Good Samaritan Society - Waconia And Westview Acre
Inspection history, citations, penalties and survey trends for this long-term care facility in Waconia, Minnesota.
- Location
- 333 Fifth Street West, Waconia, Minnesota 55387
- CMS Provider Number
- 245234
- Inspections on file
- 24
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 22 (1 serious)
Citation history
Health deficiencies cited at Good Samaritan Society - Waconia And Westview Acre during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a documented high risk for elopement and falls was admitted without appropriate safety interventions in place. Despite assessments identifying the risk, staff failed to apply a wanderguard or implement increased supervision due to lack of training, unclear responsibilities, and poor communication. The resident was able to leave the facility unsupervised and was found by police offsite, resulting in an immediate jeopardy deficiency.
A resident was discharged with another resident's medications, including a blood pressure-lowering drug not prescribed to her. Due to incomplete medication reconciliation and lack of verbal education, the resident ingested the incorrect medications, resulting in multiple falls, acute facial trauma, and hospitalization for orthostatic hypotension. The error was discovered during a follow-up clinic visit when the medications were reviewed and identified as belonging to another patient.
A resident with significant cognitive and physical impairments was left on a bedpan for over eleven hours after staff failed to follow care plan instructions for regular repositioning and toileting assistance. The lack of communication between staff and failure to check on the resident led to the development of multiple deep tissue injuries on the buttocks, as confirmed by wound assessments and hospital evaluation.
The facility did not update care plans to reflect current needs for several residents, including those with behavioral issues, toileting assistance, discontinued medications, changes in diet orders, and frequent falls. Staff observations and interviews confirmed that care plans were not revised to address changes in resident status or interventions, contrary to facility policy.
A resident with severe cognitive impairment and multiple psychiatric diagnoses was receiving both routine and PRN quetiapine while on hospice care. The pharmacy consultant recommended a gradual dose reduction and required prescriber evaluation for continued PRN use, but this recommendation was not communicated to the hospice prescriber. Facility staff believed hospice was responsible for GDRs, and the hospice nurse confirmed the recommendation was never received, with no documentation showing it was addressed.
Two residents experienced significant incidents—one developing a deep tissue injury after being left on a bedpan for over eleven hours, and another sent home with and ingesting medications prescribed to someone else, resulting in multiple falls and a hospital visit. In both cases, the facility did not report the incidents to the State agency within the required timeframe, contrary to policy and regulatory requirements.
A resident with multiple health conditions was discharged with medications, some of which were prescribed for another individual. After taking these medications at home and experiencing falls and a hospitalization, the error was reported to facility staff by an external clinic. Despite this, there was no documentation of an investigation or protective measures, contrary to facility policy.
The facility did not accurately code the MDS for two residents, resulting in missing documentation of falls for one resident and an incorrect discharge status for another. Staff confirmed that the MDS assessments did not match the information in the electronic medical records, and no facility policy on MDS completion was provided when requested.
Three newly admitted residents with complex medical needs did not have baseline care plans developed within 48 hours of admission, as required by facility policy and regulations. Instead, their care plans were completed several days after admission, leaving staff without documented guidance for immediate care. This deficiency was confirmed by a nurse manager and supported by review of electronic health records.
A resident with a history of heart failure and edema had a physician order for PRN Torsemide if their weight exceeded a specified threshold. For several consecutive days, the resident's weight was above this limit, but the PRN medication was not administered or documented. Staff interviews revealed a lack of awareness of the PRN order, which was not readily visible in the electronic MAR, and the resident subsequently developed worsening symptoms and was hospitalized for fluid overload.
A nursing assistant did not perform hand hygiene or wear gloves while assisting a resident with moderate cognitive impairment and multiple medical conditions during meal set-up. The assistant used ketchup packets from the table to spread ketchup on the resident's sandwich, contrary to facility policy and infection control expectations.
The facility did not consistently post daily nurse staffing and census information in a location accessible to all, with postings sometimes missing, outdated, or placed too high for individuals in wheelchairs to read. This failure had the potential to affect all residents and visitors seeking staffing information.
A resident with severe cognitive impairment and a Stage 3 pressure ulcer did not receive consistent care as per the care plan and physician orders. The facility failed to apply an off-loading boot as required, and wound assessments were not completed regularly. Staff interviews and observations revealed a lack of adherence to wound care protocols and inadequate communication among staff regarding the resident's care needs.
A resident with multiple sclerosis and bilateral broken legs did not receive routine toenail care, leading to long, painful toenails. The care plan lacked toenail care instructions, and there was no documentation of care or refusal in the EMR. Staff interviews revealed confusion about documentation and responsibility for nail care, and the resident was on a list to see a podiatrist without a set date.
The facility failed to assess and prevent falls for two residents, R2 and R4, by not performing comprehensive assessments or implementing appropriate interventions. R2 was found on the floor without immediate intervention documented, and R4 experienced multiple falls despite existing care plan measures. Staff interviews revealed inconsistencies in completing fall huddle worksheets and risk management forms, hindering root cause analysis and effective intervention implementation.
The facility failed to thoroughly investigate quality of care concerns reported by two residents. The DON was informed of issues involving an LPN and a nursing assistant but did not interview other residents or staff, nor did she make schedule changes or speak directly with the implicated staff. The investigation lacked comprehensive interviews or assessments, and the DON did not follow up with the residents after the initial report.
A resident with Parkinson's disease did not receive their medication, Sinemet, within the required time frame on multiple occasions, leading to a deficiency. The medication was often administered late, particularly during the morning pass, causing the resident to experience increased stiffness and pain. The facility's policy required medications to be given within one hour of the scheduled time, but this was not consistently followed.
The facility failed to maintain cleanliness in the main kitchen, with significant lint buildup on three kitchen fans located in critical areas. The kitchen manager acknowledged the issue, and further investigation revealed no set cleaning schedule for the fans. Although a cleaning schedule existed, it was not adhered to, as confirmed by the director of environmental services and the director of nutritional services.
The facility failed to maintain cleanliness of wheelchairs for two residents and a tube feeding pump and pole for another resident. One resident's wheelchair was soiled with food debris, while another's motorized wheelchair had rust and torn armrests. A third resident's tube feeding equipment was covered in dried substances. Staff were unclear on cleaning responsibilities, and no policies were provided, leading to unsanitary conditions.
A resident with cognitive impairments reported feeling abused during toileting care, but the facility failed to report the allegation within the required two-hour timeframe. Staff interviews revealed a lack of immediate action, with the incident only being acknowledged days later. The facility's policy mandates immediate reporting of abuse allegations, which was not adhered to, resulting in a deficiency.
A resident with cognitive impairments and mood issues accused a nursing assistant of abuse during toileting care. Despite facility policies requiring immediate reporting and investigation of abuse allegations, no investigation was conducted, and the incident was not documented in the resident's health record. Interviews with staff revealed a lack of follow-up, highlighting a deficiency in handling abuse allegations.
A facility failed to monitor orthostatic blood pressure for a resident on psychotropic medications, risking increased falls due to dizziness. Additionally, another resident went ten days without a bowel movement, despite being on a constipation protocol, with no as-needed medications administered. The facility's policies on medication monitoring and bowel management were not followed, leading to these deficiencies.
A facility failed to maintain proper infection control practices for a resident with a urinary catheter and did not utilize enhanced barrier precautions (EBP) for another resident with a pressure ulcer. The catheter bag was repeatedly found on the floor, and staff did not wear gowns during high-contact care activities for the resident on EBP. Staff misunderstandings and lack of adherence to protocols contributed to these deficiencies.
Failure to Implement Elopement Prevention for High-Risk Resident
Penalty
Summary
A deficiency occurred when a newly admitted resident with severe cognitive impairment, Alzheimer's disease, and dementia, who was identified as being at high risk for both falls and elopement, was not provided with adequate supervision or safety interventions. Upon admission, assessments documented the resident's high risk for elopement and falls, citing factors such as recent admission, disorientation, confusion, inability to communicate needs, and a history of wandering. Despite these documented risks, the resident's care plan did not include elopement or fall prevention interventions until after the resident had already eloped from the facility. Staff interviews and documentation revealed that although the need for a wanderguard device was identified, it was not applied because the admitting nurse did not know where the devices were kept or how to activate them, and believed it was the nurse manager's responsibility. The nurse manager was informed of the risk but left the facility, assuming the device would be applied later. Other staff members, including nurses and nursing assistants, were either unaware of the resident's risk status or did not know what the resident looked like, and increased safety checks were not implemented prior to the incident. The lack of communication and training regarding elopement prevention measures contributed to the failure to supervise the resident adequately. As a result of these failures, the resident was able to leave the facility unsupervised, travel through an attached assisted living area, cross a parking lot and a busy street, and was eventually found by police in a parking lot across the street. The facility's policy required individualized interventions for residents at risk of elopement, but these were not implemented in this case, leading to an immediate jeopardy situation.
Medication Error on Discharge Leads to Resident Harm
Penalty
Summary
A medication error occurred when a resident was discharged from the facility and sent home with another resident's medications, including a blood pressure-lowering agent not prescribed to her. The discharge documentation lacked verification of medication reconciliation, and the education provided to the resident was limited to paper handouts without verbal instruction. The resident, who had intact cognition and no memory concerns, assumed the medications were intended for her and ingested approximately 11 doses of the incorrect medications at home. As a result of taking the wrong medications, the resident experienced multiple falls at home, including one that caused acute facial trauma requiring sutures. She was hospitalized for orthostatic hypotension, which was likely exacerbated by the unprescribed blood pressure medication. Clinic records confirmed that the medication error contributed to her low blood pressure and subsequent hospital admission. Interviews with facility staff revealed that the discharge process involved sending all medications in the facility belonging to the resident, but there was no thorough review to ensure the medications matched the resident's current orders. The discharge summary and medication list were incomplete, and the error was only discovered after the resident's follow-up clinic visit, where medications labeled for another resident were identified and destroyed.
Failure to Prevent Pressure Ulcer Due to Prolonged Bedpan Use
Penalty
Summary
A resident with moderate cognitive impairment and multiple complex medical conditions, including depression, anxiety, cancer, muscle weakness, metabolic encephalopathy, diabetes, and acute kidney failure, was dependent on staff for all activities of daily living. The resident's care plan and kardex required staff to reposition the resident every two to three hours and provide assistance with toileting, including anticipating toileting needs and checking/changing as needed. Despite these instructions, a nursing assistant placed the resident on a bedpan and failed to return, neglecting to inform the next shift that the resident remained on the bedpan. During the following shift, another nursing assistant interacted with the resident, providing food, fluids, and repositioning, but did not check or change the resident or notice the bedpan. The resident, who was more fatigued and less communicative than usual, did not alert staff to her situation. The oversight continued for approximately eleven and a half hours until a registered nurse discovered the resident still on the bedpan during a routine check. The resident subsequently developed multiple deep tissue injuries on the buttocks, as confirmed by wound assessments and hospital evaluation, with the injuries corresponding to the outline of the bedpan. Interviews with staff revealed a lack of communication regarding the resident's status and care needs, as well as a failure to follow the care plan's directives for frequent repositioning and toileting assistance. The care plan did not specify the use of a bedpan, and staff assumptions about the resident's ability to communicate her needs contributed to the incident. The prolonged pressure from the bedpan resulted in actual harm, including the development and progression of deep tissue injuries.
Failure to Revise and Update Resident Care Plans
Penalty
Summary
The facility failed to revise and update care plans to reflect the current needs and conditions of several residents, as required by policy and regulation. For one resident with Alzheimer's disease and behavioral disturbances, the care plan did not address the resident's refusal of assistance with personal hygiene, such as nail trimming and shaving, despite staff observations and interviews indicating the resident was not independent and required reminders and cues. Staff reported repeated attempts to assist, which were refused, but this behavior and the need for partial assistance were not documented in the care plan. Another resident with a neurostimulator implant and recent back surgery required extensive assistance with toileting and had ongoing issues with bowel regulation. The resident expressed concerns about bowel management and was noted to refuse toileting and incontinence care, with staff making specific agreements to provide care. However, the care plan lacked any mention of these toileting needs or the interventions being provided. Similarly, a resident receiving hospice care had a discontinued medication (anastrozole) that remained listed in the care plan, even after the medication was stopped and hospice services began. Additional deficiencies included a resident with a feeding tube whose care plan was not updated after a significant change in diet order, allowing oral intake for quality of life, and a resident with a history of falls whose care plan was not revised to reflect frequent falls and new interventions. In each case, staff interviews confirmed that care plans were not updated in a timely manner to reflect changes in resident status, behaviors, or interventions, despite facility policy requiring such updates with each assessment or change in condition.
Failure to Communicate Pharmacy GDR Recommendation to Hospice Prescriber
Penalty
Summary
The facility failed to ensure that a pharmacy consultant's (PharmD) recommendation for a gradual dose reduction (GDR) of an antipsychotic medication was communicated to the hospice prescriber for a resident with severe cognitive impairment and multiple psychiatric diagnoses, including dementia, visual hallucinations, psychotic disturbance, mood disturbance, and anxiety. The resident was receiving hospice care for vascular dementia following a stroke and had active orders for quetiapine fumarate, both as a routine and as-needed (PRN) medication for agitation and hallucinations. The PharmD reviewed the resident's medication regimen and recommended either discontinuing the PRN antipsychotic, issuing a new order with a specified duration and rationale, or adjusting the routine order, in accordance with regulations that PRN antipsychotic orders cannot exceed 14 days without direct prescriber evaluation. Despite this recommendation, there was no documentation in the resident's electronic medical record or hospice communication folder indicating that the recommendation had been reviewed or addressed by the hospice prescriber. Interviews with facility staff revealed a belief that GDRs for hospice residents were the responsibility of hospice providers, but the hospice nurse confirmed that the recommendation had not been received. Facility policy required staff to facilitate communication between the resident, family, and hospice employees, but this process was not followed, resulting in the PharmD's recommendation not being communicated or acted upon.
Failure to Timely Report Suspected Abuse, Neglect, or Misappropriation to State Agency
Penalty
Summary
The facility failed to ensure timely reporting of incidents to the State agency for two residents. In the first case, a resident with moderate cognitive impairment, multiple comorbidities, and total dependence on staff for activities of daily living was left on a bedpan for approximately eleven and a half hours. The nursing assistant who placed the resident on the bedpan did not return to check on her, nor did she inform the next shift that the resident was still on the bedpan. The subsequent nursing assistant also failed to check or change the resident during her shift. The resident was eventually found by a registered nurse with a bedpan still underneath her, resulting in a deep tissue injury. The incident was reported to the State agency about twelve hours after discovery, exceeding the required two-hour reporting window for incidents involving harm. In the second case, another resident with intact cognition and several chronic conditions was discharged from the facility and later attended a clinic appointment, bringing all her medications with her. It was discovered that she had been sent home with medication cards containing drugs prescribed to another resident. The resident reported taking these incorrect medications at home, which led to episodes of dizziness, multiple falls, and a hospital visit for low blood pressure. The clinic notified the facility of the medication error, but the incident was not reported to the State agency as required. Facility staff acknowledged that the incident should have been reported immediately upon becoming aware of it. Interviews with facility staff and review of the facility's abuse and neglect policy confirmed that the expectation was to report incidents of abuse, neglect, or significant bodily harm to the State agency within two hours, and all other reportable incidents within twenty-four hours. However, in both cases, the facility did not adhere to these timelines, resulting in a failure to meet regulatory requirements for timely reporting of suspected abuse, neglect, or misappropriation of resident property.
Failure to Investigate and Protect Resident After Medication Error Allegation
Penalty
Summary
The facility failed to thoroughly investigate and protect a resident following an allegation of neglect related to a medication error. A resident with intact cognition and multiple diagnoses, including hypertension, atrial fibrillation, anemia, and depression, was discharged from the transitional care unit and later attended a clinic appointment. During this appointment, it was discovered that the resident had been given bubble medication cards at discharge, some of which contained medications prescribed for another resident. The resident reported taking these medications at home, which included a blood pressure medication, and had experienced falls and a recent hospitalization for low blood pressure. The incident was reported to the facility by an external clinic, and staff interviews confirmed that the information was relayed to a nurse and then to the nurse manager. However, a review of the resident's electronic health record revealed a lack of documentation regarding any investigation into the reported medication error. Staff acknowledged that the incident should have been reported to the state agency and that an investigation should have been initiated immediately upon learning of the event, but this did not occur. The facility's own Abuse and Neglect policy requires immediate reporting, assessment, and investigation of any allegations of abuse, neglect, or misappropriation of resident property. The policy outlines specific steps for protecting residents and notifying appropriate agencies, but these procedures were not followed in this case. The failure to initiate an investigation and ensure resident protection constituted a deficiency in responding to the reported allegation of neglect.
Inaccurate MDS Coding for Falls and Discharge Status
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for two residents, resulting in inaccurate documentation of falls and discharge status. For one resident, the quarterly MDS did not reflect two falls that had occurred since admission, despite these incidents being documented in the electronic medical record. Both the nurse manager and interim DON confirmed that these falls should have been included in the MDS assessment. For another resident, the discharge MDS was incorrectly coded as a transfer to a short-term general hospital, while the electronic medical record and progress notes indicated the resident was actually discharged home with family. Facility staff acknowledged the MDS was coded incorrectly and verified the actual discharge destination. No facility policy on MDS completion was provided when requested. These inaccuracies in MDS coding were identified through interviews and document review, with staff confirming the errors and the discrepancies between the MDS and the residents' medical records.
Failure to Initiate Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to complete and implement a baseline care plan within 48 hours of admission for three residents who required varying levels of assistance with activities of daily living (ADLs) and had complex medical conditions. For each of these residents, the electronic health record (EHR) did not show evidence that a baseline care plan was initiated within the required timeframe after admission. Instead, the baseline care plans were developed several days after admission, as indicated by the dates in the EHR. The residents involved had diagnoses including end stage renal disease, heart failure, hypertension, cirrhosis, diabetes mellitus, arthritis, depression, dependence on renal dialysis, chronic pain, acute on chronic systolic heart failure, atrial fibrillation, coronary artery disease, localized edema, prosthetic heart valve, coronary angioplasty implant and graft, fracture, and anxiety disorder. During an interview, a registered nurse manager confirmed that baseline care plans should be completed within 24 hours of admission and acknowledged that this was not done for the three residents in question. The facility's own care plan policy required the development of a baseline care plan upon admission, in accordance with federal and state regulations, to provide effective and person-centered care. The lack of timely baseline care plans meant that staff did not have documented guidance on how to care for these residents immediately after admission.
Failure to Administer PRN Medication per Physician Order
Penalty
Summary
A deficiency occurred when the facility failed to administer a prescribed as needed (PRN) medication, Torsemide, according to physician orders for a resident with a history of congestive heart failure, atrial fibrillation, coronary artery disease, hypertension, renal failure, and localized edema. The resident had an order for daily weights and to receive PRN Torsemide if their weight exceeded 116.0 pounds. Over a seven-day period, the resident's weight was consistently above this threshold, but there was no documentation of the PRN medication being administered as ordered. Review of the electronic health record (EHR) and medication administration record (MAR) confirmed the absence of PRN Torsemide administration on the days when the resident's weight exceeded the specified limit. Observations during this period noted the resident had 2+ pitting edema in the lower extremities and later required oxygen for low saturations, eventually being hospitalized for pneumonia and fluid overload. Interviews with nursing staff revealed a lack of awareness of the PRN order, with some staff stating there were no parameters related to daily weights and others discovering the PRN order only upon review. The PRN order was not visible in the usual workflow of the electronic MAR, requiring staff to access a separate tab to view it. The facility's medication administration policy required correct and timely administration of medications and documentation of PRN medication efficacy. However, the process for entering and displaying PRN orders in the electronic system led to the order being overlooked, resulting in the resident not receiving the prescribed PRN Torsemide despite clear indications based on daily weight measurements.
Failure to Perform Hand Hygiene and Use Gloves During Meal Assistance
Penalty
Summary
A nursing assistant (NA) failed to perform proper hand hygiene and did not wear gloves while assisting a resident with meal set-up. The NA handled ketchup packets from the middle of the table, removed the top of the resident's hamburger bun, applied ketchup, and used the packet itself to spread the condiment before replacing the bun. The NA did not sanitize hands before or after assisting the resident, despite being expected to do so according to facility policy. The NA also confirmed during an interview that she did not follow the required hand hygiene or glove use protocols during this interaction. The resident involved had moderate cognitive impairment and required assistance with all activities of daily living, with multiple diagnoses including hypertension, neurogenic bladder, diabetes mellitus, arthritis, cerebral palsy, epilepsy, atrial fibrillation, and depression. Facility staff, including the infection preventionist and a registered nurse, confirmed that the expected practice was to wash hands and wear gloves when assisting residents with meals, and that using ketchup packets as utensils was inappropriate due to potential contamination. The facility's food handling policy also specified that food should not be touched with bare hands and that proper utensils and hand hygiene must be used.
Failure to Consistently and Accessibly Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to consistently and properly post daily nurse staffing information, including the resident census, in a location and manner that was accessible to residents, staff, and visitors. Observations over several days revealed that the staff posting was sometimes missing entirely or not updated with the current date. When the posting was present, it was often clipped to the administration office doorframe at a height of about six feet, making it difficult for individuals in wheelchairs to access and read the information. On multiple occasions, the posting displayed outdated information or was not visible upon arrival at the facility. Interviews confirmed that the administrator was responsible for posting the staffing information, typically around 9:00 a.m. on weekdays and for the entire weekend at once. The administrator acknowledged that the posting's height was not accessible for all individuals, particularly those in wheelchairs. The facility's own policy required that the nurse staffing posting be prominently displayed daily in a clear, readable format where residents, staff, and the public could view it. These failures had the potential to affect all 69 residents and any visitors seeking this information.
Failure to Implement Comprehensive Pressure Ulcer Care
Penalty
Summary
The facility failed to comprehensively assess and manage the pressure ulcer care for a resident, identified as R3, who had a severe cognitive impairment and required substantial assistance with daily activities. R3 had a Stage 3 pressure ulcer on her left lateral ankle and was at risk for developing additional ulcers. The care plan for R3 included the use of a pressure-reducing mattress and cushion, and the application of an off-loading boot to her left foot while in bed, as per physician orders. However, the care plan lacked specific information about the off-loading boot, and the physician's orders were not consistently followed, as R3 was observed without the boot on multiple occasions. Interviews with staff revealed a lack of adherence to the prescribed wound care protocols. RN-B admitted to not applying the boot during the day shift, citing the absence of an order in the treatment administration record. Additionally, the wound data assessment, which should have been completed daily, was not consistently performed, leading to a lack of information on the wound's condition. The nurse manager and director of nursing confirmed that the wound data assessment and RN wound assessment were not completed as required, which hindered the ability to monitor the wound's healing process effectively. Observations and interviews with family members and nursing assistants further highlighted the inconsistency in following the care plan. R3 was seen without the off-loading boot while in bed, and there was confusion among the staff regarding the correct footwear for R3. The nursing assistants were not adequately informed about the need for the off-loading boot, as it was not documented in their shift documentation or R3's Kardex. This lack of communication and documentation contributed to the failure in providing appropriate pressure ulcer care and preventing the development of new ulcers.
Failure to Provide Routine Toenail Care
Penalty
Summary
The facility failed to provide ongoing, routine toenail care for a resident, leading to potential foot-related complications. The resident, who had intact cognition and diagnoses including multiple sclerosis and bilateral broken legs, required assistance for weekly bed baths. However, the care plan did not address toenail care, and the medical record lacked documentation of toenail care or any refusal by the resident. Interviews with staff revealed that nursing assistants were responsible for clipping nails on bath days unless the resident was diabetic or on blood thinners, which was not the case for this resident. Despite this, there was no documentation of toenail care in the electronic medical record, and the resident reported that her toenails were long and painful, with no action taken despite requests for care. Observations confirmed the resident's toenails were long, uneven, and jagged, with the great toe's nail thickened. Staff interviews indicated a lack of clarity on where to document nail care, and the resident was on a list to see a podiatrist, but no date was set. The facility's policy stated that residents unable to carry out activities of daily living should receive necessary services, including nail care, but this was not adhered to in this case. The deficiency was identified through a combination of resident interviews, staff interviews, and direct observation, highlighting a gap in the facility's care processes and documentation practices.
Failure to Assess and Prevent Falls
Penalty
Summary
The facility failed to perform a comprehensive assessment of falls and implement appropriate interventions to reduce the risk of falls for two residents, R2 and R4. R2's care plan indicated he was at risk for falls due to weakness and shortness of breath, with interventions such as using assistive devices and ensuring appropriate footwear. However, after R2 was found on the floor on 2/21/25, there was no immediate intervention documented to prevent future falls, and the fall huddle worksheet was not completed by the end of the shift. R4's care plan included interventions for fall prevention, such as keeping the door open for checks, using a reacher device, and ensuring appropriate footwear. Despite these measures, R4 experienced multiple falls, including one on 2/17/25 while reaching for a brief and another on 2/24/25 while attempting to sit on the toilet. The facility's documentation lacked immediate interventions and a root cause analysis for these incidents, and the fall huddle worksheets were not completed or located. Interviews with facility staff revealed that the fall huddle worksheets and risk management forms were not consistently completed or reviewed, hindering the ability to determine the root cause of the falls and implement effective interventions. The facility's policies required a comprehensive investigation and documentation process following falls, but these procedures were not followed, contributing to the deficiency in fall prevention and management.
Inadequate Investigation of Quality of Care Concerns
Penalty
Summary
The facility failed to conduct a thorough investigation into reported concerns related to the quality of care for two residents. The Director of Nursing (DON) was notified via email about issues involving two staff members, an LPN and a nursing assistant, who allegedly neglected their duties and behaved inappropriately towards residents. Despite being informed of these allegations, the DON did not interview other residents or staff to gather additional information about the reported incidents. The investigation lacked evidence of comprehensive interviews or assessments to substantiate the claims made by the residents. The facility's investigation was inadequate as the DON did not make any changes to the staff schedule or speak directly with the implicated staff members during their shifts. The DON only communicated with the two residents who reported the concerns and did not review any charting or follow up with them after the initial report. The facility administrator expected complaints to be addressed promptly, but the DON did not adhere to this expectation, resulting in an incomplete investigation into the quality of care concerns.
Medication Administration Timing Deficiency
Penalty
Summary
The facility failed to consistently administer medication within the required time frame for a resident with Parkinson's disease, leading to a deficiency. The resident, who was cognitively intact and able to communicate needs, was prescribed Sinemet to be administered five times a day. However, the medication administration record revealed multiple instances where the medication was not given within the one-hour window before or after the scheduled time, as required by the facility's policy. The report highlights specific dates where the medication was administered late, ranging from 6 minutes to 1 hour and 49 minutes beyond the allowed time frame. The delays were particularly noted during the morning medication pass at 8:00 a.m., which the resident reported caused increased stiffness and pain. The clinical manager acknowledged these concerns and noted that other residents could potentially be affected by similar issues with time-sensitive medications. The consultant pharmacist confirmed that the delayed administration of Sinemet, a medication with a short half-life, could lead to side effects for the resident. The facility's policy on medication administration emphasized the importance of timely administration, yet the observed practices did not align with these guidelines, resulting in the identified deficiency.
Lint Buildup on Kitchen Fans
Penalty
Summary
The facility failed to maintain cleanliness in the main kitchen, specifically regarding the buildup of lint on three out of four kitchen fans. These fans were located in critical areas of the kitchen, including the dish return and cleaning area, the area near a refrigerator and freezer, and the kitchen prep zone. The lint buildup was significant, with strands measuring approximately 1 1/2 to 2 inches, and was observed on both the front and rear portions of the fan guards. This deficiency was confirmed during an observation and interview with the kitchen manager, who acknowledged the issue and indicated it was on their list of tasks to address. Further investigation revealed that there was no set schedule for cleaning the fans, as confirmed by the director of environmental services. The director of nutritional services also admitted that it had been a while since the fans were last cleaned and could not recall the exact timing of the last cleaning. Although a kitchen cleaning schedule was provided, it indicated that the fans were supposed to be cleaned during the third week of each month on Thursdays, suggesting a lapse in adherence to the schedule.
Failure to Maintain Cleanliness of Resident Equipment
Penalty
Summary
The facility failed to maintain wheelchairs in a clean and sanitary manner for two residents, R20 and R15, and did not ensure the cleanliness of a tube feeding (TF) pump and pole for resident R31. R20, who had diagnoses including cerebral hemorrhage and Parkinsonism, was observed with a soiled wheelchair covered in food debris. Despite a checklist for cleaning wheelchairs being presented to staff, R20's wheelchair had not been cleaned as scheduled. R15, diagnosed with ataxia, used a motorized wheelchair that was observed with rust and debris, and torn armrests secured with tape. The motorized wheelchair could not be cleaned in the wheelchair washer, and staff failed to notice or report its condition. For resident R31, who was dependent on staff for most activities of daily living and had a history of stroke and malnutrition, the TF pump and pole were observed with dried substances covering more than 50% of the legs and pump. Despite the resident's complaints, the equipment remained uncleaned. Staff, including a nursing assistant and a licensed practical nurse, were unaware of who was responsible for cleaning the TF equipment, and the director of nursing could not provide clarity on the responsibility. The facility did not provide policies for the maintenance of resident equipment or cleaning of the TF pump and pole when requested. The lack of clear responsibility and adherence to cleaning schedules contributed to the unsanitary conditions observed for the residents' equipment, indicating a failure to provide a safe, clean, and comfortable environment.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident, identified as R5, within the required two-hour timeframe. R5, who had moderately impaired cognitive skills and required assistance with daily living activities due to conditions such as hemiplegia, dementia, and other mental health disorders, reported feeling abused during toileting care. The incident was noted in a progress note by a nursing assistant, but there was no documentation of an incident report or investigation in the resident's electronic health record or the Aspen Complaint/Incidents Tracking System. Interviews with facility staff revealed a lack of immediate action following the allegation. A registered nurse confirmed the incident and stated that the nurse manager was notified via email, but no follow-up was recalled. The director of nursing acknowledged awareness of the allegation only during a meeting two days later, attributing the resident's behavior to her known patterns. The facility's policy required immediate reporting of abuse allegations to the administrator or designated personnel, but this protocol was not followed. The administrator and social services staff emphasized the importance of adhering to the abuse reporting guidelines, stating that all allegations should be reported immediately to initiate an investigation. Despite this, the facility did not report the incident within the mandated timeframe, resulting in a deficiency in their handling of the abuse allegation.
Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident, identified as R5, who had moderately impaired cognitive skills and required assistance with daily living activities due to conditions such as hemiplegia, dementia, and other mental health disorders. R5's care plan indicated a preference for no male caregivers and noted mood problems, including unrealistic fears and resistance to care. On a specific date, a nursing assistant reported that R5 accused them of abuse during toileting care, but there was no documentation of an incident report or investigation in R5's electronic health record. Interviews with facility staff revealed that the registered nurse familiar with R5's care was aware of the allegation but did not recall any follow-up actions being taken. The nurse manager was notified via email, but no investigation was conducted. The social services staff expressed that it was unacceptable to disregard an abuse allegation based on a resident's behavior history and emphasized the importance of following procedures. The director of nursing acknowledged the lack of investigation and stated that staff were expected to report allegations immediately to initiate the investigation process. The facility's policy on abuse and neglect required prompt reporting and investigation of all alleged or suspected abuse incidents. However, the administrator confirmed that staff were expected to report allegations as soon as possible, regardless of their validity, to allow for a timely investigation. Despite this policy, the facility did not follow through with the necessary steps to investigate R5's allegation, resulting in a deficiency in handling abuse allegations appropriately.
Deficiencies in Monitoring and Care for Residents on Psychotropic Medications and Constipation Protocols
Penalty
Summary
The facility failed to ensure appropriate orthostatic blood pressure monitoring for a resident who was on psychotropic medications. The resident, who had a history of hemiplegia, high blood pressure, dementia, and several mental health disorders, was prescribed quetiapine fumarate, which required monthly orthostatic blood pressure checks. However, the treatment administration records for June and July 2024 showed checkmarks indicating the task was completed, but there was no documentation of the actual blood pressure readings. The director of nursing confirmed the absence of documented readings, acknowledging the risk of increased falls due to dizziness from unmonitored blood pressure. Additionally, the facility did not implement a bowel movement protocol for another resident who was dependent on staff for all activities of daily living and had a history of dementia and gastro-esophageal reflux disease. The resident's medication administration records indicated the use of laxatives and other medications for constipation, with instructions to contact a provider if there were three days without a significant bowel movement. Despite this, the resident went ten consecutive days without a documented bowel movement, and no as-needed medications were administered during this period. The director of nursing and infection preventionist confirmed the oversight, noting that the resident's care plan lacked documentation regarding constipation management. The facility's policies on psychotropic medication monitoring and bowel and bladder management were not adhered to, leading to these deficiencies. The psychotropic medication policy required monitoring for side effects and effectiveness, while the bowel management policy outlined interventions for constipation, including medication administration. The failure to follow these protocols resulted in inadequate monitoring and care for the residents involved.
Infection Control Deficiencies in Catheter and EBP Practices
Penalty
Summary
The facility failed to ensure proper infection control practices for a resident with an indwelling urinary catheter. The resident, who was cognitively intact and dependent on most activities of daily living, was observed with their catheter bag placed on the floor without a barrier on multiple occasions. Despite the care plan indicating the need for catheter care every shift and monitoring for signs of infection, the catheter bag was repeatedly found on the floor, which was confirmed by both a licensed practical nurse and a nursing assistant. The director of nursing and the infection preventionist acknowledged the infection control risk associated with the catheter bag being on the ground, and the infection preventionist was unaware that the resident's behavior of placing the bag on the floor had returned. The facility also failed to utilize enhanced barrier precautions (EBP) for a resident with an unstageable pressure ulcer. The care plan did not address EBP, and during observations, staff did not wear gowns while performing high-contact care activities, such as wound care and perineal care, despite a magnetic sign indicating the resident was on EBP. Interviews with staff revealed a misunderstanding of when EBP should be applied, with some staff believing it was only necessary for wounds with active infections. The director of nursing confirmed that gowns and gloves should be worn during such care for residents on EBP. The infection preventionist noted that implementing EBP has been challenging for the facility, requiring constant reeducation of staff on the use of personal protective equipment. The facility's EBP protocol indicated that gowns and gloves are needed during high-contact care activities, but this was not consistently followed, leading to a deficiency in infection control practices.
Latest citations in Minnesota
A resident with dry eye syndrome and degenerative eye disease had orders for cyclosporine ophthalmic emulsion and Refresh Tears, both scheduled at the same time. Medication records and direct observation showed a TMA instilled cyclosporine drops in both eyes and immediately followed with Refresh Tears in both eyes without waiting between medications. This practice conflicted with referenced professional guidance recommending several minutes between multiple eye drops and with the medical provider’s recommendation to wait fifteen minutes between the two ophthalmic medications. No facility policy on ophthalmic medication administration was provided when requested.
A resident with severe cognitive impairment, impaired mobility, and high fall risk was care planned to have wheelchair footrests in place at all times, with staff ensuring proper positioning and monitoring for leaning during transport. A NA transported the resident in a manual wheelchair from the shower without the footrests, and while going through the doorway the wheelchair struck the door frame, causing the resident, who was leaning forward, to fall out. The resident sustained a T12 fracture, head injury with concussion, abrasions and contusions, and multiple right-hand lacerations requiring sutures, and the DON confirmed the care plan had not been followed.
A high‑risk, immobile resident with MS and prior heel DTI developed an avoidable unstageable coccygeal pressure ulcer after staff failed to consistently assess and document skin status, did not transfer or timely provide ordered pressure‑relieving mattresses, and did not reliably perform q2h repositioning. The resident was repeatedly left on a bedpan for prolonged periods despite early reports of this issue, and the toileting care plan was not revised to a bedside commode until after the coccygeal wound had significantly worsened. Wound assessments lacked complete measurements and staging, changes in wound size and color were not promptly recognized as deterioration or reported to providers, and recommended interventions from a wound NP (including an air mattress and offloading) were not promptly implemented. As a result, the coccygeal ulcer rapidly progressed to a large, necrotic, malodorous wound requiring hospital transfer and surgical debridement.
A resident with spastic hemiplegia, muscle weakness, and moderate cognitive impairment was observed using bilateral bed grab bars for bed mobility and transfers, but the care plan did not address grab bar or side rail use. Review of the EMR showed no completed bed mobility device or side rail assessment to determine the necessity or safety of the grab bars, and no documentation that risks and benefits were discussed or that informed consent was obtained. An LPN and the ADON stated that a bed mobility device assessment is required before grab bars are installed and confirmed that no such assessment existed for this resident.
A resident with bilateral heel pressure ulcers and multiple comorbidities received wound care during which an RN removed dressings from both heels, cleansed both wounds, and wiped each heel without changing gloves or performing hand hygiene between wounds or after disposing of soiled dressings. This practice conflicted with the facility’s written wound care procedure, which requires glove removal and hand hygiene after dressing removal and after wound cleansing. In interviews, the RN, NP, and DON/IP acknowledged that hand hygiene and glove changes are expected between dirty and clean tasks and between separate wounds to prevent infection.
A resident with MS, neurogenic bladder, mobility limitations, and existing pressure injuries was identified as dependent for toileting hygiene and at risk for pressure ulcers, yet the care plan lacked an individualized toileting/incontinence plan and a defined repositioning schedule. Despite a new coccyx pressure ulcer and documentation that interventions such as increased repositioning and incontinent care were needed, the care plan was not revised for a period of time to reflect these changes. During this time, the resident sometimes fell asleep on a bedpan and remained on it until staff removed it, and staff were not initially informed that the bedpan should no longer be used. The DON later acknowledged that the care plan revisions for turning, repositioning, and toileting were delayed until after the resident’s coccyx ulcer had significantly worsened.
A resident with diabetes, Crohn’s disease, bowel incontinence, and a history of MASD on the right gluteus developed an open, painful lesion on the right gluteal area that was documented over time without complete wound characteristics, clear etiology, or timely provider notification. Wound care orders were written for a stage 3 pressure ulcer on the left buttocks, while staff reported the wound was only on the right side and applied the left‑sided orders to the right gluteal wound in the absence of specific right‑side treatment orders. The DON acknowledged discomfort with staging the wound, lack of early physician notification, and confusion over wound classification, despite a facility policy requiring comprehensive wound assessment, consistent measurement, and provider notification when treatment orders are absent.
A resident with diabetes, chronic leg ulcer, kidney transplant, and a documented gluteal wound was care-planned for Enhanced Barrier Precautions (EBP), with posted instructions requiring gown and gloves for high-contact care such as transfers and wound care. During a telehealth wound assessment, the DON donned a gown and initially performed hand hygiene but then applied gloves without hand hygiene, removed a soiled dressing from the resident’s gluteal area, discarded it, removed gloves, and applied new gloves again without performing hand hygiene between glove changes. On another occasion, during use of a sit-to-stand lift, an NA wore gown and gloves, but the DON handled the lift harness, the resident’s clothing, and assisted with the transfer and repositioning while wearing a gown but no gloves, despite EBP requirements for transfers. The DON stated EBP was only needed for catheter or wound care and not for transfers, contradicting the posted EBP instructions and facility policy.
A resident with severe dementia, psychiatric disorders, and high dependence for ADLs was verbally abused during evening care when a NA, frustrated with the resident’s crying and resistance, loudly ridiculed her as acting like a two-year-old, threatened to hit her back if struck, told her she would be sent to a locked unit, and questioned who would want to care for her when she cried like a baby. Multiple staff witnessed the loud, stern, and intimidating tone and reported it to an LPN, who recognized it as verbal abuse but did not immediately remove the NA from duty or promptly report the allegation per policy, allowing the NA to continue working on the unit. Following this incident, the resident demonstrated increased crying, combativeness, resistance to care, wandering, self-isolation, and refusal of food, fluids, and medications above baseline, with documentation of significant emotional distress and subsequent ED evaluation for aggressive behaviors and poor intake.
A resident with dementia, bilateral above‑knee amputations, vascular disease, and severe protein‑calorie malnutrition developed a wound on an amputation stump that had a dressing dated several days before any documentation or treatment orders appeared in the record. Although bath audits and nursing notes initially reported no skin issues, a later assessment described a full‑thickness stage 4 ulcer/diabetic ulcer on the stump with exposed bone, erythema/edema, slough, and moderate serosanguineous drainage. Nursing staff interviews showed no one could identify who first discovered the wound or applied the initial dressing, and there was no evidence that the wound was assessed, the provider notified, or standing orders implemented when it was first present, despite facility expectations that new wounds be promptly evaluated and reported.
Failure to Follow Professional Standards for Ophthalmic Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice for administering ophthalmic medications to a resident with dry eye syndrome and degenerative eye disease. The resident was cognitively intact, required assistance with ADLs, and had physician orders for cyclosporine ophthalmic emulsion 0.05% one drop in both eyes twice daily and Refresh Tears ophthalmic solution one drop in both eyes four times daily for dry eyes. The administration summary showed that both eye medications were scheduled for the same time and were documented as being given at the same time on multiple dates. During a medication pass observation, a trained medication aide administered the ordered oral medications, then applied gloves and instilled one drop of cyclosporine in each eye, immediately followed by one drop of Refresh Tears in each eye, without any waiting period between the two medications. The surveyors referenced guidance from the American Academy of Allergy, Asthma, and Immunology stating that when more than one eye drop is ordered, three to four minutes should be allowed between drops in the same eye, and five to fifteen minutes should be allowed between different eye medications to prevent dilution. Interviews with the DON, pharmacy consultant, and medical provider confirmed that best practice and the provider’s recommendation were to wait between administration of cyclosporine and Refresh Tears, with the medical provider specifying a fifteen-minute interval. The facility did not provide a policy on ophthalmic medications when requested. The observed practice and documented administration times demonstrated that staff did not follow these professional standards or the medical provider’s recommended interval between the two eye medications.
Failure to Follow Wheelchair Transport Care Plan Leads to Fall With Injuries
Penalty
Summary
The deficiency involves the facility’s failure to implement care-planned fall prevention interventions for a resident at high risk for falls, resulting in a fall with injury. The resident had diagnoses including aphasia, dysphagia, muscle weakness, traumatic brain injury, and impaired mobility, with severe cognitive impairment documented on the MDS and dependence on staff for transfers and wheelchair transport. A care plan addressing wheelchair transport safety and positioning directed staff to ensure the resident was fully positioned and supported in the wheelchair prior to transport, verify footrests were in place prior to transport, and monitor for leaning, sliding, or unsafe positioning. An additional care-planned approach required wheelchair pedals to be on at all times. On the date of the incident, a nursing assistant transported the resident in a manual wheelchair from the shower room to the resident’s room without the foot pedals in place, contrary to the care plan. While being wheeled through the doorway, the wheelchair struck the door frame, causing the chair to stop and the resident, who had begun leaning forward, to fall out of the wheelchair onto the floor. Progress notes and ED documentation identified that the resident sustained a T12 vertebral fracture, a head injury with concussion, an abrasion and contusion to the head, a bruise to the left knee, and multiple lacerations to the right hand requiring sutures. The nursing assistant later acknowledged awareness that the foot pedals should have been on but did not apply them because the transport was only from the shower to the room. The DON confirmed that the resident’s care plan had not been followed when the fall occurred.
Failure to Implement and Update Pressure Ulcer Prevention and Treatment Led to Avoidable Unstageable Coccygeal Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, monitor, and implement individualized pressure ulcer prevention and treatment interventions for multiple high‑risk residents, resulting in an avoidable, unstageable coccygeal pressure ulcer for one resident that required surgical debridement and hospitalization. The resident had primary progressive multiple sclerosis, hereditary spastic paraplegia, obesity, and pre‑existing pressure‑related deep tissue injury to the left heel, and was identified as high risk for pressure ulcers on the Braden Scale due to constant moisture, chairfast status, very limited mobility, inadequate nutrition, and friction/shear risk. Hospital records on readmission documented irritant contact dermatitis of the bilateral gluteal cleft with specific cleansing and barrier cream orders, and facility documentation showed the resident could not reposition in bed or chair and required assist of two and a full‑body mechanical lift for transfers. Despite this, the admission/readmission skin assessment and weekly skin checks lacked measurements and detailed wound characteristics for the heel ulcer and gluteal dermatitis, and the care plan did not include comprehensive, individualized interventions beyond generic repositioning and wound care orders. After a new coccyx pressure ulcer was identified and documented as a stage 2 lesion, the facility failed to promptly and accurately update the care plan and implement recommended pressure‑relieving interventions. The wound nurse practitioner on 3/5 ordered coccyx wound care, an air mattress, pressure offloading, and a dietician consult, but the care plan was not revised and there was no evidence that an air mattress was placed on the bed for nearly two weeks. The environmental services director later confirmed that when the resident was moved to a new room, the gel mattress was not transferred, and the air mattress requested on 3/17 was not actually placed until the following day, despite being marked as completed. During this period, TAR documentation showed gaps in the every‑2‑hour repositioning order, and staff interviews revealed that CNAs were unaware of which residents were on repositioning programs, were not consistently repositioning residents, and had not received recent education on pressure ulcer prevention. The DON and RN case manager acknowledged that the coccyx wound increased in size and changed color between assessments, that the bed lacked the ordered gel mattress, and that the physician was not notified of the wound’s deterioration at that time. The facility also failed to timely modify toileting and incontinence care practices despite knowledge that the resident was being left on a bedpan for extended periods. The DON reported hearing before an IDT meeting that the resident had fallen asleep on a bedpan for an undetermined amount of time, but the care plan was not revised to discontinue bedpan use and implement a bedside commode until after the coccyx wound had significantly worsened. CNAs confirmed that the resident sometimes fell asleep on the bedpan and that they were not informed she should no longer use it until after the sore had worsened. Subsequent wound assessments documented rapid progression of the coccyx wound from a small stage 2 ulcer to a large, malodorous, necrotic wound with eschar, slough, erythema, and purulent drainage, ultimately classified as an unstageable pressure ulcer. The DON, NP, PA, and medical director all indicated that the lack of a pressure‑relieving mattress, failure to adjust pressure‑reducing interventions, and prolonged time on a bedpan likely contributed to the development and deterioration of the resident’s pressure ulcer, which was determined to be avoidable and resulted in hospitalization and surgical debridement. Additional documentation and interviews showed systemic assessment and communication failures related to pressure ulcer management. Weekly skin checks and wound assessments often omitted complete measurements, staging, and wound characteristics, and changes in wound size and appearance were not consistently recognized as deterioration or communicated to providers. The DON acknowledged that a 3/12 assessment showing increased wound size and purple discoloration should have been identified as a deep tissue injury and reported to the physician, but this did not occur. When nursing later documented foul odor, increased pain, and expanding necrotic tissue, telemedicine and PA responses deferred in‑person evaluation and ED transfer despite earlier recommendations that the resident be sent to the ED if an in‑person provider could not assess the wound. The NP ultimately found a large, malodorous, purulent wound with expanding eschar and ordered transfer to the hospital, where imaging and surgical findings confirmed a large necrotic sacral wound requiring extensive debridement. Throughout this sequence, the facility did not consistently follow its own pressure ulcer protocols, did not ensure ordered pressure‑relieving equipment was in place, and did not promptly revise care plans or interventions in response to known risk factors and documented wound changes. The report also notes that other residents reviewed for pressure ulcers were affected by similar failures in monitoring and individualized intervention, though detailed narratives focus primarily on this resident. Staff interviews revealed that CNAs relied on paper care guides that did not clearly identify residents on repositioning programs or at risk for skin breakdown, and that they were unaware of some residents’ special mattress orders or toileting restrictions. The DON and medical director stated that residents at risk for pressure ulcers should have immediate pressure‑relieving interventions and that existing ulcers require ongoing evaluation to prevent deterioration, but the documented practices for this resident did not align with those expectations. These combined actions and inactions—insufficient assessment detail, delayed or missing care plan revisions, failure to implement ordered support surfaces and repositioning, and delayed response to wound deterioration—constituted the deficiency in providing appropriate pressure ulcer care and preventing new ulcers from developing.
Failure to Assess, Care Plan, and Obtain Consent for Bed Grab Bar Use
Penalty
Summary
The deficiency involves the facility’s failure to follow required procedures before installing and using bed grab bars for a resident. The resident had diagnoses including spastic hemiplegia affecting the left side and muscle weakness, and an admission MDS indicating moderate cognitive impairment. During observation, the resident was seen in a power chair with bilateral grab bars on the bed and reported using them to roll in bed and for transfers. The resident’s care plan, dated 1/23/26, documented a need for assistance with bed mobility and independence with transfers but did not mention or address the use of grab bars or side rails. Review of the electronic medical record showed no completed grab bar/side rail or bed mobility device assessment to determine the necessity of the grab bars or whether the resident could safely use them. There was also no evidence that the resident or the resident’s representative had been educated on the risks of having a grab bar on the bed or that informed consent had been obtained. In interviews, an LPN and the ADON both stated that a bed mobility device assessment was required to determine need and safety prior to installing grab bars, and both confirmed that no such assessment was present in the resident’s record.
Failure to Perform Hand Hygiene and Change Gloves During Wound Care
Penalty
Summary
Surveyors observed that a registered nurse (RN) and a nurse practitioner (NP) did not follow the facility’s established infection control practices during wound care for one resident. During a wound treatment, the RN wore gloves while removing the dressing from the resident’s left heel, then removed the dressing from the right heel, sprayed both wounds with wound cleanser, wiped the left heel with gauze, and then used a clean gauze pad to wipe the right heel. The RN did not remove her gloves or perform hand hygiene after disposing of the soiled dressings or between cleaning the left and right heel wounds, contrary to the facility’s written wound care procedure, which requires glove removal and hand hygiene after removing the previous dressing and again after cleaning the wound. The resident’s admission MDS documented diagnoses including multiple rib fractures, heart failure, dementia, anxiety, and the presence of a pressure ulcer, and indicated the resident was cognitively intact and required staff assistance with care and transfers. The resident’s care plan identified pressure ulcers on both heels requiring wound care. In interviews, the RN, NP, and the DON/infection prevention nurse each stated that gloves should be changed when moving from dirty to clean areas and that hand hygiene is expected after glove removal and between wounds to prevent infection, confirming that the observed practice did not align with facility policy or expected infection control standards.
Failure to Timely Revise Care Plan for Toileting and Skin Integrity
Penalty
Summary
The deficiency involves the facility’s failure to timely revise and individualize a resident’s care plan to address toileting and incontinence needs in relation to impaired skin integrity. The resident had diagnoses including primary progressive multiple sclerosis, hereditary spastic paraplegia, obesity, and a pressure-induced deep tissue injury to the left heel. A Significant Change MDS identified the resident as dependent for toileting hygiene, with lower extremity range-of-motion limitations, wheelchair use, dependence for transfers, occasional urinary incontinence, intact cognition, and at risk for pressure ulcers with existing unhealed pressure injuries and MASD. The resident’s skin-focused care plan, revised on various dates, included skin inspections, wound care orders, weekly skin checks, pressure ulcer care to the left heel, nutritional supplements, and a gel mattress, but did not include an individualized toileting or incontinence plan. On a weekly skin check dated 3/3/26, nursing staff identified a new Stage 2 pressure ulcer on the coccyx and contact dermatitis on both gluteal folds. An IDT Final Post Review Follow Up dated 3/10/26 (signed 3/23/26) documented that a new skin issue had occurred and that interventions after the incident included wound care treatment orders, increased repositioning, and increased incontinent care. However, the resident’s care plan from 3/3/26 through 3/16/26 did not show revisions reflecting increased incontinence care or a repositioning schedule, and the care plan was not updated to include these elements until 3/17/26. During this period, the care plan still lacked an individualized toileting plan despite the resident’s identified incontinence and new coccyx pressure ulcer. Progress notes on 3/17/26 documented that the resident’s coccyx wound had declined, with an evaluation describing a deteriorating wound characterized as a Kennedy terminal ulcer/End of Life, staged as a Stage 4 pressure ulcer, in-house acquired, with increased size, exudate, odor, pain, and surrounding erythema. On that same date, the skin focus care plan was revised to include prompt incontinence care and keeping the skin clean and dry, and the elimination focus care plan was revised to address incontinence due to neurogenic bladder with use of a bedside commode offered every 2–3 hours. A nursing assistant reported that when working with the resident, the resident would sometimes fall asleep on the bedpan and forget to ask staff to remove it, and that she was not aware the resident was not supposed to use the bedpan until after the sore had worsened. The DON stated that the resident’s care plan had not been revised earlier to include a turning and repositioning schedule or toileting changes, and that it should have been revised as soon as staff learned the resident was falling asleep on the bedpan, rather than waiting until after the pressure ulcer worsened.
Failure to Assess and Notify Provider for Right Gluteal Wound
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess and appropriately manage a non‑pressure skin issue on a resident’s right gluteal area, and to notify the physician in a timely manner. The resident had diagnoses including diabetes, Crohn’s disease, and a kidney transplant, and the MDS indicated occasional bowel incontinence, no pressure ulcers, and no moisture‑associated skin damage at that time. Earlier documentation identified a resolved MASD to the right gluteus, and a progress note later described a sacral wound with creams applied, noting that sores were still open and painful during application, but without any measurements, wound characteristics, or evidence of physician notification. Subsequent wound assessments documented an open lesion on the right gluteus with specific measurements on multiple dates, but did not identify the wound type or other characteristics, and the record did not show physician notification or treatment orders for the right gluteal lesion. Provider orders in place initially addressed cleansing the buttocks and applying barrier cream, and later included a detailed wound care order for a stage 3 pressure ulcer documented on the left buttocks. However, the resident’s record did not contain a specific treatment order for the right gluteal wound, despite the ongoing documentation of an open lesion in that area. Interviews revealed confusion and inconsistency in wound identification and classification. The DON stated that the right gluteal wound was documented as an open lesion because she did not feel comfortable determining the wound type, and acknowledged that the physician should have been notified when the wound was first identified. The DON was unaware that the NP had documented the wound as being on the left buttocks and as a stage 3 pressure ulcer, while the RN reported that the wound had never been on the left buttocks and that she had been applying the left‑sided wound orders to the right gluteal area because there was no open area on the left. The resident reported a recurring painful area on the right buttocks and chronic stool leakage since prior anal fistula surgery. The facility’s own wound treatment policy required comprehensive assessment of wound etiology and characteristics, consistent measurement and documentation, and provider notification in the absence of treatment orders, which were not followed for this resident’s right gluteal wound. The deficiency centers on the lack of a comprehensive wound assessment for the right gluteal lesion, incomplete documentation of wound characteristics, failure to clearly determine and document the wound etiology, and failure to notify the physician and obtain appropriate treatment orders when the wound was identified and remained open. These actions and inactions resulted in a discrepancy between the documented wound location and type and the actual clinical presentation, as well as a period during which the right gluteal wound had no specific, clearly ordered treatment despite being open and painful.
Failure to Perform Hand Hygiene and Implement Enhanced Barrier Precautions During Wound Care and Transfers
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper hand hygiene during wound care and to consistently implement Enhanced Barrier Precautions (EBP) for a resident requiring such measures. The resident had diagnoses including diabetes, a non-pressure chronic ulcer of the right lower leg, and a kidney transplant, and a wound assessment documented an open lesion on the right gluteal area. The resident’s care plan and a sign posted outside the room specified that EBP, including gown and gloves, were required for high-contact care activities such as dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, catheter care, and wound care. During one observation, the DON performed hand hygiene and donned a gown before entering the resident’s room for a telehealth wound assessment. Inside the room, the DON went into the bathroom, applied gloves without performing hand hygiene, removed the resident’s brief, and removed a foam dressing from the right gluteal area that had stool on one corner. After discarding the soiled dressing, the DON removed gloves and then applied new gloves without performing hand hygiene between glove changes. When questioned, the DON stated that hand hygiene should be done when hands or gloves are visibly soiled and before and after removing or applying gloves, and acknowledged that hand hygiene had not been performed each time gloves were removed and reapplied. In a separate observation, the resident was transferred using a sit-to-stand mechanical lift while EBP requirements were not fully followed. An NA entered the room wearing a gown and gloves with the lift, and the DON applied the lift harness under the resident’s arms and cinched the waist strap, encountering the resident’s clothing, while not wearing gloves. After the transfer to bed, the DON pulled down the resident’s pants and removed the harness while touching the resident’s clothes. Following wound care by a CNP-WOC, the DON again assisted the resident by sitting the resident on the edge of the bed, applying the lift harness, and adjusting the resident’s pants and shirt while wearing a gown but no gloves. The DON stated that EBP was only needed for catheter or wound care and not for transfers, and only upon reading the posted EBP sign acknowledged that EBP was required for all high-contact resident care activities, including transfers.
Failure to Protect Resident From Verbal Abuse and Delay in Removing Alleged Perpetrator
Penalty
Summary
The deficiency involves the facility’s failure to protect a vulnerable resident from mental abuse and to respond appropriately to an allegation of abuse. The resident had severe cognitive impairment, Alzheimer’s disease, dementia, anxiety, depression, psychotic disorder, and significant functional dependence, including frequent incontinence and the need for extensive assistance with ADLs and transfers. Her care plan identified behavioral and mood issues such as wandering, yelling, combative behavior, and calling staff names, with interventions including calm approaches, emotional support, redirection, and monitoring for emotional distress and mood/behavior changes. She was identified as a vulnerable adult, with instructions to monitor for signs of emotional distress and to follow the facility’s abuse reporting policy. On the evening in question, while the resident was crying on the phone with her son and expressing a desire to leave, NA-A and NA-B entered to provide evening care using an EZ stand lift. After the resident ended the phone call, multiple staff reported that NA-A spoke to the resident in a loud, stern, and frustrated tone, telling her to stop crying and that she was acting like a two-year-old. When the resident swatted at NA-A, NA-A stated, “If you hit me, I’m going to hit you back,” and later told the resident she was “in trouble now.” Staff reported that NA-A told the resident she would be sent to a locked unit so she could not get out, and questioned who would want to care for her when she cried like a baby, and that nobody would want to keep working with her. NA-C described NA-A yelling commands such as “HOLD ON!” and “Stop crying! Where would you be if you were not here? Probably lying on the floor,” and felt NA-A was obviously upset and overwhelmed. These statements were made in the presence of the resident while she was already distressed and crying. Following this interaction, the resident exhibited crying, yelling, combativeness, resistance to care, wandering into other residents’ rooms, self-isolation, and refusal of food, fluids, and medications above her prior baseline, as documented in behavior charts, target behavior monitoring, and nursing progress notes. Staff documented that she cried most of the morning, was very restless, difficult to redirect, hit and pinched staff, called staff names, and refused care and meals. She required repeated redirection, 1:1 attention, and non-pharmacological interventions, and was ultimately sent to the ED for evaluation of combativeness and emotional distress, where she was treated for dementia with aggressive behavior and hypoglycemia related to poor intake. The report identifies that the resident’s actual response and the reasonable person concept showed serious psychosocial harm, including increased crying and combative behavior above baseline, fear/anxiety manifested as combativeness, resistance to care and social interaction, and self-isolation. The facility also failed to immediately remove the alleged perpetrator from resident care and to promptly report and investigate the allegation in accordance with its abuse policy. After NA-B and NA-C reported to LPN-A that NA-A had yelled at and threatened the resident, LPN-A acknowledged it as verbal abuse but did not initiate immediate protective measures or timely reporting. LPN-A stated she believed she had 24 hours to report because there was no injury, despite facility policy requiring reporting within two hours. NA-A remained on the unit and continued working until the end of her shift, including after staff had clearly communicated their concerns to LPN-A. TMA and NA staff described uncertainty about their authority to remove NA-A and reliance on the nurse to act, while the DON later informed LPN-A that NA-A should have been removed from the floor to prevent further danger to residents. The Immediate Jeopardy was determined to have begun when NA-A’s derogatory, intimidating, and threatening statements were made and continued while she remained on duty with access to the resident and other vulnerable residents.
Failure to Timely Assess and Treat Newly Discovered Stump Wound
Penalty
Summary
The deficiency involves the facility’s failure to provide timely treatment and care for a newly discovered wound on a resident’s above‑knee amputation stump. The resident was admitted with diagnoses including unspecified dementia with behavioral disturbances, vascular dementia, bilateral above‑knee amputations, vascular disease, reduced mobility, and severe protein‑calorie malnutrition, and had no documented ulcers or skin problems on admission or on the most recent MDS. A weekly bath audit on 3/17/26 documented only non‑tender lymph nodes on the right upper hip and did not identify any open areas. However, when the wound was later assessed, the dressing on the stump was dated 3/16/26, indicating that a wound and dressing existed at that time, even though no corresponding assessment, provider notification, or treatment orders were documented. On 3/23/26, nursing staff documented a new skin issue above the resident’s knee at the amputation site, describing a stage 4 pressure ulcer/injury with full‑thickness skin and tissue loss, exposed bone, erythema/edema, and moderate serosanguineous exudate. The wound measured 1.56 cm by 1.64 cm, with 20–29% granulation tissue and 80% slough. A progress note and skin issues assessment on that date confirmed the wound characteristics and staging, and the NP, after reviewing a picture, determined the wound to be a diabetic ulcer with peripheral vascular disease and severe protein‑calorie malnutrition as contributing factors. On that same date, the NP was notified, antibiotic therapy (doxycycline) was ordered for possible cellulitis, and specific wound care orders were initiated, with documentation on the MAR that these treatments were carried out beginning 3/23/26. Multiple interviews with nursing staff revealed that no one could identify who discovered the wound or who applied the initial dressing dated 3/16/26, and there was no documentation of a wound assessment, provider notification, or interim treatment between 3/16/26 and 3/22/26. Several RNs and LPNs who worked shifts from 3/16/26 through 3/20/26 stated they did not notice a wound on the stump and that, per their usual practice, they would have contacted the provider and initiated treatment if they had found one. One LPN recalled seeing a band‑aid with a date on the stump but could not recall the date, and another LPN stated she did not see the wound because she was not looking for one. The facility’s standing orders required staff to assess all wounds daily, change dressings every three days and as needed, treat with normal saline or non‑cytotoxic cleanser and appropriate dressings, and notify the provider the next business day when a new wound or injury was found. Despite these expectations, the wound identified by the dated dressing on 3/16/26 was not assessed, reported, or treated according to orders and facility policy until 3/23/26.
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