Green Lea Senior Living
Inspection history, citations, penalties and survey trends for this long-term care facility in Mabel, Minnesota.
- Location
- 115 North Lyndale, Rr 2 Box 49, Mabel, Minnesota 55954
- CMS Provider Number
- 245536
- Inspections on file
- 24
- Latest survey
- October 17, 2025
- Citations (last 12 mo.)
- 10 (2 serious)
Citation history
Health deficiencies cited at Green Lea Senior Living during CMS and state inspections, most recent first.
Two residents with significant fall risk factors experienced multiple unwitnessed falls, including one resulting in a subarachnoid hemorrhage, due to the facility's failure to conduct root cause analyses, implement appropriate interventions, and update care plans. Staff were often unaware of current fall prevention measures, and documentation was inconsistent, leading to repeated incidents without effective prevention.
Four nursing assistants worked with expired certifications, as the facility did not have a process to verify current credentials. The DON and administrator were unaware of the expired statuses, and the policy assigning responsibility to Human Resources was not followed, potentially affecting all residents.
The facility did not ensure its QAPI committee properly identified, investigated, or responded to a significant increase in resident falls, including multiple falls by a resident that led to a subarachnoid hemorrhage and hospitalization. Despite documentation of the rise in falls and concerns raised by the medical director, the committee failed to conduct a root cause analysis or develop an action plan, and meeting minutes contained inaccuracies regarding the number and nature of falls.
Two residents with severe cognitive impairment and mobility limitations did not have their call lights within reach, as observed during surveyor visits. Both residents required assistance for transfers and were at risk for falls, yet their call lights were found on the floor and inaccessible. Staff confirmed that call lights should have been within reach, in accordance with facility policy.
A resident with a history of multiple falls and neurological impairment suffered a fall resulting in a brain bleed, but the facility did not complete a comprehensive fall investigation or report the serious injury to the State Agency within the required timeframe. Staff interviews revealed confusion about reporting responsibilities, and the facility's policy for prompt reporting of serious injuries was not followed.
A resident with hemiplegia and hemiparesis experienced multiple documented falls after admission, but the 5-day MDS assessment was inaccurately coded to indicate no falls had occurred. The MDS-RN acknowledged missing the falls during the assessment process, despite facility policy requiring consistency between MDS data and resident records.
A resident with hemiplegia and hemiparesis following a stroke was admitted and assessed as being at moderate risk for falls, but the baseline care plan did not include fall prevention interventions or specify transfer status. Therapy recommendations for transfer assistance were not promptly incorporated into the care plan, leading to staff confusion and lack of clear instructions. The facility's policy requiring a baseline care plan within 48 hours was not followed, resulting in missing essential safety information.
A resident with Huntington's disease, initially continent on admission, experienced fluctuating urinary incontinence and urgency. The facility did not conduct a comprehensive bladder assessment, failed to develop or implement an individualized toileting program, and delayed updating the care plan to address the resident's changing continence status. Staff interviews revealed a lack of awareness of the resident's specific needs, and the resident reported inadequate toileting assistance, leading to distress and falls.
A nursing assistant did not follow hand hygiene protocols during toileting and incontinence care for a resident with hemiplegia and hemiparesis. The NA applied gloves without hand hygiene, performed peri care, then pulled up the resident's pants and handled the wheelchair with the same gloves, only washing hands after all tasks were completed. This was contrary to facility policy and staff expectations.
A resident with significant mobility limitations was injured during a transfer when staff failed to follow proper procedures for mechanical lift use, including using two slings and not ensuring all straps were securely attached. This resulted in the resident falling and sustaining a head hematoma, multiple rib fractures, and a spinal compression fracture. Staff interviews and documentation confirmed that facility protocols and manufacturer instructions were not followed, leading to an Immediate Jeopardy situation.
The facility did not ensure an RN was onsite for at least 8 consecutive hours each day, as required by policy. Staffing records and interviews confirmed multiple days with either no RN coverage or insufficient hours, with staff acknowledging ongoing challenges in maintaining adequate RN presence, especially on weekends.
A resident's room was searched and personal items were removed by a previous administrator without the resident's consent, based on suspicions of prohibited activity. The resident, who was cognitively intact and largely independent, reported feeling mistrustful and socially isolated as a result. Staff and documentation confirmed the unauthorized entry and removal of property, which was not in accordance with facility policy requiring respect for residents' privacy and belongings.
A resident with intact cognition and a need for substantial assistance was not provided showers or baths according to their stated preference of three specific days per week, despite assurances from staff. Documentation and care planning failed to include the resident's bathing preferences, and staff interviews revealed confusion about responsibility for recording such preferences, resulting in the resident receiving showers or baths on a different schedule than requested.
Two residents with complex medical and functional needs did not have person-centered, comprehensive care plans developed as required. Although baseline and temporary care plans were in place, they lacked the necessary detail and scope to address all triggered care areas. Staff interviews confirmed that comprehensive care plans had not been completed for these residents.
The facility did not provide required quarterly statements for resident trust accounts, as confirmed by both the business office manager and the administrator, despite facility policy mandating this practice. This failure was identified during a survey following a complaint about access to funds and had the potential to affect all residents with trust accounts.
The facility failed to maintain two mechanical lifts in proper working condition. A sit-to-stand lift had non-functional switches and clogged wheels, while a full-body lift had a remote with buttons held by tape and similarly clogged wheels. Despite these issues, the lifts were still in use. Maintenance records showed weekly checks but lacked details on repairs or cleaning, and the last inspection by the lift company was in June 2021.
The facility's assessment failed to accurately identify staffing needs based on resident care requirements. The assessment lacked details on necessary nursing roles and staffing ratios, leading to incomplete documentation. The administrator admitted to misunderstanding the staffing plans, resulting in an inability to provide evidence of sufficient staffing to meet resident needs.
A facility failed to implement an ambulation program for a resident with a history of falls, as ordered by physical therapy. Despite recommendations for ambulation three times a day, there was no documentation of the program being completed. Interviews revealed that staff were too busy to assist with walking, and there was a lack of awareness about the program. The facility's Walking Program policy was not provided.
A facility failed to maintain complete and accurate medical records for a resident, as required by professional standards. The resident's treatment administration record (TAR) indicated that weekly Body Audit assessments were completed, but the electronic health record (EHR) lacked documentation for several dates. Interviews with staff, including an LPN and the DON, confirmed the discrepancy, and the facility's policy did not adequately address the maintenance of accurate medical records.
The facility failed to follow enhanced barrier precautions (EBP) for two residents with chronic wounds and indwelling devices. Staff, including an LPN and nursing assistants, did not wear gowns during high-contact care activities despite the presence of signage and training. The director of infection prevention confirmed the necessity of EBP for such conditions.
The facility failed to submit accurate staffing data to CMS for Q1 of FY 2024, leading to a report of excessively low weekend staffing. The error was due to the exclusion of agency pool staff hours and miscoded staffing hours.
The facility failed to offer pneumococcal and influenza vaccinations to eligible residents, as required by CDC guidelines and facility policies. The infection preventionist and director of nursing acknowledged the oversight and confirmed that necessary consents and declinations were missing from the records.
The facility failed to provide a written notification of the bed hold policy to a resident or their representative during a hospitalization. Despite attempts to contact the representative and a stated procedure for mailing the form, there was no evidence that the form was ever provided or signed.
A resident with severe cognitive impairment and dementia was observed multiple times with unshaven facial hair, despite expressing a preference to be clean-shaven. The facility failed to provide consistent grooming care due to a broken shaver and inconsistent staff assignments. Staff and family confirmed the resident's usual preference for being clean-shaven, highlighting a deficiency in meeting the resident's personal hygiene needs.
The facility failed to offer the COVID-19 vaccine to an eligible resident with medically complex conditions, including diabetes and a pulmonary disease. Despite the facility's policy requiring vaccination opportunities upon admission, the infection preventionist and director of nursing confirmed that the necessary steps for offering and documenting the vaccine were not followed for this resident.
The facility failed to notify a physician of a resident's skin injury, leading to delayed treatment and significant pain during wound care. The wound was initially observed by staff but not documented or reported, and the resident's family member eventually brought it to the physician's attention. Staff interviews revealed that protocols for documenting and reporting skin alterations were not consistently followed.
The facility failed to revise the care plan for a resident who developed substantial bruising due to a new diagnosis of nonthrombocytopenic purpura. Despite multiple progress notes and body audits documenting significant bruising and other skin issues, the care plan was not updated to include new interventions. Interviews with staff revealed a lack of awareness and responsibility for updating the care plan.
The facility failed to complete comprehensive pressure ulcer risk assessments, monitor pressure ulcers, notify the physician, and follow physician orders for a resident with multiple skin conditions. Despite the resident's history of chronic right heart failure, acute respiratory failure, type 2 diabetes, and pressure ulcers, the care plan was not updated, and weekly comprehensive assessments were not conducted. Staff interviews revealed a lack of adherence to protocols and policies, leading to inadequate care and monitoring.
Failure to Assess and Prevent Falls Resulting in Major Injury
Penalty
Summary
The facility failed to comprehensively assess falls for root cause, implement appropriate interventions, and update or revise care plans to prevent or reduce the risk of falls with major injury for two residents who experienced multiple falls. One resident, with a history of stroke, hemiplegia, and cognitive impairment, experienced several unwitnessed falls, including one that resulted in a subarachnoid hemorrhage and hospitalization. Despite documented risk factors such as impulsivity, incontinence, and poor safety awareness, the resident's care plan was not consistently updated to reflect these risks or to include interventions recommended by therapy staff. Incident reports and progress notes repeatedly lacked evidence of comprehensive fall investigations or causal analyses, and interventions such as supervision, use of fall mats, and toileting schedules were either not implemented or not documented in the care plan. Another resident, diagnosed with Huntington's disease and a history of falls, also experienced multiple unwitnessed falls. The care plan for this resident identified high fall risk but did not include specific interventions tailored to the resident's needs, such as regular toileting or ensuring the call light was within reach. After each fall, there was no indication that a comprehensive analysis was conducted to identify causal factors, nor was the care plan revised to address the circumstances of the falls. Documentation was inconsistent, and staff interviews revealed a lack of awareness regarding current fall prevention interventions for these residents. Staff interviews further revealed that nursing assistants and other clinical staff were often unaware of the specific fall prevention interventions in place for high-risk residents. There was confusion about where to find care plan information, and some staff were not trained on how to update care plans or conduct root cause analyses after falls. The facility's own policy required individualized, resident-centered fall prevention plans and prompt documentation and care plan updates after each fall, but these procedures were not followed, resulting in repeated falls and a major injury for one resident.
Removal Plan
- R1 had an updated fall risk assessment completed.
- R1's falls had a root cause analysis and appropriate fall prevention interventions added to the clinical chart.
- Interdisciplinary team reviewed R1's falls and root cause analysis to ensure appropriate fall interventions in place based on resident needs and resident's status based on the individual falls and root cause analysis.
- R1's care plan updated to include current fall interventions and fall risk level.
- All high risk fall residents who had a fall had a root cause analysis completed and care plans were updated to remove/negate the risk of falls based on potential risks of falls.
- Staff were re-educated on the facility's falls and fall risk, managing, fall risk assessment, assessing falls and their causes, falls-clinical protocol, baseline care plan, and comprehensive care plan policies.
- All clinician staff was re-educated on the facility policies, ensuring licensed staff adding immediate intervention post fall, updating care plan.
- Agency nursing staff orientation checklist update to include education on fall prevention policies and procedures.
Failure to Ensure Nursing Assistant Certification Status
Penalty
Summary
The facility failed to ensure that four of seven employed nursing assistants maintained current certification with the state nursing assistant registry. Review of the registry and facility employee records showed that these nursing assistants had expired certificates but continued to be scheduled and worked shifts during the period their certifications were not valid. This lapse had the potential to affect all thirty-two residents residing in the facility. Interviews with the Director of Nursing (DON) and the administrator revealed a lack of awareness regarding the expired certifications and an absence of a process to verify the current status of licensed or certified staff. The DON stated she was not responsible for monitoring certification status and was unsure who held that responsibility. The administrator acknowledged that there was no system in place to ensure verification of credentials and accepted ultimate responsibility for the oversight. Review of the facility's policy indicated that the Human Resources Director or designee was responsible for maintaining and verifying certification status, but this was not followed.
Failure to Analyze and Respond to Increased Resident Falls
Penalty
Summary
The facility failed to ensure its Quality Assurance and Performance Improvement (QAPI) committee effectively identified, investigated, analyzed, and responded to resident care issues, specifically regarding a high number of falls. Over several months, QAPI meeting minutes consistently documented falls as isolated incidents, with no trends identified, despite a significant increase in the number of falls in September. The committee did not comprehensively analyze the data or develop an action plan in response to the sudden rise in falls, and inaccuracies were noted in the documentation of fall incidents, including underreporting the number of falls and failing to identify multiple falls by the same resident. One resident experienced multiple falls since admission, culminating in a fall that resulted in a subarachnoid hemorrhage and hospitalization, which was classified as an immediate jeopardy event. The QAPI committee's meeting minutes did not reflect a thorough review or root cause analysis of the increased falls, nor did they document any systematic approach to identifying quality deficits in the fall management program. Although the medical director raised concerns and suggested forming an interdisciplinary team to address the issue, no formal action plan or investigation was initiated by the committee. Interviews with facility leadership confirmed that, despite recognizing a sharp increase in falls, the QAPI committee did not take steps to analyze or investigate the underlying causes. The facility's own policy outlines a systematic approach to performance improvement, including data analysis, root cause identification, and corrective action planning, but these processes were not followed in response to the increase in falls. As a result, the facility did not address the quality concern in a timely or effective manner.
Failure to Ensure Call Lights Accessible for Residents at Risk for Falls
Penalty
Summary
The facility failed to ensure that call lights were accessible and within reach for two of three residents reviewed for falls. One resident with Parkinson's disease and dementia, who required extensive assistance for all transfers and was at risk for falls, was observed sitting in his wheelchair with his call light on the floor behind him, out of reach. The resident requested assistance from the surveyor to pick up a glass, and stated he did not have his call button. A nursing assistant confirmed that the call light should have been within the resident's reach due to his agitation and risk of self-transfer. Another resident with Alzheimer's disease, severe cognitive impairment, and limited physical mobility was observed sitting in a recliner with her call light on the floor next to her foot, not within reach. She requested help from the surveyor to pick up items from the floor and explained she could not find her call button. A nursing assistant confirmed the call light was not within reach and should have been accessible. The facility's policy requires staff to ensure call lights are within reach and secured as needed, but this was not followed in these instances.
Failure to Timely Report Serious Fall Injury to State Agency
Penalty
Summary
The facility failed to timely report a fall with serious injury to the State Agency (SA) for a resident with a history of multiple falls and significant neurological impairment, including hemiplegia and hemiparesis following a stroke. The resident experienced several falls over a short period, with no comprehensive analysis or implementation of appropriate interventions to prevent further incidents. On one occasion, the resident was found on the floor with a head injury and was subsequently sent to the emergency department, where a brain bleed was identified. Despite this serious injury, there was no evidence that a comprehensive fall investigation or analysis was completed by the facility. Interviews revealed that staff were unclear about reporting requirements, with an LPN assuming that the assistant director of nursing (ADON) would notify the administrator and being unaware of the obligation to report to the SA. The administrator and director of nursing (DON) both acknowledged that the incident should have been reported to the SA within two hours of learning about the brain bleed, but this did not occur. The facility's own policy required prompt reporting of serious injuries, but this was not followed in this case.
Inaccurate MDS Assessment for Resident with Multiple Falls
Penalty
Summary
The facility failed to accurately complete a Minimum Data Set (MDS) assessment for a resident with a history of falls. The resident, who had diagnoses of hemiplegia and hemiparesis following a stroke, experienced three documented falls after admission. Incident reports and progress notes detailed unwitnessed falls from a wheelchair and bed, with specific dates and circumstances recorded in the resident's medical record. Despite this documentation, the 5-day MDS assessment for the resident was incorrectly coded to indicate that no falls had occurred since admission. The MDS Coordinator/registered nurse acknowledged during an interview that the assessment was inaccurate and that the falls had been missed during the review of risk management reports and progress notes. Facility policy requires that MDS assessments consistently reflect information in progress notes and other records, which was not followed in this instance.
Failure to Timely Update Baseline Care Plan for Fall Risk and Transfer Needs
Penalty
Summary
The facility failed to develop and implement an adequate baseline care plan within 48 hours of admission for a resident with significant fall risk factors. The resident, who had hemiplegia and hemiparesis following a stroke, was assessed as being at moderate risk for falls according to the Morse Fall Scale. Despite this, the temporary care plan did not include a focus area or interventions for fall prevention, nor did it address a toileting program for the resident's incontinence. The care plan also failed to specify the resident's transfer status, even though therapy notes and recommendations indicated changes in required transfer methods and equipment. Multiple staff interviews and document reviews revealed that the care plan was not updated in a timely manner to reflect changes in the resident's condition and therapy recommendations. Nursing assistants were unable to locate current transfer instructions in the electronic health record or on the therapy clipboard, leading to confusion about the appropriate transfer method. The physical therapist confirmed that updated transfer recommendations were communicated to nursing, but these were not incorporated into the care plan as expected. The director of nursing acknowledged that the care plan had not been updated to include fall risk, fall prevention interventions, or the resident's new transfer status. The facility's own policy requires that a baseline care plan be developed within 48 hours of admission, including interventions to address health and safety concerns such as fall risk. However, the resident's care plan did not meet these requirements, as it lacked essential information needed to prevent decline or injury. This failure resulted in staff not having access to up-to-date instructions for safe care, particularly regarding fall prevention and transfer assistance.
Failure to Provide Individualized Continence Care and Assessment
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent a decline in continence and urinary symptoms for a resident diagnosed with Huntington's disease. Upon admission, the resident was continent of bowel and bladder, but began experiencing fluctuating symptoms of incontinence, urgency, and frequency. The facility's continence evaluation assessment lacked detailed information regarding the circumstances and type of incontinence, and did not document interventions or treatments that had previously improved the resident's condition. The assessment inconsistently identified the type of incontinence and omitted a summary, while the resident's risk factors, such as cognitive impairment and use of antipsychotics, were not fully addressed. Documentation revealed that the resident experienced a change in continence status, with multiple episodes of incontinence and urinary urgency noted over several weeks. Despite these changes, the care plan addressing urinary continence was not initiated until several weeks after the initial assessment, and it did not include individualized goals or interventions to prevent further decline or manage urinary symptoms. The care plan focused on activities of daily living and fall prevention, but lacked a comprehensive bladder assessment or a voiding diary to inform an appropriate toileting schedule. Incident reports indicated that toileting was a causal factor in several falls, yet there was no evidence of a thorough assessment to determine the type of incontinence or to develop a tailored toileting program. Interviews with staff revealed a lack of awareness regarding the resident's specific toileting needs, with staff following a standard two-hour toileting schedule for all residents rather than an individualized plan. The resident reported feeling unsupported, stating that staff did not offer regular toileting assistance and that she sometimes attempted to toilet herself, resulting in falls and emotional distress. The facility's incontinence policy required appropriate treatment and services to maintain continence, but the documentation and staff interviews demonstrated that these standards were not met for this resident.
Failure to Perform Proper Hand Hygiene During Resident Care
Penalty
Summary
A nursing assistant (NA) failed to follow proper hand hygiene protocols during toileting and incontinence care for a resident with hemiplegia and hemiparesis following a stroke, who was dependent for all transfers and toileting. The NA applied gloves without performing hand hygiene before care, cleaned the resident after a bowel movement using wet wipes, and then proceeded to pull up the resident's pants and handle the wheelchair with the same soiled gloves. The NA did not remove gloves or perform hand hygiene between these tasks, despite being prompted by the surveyor. The NA only washed her hands after completing all care tasks and handling the resident's blanket. Interviews with the NA, a registered nurse (RN), and the director of nursing (DON) confirmed that the expected protocol was not followed, as hand hygiene should have been performed before and after glove use, and gloves should have been changed after peri care. The facility's hand hygiene policy also indicated that hand hygiene is required when moving from a contaminated to a clean body site during resident care. The failure to adhere to these procedures was observed and documented during the survey.
Failure to Ensure Safe Mechanical Lift Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when facility staff failed to ensure safe transfers for a resident requiring maximum assistance and the use of a mechanical lift. During a transfer from a wheelchair to a shower chair, staff did not follow manufacturer instructions or facility protocol for applying and securing the sling to the mechanical lift. Instead of removing an ill-fitting sling, staff placed a second sling under the resident and attached both to the lift, which is contrary to proper procedure. The slings were not properly secured, and the staff did not verify that all straps were correctly attached before lifting the resident. As a result of these actions, the sling became unhooked from the mechanical lift during the transfer, causing the resident to fall to the floor. The resident sustained a hematoma to the back of the head and multiple fractures to the left ribs, as well as a severe compression fracture at the T12 vertebra. The resident, who had a history of spondylosis, muscle weakness, and pain, experienced significant pain and limited mobility following the incident. The incident was witnessed and described by both the resident and the staff involved, who acknowledged not following proper procedures and failing to double-check the sling attachments. Documentation and interviews confirmed that the staff involved did not adhere to the facility's policy for mechanical lift use, including ensuring the correct sling size and secure attachment. The improper use of two slings, failure to remove the incorrect sling, and lack of verification of secure connections directly led to the resident's fall and subsequent injuries. The event was identified as an Immediate Jeopardy situation due to the severity of harm caused by the unsafe transfer.
Removal Plan
- NAR's immediately removed from the floor and given education on mechanical lifts, safe transfers, and sling safety with return demonstration.
- All nursing staff education on mechanical lifts, safe transfers, and sling safety with return demonstration until all staff were trained and completed.
- Disciplinary action for NAR's involved in the incident.
- Mandatory staff meeting regarding mechanical lifts and sling safety completed.
- Audits will be completed bi-weekly and reviewed with the Quality Assurance and Performance Improvement team.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was onsite for at least 8 consecutive hours per day, 7 days a week, as required. Review of the payroll based journal (PBJ) staffing report for the first quarter of 2025 revealed multiple days with either no RN hours reported or insufficient RN coverage. Specifically, there were several dates with no RN coverage at all, and at least one date with only 4 hours of RN coverage. Facility payroll and staffing schedules confirmed these gaps in RN coverage. Interviews with facility staff, including the regional nurse consultant, assistant director of nursing (ADON), and staffing coordinator, confirmed the lack of RN coverage on the identified dates. The staffing coordinator acknowledged ongoing difficulties in maintaining RN coverage, particularly on weekends, and stated that only two RNs were employed at the facility, with one working full time overnight and the other recently starting on evenings. The facility's own policy requires an RN to provide services for at least 8 consecutive hours every 24 hours, 7 days a week.
Failure to Respect Resident's Rights and Personal Property
Penalty
Summary
A resident with no cognitive impairment and minimal assistance needs reported that the previous facility administrator entered his room without permission, searched his personal belongings, and confiscated items including vape pens, cups, and dishes. The administrator stated the search was conducted due to suspicions that the resident was making moonshine with orange peels, water, or mouthwash, and possibly had illegal substances. The resident expressed feelings of mistrust and social isolation following the incident, stating that staff entered his room whenever they wanted. A certified nursing assistant confirmed that the previous administration had searched the resident's room without consent and confiscated his vape pens, with no law enforcement involvement. The current DON and administrator acknowledged that documentation in the resident's chart indicated staff had entered the room and removed property without permission. Facility policy requires staff to knock and request permission before entering a resident's room and to respect residents' private space and belongings at all times.
Failure to Accommodate Resident Bathing Preferences
Penalty
Summary
The facility failed to honor and facilitate a resident's preference for showering/bathing days, as required by regulations supporting resident self-determination and choice. The resident, who was cognitively intact and required substantial to maximal assistance for bathing, expressed a clear preference to receive showers or baths on Mondays, Wednesdays, and Fridays. Despite communicating this preference upon admission and being assured it could be accommodated, the resident routinely received showers or baths only on Tuesdays and Fridays, and occasionally on a Saturday, as documented in the treatment administration record. The resident reported rarely receiving showers or baths three times per week as preferred. Review of the resident's care plan revealed it lacked documentation of personal preferences for showering or bathing, containing only information related to a potential nutritional deficit. Interviews with facility staff, including a CNA and the ADON, indicated uncertainty about who was responsible for documenting resident preferences, especially following a change in leadership. The ADON confirmed that the baseline care plan should have included the resident's showering/bathing preferences, but this was not done, and a comprehensive care plan was not in place for the resident. Facility policy requires that a baseline care plan addressing immediate needs, including preferences, be developed upon admission.
Failure to Develop Person-Centered Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered, comprehensive care plans for two residents who were reviewed for care planning. For one resident, the admission Minimum Data Set (MDS) assessment indicated multiple complex medical conditions, including atrial fibrillation, heart failure, hypertension, peripheral vascular disease, renal insufficiency, diabetes, anxiety, and schizophrenia, as well as a history of falls and frequent incontinence. Although several care areas were triggered by the MDS and documented as addressed, the resident's record lacked a comprehensive, person-centered care plan. The temporary care plan provided to nursing assistants only included basic information such as diagnoses, diet, and assistance needs, but did not constitute a full care plan as required. For the second resident, the admission MDS assessment also identified significant functional impairments, including the need for assistance with eating, oral hygiene, toileting, dressing, and mobility, as well as frequent bowel incontinence and the presence of an indwelling catheter. Multiple care areas were triggered, but the only care plan item documented was a potential nutritional deficit, with no comprehensive care plan completed at the time of the survey. Interviews with staff confirmed that comprehensive care plans had not been developed for either resident, despite facility policy requiring such plans to be completed within 21 days of admission.
Failure to Provide Quarterly Trust Account Statements
Penalty
Summary
The facility failed to provide residents or their representatives with quarterly statements for trust accounts, as required by facility policy. During a recertification survey, a complaint regarding access to funds led to the discovery that the business office manager and the administrator both confirmed that quarterly statements were not being sent out. Document review showed that the facility's own policy mandates the availability of individual accounting records through quarterly statements and upon request, but this practice was not being followed. This deficiency had the potential to affect all residents with trust accounts at the care center. No specific residents or their medical histories were mentioned in the report, and the deficiency was identified through interviews and document review during the survey process.
Mechanical Lifts Not Maintained Properly
Penalty
Summary
The facility failed to maintain two mechanical lifts in proper working condition, as observed during a survey. The Volara brand mechanical sit-to-stand lift, identified as B01-18, had non-functional handlebar switches and a remote with a malfunctioning button for lowering a resident. Additionally, the wheels of this lift were clogged with hair, making it difficult to maneuver. Another full-body mechanical lift, A02-16, had a remote with buttons held together by electrical tape, and its wheels were similarly clogged with hair. Despite these issues, the lifts were still in use, and the maintenance director acknowledged the need for repairs but had not yet addressed them. The maintenance records for the lifts indicated weekly checks in August 2024, but these records did not specify whether repairs or cleaning were completed. The last documented inspection by the lift company was in June 2021. The facility's administrator expected the lifts to be in proper working order, but the maintenance director stated that staff needed to inform him of repair needs through an electronic request system. The manufacturer's manual for the lifts emphasized regular cleaning and inspection, which was not adhered to, contributing to the deficiency.
Incomplete Facility Assessment of Staffing Needs
Penalty
Summary
The facility failed to ensure that its Facility Assessment accurately identified the staffing needs based on the care requirements of its resident population. The assessment, which was intended to determine the necessary resources for competent resident care during both regular operations and emergencies, was found to be incomplete. Specifically, the Overall Staffing Needs table lacked details on the number of staff members required in various nursing roles, and the Staffing Needs as per Resident Unit table was entirely blank. Additionally, the Staffing Needs as per Shift table was incomplete, failing to specify the ratio of staff to residents or the hours per resident day of direct care needed for nursing positions across different shifts. During an interview, the administrator acknowledged the deficiencies in the Facility Assessment, noting that the tables were intended to indicate the number of registered nurses and nursing assistants needed to be fully staffed. However, she admitted to misunderstanding the Information About Nurse Staffing Plans section, which led to the incomplete documentation. The administrator also mentioned that the Facility Assessment had been recently updated with her supervisor's involvement, but she was unable to provide evidence that the assessment accurately identified the facility's staffing needs to ensure sufficient care for residents.
Failure to Implement Ambulation Program for Resident
Penalty
Summary
The facility failed to provide an ambulation program for a resident (R2) with a history of falls, as ordered by physical therapy. R2's care plan indicated a need for ambulation three times a day with a two-wheeled walker and contact guard assistance, following therapy recommendations. However, a review of R2's records between July 14 and August 14 showed no documentation of the ambulation program being completed or offered. Interviews with R2 and staff revealed that the resident was not asked to walk, and staff were often too busy to assist with walking programs. Staff interviews indicated a lack of awareness and time to complete the walking program. Nursing assistants and an LPN stated that walks were not done due to being busy and not knowing who was supposed to be walked. The physical therapist confirmed that walking recommendations were given to nursing staff, who were expected to continue the program. The director of nursing also expected staff to follow therapy recommendations. Despite these expectations, there was no documentation or tracking of the walking program, and the facility's Walking Program policy was not provided.
Incomplete Medical Record Documentation
Penalty
Summary
The facility failed to maintain a complete and accurately documented medical record for a resident, as required by professional standards. The deficiency was identified during a review of the resident's treatment administration record (TAR) and electronic health record (EHR). The resident had a provider order for a weekly Body Audit assessment to be completed every Friday. The TAR indicated that the assessments were completed on specific dates in July and August, but the EHR only contained records for some of these dates, specifically missing records for 7/19, 7/26, and 8/2. Interviews with facility staff, including an LPN and the DON, revealed that the Body Audit assessments were supposed to be documented in the EHR on the scheduled days. The DON confirmed that the assessments were charted as completed in the TAR but were not found in the EHR, indicating a discrepancy in the medical records. The facility's policy on online documentation did not address the maintenance of complete and accurate medical records, contributing to the deficiency.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure proper infection control procedures were followed for two residents, R3 and R4, when staff did not adhere to enhanced barrier precautions (EBP) during care and treatment. R3, who had severe cognitive impairment, a stage 4 pressure ulcer, and an indwelling bladder catheter, required EBP for wound treatment and catheter care. However, during observations, LPN-A and NA-A did not wear gowns while performing these tasks, despite signage indicating the need for EBP. Both staff members admitted to not using EBP, citing reasons such as forgetfulness, being too busy, and not recalling training on EBP. Similarly, R4, who had dementia, chronic pain syndrome, and an unstageable pressure ulcer, also required EBP for wound care and toileting assistance. Observations revealed that LPN-A, NA-A, and NA-B did not wear gowns during these activities, and there was no signage or supply cart for EBP in R4's room. Interviews with the staff indicated a lack of consistent use of EBP and uncertainty about training. The director of infection prevention and quality assurance confirmed that EBP should be used for catheters, chronic wounds, and other specified conditions.
Inaccurate Staffing Data Submission to CMS
Penalty
Summary
The facility failed to submit accurate and complete staffing data to CMS for the first quarter of the Federal Fiscal Year 2024. The CMS Payroll Based Journal (PBJ) Staffing Report indicated excessively low weekend staffing, which was triggered by the data submitted by the facility. However, a review of daily staff postings and census data for this period did not show significant differences between weekend and weekday staffing levels. Additionally, staffing schedules and staff timecards confirmed that licensed nursing staff were present on the weekends during the referenced time period. During interviews, the Director of Nursing (DON) stated that staffing needs were determined based on resident acuity and census, and that weekend staffing levels were the same as weekdays. The administrator admitted that the facility incorrectly reported staffing data to CMS by not including agency pool staff hours and miscoded staffing hours, leading to the appearance of low weekend staffing. A facility policy for staff reporting was requested but not received.
Failure to Offer Pneumococcal and Influenza Vaccinations
Penalty
Summary
The facility failed to ensure that three residents were offered and/or provided the pneumococcal vaccine series as recommended by the CDC. Specifically, residents with diagnoses such as stroke, COPD, diabetes mellitus, and other medically complex conditions were not given the pneumococcal vaccine, and there was no documentation indicating that the vaccine was offered or refused. Additionally, two residents were not offered the influenza vaccine, and there was no record of consent or declination for these vaccinations. The infection preventionist (IP) and the director of nursing (DON) acknowledged the oversight and confirmed that the facility is responsible for offering these vaccinations to eligible residents. The facility's policies on pneumococcal and influenza vaccinations indicated that all residents should be offered these vaccines, with consents and declinations documented in the resident records. However, the review revealed that these policies were not followed for the residents in question. The IP admitted to being unaware of the recent CDC recommendations for pneumonia vaccinations and confirmed that the necessary consents and declinations were missing from the records. The DON emphasized the importance of vaccinations and stated that they should be addressed during the admission process.
Failure to Provide Bed Hold Notification
Penalty
Summary
The facility failed to provide a written notification of the bed hold policy to a resident or their representative during a hospitalization. The resident, who had multiple diagnoses including hypothyroidism, traumatic brain injury, and dementia, was sent to the emergency room after experiencing nausea and emesis. Despite attempts to contact the resident's representative via phone, the facility was unable to reach them and decided to send the bed hold policy via mail. However, there was no evidence in the resident's medical record that the bed hold form was ever provided or signed by the resident or their representative before or during the hospitalization. Interviews with facility staff, including an LPN and the Director of Nursing (DON), revealed that the standard procedure was to obtain a signed bed hold form before a resident is sent to the hospital. The DON stated that if verbal consent could not be obtained, a copy of the bed hold form should be mailed within 24 hours. Despite searching, the facility could not locate the bed hold form for this resident. Additionally, the facility's bed hold policy was requested but not provided to the surveyor.
Failure to Provide Adequate Facial Grooming for Dependent Resident
Penalty
Summary
The facility failed to provide adequate facial grooming for a resident (R24) who was dependent on staff for personal hygiene tasks. R24, who has severe cognitive impairment and is diagnosed with dementia, was observed multiple times over several days with unshaven facial hair, despite expressing a preference to be clean-shaven. The resident's care plan indicated that staff should assist with personal hygiene daily, but observations and interviews revealed that R24's facial grooming needs were not consistently met. Staff reported that the resident's electric shaver was broken, causing discomfort when used, and there was a lack of documentation regarding the broken shaver or any refusal of care by the resident. Interviews with various staff members, including nursing assistants and a trained medication aide, indicated that R24's grooming was neglected due to the broken shaver and inconsistent staff assignments. Some staff members were unaware of the issue, while others mentioned that the resident's facial hair had been growing for months. The facility had disposable razors available, but these were not utilized to address the resident's grooming needs. The Director of Nursing (DON) and the social worker were also unaware of the broken shaver, and there was no specific policy regarding ADLs, only an expectation for staff to follow standards of care. The resident's family member confirmed that R24 was typically clean-shaven and that the current state of facial hair was unusual and likely bothersome to the resident. Despite multiple observations and interviews highlighting the issue, the resident remained unshaven until the evening or night shift on the final day of observation. The facility's failure to provide consistent and adequate grooming care for R24, despite the resident's dependency and expressed preference, constitutes a deficiency in meeting the resident's personal hygiene needs.
Failure to Offer COVID-19 Vaccine to Eligible Resident
Penalty
Summary
The facility failed to offer the COVID-19 vaccine to a resident eligible to receive the vaccine. Resident 7, who was moderately cognitively impaired and had medically complex conditions including diabetes mellitus and a pulmonary disease, was admitted on a specified date. The facility's documentation indicated that Resident 7 had not received any of the COVID-19 vaccination series. During interviews, the infection preventionist (IP) and the director of nursing (DON) confirmed that the vaccination status should be reviewed during the admission process, and the COVID-19 vaccine should be offered with proper consent and documentation. However, the IP was unable to find any records indicating that the COVID-19 vaccine had been offered, administered, or declined by Resident 7. The facility's policy, dated April 1, 2024, stated that all residents should be provided the opportunity and encouraged to receive the COVID-19 vaccinations upon admission. Despite this policy, the IP and DON acknowledged that the necessary steps for offering and documenting the COVID-19 vaccine for Resident 7 were not followed. The IP provided a blank consent form as an example of what should have been completed and uploaded into the resident's record during the admission process. The failure to offer and document the COVID-19 vaccination for Resident 7 was identified as a deficiency during the survey.
Failure to Notify Physician of Skin Injury
Penalty
Summary
The facility failed to ensure physician notification of a skin injury that required treatment for a resident with multiple health conditions, including chronic right heart failure, type 2 diabetes mellitus with foot ulcer, and a stage 2 pressure ulcer. The resident's care plan identified several skin issues, including a pressure injury on the left buttock and a diabetic ulcer on the right great toe. On a specific date, a registered nurse and nursing assistant noted an old bandage on the resident's left lower leg, which covered a wound of unknown cause. The wound appeared to be healing but was not documented or reported to the physician at that time. The resident's skin integrity log later identified the wound as a facility-acquired abrasion, but there was no evidence that the physician was notified between the initial observation and a later date. A family member discovered the wound during a visit and brought it to the physician's attention, who then ordered a treatment plan. However, the dressing was not changed as ordered, and the resident experienced significant pain during wound care. The clinical manager confirmed that the process for the resident's leg wound had not been followed properly. Interviews with staff revealed that the nurses did not always follow the protocol for documenting and reporting skin alterations. The director of nursing stated that body audits should be completed weekly, and any skin alterations should be reported immediately. The facility's policies required physician notification for new skin alterations and weekly documentation by the wound nurse, but these procedures were not followed in this case.
Failure to Revise Care Plan for Resident with New Diagnosis of Nonthrombocytopenic Purpura
Penalty
Summary
The facility failed to revise the care plan for a resident who developed substantial bruising due to a new diagnosis of nonthrombocytopenic purpura. The resident's admission record indicated diagnoses including chronic pain and nonthrombocytopenic purpura. Despite the resident's quarterly Minimum Data Set (MDS) identifying no cognitive impairment and dependence on staff for various activities, the care plan dated 4/6/23 did not include interventions for the risk of bruising or monitoring for such conditions. The resident's progress notes and weekly body audits documented multiple instances of bruising and other skin alterations, yet the care plan was not updated to address these issues. On 1/4/24, a progress note directed the addition of a diagnosis for senile purpura due to easy bruising, but the care plan was not revised to include this new diagnosis. Subsequent progress notes and body audits continued to document significant bruising and other skin issues, including a large hematoma that led to a hospital transfer on 2/14/24. Despite these ongoing issues, the care plan remained unchanged, and no new interventions were implemented to address the resident's condition. Interviews with the clinical manager and the director of nursing revealed a lack of awareness and responsibility for updating the care plan. The clinical manager admitted to not updating the care plan despite entering the new diagnosis into the computer system. The director of nursing acknowledged that the care plan should have been updated with new diagnoses and interventions but was unaware that this had not been done. The facility's document on person-centered care plans indicated that care plans should be developed, reviewed, and revised as needed, but this process was not followed in this case.
Failure to Assess and Monitor Pressure Ulcers
Penalty
Summary
The facility failed to complete a comprehensive pressure ulcer risk assessment, monitor pressure ulcers, notify the physician, and follow physician orders for a resident with multiple skin conditions. The resident had a history of chronic right heart failure, acute respiratory failure, type 2 diabetes with diabetic polyneuropathy, and pressure ulcers. Despite these conditions, the facility did not update the resident's care plan after new skin impairments were identified, nor did they conduct weekly comprehensive assessments and ongoing monitoring as required. The resident's care plan had not been revised since 9/20/23, even though new skin issues were documented on 3/4/24, 3/7/24, and 3/9/24. The facility's documentation and communication were inconsistent and incomplete. For instance, a weekly body audit on 3/4/24 identified redness on the resident's buttocks but lacked further description, etiology, measurement, and a treatment plan. Similarly, a progress note on 3/7/24 documented a suspected deep tissue injury on the right heel, but the facility's skin integrity log form did not match the progress note. Additionally, a wound on the resident's left lower leg was discovered on 3/9/24, but it was not comprehensively assessed, monitored, or treated until 3/19/24, ten days after it was identified. The facility also failed to follow physician orders for skin treatments, as evidenced by the treatment administration record (TAR) showing discrepancies in the start dates and application of prescribed treatments. Interviews with staff revealed a lack of adherence to protocols and policies. The licensed practical nurse (LPN) admitted to not notifying the doctor about the leg injury and stated that comprehensive skin assessments were not being completed weekly. The clinical manager (CM) acknowledged that the weekly body audits and skin integrity logs did not always match and were not comprehensive. The director of nursing (DON) confirmed that the body audits were supposed to be comprehensive skin assessments but were often missing details such as wound descriptions, measurements, and locations. The facility's policies on weekly skin assessments and skin management were not followed, leading to inadequate care and monitoring of the resident's pressure ulcers and other skin conditions.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
