventionist reported being unable to provide adequate oversight due to multiple responsibilities, and the facility's infection control policy was outdated and lacked necessary procedures.
The facility did not ensure the infection preventionist had adequate time or competency to oversee the infection control program, resulting in incomplete infection surveillance, lack of antibiotic stewardship practices, and insufficient documentation of infection management for residents and staff. Staff also failed to follow proper procedures for handling soiled linens, and the facility lacked updated policies for infection control and employee health.
A bottle of Lysol toilet bowl cleaner was found left out and spilled on the counter in an unlocked soiled utility room, with hazardous chemicals not properly secured as required. The maintenance director could not recall the last inspection of the utility rooms, and staff confirmed that chemicals are expected to be kept locked away from resident areas.
Two residents received medications not in accordance with physician orders or manufacturer guidelines, including one instance where a topical medication was administered in an unmeasured amount and another where multiple oral medications were crushed and given without a provider order. Staff were unsure of the correct procedures, and required documentation and orders were missing from the EMR, resulting in a medication error rate of 26.9%.
The facility did not have an effective antibiotic stewardship program in place, resulting in antibiotics being prescribed and administered without consistent documentation of symptoms, cultures, or antibiotic time outs. Multiple residents received antibiotics without clear indication or follow-up, and staff lacked training and awareness of stewardship practices. Facility policies did not provide specific guidance for monitoring or communicating about antibiotic use, leading to inadequate oversight and documentation.
Two residents with severe cognitive impairment and dependent on staff for ADLs were found with overgrown, unclean nails despite care plans and documentation indicating nail care should be provided. Observations and family reports showed nail care was not performed as required, and staff interviews revealed a lack of oversight by licensed nurses, who relied on nursing assistant documentation without verification.
A resident with severe cognitive impairment and multiple diagnoses was receiving hospice services, but the facility's care plan did not specify the services hospice was to provide during visits. The nurse consultant confirmed the lack of integration between the hospice and facility care plans, which was not in accordance with facility policy.
A resident with multiple diagnoses did not have pharmacy consultant recommendations regarding psychotropic medication reassessment, prednisone dosing, and diagnosis documentation addressed or communicated to the physician in a timely manner. Facility staff confirmed the absence of an organized process and required documentation for following up on these recommendations.
A resident with multiple medical conditions was given Tramadol by an LPN according to a scheduled order, but the medication label incorrectly indicated it was to be given as needed. The LPN and DON confirmed that labels should match current provider orders, but the label did not reflect the scheduled dosing, contrary to facility policy requiring accurate label checks before administration.
The facility did not ensure proper cleanliness, temperature monitoring, and food dating in both a dining room refrigerator and personal refrigerators in resident rooms. Several refrigerators contained undated and unlabeled foods, lacked temperature logs, and in some cases, did not have thermometers. Staff were unclear about their responsibilities for monitoring and cleaning, and the facility's policy did not address personal refrigerators, leading to improper food storage and sanitation practices.
Failure to Follow Wheelchair Lift Safety Protocols Results in Resident Injury
Penalty
Summary
A deficiency occurred when facility staff failed to follow the manufacturer's safety guidelines for operating a wheelchair lift, resulting in a resident falling from the facility transport bus and sustaining a head laceration that required emergency department treatment. The incident took place as the resident, who had a history of falls, impaired mobility, and required staff assistance for activities of daily living, was being loaded onto the bus by a staff member trained to operate the lift. The resident was dependent on staff for self-care, used a manual wheelchair, and had cognitive capacity but exhibited anxiety and behavioral symptoms on the day of the incident. During the transfer, the staff member backed the resident's wheelchair onto the lift, locked the brakes, and began raising the lift. The lift stopped unexpectedly about six inches from the ground. The staff member, while attempting to determine the cause of the stoppage, stepped off the lift, leaving the resident unattended. At this point, the resident's wheelchair rolled forward, and the resident fell off the lift, hitting her head on the ground. The investigation revealed that the front wheels of the wheelchair were not properly positioned behind the yellow foot stop, and the resident was not secured with a seatbelt or torso restraint. Additionally, the staff member did not instruct the resident to hold onto the handrails, and the wheelchair brakes were not fully engaged. Further review found that the facility did not have the owner's manual for the lift on hand, and staff training documentation was incomplete, with skills validation checklists lacking proper markings or evaluations. The facility's policy required staff to be trained in the use of wheelchair lifts and to ensure proper securement of residents during transport, including the use of occupant restraints. However, these procedures were not followed, directly contributing to the resident's fall and injury.
Failure to Ensure Dignified and Respectful Care by Nursing Assistant
Penalty
Summary
The facility failed to ensure that four residents were treated with dignity and respect during care provided by a nursing assistant (NA-P). Multiple grievances and interviews revealed that NA-P performed care too quickly, used a harsh tone, and made inappropriate or demeaning comments. One resident reported increased anxiety and feelings of worthlessness when assisted by NA-P, while another described NA-P as rough and preferred not to receive care from her. Additional residents stated they would avoid requesting assistance from NA-P due to her behavior, which included loud, inappropriate remarks and a lack of bedside manner. Staff interviews corroborated these concerns, with one nursing assistant observing NA-P intentionally agitating residents and reporting this behavior to management. Review of NA-P's employee file showed prior coaching and written warnings for disrespectful, condescending, and rushed care, as well as complaints from both staff and residents about her tone and conduct. Despite these documented issues, management responses focused on coaching NA-P to slow down and treat residents as individuals, but residents and staff did not observe significant improvement. Facility policy defines personal degradation and mental abuse as actions or statements that harm a resident's dignity or cause humiliation, fear, or agitation, which aligns with the behaviors reported in this case.
Failure to Investigate and Protect Residents After Allegations of Abuse
Penalty
Summary
The facility failed to ensure a thorough investigation was completed and to protect residents after allegations of rushed, harsh, and physically abusive care by a nursing assistant were reported. Multiple residents described ongoing inappropriate behavior and treatment by the nursing assistant, including being handled roughly during care, experiencing pain, and being subjected to demeaning or condescending remarks. Despite these complaints, there was no documentation of a comprehensive investigation, no identification of the residents involved in the initial written warning, and no evidence that follow-up with affected residents was completed. Interviews with residents revealed specific concerns about the nursing assistant's conduct, such as being moved too quickly or roughly during transfers, causing pain, and making residents feel anxious, worthless, or angry. Some residents reported avoiding care from the nursing assistant or refusing showers due to discomfort. Staff interviews confirmed that concerns about the nursing assistant's behavior had been reported to facility leadership, but there was no indication that these reports led to a formal investigation or protective measures for the residents. Facility records showed that the nursing assistant continued to work with all residents until the state agency brought the allegations to the attention of the administrator. The facility's own abuse prevention policy requires immediate notification of the administrator, documentation, investigation, and protective actions when abuse is alleged. However, the facility did not follow these procedures, as there was no evidence of resident assessments, witness interviews, or separation of the accused staff member from residents during the investigation period.
Failure to Complete Annual Performance Evaluations for Nursing Assistants
Penalty
Summary
The facility failed to provide annual performance evaluations for four nursing assistants, as required. Employee records showed that one nursing assistant, hired in October 2023, had not received any performance evaluation since hire. Two other nursing assistants, hired in November 2022 and April 2022, each had only one performance evaluation on file from March 2023, with no subsequent evaluations documented. Another nursing assistant, hired in February 2020, had a performance evaluation from 2022 but none after that. Interviews with the nursing assistants confirmed they did not recall receiving recent evaluations. The Director of Nursing stated she had not conducted any performance evaluations for nursing assistants during her three-year tenure, and the Administrator acknowledged there was no policy for annual evaluations, though it was expected they be completed.
Failure to Timely Report Allegation of Abuse to State Agency
Penalty
Summary
The facility failed to timely report an allegation of staff-to-resident physical abuse to the State Agency as required. On 8/28/25, a resident without cognitive impairment made a statement to a physician during a clinic appointment, alleging that staff at the facility were 'beating me up.' The facility scheduler who heard the allegation informed the administrator the same day. However, the administrator did not consider the incident reportable because the resident could not provide specific details or identify the staff member involved and was unwilling to discuss the incident further. As a result, the allegation was not reported to the State Agency at that time. Additionally, the DON became aware of a related grievance from the same resident on 9/5/25, regarding rough care by a nursing assistant. The DON completed a grievance form and spoke with the staff member involved but did not report the incident to the State Agency, as she did not consider rough care to be a reportable event. Facility policy requires that all allegations of abuse be reported immediately to the administrator and to the appropriate state entity within two hours of the allegation. The failure to report the resident's allegation of abuse in a timely manner constitutes a deficiency.
Lack of Formalized QAPI Plan and Documentation
Penalty
Summary
The facility failed to provide a formalized Quality Assurance and Performance Improvement (QAPI) plan that included necessary policies and procedures for identifying and correcting quality deficiencies. During interviews, the administrator acknowledged that there was no QAPI plan in place to track and measure performance, no established goals, and no evidence of corrective action or performance improvement activities. Although attendance rosters for quarterly QAPI meetings were available, there was no documentation reflecting the QAPI process, and the administrator, who was new to the facility, had not yet implemented such a process. Further review revealed that while the director of nursing (DON) attended quarterly quality assurance meetings and provided updates on infection control and facility status, there was no documentation of QAPI presentations or evidence of any current or previous QAPI programs. The only policy provided was a general QAPI/QAA plan updated earlier in the year, which referenced facility-specific goals and documentation that could not be produced for the current year. This deficiency had the potential to affect all 29 residents in the facility.
Failure to Develop and Document Effective QAPI Program for Infection Control
Penalty
Summary
The facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI) team developed and revised a quality improvement program to address infection control concerns identified through tracking and trending, as well as the infection control process presented by the DON during routine QAPI meetings. Review of QAPI meeting attendance rosters and minutes revealed a lack of documentation regarding the program's focus, benchmarks, goals, or current Performance Improvement Plan (PIP) initiatives. Handwritten notes from a meeting referenced infection control but did not provide context or identify patterns of infection, despite noting staff illness and COVID-19 cases. Subsequent meeting records were incomplete, with gaps in documentation and minimal information on infection control activities or action plans. During an interview, the administrator reported being unable to locate any program-specific information about the QAPI program or PIP initiatives prior to her recent arrival. She stated that the facility was only beginning to formalize the QAPI program and develop a PIP, with plans to use current survey results to identify focus areas. The facility's QAPI policy indicated that the program should be ongoing and comprehensive, but the documentation and interviews demonstrated that these requirements were not being met, potentially affecting all 28 residents in the facility.
Infection Control Program Deficiencies and Lapses in Surveillance, Staff Illness Tracking, and Daily Practices
Penalty
Summary
The facility failed to maintain a current and effective infection prevention and control program, as evidenced by incomplete and inconsistent infection surveillance logs, lack of data analysis, and insufficient tracking of infections and staff illnesses. Infection surveillance logs from January to March 2025 were missing critical information such as dates of symptom onset, details of implemented precautions, symptoms, culture results, and documentation of antibiotic time outs (ATO). In several cases, there was no evidence that appropriate cultures were taken, that the appropriateness of antibiotic therapy was evaluated, or that follow-up was conducted to determine if infections resolved or if treatment needed to be altered. The infection preventionist (IP) reported being unable to provide adequate oversight due to multiple competing responsibilities and insufficient time, and the director of nursing (DON) was unaware of the requirement for antibiotic time outs. Employee illness surveillance was also deficient. For example, a staff member diagnosed with Strep throat worked while symptomatic and returned to work without documentation of meeting CDC-recommended criteria for return, such as being fever-free and having received antibiotics for the appropriate duration. The facility lacked a policy specifying when staff should be excluded from work or the criteria for returning to work after illness. The infection control policy had not been updated since 2022 and did not reflect current standards or include necessary procedures for employee health surveillance. Additional infection control lapses were observed in daily practices. Staff were seen transporting soiled linens without proper bagging, allowing them to come into contact with their clothing and the environment, despite being aware of the correct procedure. In another instance, a nurse cleaned a resident's glucometer with an alcohol wipe instead of an EPA-approved disinfectant wipe, contrary to manufacturer recommendations and facility policy. The facility's policy on glucometer cleaning was vague and did not specify the required cleaning product. These failures in infection control practices and oversight had the potential to affect all residents in the facility.
Inadequate Infection Prevention Oversight and Documentation
Penalty
Summary
The facility failed to ensure that the designated infection preventionist (IP) had sufficient time and competency to oversee the infection prevention and control program. The IP was responsible for multiple duties, including wound care, supply ordering, and occasionally working floor shifts, which limited her ability to focus on infection control tasks. The IP reported not having enough time to complete her infection control responsibilities and lacked documentation of competencies related to oversight of the infection control program. Surveillance logs maintained by the IP were incomplete, missing critical information such as infection onset dates, symptoms, culture results, antibiotic time outs (ATO), and follow-up on the effectiveness or appropriateness of prescribed antibiotics. The IP only documented infections treated with medication and did not monitor all infections as required. Multiple instances were identified where residents with infections did not have complete documentation regarding cultures, causative organisms, isolation precautions, or ATOs. For example, one resident was prescribed antibiotics for both a viral and bacterial infection without clear justification, and another resident with a surgical site infection was not placed on enhanced barrier precautions upon return from the hospital. There was also a lack of evidence that the facility followed up on culture results or communicated with providers regarding antibiotic appropriateness. Additionally, the facility's antibiotic stewardship policy did not specify how the IP should monitor or communicate with providers about antibiotic use, and there was no evidence that the policy had been updated since 2022 to reflect current standards. Employee infection surveillance was also deficient. An employee diagnosed with Strep throat worked while symptomatic and returned to work without documentation of meeting criteria for return, such as being fever-free and having received antibiotics for the recommended period. The facility lacked a policy specifying when staff should be excluded from work due to infection. Observations revealed improper handling of soiled linens, with staff failing to bag contaminated items before transport, increasing the risk of cross-contamination. Staff interviews confirmed awareness of proper procedures but admitted to not following them due to being in a hurry. The director of nursing was unaware of the requirement for antibiotic time outs, and the infection preventionist had not performed or documented any such reviews.
Hazardous Chemical Left Unsecured in Unlocked Utility Room
Penalty
Summary
A deficiency was identified when a bottle of Lysol toilet bowl cleaner was found sitting on the counter in an unlocked soiled utility room in hall A, with some of the cleaner spilled on the countertop. This area was accessible and not secured, potentially affecting 16 of 29 residents in that hall. The maintenance director confirmed the presence of the hazardous chemical and was unable to recall the last time the utility rooms were checked, noting that hazardous chemicals are supposed to be stored in a locked closet. The nurse consultant and administrator stated that staff are expected to keep all hazardous chemicals locked away from resident areas. Facility policy requires ongoing assessment for hazards and measures to prevent resident access to hazardous areas.
Failure to Administer Medications per Physician Orders and Manufacturer Guidelines
Penalty
Summary
The facility failed to ensure medications were administered in accordance with physician orders and manufacturer guidelines for two residents, resulting in a medication error rate of 26.9%. In one instance, an LPN administered Voltaren External Gel to a resident without using the required dispensing film to measure the prescribed two grams, instead providing a 'pea-sized' amount at the resident's request. The LPN was unsure how this amount compared to the ordered dose and did not contact the provider for clarification or an alternate order, despite the medication administration record and label specifying the required dosage. For another resident, a TMA prepared and administered multiple medications by crushing them and mixing with applesauce, including medications such as Aspirin, Colace, Furosemide, Metoprolol, Acetaminophen, and Vitamin D3. The Gabapentin capsule was opened and mixed with applesauce, and Potassium Chloride ER was mixed with water. The TMA stated that orders to crush medications typically came from therapy and would be communicated during shift reports or displayed in the electronic medical record (EMR) banner. However, a review of the EMR and order summary revealed no provider order authorizing the crushing of medications for this resident. Interviews with the ADON, DON, and consulting pharmacist confirmed that a provider order is required before medications can be crushed and administered in this manner. The facility's own policies also require physician authorization and documentation for crushing medications. Despite this, medications were administered crushed without the necessary provider order, and the required documentation was not present in the EMR or on the medication administration record.
Failure to Implement Effective Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program to monitor and ensure the appropriate use of antibiotics for all sampled residents. Review of infection surveillance logs from January through March 2025 revealed that antibiotics were prescribed and administered without consistent documentation of symptoms, cultures, or evidence of antibiotic time outs (ATO) to assess the appropriateness of therapy. In several cases, antibiotics were given for viral infections, such as COVID, or without clear indication, and there was no documentation of start and stop dates, symptom resolution, or follow-up on culture results. For example, one resident received antibiotics for both COVID and a urinary tract infection without documentation of symptoms or rationale, and another was treated for pneumonia without evidence of an ATO or follow-up on culture results. Interviews with facility staff, including the director of nursing (DON) and the infection preventionist (IP), revealed a lack of awareness and training regarding antibiotic stewardship practices, specifically the use of ATOs. The IP, who also served as the assistant director of nursing and had multiple other responsibilities, acknowledged missing information in the surveillance logs and not performing ATOs or following professional criteria for antibiotic appropriateness. The IP also reported being unable to provide adequate oversight of the infection control program due to time constraints and competing duties, and only documented infections that were treated with medication, omitting others. Policy review showed that while the facility had an antibiotic stewardship policy and an infection prevention and control program policy, these documents lacked specific processes for monitoring antibiotic use, communicating with prescribers, or performing ATOs. The policies did not outline criteria for determining the appropriateness of antibiotics or require documentation of key elements such as symptoms, culture results, or therapy adjustments. As a result, the facility did not have a functional system in place to ensure antibiotics were used appropriately, and staff were not adequately trained or competent in antibiotic stewardship practices.
Failure to Provide Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate nail care for two residents who were dependent on staff for activities of daily living. One resident, with severe cognitive impairment and multiple diagnoses including Alzheimer's disease and cerebral palsy, was observed on multiple occasions to have untrimmed nails extending beyond the fingertips with a black substance underneath. Despite the care plan specifying nail care twice weekly on bath days, and documentation indicating nail care was completed, direct observation contradicted these records. A family member also reported repeated requests for nail care that were not addressed. Another resident, also with severe cognitive impairment and multiple diagnoses, was observed to have overgrown, unkempt nails with sharp, broken edges and a black dirt-like substance underneath. Documentation for this resident did not indicate that nail care was completed as required. Interviews with nursing staff revealed that while nursing assistants were responsible for documenting nail care on bath sheets, licensed nurses did not verify whether the care was actually provided, relying solely on the documentation submitted. The facility was unable to provide a policy regarding nail care during the survey.
Failure to Integrate Hospice and Facility Care Plans
Penalty
Summary
The facility failed to ensure that the hospice plan of care was integrated with the facility care plan for one resident who was receiving hospice services. The resident had severe cognitive impairment, was dependent on staff for activities of daily living, and had diagnoses including Parkinson's disease, respiratory failure, and diabetes. Review of the resident's care plan showed it noted hospice involvement but did not specify what services hospice was to provide during their visits. The nurse consultant confirmed that the hospice care plan was not integrated with the facility care plan as required. Facility policy stated that care plans for residents on hospice should include the most recent hospice plan of care and delineate the care and services provided by both the facility and hospice.
Failure to Follow Up on Pharmacy Consultant Recommendations
Penalty
Summary
The facility failed to ensure timely follow-up and documentation of pharmacy consultant recommendations for one resident. Multiple monthly drug regimen reviews by the pharmacy consultant included recommendations regarding the continued use and reassessment of divalproex, clarification of prednisone dosing, and the addition of diagnoses for certain medications. In each instance, there was no documentation that the physician had been updated or had addressed the recommendations, nor was there evidence of physician signatures on the pharmacy reviews. The facility was unable to provide records showing that these recommendations were communicated to or acted upon by the physician within the required timeframe. The resident involved had an intact cognitive status and was independent with activities of daily living, with diagnoses including adjustment disorder with depressed mood, hypertension, diabetes, anxiety, orthostatic hypotension, repeated falls, and stroke. Interviews with the DON and nurse consultant confirmed the lack of an effective process for organizing and following up on pharmacy consultant medication reviews, as well as the absence of required documentation in the medical record. No relevant policy was provided by the facility during the survey period.
Medication Labeling Discrepancy for Scheduled Tramadol Administration
Penalty
Summary
A deficiency occurred when a resident with intact cognition and multiple medical diagnoses, including a medically complex condition, was observed receiving medication from an LPN. During the medication pass, the LPN retrieved Tramadol HCl 50 mg from the locked medication cart and stated it was administered every eight hours on a routine basis. However, the medication label indicated it was to be given every eight hours as needed, not as a scheduled dose. Review of the electronic medical record and printed orders confirmed the medication was ordered to be given three times daily, not on an as-needed basis. The LPN acknowledged the discrepancy between the medication label and the physician's order, stating that prescription labels should accurately reflect provider orders. The DON confirmed that medication labels are required to match current orders and that staff are expected to verify and request corrections if discrepancies are found. Facility policy directs staff to check medication labels three times to ensure accuracy before administration. Despite these policies, the medication label did not reflect the current physician-ordered administration instructions, creating a risk for administration error.
Failure to Maintain Cleanliness and Temperature Monitoring in Facility and Personal Refrigerators
Penalty
Summary
The facility failed to ensure proper cleanliness, temperature monitoring, and food dating in both a dining room refrigerator and personal refrigerators located in resident rooms. Observations revealed that several personal refrigerators contained undated and unlabeled leftover foods, lacked temperature logs, and in some cases, did not have thermometers. One resident's refrigerator was found to be dirty, containing uncovered and undated juice and a spoiled banana. The dining room refrigerator had incomplete temperature logs, with many days missing entries, and was observed to be unclean, with substances and debris present in the freezer and on the ice dispenser. Staff were unclear about who was responsible for monitoring and cleaning these refrigerators, and there was no established cleaning schedule for the dining room refrigerator. Interviews with facility staff, including the kitchen manager and DON, revealed confusion regarding responsibility for monitoring and maintaining personal refrigerators in resident rooms. The facility's policy on refrigerator and freezer maintenance required daily temperature checks and regular cleaning, but did not address personal refrigerators in resident rooms. The lack of adherence to these procedures resulted in improper food storage and sanitation practices, as well as inadequate monitoring of refrigerator temperatures and food expiration dates.
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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