Grand Avenue Rest Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Minneapolis, Minnesota.
- Location
- 3956 Grand Avenue S0uth, Minneapolis, Minnesota 55409
- CMS Provider Number
- 24E150
- Inspections on file
- 27
- Latest survey
- November 26, 2025
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Grand Avenue Rest Home during CMS and state inspections, most recent first.
A staff member transported soiled linen in an uncovered, unlined basket through common areas where residents were present, contrary to facility policy requiring soiled linen to be covered and lined during transport. Interviews with staff confirmed the expectation to cover and bag soiled linen to prevent contamination.
Several residents with psychiatric diagnoses were administered PRN psychotropic medications without documentation of nonpharmacological interventions being attempted beforehand, despite facility policy and physician orders requiring such actions. Nursing staff and leadership confirmed that these interventions should have been offered and documented, but medical records lacked evidence of compliance.
A resident with intact cognition and psychiatric symptoms repeatedly expressed a desire to move out and pursue alternative living arrangements, but the care plan was not updated to reflect these preferences. Despite multiple documented requests and assessments for discharge, the care plan continued to state the resident wished to remain, and staff interviews confirmed the plan was not current with the resident's goals.
A resident with multiple mental health diagnoses, including PTSD, was identified as high risk and required psychotherapy with an outside provider. The facility did not have a process to obtain or review therapy notes from the external provider, and there was no evidence of collaboration documented in the EMR. Leadership confirmed the lack of a process for ensuring communication with outside therapists, and the resident reported that her specific PTSD triggers were not assessed by the facility.
The facility did not ensure timely action on pharmacist recommendations for two residents prescribed psychotropic medications. One resident's monthly medication review was missing, and for another, a pharmacist's recommendation for a gradual dose reduction was not addressed by the physician, with no documentation of follow-up or rationale. The facility also could not provide a policy on pharmacy recommendations when requested.
A resident was not offered or educated about influenza, pneumococcal, and Covid-19 vaccinations, and there was no documentation in the EMR regarding vaccine education, offer, receipt, or refusal, despite facility policy and CDC guidelines requiring these actions.
Three bedrooms were found to house three residents each, but did not meet the required 80 square feet per resident, with actual space ranging from 65.9 to 79.6 square feet per person. Affected residents reported insufficient space for movement and personal activities, and the administrator confirmed no recent changes to room configurations.
The facility failed to prepare resident care plans with an interdisciplinary team (IDT) that included a nursing aide, attending physician, or resident/resident representative, potentially affecting all 19 residents. Discrepancies were noted in the IDT composition as described by the DON and administrator. The DON admitted that no notes are taken during IDT meetings, which are used to update care plans based on risk management discussions. The facility's IDT policy outlined specific roles for the team.
The facility failed to appoint a registered nurse (RN) as the Director of Nursing (DON), instead having a licensed practical nurse (LPN) in the role since July 2024. The administrator acknowledged the requirement for an RN in the DON position, and the facility lacked a signed job description for the current DON. The deficiency could impact all 19 residents.
The facility did not schedule a registered nurse (RN) for a minimum of eight consecutive hours a day, affecting all 18 residents. Staff schedules from January to March 2024 showed multiple dates without RN coverage. The interim DON confirmed the absence of RN coverage and acknowledged the requirement for RN presence. No staffing policy was provided.
The facility failed to identify and address quality deficiencies, lacking documentation and implementation of corrective actions. The QAPI meeting minutes and reports for the second quarter did not include improvement activities or analysis of adverse events and medical errors. Deficiencies noted in the CASPER report, such as RN coverage and infection control, were not addressed through a Performance Improvement Project (PIP).
The facility failed to handle linen properly, with staff observed carrying both clean and dirty laundry through the kitchen, posing an infection control risk. Additionally, the facility lacked functioning infection surveillance and water management programs, as identified by the newly appointed infection preventionist.
The facility lacked a functioning antibiotic stewardship program, potentially affecting residents needing antibiotics. The infection preventionist, new to the role, identified this issue and intended to rebuild the program. The existing policy was insufficient, lacking protocols and criteria for appropriate antibiotic use.
The facility failed to conduct orthostatic blood pressure monitoring for residents on psychotropic medications, as required for monitoring potential side effects. Four residents with conditions such as schizophrenia and bipolar disorder had orders for such monitoring, but their treatment records lacked documentation over several months. The interim DON acknowledged the absence of active orders and documentation, which is crucial for assessing medication effectiveness and side effects.
A resident with a history of respiratory issues reported symptoms and requested a COVID-19 test, but the facility failed to document the test results or notify the physician. The resident expressed concerns about her health over several days, but staff did not promptly address her requests or document her symptoms, leading to a deficiency in care.
A resident with intact cognition and mental health diagnoses expressed discomfort when staff entered her room without waiting for a response, highlighting a lack of privacy provisions in shared rooms. Observations confirmed the absence of privacy curtains, and staff interviews acknowledged limited privacy options, with the facility considering improvements.
A fire occurred in the smoking room of an LTC facility, but the incident was not reported to the State Agency (SA) or investigated as required by the facility's policies. The interim DON and Administrator were aware of the fire, but no investigation was conducted, and the incident was not reported. A resident attempted to extinguish the fire, and a cook eventually put it out before the fire department arrived.
A resident with schizophrenia and depression did not receive her prescribed sertraline and Serevent Diskus due to the facility's failure to reorder medications timely. The resident experienced nervousness and restlessness, resorting to smoking to calm down. The facility's policy required reordering with less than a five-day supply, but documentation was lacking, and the new process was not effectively implemented.
A resident with COPD and emphysema experienced worsening respiratory symptoms, including shortness of breath and a harsh cough, which were not adequately assessed or documented by the facility. Despite the resident's requests for a COVID test and medical attention, staff did not perform a thorough assessment or comply with her request to call 911, leading her to call an ambulance herself. The facility's failure to recognize and respond to the resident's change in condition resulted in a deficiency.
A resident with a history of smoking-related injuries was observed with a lighter in her room and independently smoking, despite assessments indicating smoking supplies should be stored by staff. Interviews revealed staff were unaware of restrictions on smoking materials, and the DON confirmed the resident should not have had access to a lighter. No safe smoking policy was provided.
A resident did not receive prescribed medications due to an 8% medication error rate at the facility. The LPN could not find the Sertraline HCl medication card, and the Serevent Diskus was expired. Interviews revealed that nurses were responsible for medication orders and refills, but no policy was provided for reordering medications.
The facility did not meet the required minimum square footage per resident in three rooms, affecting nine residents. Rooms 101, 102, and 103 housed three residents each but did not provide the required 80 square feet per resident. Despite this, the rooms were safe and adequately furnished, with no negative impact on the residents observed.
A resident with schizoaffective disorder received a monthly Invega Sustenna injection twice over two days due to documentation and communication errors among staff. The initial dose was missed, and upon discovery, the injection was given on one day and mistakenly repeated the next day. The facility's policy requires verification before administration, but the lack of proper documentation led to the error. The resident was monitored for adverse effects, but none were reported.
The facility failed to maintain accurate accounting of resident trust funds, with discrepancies totaling $7,061.96 and did not provide quarterly statements to 5 of 14 residents. The DON and CFO confirmed the discrepancies and the lack of documentation for statement distribution.
The facility failed to ensure the surety bond contained sufficient funds to protect the total balance of the resident trust fund, which was $24,419.88. The surety bond was only for $20,000, leaving the resident trust funds inadequately insured. The CFO acknowledged this discrepancy during an interview.
A facility failed to update a care plan for a resident with a history of leaving the facility against the leave of absence policy. Despite the resident's repeated absences and noncompliance, the care plan did not reflect these behaviors, and staff acknowledged the need for updates. The oversight was compounded by the fact that the resident's medication administration record indicated she received her scheduled medications despite her absences.
Uncovered Soiled Linen Transported Through Common Areas
Penalty
Summary
A staff member was observed transporting soiled linen in an uncovered basket without a liner or bag through common areas of the facility, including the living room and dining room, where several residents were present. The staff member carried the uncovered linen outside and around the building to the laundry area, confirming during an interview that the basket was not covered or lined during transport. The staff member acknowledged awareness of the expectation to keep soiled linen covered for infection control purposes. Interviews with the infection control preventionist and a nursing assistant confirmed that facility policy requires all soiled linen to be transported in covered containers with a plastic liner, which should be cinched prior to transport. Both staff members reiterated the importance of covering dirty laundry during transport to prevent contamination, in accordance with the facility's updated Linen and Laundry policy. The failure to follow these procedures had the potential to impact all 19 residents in the facility.
Failure to Document Nonpharmacological Interventions Prior to PRN Psychotropic Medication Administration
Penalty
Summary
The facility failed to provide and document appropriate nonpharmacological interventions prior to administering as-needed (PRN) psychotropic medications for three of five residents reviewed for unnecessary medication use. For one resident with diagnoses including anxiety, depression, psychotic disorder, schizophrenia, and PTSD, the medical record showed frequent administration of PRN diazepam over several months. However, there was no documentation of nonpharmacological interventions attempted before medication administration, despite explicit instructions from the consulting pharmacist and physician orders requiring such documentation. Another resident with diagnoses of bipolar disorder with psychotic features, anxiety disorder, and schizoaffective disorder was administered PRN hydroxyzine multiple times. The medication administration records indicated the medication was effective but lacked any documentation of nonpharmacological interventions prior to administration. The resident's care plan listed several nonpharmacological strategies, but progress notes and the electronic medical record did not reflect that these were attempted before giving the medication. Interviews with nursing staff and the assistant director of nursing confirmed the expectation that nonpharmacological interventions should be offered and documented prior to PRN psychotropic medication administration. Review of facility policy also indicated that nurses are required to attempt an intervention before administering PRN psychotropic medication. Despite these requirements, documentation in the medical records did not show that nonpharmacological interventions were attempted or recorded prior to medication administration for the residents reviewed.
Failure to Update Care Plan for Resident's Discharge Preferences
Penalty
Summary
The facility failed to maintain an up-to-date comprehensive care plan for a resident who was reviewed for discharge planning. The resident, who had intact cognition but experienced hallucinations, delusions, and fluctuating disorganized thinking, was independent with all activities of daily living. Despite multiple documented expressions of the desire to move out of the facility and pursue alternative living arrangements, such as assisted living or independent living, the resident's care plan was not updated to reflect these preferences. The care plan continued to state that the resident wished to remain in the facility and only wanted to be asked about discharge plans annually, with the last revision not reflecting the resident's ongoing requests for discharge. Progress notes and interviews with staff confirmed that the resident repeatedly communicated her wish to leave the facility, and assessments for relocation services were initiated. However, the care plan did not document these changes in the resident's goals or preferences. Staff interviews further revealed a lack of awareness or clarity regarding the resident's discharge plans, and both the assistant director of nursing and the social worker acknowledged that the care plan should have been updated to reflect the resident's expressed wishes. The facility's own policy required care plans to be regularly reviewed and updated to reflect changes in condition or preferences, which was not followed in this case.
Failure to Collaborate with External Mental Health Provider for Behavioral Health Services
Penalty
Summary
The facility failed to collaborate with a resident's external mental health provider to ensure necessary behavioral health services were provided. The resident, who was cognitively intact and had diagnoses including major depressive disorder, ADHD, generalized anxiety disorder, panic disorder, and PTSD, was identified as high risk and in need of psychotherapy for PTSD. The care plan specified therapy with an outside provider, but the electronic medical record did not show evidence of collaboration or receipt of therapy notes from the external provider. The director of social services confirmed there was no established process for obtaining therapy notes or collaborating with outside providers, and that such notes were rarely received unless there was a specific issue. Interviews with facility leadership indicated that it was expected for social services to review and upload therapy notes into the resident's EMR, but this was not occurring. The resident reported that while the facility assessed her for PTSD, it did not assess her specific triggers, and she confirmed she attended therapy outside the facility. A request for the facility's behavioral health policy was made but not fulfilled.
Failure to Act on Pharmacist Recommendations and Missing Medication Review
Penalty
Summary
The facility failed to ensure that pharmacist recommendations were acted upon in a timely manner for two residents reviewed for unnecessary medication use. For one resident with diagnoses including hallucinations, delusions, anxiety, and schizophrenia, the facility was unable to provide documentation of a required monthly medication regimen review for June, as confirmed by the administrator. This resident was prescribed multiple antipsychotic and antidepressant medications, and the absence of the June review indicated a lapse in the facility's process for ensuring regular pharmacist oversight. For another resident with intact cognition and psychiatric symptoms, the consulting pharmacist made a recommendation for a gradual dose reduction (GDR) of trazodone, requesting physician review and response. However, the physician did not sign or indicate acceptance or rejection of the recommendation, and there was no documentation of a patient-specific rationale if the recommendation was contraindicated. The assistant director of nursing confirmed that the recommendation was sent to the provider but no response was received, and there was uncertainty about whether any follow-up was attempted. Additionally, the facility was unable to provide a policy on pharmacy recommendations when requested.
Failure to Offer and Document Required Vaccinations
Penalty
Summary
The facility failed to ensure that recommended influenza, pneumococcal, and Covid-19 vaccinations were offered and/or provided in a timely manner, as outlined by CDC guidelines, for one of five residents reviewed for immunizations. Review of the electronic medical record (EMR) for this resident showed no evidence that the resident was educated about, offered, or received or declined the influenza, pneumococcal, and Covid-19 vaccines. During an interview, the infection control preventionist confirmed that the facility's expectation is to offer and document vaccine status for all residents, including documentation of education, what was offered, and whether the vaccine was received or declined. The infection control preventionist also verified that the EMR lacked documentation of refusals and follow-up for the resident's vaccine status. The facility's policy requires that all residents and their legal representatives be offered these vaccines and that the EMR reflect education provided, receipt, or refusal, but this was not followed in the case reviewed.
Failure to Meet Minimum Room Size Requirements for Multiple Residents
Penalty
Summary
The facility failed to provide the required minimum square footage per resident in three multi-resident bedrooms, affecting nine residents. Observations revealed that each of these rooms housed three residents but measured less than the mandated 80 square feet per resident, with actual measurements ranging from 65.9 to 79.6 square feet per person. Interviews with affected residents indicated dissatisfaction with the available space, with one resident stating there was not enough room to move around and another expressing difficulty engaging in personal activities such as crafting due to limited space. The administrator confirmed that no changes or updates had been made to the rooms since the previous survey.
Deficiency in Interdisciplinary Team Care Plan Preparation
Penalty
Summary
The facility failed to prepare resident care plans with an interdisciplinary team (IDT) that included a nursing aide (NA), the attending physician, or a resident/resident representative. This deficiency had the potential to affect all 19 residents in the facility. During interviews, discrepancies were noted in the composition of the IDT as described by the director of nursing (DON) and the administrator. The DON mentioned that the IDT consisted of an RN, the administrator, herself, the social worker, a member from medical records, the infection preventionist (IP) nurse, the minimum data set (MDS) nurse, and a compliance nurse. In contrast, the administrator stated that the IDT included a RN, the DON, a member of the activities department, herself, the social services director, the social services assistant, and a member of the kitchen. Additionally, the DON admitted that they do not take notes during IDT meetings, which are used to update care plans based on risk management discussions. The facility's IDT policy, revised in December, stated that the IDT should include the DON, one other nurse designated by the DON, the social services director and/or assistant, the activity director and/or designee, and other staff members as established by the Administrator.
LPN Serving as Director of Nursing Instead of Required RN
Penalty
Summary
The facility failed to ensure that their Director of Nursing (DON) was a registered nurse (RN), as required. Instead, a licensed practical nurse (LPN) has been serving in the DON role since July 30, 2024. This deficiency was identified during an interview with the facility's administrator, who acknowledged the requirement for an RN in the DON position and confirmed that the current DON is an LPN. The facility did not have a signed job description for the current DON, and the provided job description for the DON role specified that an RN must be hired. Additionally, the DON's educational records did not include any training specific to the DON role. This deficiency had the potential to affect all 19 residents in the facility.
Failure to Schedule RN for Required Hours
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was scheduled for a minimum of eight consecutive hours a day, which had the potential to affect all 18 residents at the facility. A review of the facility staff schedules and staffing hours from January 1, 2024, to March 31, 2024, revealed that there was no RN scheduled on multiple dates, including January 14, 20, 21, 27, 28; February 3, 4, 16, 17, 18, 24; and March 2, 3, 9, 10, 16, 17, 23, 30, and 31. During an interview on August 26, 2024, the interim Director of Nursing (DON) confirmed the absence of RN coverage on these dates. In a follow-up interview on August 28, 2024, the interim DON acknowledged the requirement to have an RN in the building for at least 8 hours a day. The facility was unable to provide a policy regarding staffing when requested.
Facility Fails to Address Quality Deficiencies and Implement Corrective Actions
Penalty
Summary
The facility failed to identify and address quality deficiencies effectively, as evidenced by a lack of documentation and implementation of corrective actions. The facility's Quality Assurance and Performance Improvement (QAPI) meeting minutes for the second quarter lacked documentation of improvement activities, tracking of adverse events, medical errors, and analysis of causes. Additionally, the QAPI reports for the same period included infection control tracking, skin and wounds, and medication errors but did not document any analysis of their causes or preventive actions implemented. This indicates a failure to develop and implement appropriate actions to correct identified deficiencies. The facility had several deficiencies noted in the Certification and Survey Provider Enhanced Reporting (CASPER) system report, including issues with RN coverage, unnecessary psychotropic medications, infection prevention and control, antibiotic stewardship, and emergency preparedness. These deficiencies were not addressed through a Performance Improvement Project (PIP) focusing on high-risk or problem-prone areas, as there was no evidence of such a project being implemented. The social services representative was unaware of any ongoing PIPs, despite the facility's QAPI plan indicating the need for proactive approaches to improve quality of care and life for residents.
Deficiencies in Linen Handling and Infection Control Programs
Penalty
Summary
The facility failed to properly handle linen, which posed an infection control concern. During observations, a nursing assistant was seen carrying dirty resident clothing through the kitchen in a mesh-designed hamper, and later, an uncovered basket of clean linen was also carried through the kitchen. Interviews with the cook aide and the interim director of nursing confirmed that staff were using the kitchen as a passageway for laundry, both clean and dirty, which was against infection control protocols. The interim director of nursing and the infection preventionist both acknowledged that linen should not be transported through the kitchen due to the risk of contamination, but no policy regarding the transportation of linen was provided. Additionally, the facility lacked a functioning infection surveillance program and a water management program. The infection preventionist, who had been in the role for two weeks, identified these deficiencies and expressed the intention to rebuild both programs. The absence of these critical programs indicated a significant gap in the facility's infection prevention and control measures, potentially affecting all residents in the facility.
Lack of Functioning Antibiotic Stewardship Program
Penalty
Summary
The facility failed to have a functioning antibiotic stewardship program, which could potentially affect any resident requiring antibiotics for infections. During an interview, the infection preventionist (IP), who had been in the role for two weeks, acknowledged the absence of a functioning program and expressed the intention to rebuild it. The existing policy, which was undated and only one page long, indicated that the IP would track and assess all antibiotic use to ensure appropriate usage. However, the policy lacked specific protocols and criteria for determining appropriate antibiotic use.
Failure to Monitor Orthostatic Blood Pressure in Residents on Psychotropic Medications
Penalty
Summary
The facility failed to ensure orthostatic blood pressure monitoring was conducted for residents on psychotropic medications, as required for monitoring potential side effects. This deficiency was identified for four out of five residents reviewed, who were on various psychotropic medications for conditions such as schizophrenia, anxiety, depression, and bipolar disorder. Despite having orders for orthostatic blood pressure monitoring, the treatment administration records for these residents lacked documentation of such monitoring over several months. Resident 1, who had intact cognition and was on antidepressant, antianxiety, and antipsychotic medications, had orders for orthostatic blood pressure monitoring that were not documented in the treatment administration records from May to July 2024. Although the resident refused monitoring in August 2024, the facility's records still lacked documentation of any orthostatic blood pressure readings. Similarly, Resident 8, with diagnoses including bipolar disorder and schizophrenia, also had no documented orthostatic blood pressure monitoring despite having orders for it. Resident 13, who was on multiple psychotropic medications, had sporadic documentation of blood pressure readings, but these were incomplete and did not consistently include all required positions (lying, sitting, standing). Resident 5, with a history of seizure disorder and schizophrenia, also lacked documented orthostatic blood pressure monitoring. The interim Director of Nursing acknowledged the absence of active orders and documentation for orthostatic blood pressure monitoring, which is crucial for assessing the effectiveness and side effects of psychotropic medications.
Failure to Notify Physician of Resident's COVID-19 Test and Symptoms
Penalty
Summary
The facility failed to notify and consult with a resident's physician after the resident was tested for COVID-19. The resident, who had intact cognition and a history of respiratory issues, including emphysema, reported symptoms such as a harsh cough, difficulty breathing, and feeling unwell over several days. Despite these symptoms, the resident's electronic health record lacked documentation of a COVID test or result, and there was no evidence that the physician was notified of the resident's condition or test results. The resident expressed concerns about her health to staff multiple times, including requesting a COVID test and assistance in going to urgent care. However, staff did not promptly address her requests or document her symptoms and test results. The Director of Nursing was only made aware of the resident's respiratory symptoms when the resident requested to call 911 herself. The DON confirmed that the COVID test was negative but acknowledged that the results were not documented in the resident's health record, nor was the physician notified.
Failure to Ensure Resident Privacy
Penalty
Summary
The facility failed to ensure personal privacy for a resident, identified as R8, who was reviewed for privacy concerns. R8, who had intact cognition and was independent with activities of daily living, had diagnoses of anxiety, bipolar disorder, and schizophrenia. The resident experienced hallucinations and delusions and exhibited behavioral symptoms. A progress note indicated that staff entered R8's room without waiting for a response after knocking, which made R8 uncomfortable as she was changing clothes at the time. R8 expressed a desire for privacy curtains, especially when changing clothes, but her care plan lacked documentation of her privacy preferences or assessment. Observations revealed that R8's shared bedroom did not have privacy curtains or screens, and interviews with staff confirmed the lack of privacy provisions in resident rooms. An LPN mentioned that residents needing privacy would have to go to the nursing office or bathroom. The DON acknowledged the absence of privacy curtains and stated that the facility was considering installing them. The facility's policy on resident privacy indicated that residents could request privacy screens, but some beds could not accommodate them due to accident hazards. The policy suggested alternative options, such as moving residents to different beds or rooms, or even discharge, to meet privacy needs.
Failure to Report and Investigate Fire Incident
Penalty
Summary
The facility failed to recognize and report a potential incident of neglect to the State Agency (SA) after a fire occurred in the smoking room on the second floor. The interim Director of Nursing (DON) was aware of the fire but did not see any investigation report or know if it had been reported to the SA. The Administrator acknowledged the fire and stated that the incident should have been investigated by the social worker (SW), but no investigation was completed, and the incident was not reported to the SA. Interviews revealed that a resident attempted to extinguish the fire but was unable to do so, and a cook eventually put out the fire. The fire department was called and arrived after the fire was extinguished. The facility's policy on Abuse, Neglect, and Exploitation Prevention requires immediate reporting of incidents to the SA and mandates staff training on identifying and reporting such incidents. The infection preventionist (IP) overseeing the DON confirmed the expectation for staff to report incidents to management for further investigation and instructions. Despite these policies, the incident was not reported, and no investigation was conducted, which could potentially affect all residents in the facility.
Failure to Reorder Medications Timely
Penalty
Summary
The facility failed to ensure timely re-ordering of medications for a resident, identified as R1, who was receiving treatment for multiple conditions including schizophrenia, depression, and anxiety. R1's medication administration record indicated she was prescribed sertraline for depression, among other medications. However, during a medication administration observation, it was noted that the sertraline was not available, and the Serevent Diskus was expired. This resulted in R1 not receiving her scheduled doses of sertraline and Serevent Diskus. Interviews with R1 revealed that she experienced feelings of nervousness and restlessness due to the lack of her prescribed medication. R1 expressed confusion and frustration over the facility's failure to reorder medications in a timely manner, stating that this issue had been ongoing. The resident resorted to smoking a cigarette to alleviate her restlessness, indicating the impact of the medication lapse on her mental state. The facility's policy required nurses or trained medication aides to reorder medications when there was less than a five-day supply. However, the review of refill reorder forms showed a lack of documentation for the reordering of sertraline. Interviews with the LPN and the DON confirmed that it was the nurses' responsibility to input new orders and request refills. The DON mentioned a new process for reordering medications, but it was not effectively implemented, leading to the deficiency observed.
Failure to Recognize Change in Respiratory Status
Penalty
Summary
The facility failed to recognize a change in respiratory status for a resident with a history of respiratory issues, including COPD and emphysema. The resident, who had intact cognition and was aware of her symptoms, reported shortness of breath and other respiratory symptoms to the staff on multiple occasions. Despite these reports, the facility did not adequately assess or document the resident's respiratory condition, nor did they follow up on her requests for a COVID test in a timely manner. The resident's medical records indicated she was on several medications for respiratory issues, including albuterol and Serevent Diskus. However, there was a lack of documentation in her care plan regarding her respiratory status. The resident experienced worsening symptoms, including a harsh cough and difficulty breathing, which she reported to staff. Despite her complaints, staff did not perform a thorough assessment, such as listening to her lung sounds, and there was no documentation of her COVID test results in her electronic health record. The situation escalated when the resident, feeling unwell and short of breath, requested to go to urgent care and asked staff to call 911. The staff, including the DON, did not comply with her request, leading the resident to call an ambulance herself. The DON acknowledged the resident's request for a COVID test and confirmed it was negative, but there was no documentation of this in the resident's records. The facility's failure to adequately assess and document the resident's respiratory condition and respond to her requests for medical attention and testing contributed to the deficiency.
Failure to Implement Smoking Safety Interventions
Penalty
Summary
The facility failed to implement smoking interventions to reduce the risk of avoidable injuries for a resident with a history of injuries related to smoking. The resident, who had diagnoses including depression, schizophrenia, and asthma, was assessed multiple times for smoking safety, with instructions that all smoking supplies should be stored in the nursing office. Despite this, observations revealed that the resident had access to a lighter in her room and was able to independently light cigarettes in the smoking room without staff intervention. Interviews with facility staff, including a CNA and the DON, indicated a lack of awareness and communication regarding which residents were allowed to keep smoking materials. The CNA was not informed about any restrictions on residents keeping smoking materials, and the DON, upon reviewing the resident's assessments and care plan, acknowledged that the resident should not have been allowed to keep her lighter. The facility did not provide a policy regarding safe smoking practices when requested.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in an 8% error rate during a medication pass observation. This deficiency involved two errors out of 25 opportunities, specifically affecting one resident. The resident, who was cognitively intact and independent in most activities of daily living, had a history of anxiety disorder, depression, and chronic obstructive pulmonary disease. The resident was prescribed Sertraline HCl for major depressive disorder and Serevent Diskus for shortness of breath. However, during the medication pass, the LPN was unable to locate the Sertraline HCl medication card, and the Serevent Diskus was found to be expired, leading to the resident not receiving either medication. Interviews with the LPN and the interim DON revealed that it was the nurses' responsibility to input new orders, send them to the pharmacy, and request medication refills. The interim DON stated that medications should be reordered when there was a week's worth of medication left. Despite this, the facility was unable to provide a policy regarding medication reordering. This lack of policy and oversight contributed to the medication errors observed during the survey.
Deficiency in Resident Room Square Footage
Penalty
Summary
The facility failed to provide the required minimum square footage per resident in three resident bedrooms, affecting nine residents. Specifically, the rooms in question did not meet the regulatory requirement of at least 80 square feet per resident in multiple occupancy rooms. Room 101 housed three residents with only 65.9 square feet per resident, room 102 housed three residents with 79.6 square feet per resident, and room 103 housed three residents with 73.6 square feet per resident. Despite these deficiencies, the rooms were observed to pose no safety hazards and were adequately furnished. There was no evidence that the residents were negatively impacted by the room size. The facility's administrator confirmed that there had been no changes or updates to the rooms since the prior survey.
Medication Administration Error Due to Documentation and Communication Failures
Penalty
Summary
The facility failed to ensure a once-monthly injection was administered per physician orders, resulting in a significant medication error for a resident diagnosed with schizoaffective disorder, bipolar disorder, and extrapyramidal movement disorder. The resident was supposed to receive an Invega Sustenna injection every 28 days, but due to a series of miscommunications and documentation errors, the injection was administered twice over two consecutive days. The initial dose was missed in June, and upon discovery, the nursing staff attempted to rectify the situation by administering the injection on July 3rd. However, due to a lack of proper documentation and communication, the injection was administered again on July 4th. The sequence of events leading to the error involved multiple staff members, including LPNs and DONs, who were involved in the administration and documentation process. On July 3rd, the DON instructed an LPN to administer the injection after receiving a verbal order from a nurse practitioner. However, the LPN did not document the administration in the electronic medical record, leading to another LPN administering the same injection the following day. The second administration occurred after the DON from a sister facility checked the records and found no documentation of the previous day's injection. The facility's policy on administering medications requires verification of the right resident, medication, dosage, time, and method before administration. However, the lack of proper documentation and communication among staff members led to the medication being administered twice. The resident was monitored for adverse effects, but none were reported. The facility did not provide a policy on verbal and written orders, and the staff involved had received education on medication administration, but the incident highlighted gaps in the process.
Discrepancies in Resident Trust Fund Accounting and Failure to Provide Quarterly Statements
Penalty
Summary
The facility failed to maintain a system that assured full and complete accounting of resident personal funds entrusted to the facility, affecting 14 residents with trust fund accounts. The director of nursing (DON) confirmed discrepancies in the petty cash amounts, with a total of $36.20 unaccounted for. Additionally, the facility's electronic health record (EHR) system showed a significant discrepancy of $7,025.76 between the resident trust fund total balances in the EHR and the bank account transaction statements. The chief financial officer (CFO) acknowledged the discrepancies and was attempting to reconcile the accounts but had not yet identified the source of the errors. The facility also failed to provide quarterly statements for individual resident trust fund accounts for 5 of the 14 residents reviewed. Interviews with residents and their representatives revealed that they had not received the required quarterly statements, with some indicating they had never received such statements. The administrator and CFO confirmed that the statements were supposed to be sent out quarterly, but there was no documentation to prove that the most recent statements had been distributed. The administrator and CFO provided conflicting information about the process and responsibility for distributing the statements. The facility's policy required maintaining a written record of all financial transactions involving a resident's personal funds and providing quarterly statements to residents or their representatives. However, the facility failed to adhere to this policy, resulting in unaccounted funds and a lack of transparency for the residents and their representatives. The discrepancies in the accounting system and the failure to provide quarterly statements indicate a significant lapse in the facility's financial management and oversight of resident trust funds.
Inadequate Surety Bond for Resident Trust Fund
Penalty
Summary
The facility failed to ensure the surety bond contained sufficient funds to insure and protect the total balance of the resident trust fund. The transaction history for the facility's resident trust fund savings and checking accounts from 4/1/24 to 4/11/24 identified a combined total balance of $24,419.88 on 4/11/24. However, the facility's surety bond, effective from 9/9/23, was for a sum of $20,000, which was inadequate to cover the balance of the resident trust fund. During an interview on 4/15/24, the CFO acknowledged that the surety bond did not cover the balance of $24,419.88 in the resident trust fund accounts. The facility policy dated 10/6/22 stated that the facility maintains a surety bond to ensure the security of all personal funds deposited with the facility, which was not adhered to in this instance.
Failure to Update Care Plan for Resident with History of Leaving Facility
Penalty
Summary
The facility failed to update a care plan to include a resident's history of leaving the facility against the leave of absence policy. The resident, who had diagnoses including paranoid schizophrenia, post-traumatic stress disorder, schizoaffective disorder, delusional disorders, and major depressive disorder, left the facility multiple times without informing the staff of her whereabouts or return plans. Despite the resident's repeated absences, her care plan did not reflect her noncompliance with the leave of absence policy. This oversight was noted during interviews and document reviews, where it was revealed that the care plan was not updated to address the resident's behavior and associated risks. The deficiency was further highlighted by the fact that the resident's medication administration record indicated she received her scheduled medications despite her absences, suggesting a lack of accurate documentation and monitoring. Staff members, including LPNs and the DON, acknowledged that any changes to a resident's care should be noted in their care plan and that the care plan should be updated as the resident's condition changes. However, the care plan for this resident was not updated, and the weekend nursing staff, who were agency nurses, may not have had the appropriate administrative privileges to make necessary updates in the electronic medical record system.
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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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