Good Samaritan Society - Specialty Care Community
Inspection history, citations, penalties and survey trends for this long-term care facility in Robbinsdale, Minnesota.
- Location
- 3815 West Broadway Avenue, Robbinsdale, Minnesota 55422
- CMS Provider Number
- 245279
- Inspections on file
- 28
- Latest survey
- July 30, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Good Samaritan Society - Specialty Care Community during CMS and state inspections, most recent first.
The facility did not consistently provide food that accommodated resident allergies, intolerances, and preferences, and failed to offer appealing meal options, as evidenced by observations and records showing residents were served meals not aligned with their documented dietary requirements.
The facility failed to ensure residents knew how to file grievances and that grievance forms were accessible in prominent locations. Residents were unaware of the process, and forms were not available in the lobby or nursing stations. The facility's policy outlined the grievance process, but the lack of accessible forms and clear communication led to the deficiency.
The facility failed to monitor and document dishwasher temperatures in four unit kitchenettes, compromising dish sanitation. Logs were incomplete, and dietary staff did not adhere to protocols. Additionally, the coffee machine in the Lakes unit was unsanitary, with mold observed, indicating a lack of daily cleaning. These deficiencies posed potential food-borne illness risks.
A resident with COPD and CHF was found with medications at their bedside without a completed self-administration assessment or physician's order. The facility's policy requires an assessment and a physician's order for self-administration, which were not followed, leading to the deficiency.
The facility failed to maintain clean wheelchairs for two residents with Huntington's disease and dementia, as observed by surveyors. Despite a schedule for cleaning, the wheelchairs had copious amounts of dried food and substances, indicating a lack of regular maintenance. Interviews revealed that the responsibility for cleaning was assigned to overnight staff, but the schedule was not effectively followed, and no specific policy for wheelchair cleaning existed.
A resident with central cord syndrome and obesity experienced an 8.6-pound weight gain in one week, but the facility failed to notify the physician as required. Staff interviews revealed delays in re-weighing and lack of documentation, despite the resident's worsening condition, including edema and shortness of breath, which led to a hospital evaluation recommendation.
A resident at moderate risk for pressure sores did not receive prescribed heel suspension boots as per their care plan. Observations showed the boots were not used, and staff interviews confirmed the care plan was not followed. The resident did not refuse the intervention, indicating a lapse in adherence to pressure ulcer prevention protocols.
A resident with a urinary catheter due to chronic kidney disease and urinary retention had their catheter drainage bag positioned incorrectly at the level of the bladder, contrary to standard practice. The facility's staff failed to document or communicate the resident's preference for using a leg bag, which required deviation from standard catheter care procedures. Observations and interviews revealed a lack of adherence to the facility's catheter care policy, which mandates maintaining a non-obstructed downhill flow of urine.
A resident with severe cognitive impairment and dysphagia was given a regular soda instead of the prescribed thickened liquids, despite orders for a mechanically altered diet. Staff interviews revealed a lack of adherence to dietary requirements, and the facility's policy on documenting refusals and educating on risks was not followed.
A resident with hepatic encephalopathy and alcoholic cirrhosis did not receive rifaximin as ordered due to a delay in cost approval by the facility. The medication was unavailable from the time of the order, and staff failed to notify the medical provider immediately, contrary to facility policy. The delay in communication and action among staff led to the resident not receiving the critical medication for several days.
The facility's assessment failed to specify staffing needs based on resident care requirements, lacking details on staffing levels for different shifts. Interviews with staff revealed uncertainty and insufficient documentation regarding staffing determinations, with the Facility Assessment missing specific staffing requirements.
A facility failed to develop a baseline care plan within 48 hours for a newly admitted resident with complex medical conditions, including stroke-related impairments. The care plan lacked specific goals and interventions for the resident's ADL needs and did not address safety concerns or the need for supervision while eating. Interviews revealed that the care plan was not completed on time, and staff were not adequately informed about the resident's care requirements.
A resident with a swallowing disorder was left unsupervised during meals, leading to aspiration pneumonia. Despite requiring a modified diet and supervision, the care plan was not updated, and staff were unaware of the resident's needs. The resident was found unresponsive and covered in food, resulting in hospitalization. The facility lacked a policy on meal supervision.
The facility failed to ensure call lights were accessible for four residents with cognitive impairments and mobility dependence. Observations showed call lights were not within reach, and staff did not consistently check on the residents. Interviews revealed inconsistencies in staff understanding of residents' abilities and the frequency of checks required, leading to the deficiency.
The facility failed to properly assess, document, and plan the use of physical restraints for several residents, leading to deficiencies in ensuring restraints were used appropriately. Residents with severe cognitive impairments and conditions like Alzheimer's and Huntington's disease were found with restraints without proper documentation or care planning. Interviews with staff revealed a lack of awareness of restraint requirements, contributing to the deficiencies observed.
A nursing assistant in an LTC facility failed to maintain a resident's dignity by speaking in a belittling manner during care. The resident, who has severe cognitive impairment due to Huntington's disease, perceived the comments as verbal abuse. Despite the assistant's claim of joking, the resident expressed discomfort with the communication.
The facility failed to implement and complete person-centered care plans for several residents, leading to deficiencies in meeting their medical and personal care needs. Residents with severe cognitive impairments and various medical conditions were not repositioned or checked on as required by their care plans, resulting in a lack of necessary care and attention. The facility's policy on care plans was not adhered to, and staff interviews revealed a lack of awareness and adherence to the care plans.
A resident with multiple medical conditions, including central cord syndrome, was not provided with adequate personal hygiene care, leading to complaints and a hospitalization for a catheter-related urinary tract infection. Despite being dependent on staff for ADLs, the resident experienced inadequate cleaning, as evidenced by dried blood and feces found during an observation. Staff interviews revealed unresolved complaints and a lack of timely care.
Two residents with cognitive impairments and Huntington's disease were improperly managed by being double briefed, contrary to their care plans. Staff interviews revealed a lack of awareness and adherence to proper incontinence care protocols, and the facility's quality of care policy was not provided.
A resident with dementia and mobility issues developed multiple pressure ulcers due to the facility's failure to implement appropriate preventive measures and interventions. Despite the resident's risk factors, the care plan lacked specific actions to prevent pressure ulcers, and staff did not adequately monitor or report skin changes. This led to the resident's decline and hospital admission with multiple pressure injuries.
The facility failed to serve breakfast at the proper temperature on a unit, affecting 16 residents. Observations revealed scrambled eggs were cold when served, and residents complained about the temperature. A TMA noted challenges in maintaining food temperature due to staggered delivery times and the number of residents needing assistance. The DON was unaware of complaints, and no food temperature policy was obtained.
A facility failed to report an alleged abuse incident involving a resident with severe cognitive impairments within the required timeframe. A family member's video showed a nursing assistant handling the resident roughly, not using a gait belt, and continuing care despite resistance. The DON acknowledged the mistakes but did not report the incident promptly, believing there was no intent to harm.
Failure to Accommodate Resident Dietary Needs and Preferences
Penalty
Summary
The facility failed to ensure that each resident received food that accommodated their allergies, intolerances, and preferences, and did not consistently provide appealing food options. This deficiency was identified based on observations and records indicating that residents were not always served meals that met their documented dietary needs and stated preferences.
Grievance Process and Form Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that residents were aware of how to file grievances and that grievance forms were accessible in prominent locations throughout the facility. During a resident council meeting, four residents expressed that they were unaware of the grievance filing process and did not know where to find grievance forms. They mentioned that they previously felt comfortable discussing grievances with a former social worker, but since his departure, they did not feel they could approach the current social services director (SSD). The SSD claimed that the grievance process was covered in meetings and that forms were available in the main lobby, but observations revealed no forms were present. Further interviews and observations indicated that the reception desk personnel acknowledged the absence of grievance forms in the lobby due to time constraints. The administrator stated that forms should be available at the front desk and nursing stations, but there was no provision for anonymous submission within the facility. A registered nurse also confirmed the lack of grievance forms at the nursing station, suggesting residents would need to go to the lobby to obtain one. The facility's policy and pamphlet outlined the grievance process, but the lack of accessible forms and clear communication led to the deficiency.
Dishwasher Temperature Monitoring and Coffee Machine Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure that dishwasher temperatures were consistently monitored and documented to guarantee proper sanitation of resident dishes in four of the five unit kitchenettes. Observations revealed incomplete temperature logs for the dishwashers in the Lakes, Woodland, Boundary Waters, and Arrowhead units. Dietary staff were responsible for checking and documenting dishwasher temperatures twice daily, but logs were found to be incomplete or not up to date. Interviews with dietary aides and the kitchen manager confirmed the lack of adherence to the expected protocol for monitoring and documenting dishwasher temperatures. Additionally, the facility did not maintain the coffee machine in a sanitary condition, as observed in the Lakes unit kitchenette. The coffee/hot water dispenser was found to be dirty, with a white foamy substance floating in the overflow basin, which was identified as mold by a dietary aide. The kitchen manager confirmed that the coffee maker had not been cleaned in 7-14 days, despite the expectation for daily cleaning. The cleaning logs were not signed off, indicating a failure to complete the required cleaning tasks. Facility policies required employees to ensure cleanliness and sanitation of food preparation equipment, but these were not followed, leading to potential food-borne illness risks for residents.
Failure to Complete Self-Administration Assessment for Resident
Penalty
Summary
The facility failed to ensure a self-administration of medication assessment (SAM) was completed for a resident, identified as R140, who was observed with medications at their bedside. R140's admission Minimum Data Set (MDS) indicated intact cognition and diagnoses of chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF), requiring partial assistance with most activities of daily living. Despite this, R140's physician's orders did not include an order to self-administer medication, and the medical record lacked an assessment to allow self-administration. During an observation, R140 was found with three inhalers on their nightstand, including two Breo Ellipta inhalers and one albuterol inhaler. A registered nurse (RN-C) confirmed that R140 was not assessed to self-administer medications and should not have medications at the bedside without a proper assessment and physician's order. The RN-C explained to R140 the importance of not keeping medications in the room without a lock box to prevent other residents from accessing them. The director of nursing (DON) stated that a resident must be assessed for safety and obtain a physician's order to self-administer medications. Medications should not be kept at the bedside, even if the resident is deemed safe to self-administer, and must be stored in a lock box to prevent access by other residents. The facility's policy outlined the procedure for determining if a resident could self-administer medications, which includes completing a Resident Self-Administration of Medications UDA, obtaining a physician's order, and documenting the process in the care plan. However, these steps were not followed for R140, leading to the deficiency.
Failure to Maintain Clean Wheelchairs for Residents
Penalty
Summary
The facility failed to maintain a clean and safe environment for two residents who were dependent on wheelchairs for mobility. Both residents had moderately impaired cognition and were diagnosed with Huntington's disease and dementia. During observations, it was noted that the wheelchairs of both residents had copious amounts of dried food and other substances on the wheels, indicating a lack of regular cleaning and maintenance. The care plans for these residents highlighted their dependence on wheelchairs and the need for assistance with mobility, yet their wheelchairs were not kept in a clean condition. Interviews with the nursing staff and the Director of Nursing revealed that the responsibility for cleaning the wheelchairs fell on the overnight shift staff, with a schedule in place to determine which wheelchairs should be cleaned each night. However, the schedule was not effectively followed, as evidenced by the unclean state of the wheelchairs. The facility did not have a specific policy for wheelchair cleaning, and the existing schedule indicated that the wheelchairs were to be cleaned once a week, with additional cleaning by maintenance if needed. Despite these arrangements, the wheelchairs of the two residents remained unclean, demonstrating a failure in maintaining a homelike and safe environment.
Failure to Notify Physician of Significant Weight Gain
Penalty
Summary
The facility failed to notify the physician of a significant change in condition for a resident who experienced a substantial weight gain. The resident, who had intact cognition and diagnoses including central cord syndrome, spinal stenosis, and chronic pain syndrome, required substantial assistance with activities of daily living and mobility. According to the physician's orders, the resident was to be weighed weekly, and the physician was to be notified if there was a weight gain of more than 5 pounds in a week. On February 5th, the resident weighed 397.5 pounds, and by February 12th, the weight had increased to 406.1 pounds, indicating an 8.6-pound gain. However, there was no documentation of the physician being notified of this change. Interviews with various nursing staff revealed that the resident was not re-weighed immediately due to the unavailability of the appropriate staff and equipment, and the physician was not informed of the weight gain. The resident's progress notes later indicated a change in condition, including edema and shortness of breath, leading to a recommendation for hospital evaluation. Despite the facility's policy on weighing residents, the staff did not adhere to the protocol of re-weighing immediately, notifying the physician, and documenting the incident, which contributed to the deficiency.
Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to ensure pressure ulcer prevention interventions were in place for a resident identified as R66, who was at moderate risk for developing pressure sores. R66's care plan and physician orders required the use of heel suspension boots to elevate and protect the heels at all times. However, multiple observations revealed that the boots were not being used as prescribed. During several instances, R66 was found with heels resting directly on the mattress or footrest without the protective boots, despite the care plan's instructions and the resident's acknowledgment that she did not refuse the use of the boots. Interviews with staff, including registered nurses and nursing assistants, confirmed that the care plan was not being followed, and the boots were not consistently applied. The staff acknowledged the importance of following care plans and documenting any refusals, which were not evident in this case. The wound doctor and the director of nursing reiterated the necessity of using the boots to prevent further pressure ulcer development, highlighting a lapse in adherence to the facility's policy on pressure ulcer management.
Improper Catheter Care and Positioning for a Resident
Penalty
Summary
The facility failed to ensure proper catheter care for a resident, identified as R68, who had a urinary catheter due to chronic kidney disease and urinary retention. The resident's care plan and physician's orders did not specify that the catheter drainage bag should be positioned below the bladder, which is necessary to facilitate proper urine flow and prevent complications. Observations revealed that the resident's leg catheter bag was attached at the level of the bladder, contrary to standard practice, and was over halfway full of urine. Nursing staff, including nursing assistants and registered nurses, confirmed that the drainage bag was not positioned correctly and acknowledged that the physician should have been notified if the resident's preference for using a leg bag all the time required deviation from standard practice. Interviews with various nursing staff, including registered nurses and the director of nursing, highlighted a lack of communication and documentation regarding the resident's catheter care preferences and the necessity of positioning the drainage bag below the bladder. The facility's policy on catheter care emphasized the importance of maintaining a non-obstructed downhill flow of urine, which was not adhered to in this case. The director of nursing confirmed that any changes in catheter use should be communicated with the provider, especially when deviating from the physician's orders, to ensure proper care and documentation.
Failure to Provide Thickened Liquids as Ordered
Penalty
Summary
The facility failed to ensure that beverages were served in the appropriate consistency for a resident who required a mechanically altered diet with thickened liquids due to dysphagia. The resident, who had severe cognitive impairment and a history of pneumonitis due to inhalation of food, was observed receiving a can of soda that was not thickened, contrary to her dietary requirements. The resident's care plan and physician orders specified a pureed diet with mildly thick liquids, yet the administrator provided the resident with a regular soda without thickening it, indicating a lapse in following the prescribed dietary orders. Interviews with staff, including registered nurses and the administrator, revealed a lack of adherence to the resident's dietary needs, with staff acknowledging that all liquids should be thickened and that the resident's family was aware of this requirement. The facility's policy required documentation of any refusal of the prescribed diet and education on the risks and benefits, which was not evident in the resident's medical record. The speech-language pathologist confirmed the need for thickened liquids due to silent aspiration risks, and the director of nursing emphasized the expectation for residents to receive diets as ordered.
Failure to Administer Critical Medication Due to Cost Approval Delay
Penalty
Summary
The facility failed to provide medication as ordered by the physician for a resident diagnosed with hepatic encephalopathy and alcoholic cirrhosis of the liver. The physician had ordered rifaximin, a critical medication for preventing liver failure, to be administered twice daily. However, the medication was not available at the facility from the time of the order on January 14th until January 16th. The delay was due to the need for price approval by the facility, which was not promptly addressed. The nursing staff did not notify the medical provider immediately about the unavailability of the medication, contrary to the facility's policy. The delay in medication administration was compounded by a lack of communication and action among the facility staff. The LPN did not call the medical provider because the medication was awaiting management approval due to its cost. The DON was informed of the high-cost medication on January 16th and sought an alternative from the NP, who was not updated about the missed doses until two days later. The consultant pharmacist emphasized the importance of the medication for the resident's condition, and the facility's failure to administer it could have led to an exacerbation of symptoms. The facility's policy required immediate notification to the physician if a medication was unavailable, which was not followed in this case.
Facility Assessment Lacks Specific Staffing Information
Penalty
Summary
The facility failed to ensure that its Facility Assessment accurately identified staffing needs based on the care requirements of its resident population. The assessment, which was organized into six parts, was intended to guide staffing and resource decisions, including the operating budget necessary for facility functions. However, it lacked specific information on staffing levels required for different shifts, such as day, evening, and night, and did not adjust for changes in the resident population. Interviews with facility staff revealed a lack of clarity and documentation regarding staffing determinations. A registered nurse indicated that staffing was based on resident care needs and managed by the DON and administrator. The interim DON, temporarily filling the position, stated that staffing was determined by resident acuity levels. The senior director, assisting during the administrator's leave, acknowledged that staffing was based on resident census and needs but was unsure of specific staffing numbers. The Facility Assessment did not include specific staffing requirements, and there were no additional attachments providing this information.
Failure to Develop Timely Baseline Care Plan for New Admission
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for a resident who had multiple complex medical conditions, including hemiplegia, hemiparesis, dysarthria, type 2 diabetes, dysphagia, aphasia, and a history of stroke. The resident was admitted from the hospital following an ischemic cerebrovascular accident and required skilled services such as medication administration, therapy, and assistance with activities of daily living (ADLs). However, the care plan did not include specific goals and interventions for the resident's ADL needs, such as bathing, bed mobility, dressing, eating, oral care, toileting, and transfers. Additionally, the care plan lacked safety concerns and did not address the resident's need for supervision and assistance with eating. Interviews with nursing assistants and the registered nurse responsible for care planning revealed that the care plan was not completed within the required 48-hour timeframe. The interim director of nursing confirmed that the care plan should have been updated within 48 hours, but it was not. The facility's procedure for new admission care plans was not followed, and the unit manager did not review the resident's care plan the day after admission. The director of nursing acknowledged that the care plan was incomplete and that staff were not adequately informed about the resident's care requirements during the resident's stay. The facility was unable to provide a policy related to new admissions and baseline care plans when requested.
Failure to Supervise Resident with Swallowing Disorder During Meals
Penalty
Summary
The facility failed to provide adequate supervision during meals for a resident with a swallowing disorder, leading to a serious incident. The resident, who had a history of hemiplegia, dysphagia, and other conditions following strokes, required a regular diet with soft and bite-sized textures and moderately thick liquids. Despite these needs, the resident's care plan was not updated to reflect the requirement for supervision during meals, and staff were not adequately informed of the resident's dietary needs and supervision requirements. On one occasion, a family member found the resident slumped over in a chair, unresponsive, and covered in food, indicating a lack of supervision during a meal. The family member reported that staff had left the resident unattended with a meal tray in the room, despite the resident's known swallowing difficulties. This incident resulted in the resident being admitted to the hospital with aspiration pneumonia. Interviews with staff revealed a lack of awareness regarding the resident's dietary modifications and supervision needs, and the care plan did not reflect the necessary supervision during meals. The facility's interim DON confirmed that the resident's functional assessment indicated a need for supervision while eating, but this was not communicated in the care plan. The DON also noted that staff were expected to supervise residents with dysphagia during meals, whether in the dining room or in their rooms, but this expectation was not met. The facility was unable to provide a policy on supervision during meals when requested, highlighting a gap in procedural guidance for staff.
Failure to Ensure Call Lights Accessible for Residents
Penalty
Summary
The facility failed to ensure that call lights or another means to request assistance were accessible for four residents who were dependent on staff for mobility. These residents, identified as R5, R6, R7, and R8, had varying degrees of cognitive impairment and were reliant on staff for activities of daily living. Observations revealed that call lights were not within reach for these residents, and staff did not consistently check on them to ensure their needs were met. R5, who had severe cognitive impairment and was totally dependent on staff, was observed without a call light within reach while in her Broda wheelchair. Despite being checked on by staff, the call light was not placed within her reach. Similarly, R6, who had cognitive impairment and was dependent on staff, was left in her room without a call light accessible, and staff did not check on her for over two hours. R7, with severe cognitive impairment, was also left without a call light within reach, and staff did not check on him for an extended period. R8, who had moderate cognitive impairment, was found in his room with the call light on the floor, out of reach. Staff checked on him but did not ensure the call light was accessible. Interviews with staff revealed inconsistencies in their understanding of the residents' ability to use call lights and the frequency of checks required. The facility's policy required call lights to be within easy reach, but this was not adhered to, leading to the deficiency.
Deficiencies in Restraint Use and Documentation
Penalty
Summary
The facility failed to properly assess, care plan, and re-evaluate the use of physical restraints for five residents, leading to deficiencies in ensuring that restraints were used appropriately and only when necessary for medical treatment. The report highlights that the facility did not document the need for restraints, did not provide interventions for freedom of movement, and did not ensure that the restraints were the least restrictive alternative. For instance, Resident R4, who had severe cognitive impairment and multiple diagnoses including Alzheimer's disease and hallucinations, was using a Broda chair with a back latching belt without proper documentation or care planning to address the restraint's use and necessity. The report further details that Resident R5, who had Huntington's disease and severe cognitive impairment, was observed with a thigh belt restraint instead of the pommel cushion as indicated in the physician's orders. The care plan for R5 did not include interventions for freedom of movement or specify the medical symptoms the restraint was intended to treat. Similarly, Residents R6, R7, and R8 were also found to have restraints without proper documentation, care planning, or assessment of the need for such restraints, and there was a lack of documentation of family or resident education regarding the use of these restraints. Interviews with facility staff, including the Medical Director and registered nurses, revealed a lack of awareness and understanding of the requirements for restraint use, including the need for signed physician orders, documentation of symptoms being treated, and regular assessments. The facility's policy on physical restraints and psychotropic medications outlined the risks associated with restraint use but did not provide specific guidance on the use of restraints, contributing to the deficiencies observed during the survey.
Failure to Maintain Resident Dignity and Respectful Communication
Penalty
Summary
The facility failed to uphold the resident's right to dignity and respectful communication, as evidenced by the interaction between a nursing assistant (NA-C) and a resident (R7). During an observation, NA-C was seen speaking to R7 in a belittling manner while providing care. R7, who has severe cognitive impairment due to Huntington's disease, was dependent on staff for various activities of daily living. During the care process, NA-C made inappropriate comments about R7's movements and bodily functions, which R7 perceived as verbal abuse. R7's medical condition includes unclear speech and severe cognitive impairment, making him reliant on staff for communication and care. Despite NA-C's claim that her comments were made in jest, R7 expressed that he did not feel NA-C spoke kindly to him and identified the comments as verbal abuse. The incident highlights a failure in maintaining the resident's dignity and respectful communication, as required by resident rights regulations.
Failure to Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to implement and complete person-centered care plans for several residents, leading to deficiencies in meeting their medical and personal care needs. Resident R4, who has severe cognitive impairment and multiple diagnoses including Alzheimer's disease and pulmonary fibrosis, did not have a care plan that included necessary assessments and interventions for the use of a Broda chair with a thigh strap. Similarly, Resident R5, who is severely cognitively impaired and diagnosed with Huntington's disease, was not repositioned or checked on as required by her care plan, which included specific instructions for the use of a Broda chair and incontinence care. Resident R6, with cognitive impairment and dependent on staff for daily activities, was not checked on by facility staff for over two hours, contrary to the care plan's requirements for regular checks and repositioning. Additionally, Resident R7, who is severely cognitively impaired and diagnosed with Huntington's disease, was not repositioned or offered a position change as indicated in his care plan, which was designed to prevent pressure ulcers. The care plans for these residents were not followed, resulting in a lack of necessary care and attention. The facility's policy on care plans, which requires comprehensive and measurable objectives to meet residents' needs, was not adhered to. Interviews with staff revealed a lack of awareness and adherence to the care plans, with one nursing assistant stating that the care plan for R7 was not appropriate. The Director of Nursing acknowledged that the care plans should be person-centered and up to date, indicating a gap between policy and practice in the facility.
Failure to Provide Adequate Personal Hygiene Care
Penalty
Summary
The facility failed to provide necessary services to maintain proper personal hygiene for a resident who was unable to perform activities of daily living (ADLs) independently. The resident, who had a history of central cord syndrome, post-traumatic stress disorder, and other medical conditions, was dependent on staff for personal hygiene and toileting. Despite physician orders to keep the peri-area clean and dry every shift, the resident experienced inadequate care, as evidenced by multiple complaints about improper cleaning and a recent hospitalization for a catheter-related urinary tract infection. The facility's grievance logs indicated unresolved complaints regarding care, and there was no documentation provided to show how these complaints were addressed. During an observation, it was noted that the resident's peri-care was not completed in the morning, and the catheter bag had not been emptied until the resident requested it. When staff eventually attended to the resident, dried blood and feces were found, indicating a lack of timely and adequate cleaning. Interviews with staff revealed that the resident had made multiple complaints, and there was an acknowledgment that the resident should have been cleaned earlier. However, the staff failed to report the issue or seek assistance, and the facility's policy on ADLs for dependent residents was not provided upon request.
Improper Incontinence Care Management
Penalty
Summary
The facility failed to adhere to professional standards of practice by improperly managing the incontinence care of two residents, identified as R6 and R9. Both residents were observed wearing two incontinence briefs simultaneously, which was not in accordance with their care plans. R6, who has cognitive impairment and is always incontinent of bowel and bladder due to Huntington's disease, was found with two saturated briefs during a bed bath. The hospice nursing assistant noted that double briefing was a common practice on the unit. Similarly, R9, who also suffers from severe cognitive impairment and Huntington's disease, was observed seated in a wheelchair with two briefs. Both residents' care plans specified that their briefs should be checked and changed every two hours, with no mention of double briefing. Interviews with staff, including a hospice RN, a nursing assistant, a trained medication assistant, and the director of nursing, revealed a lack of awareness and adherence to proper incontinence care protocols. The director of nursing confirmed that double briefing was inappropriate and that staff should follow the care plan instructions, which did not include double briefing. Despite the facility's policy on quality of care being requested, it was not provided, indicating a potential gap in policy enforcement or availability.
Failure to Prevent and Address Pressure Ulcers
Penalty
Summary
The facility failed to appropriately assess and initiate interventions to minimize the risk for pressure ulcer development for a resident with dementia, incontinence, and mobility issues. The resident's care plan identified a potential for pressure ulcer development but did not incorporate specific interventions to prevent them. Despite the resident's significant weight loss and inadequate protein intake, which increased the risk for pressure ulcers, the care plan lacked necessary preventive measures. The resident developed a stage 1 pressure ulcer on the right hip, which was not adequately addressed in the care plan. The nursing staff failed to implement frequent turning, maximal remobilization, and other interventions recommended for residents at mild risk for pressure ulcers. The resident's skin assessments and Braden scores indicated a need for more intensive monitoring and care, but these were not provided, leading to the development of additional pressure injuries. Interviews with staff revealed a lack of communication and follow-up regarding the resident's skin condition. Nursing assistants and registered nurses did not consistently report or address skin changes, and there was a delay in obtaining treatment orders from the nurse practitioner. The facility's policy on skin assessment and pressure ulcer prevention was not effectively implemented, resulting in the resident's decline and subsequent hospital admission with multiple pressure injuries.
Failure to Serve Breakfast at Proper Temperature
Penalty
Summary
The facility failed to ensure that breakfast was served at the proper temperature on the 2nd floor WL unit, potentially affecting all 16 residents. During an observation, scrambled eggs were noted to be cold when served to residents. A resident was heard complaining about the cold eggs, and another resident confirmed that their breakfast was cold. The food was not covered while waiting to be served, contributing to the temperature issue. A trained medication assistant acknowledged the difficulty in serving breakfast at the correct temperature due to the staggered delivery times and the number of residents needing assistance. The director of nursing was unaware of any complaints about cold food, and no policy regarding food temperatures was obtained.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of staff-to-resident abuse to the state agency within the required two-hour timeframe after the allegation was made. This deficiency involved a resident with severe cognitive impairments, including dementia and delirium, who required extensive assistance for daily activities. A family member provided a video showing a nursing assistant (NA) handling the resident roughly during care, including exposing the resident, not using a gait belt during transfer, and continuing care despite the resident's resistance. The director of nursing (DON) reviewed the video and acknowledged the NA's mistakes but did not report the incident promptly, believing there was no intent to harm. The resident's care plan indicated the need for two staff members to assist with care and recommended specific dementia care tactics, which were not followed by the NA. The NA's actions included pulling the resident's clothing, leaving the resident in an unsafe position, and failing to communicate effectively. Despite recognizing these issues, the DON did not report the incident to the state agency within the mandated timeframe, as required by the facility's policy on abuse and neglect. The NA was suspended and later terminated, but the delay in reporting the incident constituted a failure to comply with regulatory requirements.
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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