Guardian Angels Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Elk River, Minnesota.
- Location
- 400 Evans Avenue, Elk River, Minnesota 55330
- CMS Provider Number
- 245012
- Inspections on file
- 29
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Guardian Angels Care Center during CMS and state inspections, most recent first.
A resident with dementia, recent hip fracture aftercare, and frequent urinary incontinence did not receive a complete bowel and bladder assessment or an individualized incontinence care plan. Key sections of the incontinence assessment, such as symptoms, onset and pattern, contributing physical and cognitive factors, medications, and type of incontinence, were left blank. The care plan only addressed assistance with transfers and toileting, without specific urinary incontinence goals or interventions, and the NA care sheet and Kardex lacked continence status and a toileting plan. Staff reported relying on a general practice of offering toileting or checking for incontinence every 2–3 hours, while the DON acknowledged the incomplete assessment and missing urinary incontinence care planning despite a policy requiring comprehensive, individualized bowel and bladder programs.
Three cognitively intact residents did not receive timely assistance with toileting and personal care because staff turned off call lights without providing the requested help. This resulted in two residents soiling themselves and another, who was non-weight bearing, attempting to transfer herself to the bathroom. Staff interviews revealed a practice of turning off call lights to keep response times low, but sometimes failing to return, contrary to facility policy and residents' care plans.
A resident with multiple respiratory diagnoses was not consistently offered their ordered CPAP therapy after a room transfer, and staff documented CPAP care as completed even when the device was not present. The provider was not notified of the resident's repeated refusals to use the CPAP, despite care plan instructions and facility expectations.
The facility failed to implement effective infection control measures, leading to outbreaks of Influenza A and Norovirus. Residents with symptoms were not isolated promptly, and staff did not consistently use PPE or perform hand hygiene. Symptomatic employees continued working, and the dishwasher did not reach sanitizing temperatures, exacerbating the spread of infections among residents, including those with underlying health conditions.
The facility failed to consistently monitor and document dishwasher temperatures, risking inadequate sanitization of dishware. Staff were unaware of procedures to ensure temperatures met required levels, and numerous instances of unrecorded or insufficient temperatures were found. This posed a risk to infection control, especially given the presence of Covid and influenza in the facility.
A facility failed to provide necessary assistance with eating for four residents with cognitive and physical impairments. These residents were left unattended for 20 minutes during breakfast, with food served but not consumed due to lack of staff support. Interviews revealed a lack of coordination, and the facility's policy on meal assistance was not followed.
A facility failed to maintain food at a steady temperature greater than 140°F for four residents during breakfast. The residents, who required assistance with eating due to cognitive impairments, were left unattended with meals served at temperatures below the required level, affecting food palatability. Staff acknowledged the deficiency, noting that meals should not have been served without available assistance.
A resident with moderate cognitive impairment and multiple health conditions was not assisted with personal grooming, specifically shaving facial whiskers, compromising their dignity. Despite the resident's indication of wanting assistance, staff did not initially fulfill this need, and the care plan lacked specific instructions for personal hygiene. The clinical manager was unaware of the issue, which should have been addressed during routine care.
A facility failed to accurately code the MDS for a resident receiving hospice care, as the quarterly MDS did not reflect hospice services in Section O. The resident had been admitted to hospice services, but this was not documented in the MDS. The director of reimbursement and MDS coordinator confirmed the omission as a coding error, and the DON stressed the importance of MDS accuracy. The facility lacked a specific MDS policy, relying on the RAI manual.
A facility failed to administer bowel management medications per physician's order for a resident with a history of neuromyelitis optica and other conditions. Despite orders for senna-docusate sodium to prevent constipation, the resident had not had a bowel movement in six days. Interviews revealed that the facility's standing orders for bowel management were not followed, and the resident did not receive PRN medications as required.
A resident with mobility impairments was found without access to their call light, which was essential for communicating needs to staff. The resident, who was non-ambulatory and dependent on staff for mobility, was observed in a wheelchair with the call light out of reach. Staff interviews confirmed the resident's dependency on the call light, and the facility's policy required staff to ensure call lights were accessible, which was not followed in this instance.
A resident with a known shellfish allergy was served shrimp pasta salad, leading to a severe allergic reaction and hospitalization. Despite the dietary aide preparing the correct meal, the nursing assistant delivered the wrong tray. The resident was treated with epinephrine and transported to the ICU. The facility's investigation into the incident was inconclusive.
A resident with a history of falls and cognitive impairment was left unattended in the bathroom by a nurse aide, contrary to her care plan. This resulted in the resident attempting to self-transfer, leading to a fall and a right femur fracture requiring surgery. Staff interviews and observations indicated a lack of adherence to care plan interventions and insufficient staff education on the resident's needs.
The facility failed to ensure accurate documentation of advanced directives for two residents, leading to potential errors in administering life-saving treatments. One resident would have been denied CPR contrary to their wishes, while another would have received CPR against their wishes. Staff inconsistencies in checking code status between the EHR and hard chart contributed to the deficiency.
A resident was observed self-administering a nebulizer treatment without a proper assessment or provider order. The resident, who was cognitively intact, stated that staff did not observe him during the treatment. The LPN and DON confirmed the absence of an assessment or provider order in the medical record, and the facility's policy on self-administration of medications was not provided.
The facility failed to implement and maintain the recommended restorative programming for a resident with hemiplegia and contracture of the left hand. The resident's care plan included passive range of motion (PROM) exercises, but the treatment administration record lacked documentation of completion or refusals. Observations and interviews revealed that the resident was not regularly offered PROM exercises, and there was no documentation of refusals in the electronic health record.
The facility failed to ensure post-dialysis assessment and monitoring for a resident with end-stage renal disease. The resident's care plan and medical records lacked instructions and documentation for monitoring the dialysis shunt for bruit and thrill, despite the facility's policy requiring daily checks. Interviews with staff confirmed the oversight.
A resident reported physical abuse and derogatory remarks by staff, but the facility failed to suspend the accused staff members during the investigation, contrary to its abuse prevention policy.
Failure to Complete Bowel/Bladder Assessment and Individualized Incontinence Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to complete a comprehensive bowel and bladder assessment and to develop an individualized urinary incontinence care plan for one resident. The resident had diagnoses including surgical aftercare for a right hip fracture, type 2 diabetes, repeated falls, and dementia, and an admission MDS showing moderate cognitive impairment and frequent urinary incontinence requiring maximum assistance for transfers and toileting hygiene. Although the urinary incontinence care area assessment indicated that urinary incontinence would be addressed in the care plan, the bowel and bladder incontinence assessment left multiple sections blank, including incontinence symptoms, onset and pattern of incontinence, bowel movement pattern, relevant physical factors, cognitive/emotional/communication status, medications affecting incontinence, overflow incontinence, physician order for post-void residual, types of incontinence, and care plan review. The resident’s care plan addressed transfer and toileting assistance but did not include urinary incontinence goals or interventions to maintain or improve continence, and the nursing assistant care sheet contained no bowel and bladder information. Documentation from the review period showed the resident was incontinent of bladder fifty-one times and continent ten times, yet there was no individualized urinary toileting plan on the Kardex or NA care sheet. Observations found the resident in a wheelchair with a call light within reach, wearing an incontinence product and stating he needed staff assistance to use the bathroom and disliked being wet, and that he used the call light for toileting or changing. Interviews with an LPN and multiple NAs revealed that toileting information was expected to be on the Kardex or NA care sheet, but for this resident it did not indicate continence status or a urinary toileting plan; staff instead followed a general practice of offering toileting or checking for incontinence every two to three hours. The DON confirmed that the comprehensive bladder assessment for this resident was incomplete and that the care plan did not address urinary incontinence or include a urinary toileting plan, despite a facility policy requiring a comprehensive bowel and bladder assessment on admission, ongoing reassessment, and use of findings to develop an individualized bowel and bladder program and care plan with specific toileting schedules and related interventions.
Failure to Provide Dignified Care Due to Inadequate Call Light Response
Penalty
Summary
The facility failed to provide a dignified living existence for three residents by not ensuring that call lights were used appropriately to meet residents' needs. Staff responded to call lights in a timely manner but would turn off the call lights without providing the requested assistance, resulting in residents not receiving necessary help with toileting and personal care. This led to two residents soiling themselves and another resident, who was non-weight bearing, attempting to transfer herself to the bathroom, contrary to her care plan and safety instructions. One resident, who was cognitively intact and required substantial assistance with toileting due to multiple medical conditions including diabetes, morbid obesity, and lymphedema, reported that her call light was answered and turned off without assistance being provided, causing her to soil herself and develop a macerated area on her skin. Another resident, also cognitively intact and with a non-weight bearing status due to a hip fracture, reported having to self-transfer to the toilet because staff would answer the call light but not return to assist her, despite being instructed not to bear weight or transfer independently. A third resident, with a history of cancer and chronic illness, reported soiling herself while waiting for staff to return after answering her call light, resulting in soiled clothing and discomfort. Interviews with staff revealed that some nursing assistants would turn off call lights upon entering the room to keep response times low, with the intention of returning later, but sometimes forgot to return. The nurse manager and DON were not aware of this practice and stated that the facility's policy was to not turn off the call light until the resident's needs were met. The facility's dignity policy emphasized care that promotes well-being and self-worth, which was not upheld in these instances.
Failure to Follow Physician Orders and Notify Provider for CPAP Refusals
Penalty
Summary
The facility failed to follow physician orders and ensure provider notification regarding a resident's refusals for continuous positive airway pressure (CPAP) therapy. The resident, who had diagnoses including pulmonary fibrosis, acute and chronic respiratory failure, COPD, and obstructive sleep apnea, had physician orders for nightly CPAP use with documentation of hours worn and refusals. Despite these orders, staff documented CPAP use and refusals in the medication and treatment administration records, but on multiple occasions, the CPAP was not present in the resident's room after a room transfer, and the resident was not offered the device as required. Staff also failed to notify the provider of the resident's consistent refusals to use the CPAP, as confirmed by interviews with nursing staff and the nurse practitioner, who was unaware of the refusals. Additionally, the resident's care plan identified behaviors such as agitation and refusal of care, with instructions for staff to encourage CPAP use and notify the charge nurse of refusals. However, during the resident's transfer to a new room, the CPAP was not moved, and staff did not ensure its availability or offer it to the resident. Documentation in the records indicated completion of CPAP care even when the device was not present. The facility was unable to provide a policy regarding refusal of physician orders and provider notification when requested.
Inadequate Infection Control Measures Lead to Outbreaks
Penalty
Summary
The facility failed to implement effective infection control strategies to prevent the spread of Influenza A and Norovirus. This deficiency was observed when the facility did not apply appropriate transmission-based precautions for residents exhibiting symptoms of these infections. For instance, a resident with Influenza A symptoms was not placed under isolation immediately, and precautionary measures were delayed. Additionally, staff members were observed entering rooms of infected residents without donning the necessary personal protective equipment (PPE) and failed to perform hand hygiene, contributing to the spread of infections. The report highlights that the facility did not restrict employees displaying symptoms of Norovirus from working, contrary to CDC guidelines. This oversight allowed symptomatic staff to continue working, increasing the risk of spreading the virus to residents and other staff members. The facility also failed to ensure that the dishwasher reached the necessary temperature to sanitize dishes during the Norovirus outbreak, further compromising infection control measures. Several residents, including those with underlying health conditions such as dementia, hypertension, and chronic kidney disease, were affected by the outbreaks. The facility's lack of timely response and inadequate infection control practices led to a widespread outbreak, placing all residents at risk of serious illness. The report indicates that the facility did not conduct active surveillance for influenza illness among residents and staff, which is a critical component of outbreak management in long-term care settings.
Dishwasher Temperature Monitoring Deficiency
Penalty
Summary
The facility failed to consistently track and monitor dishwasher temperatures for both the wash and rinse cycles, which had the potential to affect all 108 current residents and staff who consumed food served from dishes cleaned in the dishwasher. During an observation, it was noted that the temperatures for the morning cycle had not been logged, and the dietary aide was unaware of the need to ensure the dishwasher reached the desired temperatures before starting the dishwashing process. The certified dietary manager confirmed that staff were not aware of the procedure to run two or more racks through to bring the temperatures up to the desired levels prior to starting the dishwashing cycle. A review of the dishwasher temperature logs revealed numerous instances where the wash and rinse temperatures were below the required levels. Specifically, the wash temperature was below the desired range on 36 occasions, and the rinse temperature was below the desired range on 10 occasions during the period reviewed. Additionally, there were significant gaps in documentation, with 48 incidents of unrecorded wash temperatures and 49 occasions of unrecorded rinse temperatures. The facility's policy on dishwasher temperature monitoring lacked specific instructions for staff to run multiple racks to achieve the desired temperatures and to record the temperatures on the logs. The service representative confirmed that the required temperatures for washing and rinsing were not consistently met, emphasizing the importance of reaching these temperatures to ensure proper sanitization and prevent illness. Despite the presence of Covid and influenza in the facility, there was no indication that the dishwasher's temperature issues had directly resulted in illness among residents. However, the facility had previously experienced cases of Norovirus, and disposable items were used for meals in certain situations to reduce contact and potential cross-contamination. The facility's failure to maintain and document proper dishwasher temperatures posed a risk of inadequate sanitization of dishware, potentially compromising infection control measures.
Failure to Assist Residents with Meals
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living, specifically eating, for four residents who required varying levels of help. These residents, who had significant cognitive and physical impairments, were left without assistance during a meal service. The residents included one with severe cognitive impairment and total dependence on staff for eating, another with severe cognitive impairment requiring partial assistance, a third with moderate cognitive impairment needing substantial assistance, and a fourth with severe cognitive impairment requiring supervision or touching assistance. On the morning of the incident, the residents were served breakfast but were left unattended for 20 minutes without staff assistance. During this time, the food remained uncovered and was not consumed by the residents, as they were unable to eat without help. Observations noted that only two staff members were present in the dining room, assisting other residents, leaving these four residents without the necessary support. The food was eventually replaced with fresh trays after the initial meals had been left out for an extended period. Interviews with staff, including registered nurses and dietary personnel, revealed a lack of coordination and communication regarding meal service and assistance. Staff acknowledged the importance of having personnel available to assist residents before serving meals, as serving cold food could negatively impact residents' quality of life. The facility's policy on meal assistance was not followed, as it directed that residents requiring help should receive it in a manner that meets their individual needs, ensuring safety, comfort, and dignity.
Failure to Maintain Food Temperature for Residents
Penalty
Summary
The facility failed to ensure that food was held at a steady temperature greater than 140 degrees Fahrenheit for four residents during the dining process. The deficiency was observed when residents were served breakfast without staff available to assist them, resulting in the food sitting uncovered and cooling down to temperatures below the required level for palatability. The food items, including cooked cereal, pureed eggs, scrambled eggs, French toast sticks, and sausage, were served at temperatures ranging from 76 to 123 degrees Fahrenheit, which was below the facility's policy requirement of 135 degrees Fahrenheit. The residents involved in this deficiency had various medical conditions that required assistance with eating. One resident had severe cognitive impairment and was totally dependent on staff for eating assistance. Another resident had moderate cognitive impairment and required substantial assistance with eating. The other two residents also had severe cognitive impairments and required assistance or supervision during meals. Despite these needs, the residents were left unattended with their meals, which were not at the appropriate temperature, affecting the quality and palatability of the food. Staff interviews revealed that it was the expectation that staff should be present to assist residents before meals were served. However, on the day of the observation, there were only two staff members available in the dining room, and they were assisting residents at a neighboring table. The food production manager and other staff acknowledged that the food temperatures were not adequate and that the meals should not have been served until staff were available to assist the residents. The facility's policy on food temperature and time requirements was not adhered to, leading to this deficiency.
Failure to Assist Resident with Personal Grooming
Penalty
Summary
The facility failed to assist a resident with personal grooming, specifically shaving facial whiskers, which compromised the resident's dignity and self-determination. The resident, who has a moderate cognitive impairment and is fully dependent on staff for personal hygiene due to conditions such as cerebral palsy, dementia, and multiple sclerosis, was observed with noticeable facial whiskers. Despite the resident's non-verbal indication of wanting assistance with shaving, the staff did not initially fulfill this need. The care plan for the resident lacked specific instructions regarding personal hygiene, and the staff did not address the resident's grooming needs during routine care. The clinical manager was unaware of the resident's grooming issue and acknowledged that it should have been addressed during regular care routines. The facility's policy emphasizes the importance of grooming residents according to their wishes to maintain their dignity, which was not adhered to in this instance.
MDS Coding Error for Hospice Services
Penalty
Summary
The facility failed to ensure the accurate coding of the Minimum Data Set (MDS) for a resident, identified as R15, who was receiving hospice care. The quarterly MDS for R15 did not reflect the hospice services in Section O, which is designated for Special Treatments, Procedures, and Programs. R15 had been admitted to hospice services on March 22, 2024, as confirmed by the census report printed on January 24, 2025. During interviews, the director of reimbursement and MDS coordinator acknowledged the omission as a coding error, and the director of nursing emphasized the importance of MDS accuracy to reflect resident care needs. Additionally, the regional clinical director noted that the facility lacked a specific policy on MDS, relying instead on the RAI manual for guidance.
Failure to Administer Bowel Management Medications Per Physician's Order
Penalty
Summary
The facility failed to ensure medications were administered per physician's order for a resident reviewed for bowel management. The resident, who had intact cognition and required assistance with most activities of daily living, had a history of neuromyelitis optica, hypertension, multi-drug-resistant organism, paraplegia, malnutrition, cutaneous abscess of the buttock, and osteomyelitis. The resident's electronic medication record indicated an order for senna-docusate sodium to prevent constipation, but the bowel record showed the resident had not had a bowel movement in six days. Despite the facility's standing orders for bowel management, which included administering PRN medications and performing rectal checks, there was no evidence that these protocols were followed for the resident. Interviews with the resident and nursing staff revealed that the resident was constipated due to pain medication and had not received any PRN medications since the last recorded bowel movement. The nursing staff confirmed that the facility's standing orders for bowel management were not initiated as expected, despite the resident's increased risk for constipation due to pain medication. The facility's bowel management policy required monitoring and implementing PRN medications, but this was not adhered to, leading to the deficiency.
Resident's Call Light Inaccessibility
Penalty
Summary
The facility failed to ensure that a resident, identified as R4, had access to their call light, which is essential for communicating needs to the staff. R4, who was cognitively intact but had lower extremity impairments and was non-ambulatory, was observed without access to their call light. The call light was found on the bottom right-hand corner of the bed, out of reach for R4, who was seated in a wheelchair facing away from the door. R4 expressed that this was a recurring issue, as they were unable to self-propel in the wheelchair and relied on staff for mobility assistance. Interviews with various staff members, including a nursing assistant, an LPN, and an RN, confirmed that R4 was dependent on staff for mobility and used the call light to communicate needs. The staff acknowledged that R4 did not have access to the call light during the observation. The facility's policy required staff to ensure call lights were accessible to residents, but this was not adhered to in R4's case. The director of nursing stated that staff were expected to ensure residents had access to their call lights before leaving the room.
Failure to Provide Allergen-Free Meal Results in Resident Hospitalization
Penalty
Summary
The facility failed to ensure that a resident with a known shellfish allergy received the appropriate meal tray, resulting in the resident consuming shrimp pasta salad. This incident occurred shortly after the resident's admission to the facility. The resident's care plan and meal tray ticket both indicated a shellfish allergy, yet the resident was served a meal containing shrimp. After consuming the meal, the resident experienced severe allergic reactions, including sweating, nausea, stomach pain, and difficulty breathing. The nursing assistant who served the meal tray stated that the meal ticket did not indicate any allergies, although the dietary aide and director of dining confirmed that the meal ticket did list the shellfish allergy. The dietary aide had prepared the tray correctly, substituting the shrimp pasta with a sandwich, as directed by the cook. However, the nursing assistant delivered the incorrect tray to the resident, leading to the allergic reaction. The resident was promptly assessed by an LPN who administered epinephrine and oxygen and called 911. The resident was then transported to the hospital and admitted to the ICU. Interviews with staff revealed inconsistencies in the handling and delivery of meal trays, and the facility's internal investigation was inconclusive regarding how the error occurred.
Failure to Provide Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide care-planned supervision to prevent falls for a resident, resulting in an immediate jeopardy situation. The resident, who had a history of falls and required substantial assistance for toileting and transfers, was left unattended in the bathroom by a nurse aide. This led to the resident attempting to self-transfer, resulting in a fall that caused a right femur fracture requiring surgical intervention. The resident's care plan clearly indicated that staff should not leave her alone in the bathroom due to her high fall risk. The resident had multiple medical conditions, including hypertension, atrial fibrillation, renal failure, and a history of falls. She was cognitively impaired, as indicated by a SLUMS score of 19/30, and had functional limitations in mobility. Despite these risks, the nurse aide left the resident alone in the bathroom, contrary to the care plan instructions. The resident attempted to stand up from the toilet, fell, and sustained significant injuries, including a right hip fracture and multiple skin tears. Interviews and observations revealed that staff were not consistently following the care plan interventions for the resident. Some staff members were unaware of the requirement to stay with the resident in the bathroom, and others failed to review the Kardex or care plan before providing care. The facility's investigation confirmed that the care plan was up-to-date, but staff education on the resident's specific needs was lacking, contributing to the incident.
Removal Plan
- All nursing staff on duty will be trained on the current Kardex/Care Plan and interventions for R1.
- All nursing staff not on duty will be trained at the start of their next shift, prior to beginning duties on unit.
- All nursing staff on duty will be trained on the procedures for Kardex/care plans with emphasis placed on the need to regularly and comprehensively review these documents to ensure that appropriate care is provided.
- Nursing staff not on duty will be trained on the same at the start of their next shift, prior to beginning duties on the unit.
- The policy and procedure for resident care plans has been reviewed/revised.
- The facility had a plan in place and check off system to assure all staff would be educated prior to working their next shift.
Failure to Ensure Accurate Documentation of Advanced Directives
Penalty
Summary
The facility failed to ensure that advanced directives were accurately documented on the residents' electronic health records (EHR) and Physician's Orders for Life Sustaining Treatment (POLST). This deficiency affected two residents, one of whom would have been denied cardiopulmonary resuscitation (CPR) contrary to their wishes, while the other would have received CPR against their wishes. The discrepancy between the EHR and the hard chart led to confusion among staff regarding the correct code status for these residents, which could have resulted in inappropriate life-saving measures being administered or withheld during an emergency situation. Resident 24, who had severe cognitive impairment due to dementia and a stroke, was identified as full code in the EHR but had a POLST indicating do not resuscitate (DNR) status. Similarly, Resident 79, who had severe cognitive impairment and Alzheimer's Disease, was identified as DNR in the EHR but had a POLST in the hard chart indicating full code status. Interviews with various staff members revealed inconsistent practices in checking the code status, with some relying on the EHR banner and others on the hard chart, leading to potential errors in emergency situations. The facility's policies required staff to refer to the POLST form for the resident's wishes regarding life-sustaining treatment. However, the discrepancies between the EHR and the hard chart, along with the inconsistent practices among staff, highlighted a significant risk of administering incorrect life-saving treatments. The facility's failure to ensure accurate documentation and consistent practices for verifying code status resulted in an immediate jeopardy situation for the affected residents.
Removal Plan
- The facility completed an audit of all residents' code status.
- The facility reviewed the policy regarding code status and updated the policy, which outlined where the staff would locate the code status.
- Oncoming licensed staff were educated regarding the updated POLST procedure and where to find a residents' code status.
- Education continued for staff.
Failure to Assess Resident for Self-Administration of Nebulizer Treatment
Penalty
Summary
The facility failed to assess a resident for the ability to self-administer nebulizer treatments. The resident, who was cognitively intact according to the Minimum Data Set (MDS) dated 4/9/24, was observed self-administering a nebulizer treatment without a proper assessment or provider order. The resident's self-administration of medication evaluation dated 4/8/24 indicated that the resident did not self-administer medications, including nebulizer medications, after nurse setup. However, the resident's order summary report dated 4/11/24 directed staff to administer albuterol sulfate via nebulizer four times daily, but did not include a provider order for self-administration. During an interview, the resident stated that staff did not observe him while he administered the Albuterol nebulizer. Observations on 4/11/24 confirmed that the resident was self-administering the nebulizer treatment in his room without staff supervision. The LPN and DON both confirmed that there was no assessment or provider order in the resident's medical record to allow for self-administration of the nebulizer treatment. The facility's policy on self-administration of medications was requested but not provided.
Failure to Implement and Maintain Recommended Restorative Programming
Penalty
Summary
The facility failed to implement and maintain the recommended restorative programming for a resident (R71) who had a diagnosis of hemiplegia following a stroke and contracture of the left hand. The occupational therapy (OT) discharge summary recommended a range of motion (ROM) program to decrease the risk of increased tightness, and the care plan instructed staff to complete passive range of motion (PROM) exercises to the left upper extremity (LUE). However, the treatment administration record (TAR) lacked documented evidence of completion or resident refusals to complete the PROM exercises. Observations and interviews with the resident and staff revealed that the resident was not being offered PROM exercises regularly, and there was no documentation of refusals in the electronic health record (EHR). The clinical manager confirmed that the therapy recommendation had been entered as 'prn' (as needed) instead of a scheduled frequency, which led to the lack of documentation and completion of the PROM exercises. Interviews with the licensed practical nurse (LPN) and registered nurse (RN) indicated that the resident should be offered PROM exercises but sometimes refused them. However, these refusals were not documented in the EHR. The occupational therapist and Rehab Director confirmed that the PROM was recommended and ordered at a specific frequency and should not have been entered as 'prn'. The Director of Nursing (DON) stated that therapy restorative program recommendations were given to the nursing clinical managers to update resident care plans and enter the recommendations into the EHR. The DON could not confirm if the PROM was being completed or attempted and refused, as it was not documented in the TAR. The facility policy on therapy rehabilitation referrals indicated that therapy staff would routinely screen all long-term care residents to determine if they might benefit from therapy interventions, but this was not effectively implemented for R71.
Failure to Ensure Post-Dialysis Monitoring
Penalty
Summary
The facility failed to ensure post-dialysis assessment and monitoring for a resident who required such services. The resident, who had intact cognition and required partial assistance with ADLs, had diagnoses including end-stage renal disease and received dialysis treatment outside the facility. The resident's care plan lacked pre- and post-dialysis instructions for monitoring the access site for shunt bruit and thrill. Additionally, the Medication Administration Record and medical record lacked evidence of monitoring the shunt for bruit and thrill. Interviews with the resident and staff confirmed that the resident did not have an order for such monitoring, despite the importance of ensuring the shunt's patency to prevent closure. The facility's policy indicated that residents with an internal shunt should have daily checks of shunt patency by auscultating and palpating for pulse, thrill, and bruit. However, the staff did not follow this policy for the resident in question. The Director of Nursing stated that the expectation was for staff to complete fluid monitoring, vital sign monitoring, and observation of the site, including checking for bruit and thrill, but this was not done for the resident. The clinical manager and licensed practical nurses confirmed the lack of orders and documentation for monitoring the shunt, highlighting a significant oversight in the resident's care plan and daily monitoring practices.
Failure to Protect Resident During Abuse Investigation
Penalty
Summary
The facility failed to ensure resident protection pending an investigation into an allegation of abuse. A resident, who was admitted with a diagnosis of anxiety and had intact cognition, reported being physically abused by staff. The resident alleged that a nurse attempted to grab his phone, causing scratches on his forearm, and that a nursing assistant called him derogatory names. Despite the resident's report and visible scratch marks, the facility did not remove the accused staff members from their duties during the investigation. Interviews with staff revealed that the resident had reported the incident to a registered nurse, who confirmed seeing the scratches and noted the resident's request not to be cared for by the accused staff members. The facility's administrator and director of nursing admitted that the accused staff were not suspended as per the facility's abuse prevention policy, which mandates suspension pending investigation. The director of nursing acknowledged not realizing that one of the accused staff members was still working during the investigation.
Latest citations in Minnesota
A resident with dry eye syndrome and degenerative eye disease had orders for cyclosporine ophthalmic emulsion and Refresh Tears, both scheduled at the same time. Medication records and direct observation showed a TMA instilled cyclosporine drops in both eyes and immediately followed with Refresh Tears in both eyes without waiting between medications. This practice conflicted with referenced professional guidance recommending several minutes between multiple eye drops and with the medical provider’s recommendation to wait fifteen minutes between the two ophthalmic medications. No facility policy on ophthalmic medication administration was provided when requested.
A resident with severe cognitive impairment, impaired mobility, and high fall risk was care planned to have wheelchair footrests in place at all times, with staff ensuring proper positioning and monitoring for leaning during transport. A NA transported the resident in a manual wheelchair from the shower without the footrests, and while going through the doorway the wheelchair struck the door frame, causing the resident, who was leaning forward, to fall out. The resident sustained a T12 fracture, head injury with concussion, abrasions and contusions, and multiple right-hand lacerations requiring sutures, and the DON confirmed the care plan had not been followed.
A high‑risk, immobile resident with MS and prior heel DTI developed an avoidable unstageable coccygeal pressure ulcer after staff failed to consistently assess and document skin status, did not transfer or timely provide ordered pressure‑relieving mattresses, and did not reliably perform q2h repositioning. The resident was repeatedly left on a bedpan for prolonged periods despite early reports of this issue, and the toileting care plan was not revised to a bedside commode until after the coccygeal wound had significantly worsened. Wound assessments lacked complete measurements and staging, changes in wound size and color were not promptly recognized as deterioration or reported to providers, and recommended interventions from a wound NP (including an air mattress and offloading) were not promptly implemented. As a result, the coccygeal ulcer rapidly progressed to a large, necrotic, malodorous wound requiring hospital transfer and surgical debridement.
A resident with spastic hemiplegia, muscle weakness, and moderate cognitive impairment was observed using bilateral bed grab bars for bed mobility and transfers, but the care plan did not address grab bar or side rail use. Review of the EMR showed no completed bed mobility device or side rail assessment to determine the necessity or safety of the grab bars, and no documentation that risks and benefits were discussed or that informed consent was obtained. An LPN and the ADON stated that a bed mobility device assessment is required before grab bars are installed and confirmed that no such assessment existed for this resident.
A resident with bilateral heel pressure ulcers and multiple comorbidities received wound care during which an RN removed dressings from both heels, cleansed both wounds, and wiped each heel without changing gloves or performing hand hygiene between wounds or after disposing of soiled dressings. This practice conflicted with the facility’s written wound care procedure, which requires glove removal and hand hygiene after dressing removal and after wound cleansing. In interviews, the RN, NP, and DON/IP acknowledged that hand hygiene and glove changes are expected between dirty and clean tasks and between separate wounds to prevent infection.
A resident with MS, neurogenic bladder, mobility limitations, and existing pressure injuries was identified as dependent for toileting hygiene and at risk for pressure ulcers, yet the care plan lacked an individualized toileting/incontinence plan and a defined repositioning schedule. Despite a new coccyx pressure ulcer and documentation that interventions such as increased repositioning and incontinent care were needed, the care plan was not revised for a period of time to reflect these changes. During this time, the resident sometimes fell asleep on a bedpan and remained on it until staff removed it, and staff were not initially informed that the bedpan should no longer be used. The DON later acknowledged that the care plan revisions for turning, repositioning, and toileting were delayed until after the resident’s coccyx ulcer had significantly worsened.
A resident with diabetes, Crohn’s disease, bowel incontinence, and a history of MASD on the right gluteus developed an open, painful lesion on the right gluteal area that was documented over time without complete wound characteristics, clear etiology, or timely provider notification. Wound care orders were written for a stage 3 pressure ulcer on the left buttocks, while staff reported the wound was only on the right side and applied the left‑sided orders to the right gluteal wound in the absence of specific right‑side treatment orders. The DON acknowledged discomfort with staging the wound, lack of early physician notification, and confusion over wound classification, despite a facility policy requiring comprehensive wound assessment, consistent measurement, and provider notification when treatment orders are absent.
A resident with diabetes, chronic leg ulcer, kidney transplant, and a documented gluteal wound was care-planned for Enhanced Barrier Precautions (EBP), with posted instructions requiring gown and gloves for high-contact care such as transfers and wound care. During a telehealth wound assessment, the DON donned a gown and initially performed hand hygiene but then applied gloves without hand hygiene, removed a soiled dressing from the resident’s gluteal area, discarded it, removed gloves, and applied new gloves again without performing hand hygiene between glove changes. On another occasion, during use of a sit-to-stand lift, an NA wore gown and gloves, but the DON handled the lift harness, the resident’s clothing, and assisted with the transfer and repositioning while wearing a gown but no gloves, despite EBP requirements for transfers. The DON stated EBP was only needed for catheter or wound care and not for transfers, contradicting the posted EBP instructions and facility policy.
A resident with severe dementia, psychiatric disorders, and high dependence for ADLs was verbally abused during evening care when a NA, frustrated with the resident’s crying and resistance, loudly ridiculed her as acting like a two-year-old, threatened to hit her back if struck, told her she would be sent to a locked unit, and questioned who would want to care for her when she cried like a baby. Multiple staff witnessed the loud, stern, and intimidating tone and reported it to an LPN, who recognized it as verbal abuse but did not immediately remove the NA from duty or promptly report the allegation per policy, allowing the NA to continue working on the unit. Following this incident, the resident demonstrated increased crying, combativeness, resistance to care, wandering, self-isolation, and refusal of food, fluids, and medications above baseline, with documentation of significant emotional distress and subsequent ED evaluation for aggressive behaviors and poor intake.
A resident with dementia, bilateral above‑knee amputations, vascular disease, and severe protein‑calorie malnutrition developed a wound on an amputation stump that had a dressing dated several days before any documentation or treatment orders appeared in the record. Although bath audits and nursing notes initially reported no skin issues, a later assessment described a full‑thickness stage 4 ulcer/diabetic ulcer on the stump with exposed bone, erythema/edema, slough, and moderate serosanguineous drainage. Nursing staff interviews showed no one could identify who first discovered the wound or applied the initial dressing, and there was no evidence that the wound was assessed, the provider notified, or standing orders implemented when it was first present, despite facility expectations that new wounds be promptly evaluated and reported.
Failure to Follow Professional Standards for Ophthalmic Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice for administering ophthalmic medications to a resident with dry eye syndrome and degenerative eye disease. The resident was cognitively intact, required assistance with ADLs, and had physician orders for cyclosporine ophthalmic emulsion 0.05% one drop in both eyes twice daily and Refresh Tears ophthalmic solution one drop in both eyes four times daily for dry eyes. The administration summary showed that both eye medications were scheduled for the same time and were documented as being given at the same time on multiple dates. During a medication pass observation, a trained medication aide administered the ordered oral medications, then applied gloves and instilled one drop of cyclosporine in each eye, immediately followed by one drop of Refresh Tears in each eye, without any waiting period between the two medications. The surveyors referenced guidance from the American Academy of Allergy, Asthma, and Immunology stating that when more than one eye drop is ordered, three to four minutes should be allowed between drops in the same eye, and five to fifteen minutes should be allowed between different eye medications to prevent dilution. Interviews with the DON, pharmacy consultant, and medical provider confirmed that best practice and the provider’s recommendation were to wait between administration of cyclosporine and Refresh Tears, with the medical provider specifying a fifteen-minute interval. The facility did not provide a policy on ophthalmic medications when requested. The observed practice and documented administration times demonstrated that staff did not follow these professional standards or the medical provider’s recommended interval between the two eye medications.
Failure to Follow Wheelchair Transport Care Plan Leads to Fall With Injuries
Penalty
Summary
The deficiency involves the facility’s failure to implement care-planned fall prevention interventions for a resident at high risk for falls, resulting in a fall with injury. The resident had diagnoses including aphasia, dysphagia, muscle weakness, traumatic brain injury, and impaired mobility, with severe cognitive impairment documented on the MDS and dependence on staff for transfers and wheelchair transport. A care plan addressing wheelchair transport safety and positioning directed staff to ensure the resident was fully positioned and supported in the wheelchair prior to transport, verify footrests were in place prior to transport, and monitor for leaning, sliding, or unsafe positioning. An additional care-planned approach required wheelchair pedals to be on at all times. On the date of the incident, a nursing assistant transported the resident in a manual wheelchair from the shower room to the resident’s room without the foot pedals in place, contrary to the care plan. While being wheeled through the doorway, the wheelchair struck the door frame, causing the chair to stop and the resident, who had begun leaning forward, to fall out of the wheelchair onto the floor. Progress notes and ED documentation identified that the resident sustained a T12 vertebral fracture, a head injury with concussion, an abrasion and contusion to the head, a bruise to the left knee, and multiple lacerations to the right hand requiring sutures. The nursing assistant later acknowledged awareness that the foot pedals should have been on but did not apply them because the transport was only from the shower to the room. The DON confirmed that the resident’s care plan had not been followed when the fall occurred.
Failure to Implement and Update Pressure Ulcer Prevention and Treatment Led to Avoidable Unstageable Coccygeal Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, monitor, and implement individualized pressure ulcer prevention and treatment interventions for multiple high‑risk residents, resulting in an avoidable, unstageable coccygeal pressure ulcer for one resident that required surgical debridement and hospitalization. The resident had primary progressive multiple sclerosis, hereditary spastic paraplegia, obesity, and pre‑existing pressure‑related deep tissue injury to the left heel, and was identified as high risk for pressure ulcers on the Braden Scale due to constant moisture, chairfast status, very limited mobility, inadequate nutrition, and friction/shear risk. Hospital records on readmission documented irritant contact dermatitis of the bilateral gluteal cleft with specific cleansing and barrier cream orders, and facility documentation showed the resident could not reposition in bed or chair and required assist of two and a full‑body mechanical lift for transfers. Despite this, the admission/readmission skin assessment and weekly skin checks lacked measurements and detailed wound characteristics for the heel ulcer and gluteal dermatitis, and the care plan did not include comprehensive, individualized interventions beyond generic repositioning and wound care orders. After a new coccyx pressure ulcer was identified and documented as a stage 2 lesion, the facility failed to promptly and accurately update the care plan and implement recommended pressure‑relieving interventions. The wound nurse practitioner on 3/5 ordered coccyx wound care, an air mattress, pressure offloading, and a dietician consult, but the care plan was not revised and there was no evidence that an air mattress was placed on the bed for nearly two weeks. The environmental services director later confirmed that when the resident was moved to a new room, the gel mattress was not transferred, and the air mattress requested on 3/17 was not actually placed until the following day, despite being marked as completed. During this period, TAR documentation showed gaps in the every‑2‑hour repositioning order, and staff interviews revealed that CNAs were unaware of which residents were on repositioning programs, were not consistently repositioning residents, and had not received recent education on pressure ulcer prevention. The DON and RN case manager acknowledged that the coccyx wound increased in size and changed color between assessments, that the bed lacked the ordered gel mattress, and that the physician was not notified of the wound’s deterioration at that time. The facility also failed to timely modify toileting and incontinence care practices despite knowledge that the resident was being left on a bedpan for extended periods. The DON reported hearing before an IDT meeting that the resident had fallen asleep on a bedpan for an undetermined amount of time, but the care plan was not revised to discontinue bedpan use and implement a bedside commode until after the coccyx wound had significantly worsened. CNAs confirmed that the resident sometimes fell asleep on the bedpan and that they were not informed she should no longer use it until after the sore had worsened. Subsequent wound assessments documented rapid progression of the coccyx wound from a small stage 2 ulcer to a large, malodorous, necrotic wound with eschar, slough, erythema, and purulent drainage, ultimately classified as an unstageable pressure ulcer. The DON, NP, PA, and medical director all indicated that the lack of a pressure‑relieving mattress, failure to adjust pressure‑reducing interventions, and prolonged time on a bedpan likely contributed to the development and deterioration of the resident’s pressure ulcer, which was determined to be avoidable and resulted in hospitalization and surgical debridement. Additional documentation and interviews showed systemic assessment and communication failures related to pressure ulcer management. Weekly skin checks and wound assessments often omitted complete measurements, staging, and wound characteristics, and changes in wound size and appearance were not consistently recognized as deterioration or communicated to providers. The DON acknowledged that a 3/12 assessment showing increased wound size and purple discoloration should have been identified as a deep tissue injury and reported to the physician, but this did not occur. When nursing later documented foul odor, increased pain, and expanding necrotic tissue, telemedicine and PA responses deferred in‑person evaluation and ED transfer despite earlier recommendations that the resident be sent to the ED if an in‑person provider could not assess the wound. The NP ultimately found a large, malodorous, purulent wound with expanding eschar and ordered transfer to the hospital, where imaging and surgical findings confirmed a large necrotic sacral wound requiring extensive debridement. Throughout this sequence, the facility did not consistently follow its own pressure ulcer protocols, did not ensure ordered pressure‑relieving equipment was in place, and did not promptly revise care plans or interventions in response to known risk factors and documented wound changes. The report also notes that other residents reviewed for pressure ulcers were affected by similar failures in monitoring and individualized intervention, though detailed narratives focus primarily on this resident. Staff interviews revealed that CNAs relied on paper care guides that did not clearly identify residents on repositioning programs or at risk for skin breakdown, and that they were unaware of some residents’ special mattress orders or toileting restrictions. The DON and medical director stated that residents at risk for pressure ulcers should have immediate pressure‑relieving interventions and that existing ulcers require ongoing evaluation to prevent deterioration, but the documented practices for this resident did not align with those expectations. These combined actions and inactions—insufficient assessment detail, delayed or missing care plan revisions, failure to implement ordered support surfaces and repositioning, and delayed response to wound deterioration—constituted the deficiency in providing appropriate pressure ulcer care and preventing new ulcers from developing.
Failure to Assess, Care Plan, and Obtain Consent for Bed Grab Bar Use
Penalty
Summary
The deficiency involves the facility’s failure to follow required procedures before installing and using bed grab bars for a resident. The resident had diagnoses including spastic hemiplegia affecting the left side and muscle weakness, and an admission MDS indicating moderate cognitive impairment. During observation, the resident was seen in a power chair with bilateral grab bars on the bed and reported using them to roll in bed and for transfers. The resident’s care plan, dated 1/23/26, documented a need for assistance with bed mobility and independence with transfers but did not mention or address the use of grab bars or side rails. Review of the electronic medical record showed no completed grab bar/side rail or bed mobility device assessment to determine the necessity of the grab bars or whether the resident could safely use them. There was also no evidence that the resident or the resident’s representative had been educated on the risks of having a grab bar on the bed or that informed consent had been obtained. In interviews, an LPN and the ADON both stated that a bed mobility device assessment was required to determine need and safety prior to installing grab bars, and both confirmed that no such assessment was present in the resident’s record.
Failure to Perform Hand Hygiene and Change Gloves During Wound Care
Penalty
Summary
Surveyors observed that a registered nurse (RN) and a nurse practitioner (NP) did not follow the facility’s established infection control practices during wound care for one resident. During a wound treatment, the RN wore gloves while removing the dressing from the resident’s left heel, then removed the dressing from the right heel, sprayed both wounds with wound cleanser, wiped the left heel with gauze, and then used a clean gauze pad to wipe the right heel. The RN did not remove her gloves or perform hand hygiene after disposing of the soiled dressings or between cleaning the left and right heel wounds, contrary to the facility’s written wound care procedure, which requires glove removal and hand hygiene after removing the previous dressing and again after cleaning the wound. The resident’s admission MDS documented diagnoses including multiple rib fractures, heart failure, dementia, anxiety, and the presence of a pressure ulcer, and indicated the resident was cognitively intact and required staff assistance with care and transfers. The resident’s care plan identified pressure ulcers on both heels requiring wound care. In interviews, the RN, NP, and the DON/infection prevention nurse each stated that gloves should be changed when moving from dirty to clean areas and that hand hygiene is expected after glove removal and between wounds to prevent infection, confirming that the observed practice did not align with facility policy or expected infection control standards.
Failure to Timely Revise Care Plan for Toileting and Skin Integrity
Penalty
Summary
The deficiency involves the facility’s failure to timely revise and individualize a resident’s care plan to address toileting and incontinence needs in relation to impaired skin integrity. The resident had diagnoses including primary progressive multiple sclerosis, hereditary spastic paraplegia, obesity, and a pressure-induced deep tissue injury to the left heel. A Significant Change MDS identified the resident as dependent for toileting hygiene, with lower extremity range-of-motion limitations, wheelchair use, dependence for transfers, occasional urinary incontinence, intact cognition, and at risk for pressure ulcers with existing unhealed pressure injuries and MASD. The resident’s skin-focused care plan, revised on various dates, included skin inspections, wound care orders, weekly skin checks, pressure ulcer care to the left heel, nutritional supplements, and a gel mattress, but did not include an individualized toileting or incontinence plan. On a weekly skin check dated 3/3/26, nursing staff identified a new Stage 2 pressure ulcer on the coccyx and contact dermatitis on both gluteal folds. An IDT Final Post Review Follow Up dated 3/10/26 (signed 3/23/26) documented that a new skin issue had occurred and that interventions after the incident included wound care treatment orders, increased repositioning, and increased incontinent care. However, the resident’s care plan from 3/3/26 through 3/16/26 did not show revisions reflecting increased incontinence care or a repositioning schedule, and the care plan was not updated to include these elements until 3/17/26. During this period, the care plan still lacked an individualized toileting plan despite the resident’s identified incontinence and new coccyx pressure ulcer. Progress notes on 3/17/26 documented that the resident’s coccyx wound had declined, with an evaluation describing a deteriorating wound characterized as a Kennedy terminal ulcer/End of Life, staged as a Stage 4 pressure ulcer, in-house acquired, with increased size, exudate, odor, pain, and surrounding erythema. On that same date, the skin focus care plan was revised to include prompt incontinence care and keeping the skin clean and dry, and the elimination focus care plan was revised to address incontinence due to neurogenic bladder with use of a bedside commode offered every 2–3 hours. A nursing assistant reported that when working with the resident, the resident would sometimes fall asleep on the bedpan and forget to ask staff to remove it, and that she was not aware the resident was not supposed to use the bedpan until after the sore had worsened. The DON stated that the resident’s care plan had not been revised earlier to include a turning and repositioning schedule or toileting changes, and that it should have been revised as soon as staff learned the resident was falling asleep on the bedpan, rather than waiting until after the pressure ulcer worsened.
Failure to Assess and Notify Provider for Right Gluteal Wound
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess and appropriately manage a non‑pressure skin issue on a resident’s right gluteal area, and to notify the physician in a timely manner. The resident had diagnoses including diabetes, Crohn’s disease, and a kidney transplant, and the MDS indicated occasional bowel incontinence, no pressure ulcers, and no moisture‑associated skin damage at that time. Earlier documentation identified a resolved MASD to the right gluteus, and a progress note later described a sacral wound with creams applied, noting that sores were still open and painful during application, but without any measurements, wound characteristics, or evidence of physician notification. Subsequent wound assessments documented an open lesion on the right gluteus with specific measurements on multiple dates, but did not identify the wound type or other characteristics, and the record did not show physician notification or treatment orders for the right gluteal lesion. Provider orders in place initially addressed cleansing the buttocks and applying barrier cream, and later included a detailed wound care order for a stage 3 pressure ulcer documented on the left buttocks. However, the resident’s record did not contain a specific treatment order for the right gluteal wound, despite the ongoing documentation of an open lesion in that area. Interviews revealed confusion and inconsistency in wound identification and classification. The DON stated that the right gluteal wound was documented as an open lesion because she did not feel comfortable determining the wound type, and acknowledged that the physician should have been notified when the wound was first identified. The DON was unaware that the NP had documented the wound as being on the left buttocks and as a stage 3 pressure ulcer, while the RN reported that the wound had never been on the left buttocks and that she had been applying the left‑sided wound orders to the right gluteal area because there was no open area on the left. The resident reported a recurring painful area on the right buttocks and chronic stool leakage since prior anal fistula surgery. The facility’s own wound treatment policy required comprehensive assessment of wound etiology and characteristics, consistent measurement and documentation, and provider notification in the absence of treatment orders, which were not followed for this resident’s right gluteal wound. The deficiency centers on the lack of a comprehensive wound assessment for the right gluteal lesion, incomplete documentation of wound characteristics, failure to clearly determine and document the wound etiology, and failure to notify the physician and obtain appropriate treatment orders when the wound was identified and remained open. These actions and inactions resulted in a discrepancy between the documented wound location and type and the actual clinical presentation, as well as a period during which the right gluteal wound had no specific, clearly ordered treatment despite being open and painful.
Failure to Perform Hand Hygiene and Implement Enhanced Barrier Precautions During Wound Care and Transfers
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper hand hygiene during wound care and to consistently implement Enhanced Barrier Precautions (EBP) for a resident requiring such measures. The resident had diagnoses including diabetes, a non-pressure chronic ulcer of the right lower leg, and a kidney transplant, and a wound assessment documented an open lesion on the right gluteal area. The resident’s care plan and a sign posted outside the room specified that EBP, including gown and gloves, were required for high-contact care activities such as dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, catheter care, and wound care. During one observation, the DON performed hand hygiene and donned a gown before entering the resident’s room for a telehealth wound assessment. Inside the room, the DON went into the bathroom, applied gloves without performing hand hygiene, removed the resident’s brief, and removed a foam dressing from the right gluteal area that had stool on one corner. After discarding the soiled dressing, the DON removed gloves and then applied new gloves without performing hand hygiene between glove changes. When questioned, the DON stated that hand hygiene should be done when hands or gloves are visibly soiled and before and after removing or applying gloves, and acknowledged that hand hygiene had not been performed each time gloves were removed and reapplied. In a separate observation, the resident was transferred using a sit-to-stand mechanical lift while EBP requirements were not fully followed. An NA entered the room wearing a gown and gloves with the lift, and the DON applied the lift harness under the resident’s arms and cinched the waist strap, encountering the resident’s clothing, while not wearing gloves. After the transfer to bed, the DON pulled down the resident’s pants and removed the harness while touching the resident’s clothes. Following wound care by a CNP-WOC, the DON again assisted the resident by sitting the resident on the edge of the bed, applying the lift harness, and adjusting the resident’s pants and shirt while wearing a gown but no gloves. The DON stated that EBP was only needed for catheter or wound care and not for transfers, and only upon reading the posted EBP sign acknowledged that EBP was required for all high-contact resident care activities, including transfers.
Failure to Protect Resident From Verbal Abuse and Delay in Removing Alleged Perpetrator
Penalty
Summary
The deficiency involves the facility’s failure to protect a vulnerable resident from mental abuse and to respond appropriately to an allegation of abuse. The resident had severe cognitive impairment, Alzheimer’s disease, dementia, anxiety, depression, psychotic disorder, and significant functional dependence, including frequent incontinence and the need for extensive assistance with ADLs and transfers. Her care plan identified behavioral and mood issues such as wandering, yelling, combative behavior, and calling staff names, with interventions including calm approaches, emotional support, redirection, and monitoring for emotional distress and mood/behavior changes. She was identified as a vulnerable adult, with instructions to monitor for signs of emotional distress and to follow the facility’s abuse reporting policy. On the evening in question, while the resident was crying on the phone with her son and expressing a desire to leave, NA-A and NA-B entered to provide evening care using an EZ stand lift. After the resident ended the phone call, multiple staff reported that NA-A spoke to the resident in a loud, stern, and frustrated tone, telling her to stop crying and that she was acting like a two-year-old. When the resident swatted at NA-A, NA-A stated, “If you hit me, I’m going to hit you back,” and later told the resident she was “in trouble now.” Staff reported that NA-A told the resident she would be sent to a locked unit so she could not get out, and questioned who would want to care for her when she cried like a baby, and that nobody would want to keep working with her. NA-C described NA-A yelling commands such as “HOLD ON!” and “Stop crying! Where would you be if you were not here? Probably lying on the floor,” and felt NA-A was obviously upset and overwhelmed. These statements were made in the presence of the resident while she was already distressed and crying. Following this interaction, the resident exhibited crying, yelling, combativeness, resistance to care, wandering into other residents’ rooms, self-isolation, and refusal of food, fluids, and medications above her prior baseline, as documented in behavior charts, target behavior monitoring, and nursing progress notes. Staff documented that she cried most of the morning, was very restless, difficult to redirect, hit and pinched staff, called staff names, and refused care and meals. She required repeated redirection, 1:1 attention, and non-pharmacological interventions, and was ultimately sent to the ED for evaluation of combativeness and emotional distress, where she was treated for dementia with aggressive behavior and hypoglycemia related to poor intake. The report identifies that the resident’s actual response and the reasonable person concept showed serious psychosocial harm, including increased crying and combative behavior above baseline, fear/anxiety manifested as combativeness, resistance to care and social interaction, and self-isolation. The facility also failed to immediately remove the alleged perpetrator from resident care and to promptly report and investigate the allegation in accordance with its abuse policy. After NA-B and NA-C reported to LPN-A that NA-A had yelled at and threatened the resident, LPN-A acknowledged it as verbal abuse but did not initiate immediate protective measures or timely reporting. LPN-A stated she believed she had 24 hours to report because there was no injury, despite facility policy requiring reporting within two hours. NA-A remained on the unit and continued working until the end of her shift, including after staff had clearly communicated their concerns to LPN-A. TMA and NA staff described uncertainty about their authority to remove NA-A and reliance on the nurse to act, while the DON later informed LPN-A that NA-A should have been removed from the floor to prevent further danger to residents. The Immediate Jeopardy was determined to have begun when NA-A’s derogatory, intimidating, and threatening statements were made and continued while she remained on duty with access to the resident and other vulnerable residents.
Failure to Timely Assess and Treat Newly Discovered Stump Wound
Penalty
Summary
The deficiency involves the facility’s failure to provide timely treatment and care for a newly discovered wound on a resident’s above‑knee amputation stump. The resident was admitted with diagnoses including unspecified dementia with behavioral disturbances, vascular dementia, bilateral above‑knee amputations, vascular disease, reduced mobility, and severe protein‑calorie malnutrition, and had no documented ulcers or skin problems on admission or on the most recent MDS. A weekly bath audit on 3/17/26 documented only non‑tender lymph nodes on the right upper hip and did not identify any open areas. However, when the wound was later assessed, the dressing on the stump was dated 3/16/26, indicating that a wound and dressing existed at that time, even though no corresponding assessment, provider notification, or treatment orders were documented. On 3/23/26, nursing staff documented a new skin issue above the resident’s knee at the amputation site, describing a stage 4 pressure ulcer/injury with full‑thickness skin and tissue loss, exposed bone, erythema/edema, and moderate serosanguineous exudate. The wound measured 1.56 cm by 1.64 cm, with 20–29% granulation tissue and 80% slough. A progress note and skin issues assessment on that date confirmed the wound characteristics and staging, and the NP, after reviewing a picture, determined the wound to be a diabetic ulcer with peripheral vascular disease and severe protein‑calorie malnutrition as contributing factors. On that same date, the NP was notified, antibiotic therapy (doxycycline) was ordered for possible cellulitis, and specific wound care orders were initiated, with documentation on the MAR that these treatments were carried out beginning 3/23/26. Multiple interviews with nursing staff revealed that no one could identify who discovered the wound or who applied the initial dressing dated 3/16/26, and there was no documentation of a wound assessment, provider notification, or interim treatment between 3/16/26 and 3/22/26. Several RNs and LPNs who worked shifts from 3/16/26 through 3/20/26 stated they did not notice a wound on the stump and that, per their usual practice, they would have contacted the provider and initiated treatment if they had found one. One LPN recalled seeing a band‑aid with a date on the stump but could not recall the date, and another LPN stated she did not see the wound because she was not looking for one. The facility’s standing orders required staff to assess all wounds daily, change dressings every three days and as needed, treat with normal saline or non‑cytotoxic cleanser and appropriate dressings, and notify the provider the next business day when a new wound or injury was found. Despite these expectations, the wound identified by the dated dressing on 3/16/26 was not assessed, reported, or treated according to orders and facility policy until 3/23/26.
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