Guardian Angels Health & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Hibbing, Minnesota.
- Location
- 1500 East Third Avenue, Hibbing, Minnesota 55746
- CMS Provider Number
- 245239
- Inspections on file
- 25
- Latest survey
- August 20, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Guardian Angels Health & Rehab Center during CMS and state inspections, most recent first.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist as required.
Surveyors found that milk and other beverages were served from a cart without proper cooling, resulting in milk temperatures above required guidelines on two occasions. The dietary aide confirmed the milk was not safe to serve and disposed of it after temperature checks. The DON stated that food and beverages are expected to be served at safe temperatures, but temperature logs were not provided.
A resident under droplet precautions had a nasal swab specimen placed on a medication cart without proper surface sanitization, and an LPN was unclear about hand hygiene between tasks. Laundry staff transported uncovered soiled linens through the facility, used the same gloves across multiple areas, and entered clean laundry zones without changing PPE. The facility also lacked a comprehensive water management program, with incomplete records and insufficient monitoring of water features and system flow.
The facility did not ensure an active antibiotic stewardship program or perform required antibiotic time-outs for three residents who received antibiotics for infections such as upper respiratory infection and UTI. Nursing staff showed inconsistent knowledge of infection assessment criteria, and documentation of antibiotic reviews was missing, despite facility policy requiring these reviews.
Insufficient staffing led to residents not receiving timely assistance with ADLs, toileting, and hygiene, with some left in soiled clothing or not repositioned for hours. Staff reported being responsible for up to 30 residents, resulting in missed care such as nail care, catheter care, and incomplete care plans. Food requests were not always honored, and a resident was left unsupervised during a nebulizer treatment without required assessments, all due to inadequate staffing levels.
The facility did not complete required monitoring for side effects of antipsychotic medications, such as AIMS assessments and orthostatic blood pressure checks, for several residents with significant cognitive and psychiatric conditions. Additionally, PRN psychotropic medication orders for multiple residents lacked required stop dates and were not limited to 14 days as per facility policy, with no documented physician evaluation for continued use. These deficiencies were confirmed through record review and staff interviews.
Medications and biologicals were not securely stored in locked compartments, with some cupboards left unlocked or lacking locks, and the medication room was left open and unattended by staff. The medication refrigerator, containing immunizations, insulin, and controlled drugs, was found at 48°F, above the safe range, with incomplete temperature logs and multiple missed entries. Several medications required destruction and replacement due to unsafe storage conditions.
Multiple residents requiring assistance with ADLs, including toileting, hygiene, and repositioning, did not receive necessary care as outlined in their care plans. Observations and staff interviews revealed that residents were left in the same position for extended periods, did not receive scheduled nail or catheter care, and were sometimes left in soiled briefs overnight. Staff consistently cited inadequate staffing as a reason for missed care tasks.
The facility did not consistently track or intervene for bowel movements in two residents with orders for bowel management, failed to monitor and document oxygen saturation and administration as ordered for a resident with respiratory conditions, and did not complete or document required weekly skin checks for a resident with a chronic skin condition. These deficiencies were identified through observation, interviews, and record review.
A resident with a history of heart disease and moderate cognitive function was denied a requested second serving of watermelon during a meal, despite facility policy allowing seconds unless restricted by diet. Staff did not verify food availability with the kitchen, and later it was confirmed that more watermelon was available. Staff interviews revealed inconsistent understanding of the policy, and the incident was attributed in part to staff being rushed.
Two residents were allowed to self-administer medications without proper assessment or care plan authorization. One resident with COPD and cognitive impairment was left unsupervised during a nebulizer treatment, and another was left with a cup of medications at the bedside. Staff confirmed that required assessments for self-administration were not completed, and facility policy for SAM was not followed.
The facility did not timely review and revise care plans for two residents after significant changes, including a fall and new medication orders. One resident's care plan was not updated with new fall prevention interventions after a post-fall assessment, and another resident's care plan did not reflect recent changes in antidepressant and anticoagulant therapy. Facility policy requires ongoing care plan updates, but this was not followed.
A resident dependent on tube feeding had their feeding pump paused and tubing disconnected by nurse aides who were not trained or authorized to perform these tasks. The uncapped tubing was left hanging and later touched the floor before being wiped with a tissue and reconnected to the resident. Staff interviews and facility policy confirmed that only licensed staff should manage tube feeding pumps and connections, and nurse aides had not received the necessary training or competency checks.
Two residents with significant medical conditions were not educated on or offered pneumococcal and influenza vaccinations upon admission, and their immunization histories were not documented in the EMR as required by facility policy. Review of records and staff interviews confirmed that vaccination reconciliation and documentation steps were not completed for these individuals.
Two residents with complex medical conditions were admitted without documentation of COVID-19 vaccination status, and there was no evidence they were educated on or offered the vaccine as required by facility policy. A registered nurse confirmed that the necessary vaccination reconciliation and documentation were not completed for these residents.
Surveyors found that two residents did not have accessible or properly functioning bathroom call lights—one was missing a cord entirely, and another had a frayed cord. Maintenance confirmed these issues and acknowledged the safety concern, while facility policy required call lights to be within reach but did not address the condition of the cords.
A resident with chronic pain syndrome experienced unmanaged severe pain due to a delay in receiving prescribed pain medication. Despite multiple requests and communication to nursing staff, the resident waited five hours for pain relief, resulting in severe pain and disturbed sleep. The delay required the resident to take two doses of narcotic medication to manage the pain effectively.
A resident with multiple medical conditions fell from a mechanical lift due to improper use of a toileting sling, resulting in serious brain injuries. The nursing assistants involved had not received proper training on sling use, leading to the resident's arms being placed inside the sling and the waist buckle not being secured, causing the fall.
The facility failed to secure the medication storage area on the 400 hallway, leaving it open and unattended on multiple occasions. Staff interviews revealed confusion about responsibility for securing the area, with some believing the presence of a nearby nurse manager was sufficient. The ADON clarified that all medication storage doors should be locked when not attended by a licensed nurse, as per facility policy.
A facility failed to document a resident's contracture in the right hand upon admission and during subsequent assessments. The resident had diagnoses including bilateral lower extremity amputations and minimal cognitive impairment. Despite the resident stating the contracture had been present for over two years, it was not documented in the medical records. Staff interviews revealed the oversight, and the importance of accurate assessments was emphasized by the ADON.
The facility failed to accurately assess and care plan for two residents, leading to deficiencies in their care plans. One resident receiving hospice services was not documented as such in their care plan, while another resident, who was continent, was inaccurately documented as incontinent. These discrepancies were confirmed by nursing staff and highlighted the need for accurate assessments and care planning.
The facility failed to follow provider orders for weight monitoring for two residents with impaired cognition and multiple diagnoses. One resident's care plan did not address weight monitoring despite orders, and the other lacked specific orders, resulting in missing weight entries over several weeks. Staff interviews revealed lapses in the process, including reliance on nursing assistants to record weights and issues with documentation during staff absences.
A facility failed to document a rationale for extending a PRN psychotropic medication beyond 14 days for a resident with severe cognitive impairment and multiple diagnoses. The resident received Ativan for anxiety and hallucinations 14 times over two weeks without a specified end date. The assistant director of nursing confirmed that the order should have been reviewed in a monthly pharmacy meeting, but it lacked a documented rationale from the provider, as required by CMS guidelines.
The facility failed to implement enhanced barrier precautions (EBP) for residents with indwelling catheters and a chronic wound. A nursing assistant did not use PPE for a resident with a catheter, despite signage indicating EBP. Another resident with a catheter was not initially provided PPE during repositioning. Additionally, a resident with a stage 3 pressure ulcer lacked EBP, with staff uncertain about the requirement, despite facility policy indicating the need for such precautions.
The facility failed to post required nurse staffing data daily, including over the weekend, affecting all residents, staff, and visitors. The nurse staffing data was not updated for several days, with the responsibility for posting assigned to a scheduler who was absent. Interviews revealed that the data sheets were sometimes not posted on weekends, contrary to the facility's policy requiring daily updates.
Failure to Provide Required Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Maintain Safe Food and Beverage Temperatures
Penalty
Summary
Surveyors observed that the facility failed to monitor and maintain safe temperatures for food and beverages served to residents. On two consecutive days, a beverage cart containing milk, various juices, and ice water was positioned in the dining area without any ice or cooling device. The milk on the cart was measured at 44.5°F and 41.5°F on separate occasions, both above the facility's policy requirement of 40°F or below for cold food items. The dietary aide acknowledged that the milk was above the guideline for serving cold beverages and disposed of it each time after the temperature was checked. The facility's policy, as well as the FDA Food Code, require that milk and other temperature-controlled foods be maintained at or below 40°F and 41°F, respectively, to prevent food-borne illness. The director of nursing confirmed the expectation that food and beverages be served at proper temperatures. Temperature logs for fridges, freezers, and meals were requested by surveyors but were not provided by the facility.
Infection Control, Laundry Handling, and Water Management Deficiencies
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices in several key areas. For one resident with chronic kidney disease, vancomycin resistance, and congestive heart failure, an LPN collected a nasal swab specimen while the resident was under droplet precautions. The LPN placed the specimen tube on the medication cart, did not sanitize the cart surface before placing other residents' medication bottles on the same area, and was unclear about hand hygiene practices between tasks. The specimen remained on the cart for an extended period, and the infection prevention RN later confirmed that the medication cart was not an appropriate location for collected specimens and that surfaces should have been sanitized to prevent contamination. In the laundry area, staff did not follow proper procedures for handling soiled linens. Laundry personnel transported uncovered bins of dirty linen through the facility, wore the same gloves while collecting soiled items from multiple locations, and entered the clean laundry area with contaminated gloves. The staff did not consistently use required personal protective equipment such as gowns or face shields, and dirty laundry was brought through the clean side of the laundry area, contrary to facility policy. The policy required separation of clean and soiled linens, use of PPE, and specific handling procedures to reduce environmental contamination, but these were not followed during the observed process. The facility also lacked an active water management program as required by its own policy. Observations revealed that water features, such as a fishpond and a fountain, were present, but there was no consistent water testing or documentation of water system flow, mixing valves, or shut-off points. Maintenance staff were unable to provide complete records of water feature maintenance or testing, and the facility's water management map was incomplete, lacking necessary details about the water system. The policy required mapping and monitoring to prevent hazards such as Legionella, but these measures were not fully implemented.
Failure to Implement Antibiotic Stewardship Program and Perform Antibiotic Time-Outs
Penalty
Summary
The facility failed to maintain an active antibiotic stewardship program and did not perform antibiotic time-outs for three of five residents reviewed for antibiotic use. For one resident with severely impaired cognition and a diagnosis of Alzheimer's dementia, an order for azithromycin was initiated for an upper respiratory infection, but no antibiotic time-out was documented. Another resident with moderately impaired cognition and multiple diagnoses, including UTI and heart failure, received Macrobid for a suspected UTI, despite negative culture results and absence of UTI symptoms, without an antibiotic time-out recorded. A third resident with intact cognition and a history of UTI, heart disease, and diabetes was prescribed Levaquin for a UTI, but the medical record lacked documentation of an antibiotic time-out for this course of therapy. Interviews with nursing staff revealed inconsistent knowledge and application of infection criteria, such as McGeer's, and a lack of awareness regarding the facility's chosen criteria for infection assessment. The facility's infection control software relied on user input to trigger antibiotic time-outs, but this process was not consistently followed. The facility's policy required antibiotic reviews (time-outs) 48-72 hours after initiation, but these were not found in the records of the affected residents. Staff interviews confirmed the absence of required antibiotic time-outs and inconsistent posting and understanding of infection assessment criteria.
Failure to Provide Sufficient Nursing Staff Resulting in Missed Resident Care and Supervision
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in multiple deficiencies in care. Staff and family interviews, as well as direct observations, revealed that residents were left unattended for extended periods, did not receive timely assistance with activities of daily living (ADLs), and were not consistently offered toileting or position changes. For example, one resident was left in the same pajamas for several days, was not checked on after returning from the hospital, and did not receive assistance with toileting or morning care until prompted by family. Staff reported being responsible for up to 30 residents at a time, leading to delays in care, missed check and changes, and incomplete ADL support. Documentation showed that on several days, staffing levels were below the facility's own assessment and schedule, with shifts missing both licensed and nursing assistant hours. Specific residents experienced lapses in care, such as not receiving scheduled nail care, being left in soiled briefs for extended periods, and not being repositioned or toileted according to their care plans. One resident's brief was found to have the same staff initials from the previous day, indicating it had not been changed overnight, and staff confirmed that short staffing made it impossible to complete all required checks and changes. Another resident did not receive catheter care or morning hygiene due to staff being unable to complete all tasks, and care plans were found to be incomplete or missing essential information. Staff interviews confirmed that these lapses were directly related to inadequate staffing and high resident-to-staff ratios. Additional deficiencies included failure to respond to residents' food preferences and requests, as staff did not check for available food options or offer seconds, despite facility policy allowing for it. During medication administration, a resident was left unsupervised during a nebulizer treatment, contrary to care plan instructions, and was not assessed for self-administration. The nurse responsible stated she was too busy to remain with the resident or return promptly, and did not complete required post-treatment assessments. These events were corroborated by family and staff interviews, as well as direct observation, and were attributed to insufficient staffing and high workload.
Failure to Monitor Psychotropic Medication Use and Lapse in PRN Order Management
Penalty
Summary
The facility failed to ensure that residents receiving psychotropic medications were properly monitored and that as-needed (PRN) psychotropic medication orders included required end dates, as outlined in facility policy. For multiple residents, including those with severe cognitive impairment, Alzheimer's disease, depression, psychotic disorder, and other significant medical conditions, there was a lack of documented assessments for extrapyramidal symptoms (EPS) using the Abnormal Involuntary Movement Scale (AIMS) or similar tools, as well as missing orthostatic blood pressure monitoring. These assessments are necessary to monitor for side effects of antipsychotic medications, such as tardive dyskinesia and orthostatic hypotension, but records showed that these were not completed as required by policy and physician orders. Additionally, the facility did not ensure that PRN psychotropic medication orders, such as lorazepam, clonazepam, and buspirone, included stop dates or were limited to 14 days as required by the facility's psychotropic medication policy. In several cases, PRN orders remained active without an end date, and there was no documentation of physician evaluation or rationale for extending the orders beyond the policy limit. Interviews with nursing staff and the DON confirmed that these omissions were not in line with facility expectations and policy requirements. The deficiencies were identified through review of medical records, care plans, medication administration records, and staff interviews. The lack of required monitoring and documentation for residents prescribed antipsychotic and other psychotropic medications, as well as the absence of stop dates for PRN orders, constituted a failure to prevent unnecessary medication use and to monitor for adverse effects, as required by both facility policy and standard clinical practice.
Failure to Secure Medications and Maintain Safe Refrigeration Temperatures
Penalty
Summary
The facility failed to ensure that medications and biologicals in the medication room were securely stored and maintained at safe refrigeration temperatures. During an observation, it was found that some storage cupboards in the medication room were either not locked or lacked locks entirely, including cupboards containing stock medications and bins labeled for medication destruction. Additionally, the medication room was observed being left open and unattended by staff, contrary to facility policy requiring medication rooms to be locked when not in use. The medication refrigerator, which contained immunizations, GLP-1 injectables, insulin, and controlled medications, was found to be locked but had an internal temperature of 48 degrees Fahrenheit, exceeding the safe storage range. The temperature log for the fridge was incomplete, with several missed entries over multiple months. The facility's policy required that all compartments containing drugs and biologicals be locked when not in use and that medication refrigerator temperatures be maintained between 36 to 46 degrees Fahrenheit. Despite these requirements, the medication fridge was repeatedly found out of range, and temperature documentation was inconsistent. The consulting pharmacist later recommended destruction and replacement of several medications stored in the fridge due to the unsafe temperature. No residents were reported to have received medications from the affected fridge after the temperature deviation was discovered.
Failure to Provide Assistance with Activities of Daily Living for Multiple Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for four out of five residents reviewed, resulting in unmet care needs. One resident with dementia, heart failure, and macular degeneration required substantial to maximum assistance with ADLs and was at risk for pressure ulcers. Despite care plans specifying nail care and scheduled toileting, the resident was observed with dirty, untrimmed fingernails and left seated in the same position for over three hours without repositioning or being offered toileting. Staff interviews confirmed that toileting and repositioning were not consistently provided, and nail care was not documented or performed as required. Staff cited inadequate staffing as a barrier to providing timely care. Another resident, dependent on staff for all ADLs and always incontinent of bowel, was reportedly left in soiled briefs overnight and through multiple shifts, as evidenced by staff initials remaining on the brief from the previous day. Multiple nursing assistants reported being unable to complete regular check and changes due to chronic understaffing, particularly during evening shifts. The director of nursing confirmed that the expectation was for residents to be checked and changed every two hours, but this was not consistently achieved. Additional deficiencies were noted for two other residents. One resident with multiple medical conditions, including an indwelling catheter, did not receive morning hygiene or catheter care, and the care plan lacked documentation for ADL status and catheter care. Staff confirmed that due to time constraints, only minimal care was provided, and catheter care was omitted. Another resident requiring maximum assistance for personal hygiene and dressing did not receive scheduled bathing or shaving, with staff and the resident attributing the missed care to short staffing. Documentation of refusals and care provided was incomplete or missing.
Failure to Monitor and Intervene for Bowel Movements, Oxygen Saturation, and Skin Integrity
Penalty
Summary
The facility failed to provide appropriate treatment and care according to provider orders and resident needs for several residents. For one resident with multiple diagnoses including COPD, heart failure, and dementia, the facility did not track bowel movements or provide interventions when bowel movements were not recorded for several days, despite orders for bowel management and the resident's report of chronic constipation. Additionally, the care plan did not address oxygen or bowel management, and there was a lack of documentation regarding oxygen administration, including whether oxygen was used and at what liter flow, even though there was an order to monitor daily oxygen saturation and adjust oxygen to maintain saturation above 90%. Another resident with severe cognitive impairment and Parkinson's disease had provider orders for prune juice and PRN MiraLAX if no bowel movement occurred in 48 hours. However, bowel movements were infrequently recorded, and the medication administration records did not show that MiraLAX was administered as ordered, despite daily sign-offs indicating monitoring. Family members also reported ongoing issues with constipation for this resident, and staff interviews confirmed the expectation for bowel movement tracking and intervention, which was not consistently met. A third resident with livedoid vasculitis and moderate cognitive impairment had an order for weekly skin checks to be documented in the electronic health record. However, there was no evidence of completed skin assessments in the resident's record, despite facility policy and staff statements that weekly skin checks were expected. The resident was also known to refuse baths, which may have impacted the completion of skin checks, but the required documentation and monitoring were not present.
Failure to Provide Requested Second Helping of Food
Penalty
Summary
A deficiency occurred when a resident, identified as having heart disease, hypertension, hyperlipidemia, and being moderately cognitively intact, was not provided a requested second helping of food during a meal. The resident's care plan indicated a potential for altered nutrition and included interventions such as monitoring food and fluid intake and offering snacks. During meal service, the resident requested more watermelon, but a nursing assistant informed her that there was no more available without checking with the kitchen. The dietary aide later confirmed that there was additional watermelon available and that residents could have seconds if permitted by their diet. Staff interviews revealed inconsistent understanding of the policy regarding second servings, with the nursing assistant stating residents only receive one serving, while the LPN and RN indicated that seconds are allowed unless restricted by diet. The facility's policy emphasized treating residents with dignity and offering choices at mealtime, including what to eat. The failure to provide the requested second helping was attributed by one staff member to being rushed due to staffing issues, and the dietary manager was responsible for monitoring meal service for preferences and portion sizes.
Failure to Assess and Supervise Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that two residents did not self-administer medications (SAM) as assessed and according to their care plans. One resident with chronic obstructive pulmonary disease (COPD), mild cognitive impairment, and supraventricular tachycardia required partial to moderate assistance with activities of daily living and was not assessed to self-administer medications. Despite this, an LPN set up a nebulizer treatment for the resident and left the room, not returning for 34 minutes. During this time, the resident was observed repeatedly holding the nebulizer mouthpiece, with no staff supervision or assessment of respiratory status, oxygen saturation, or lung sounds as required by the medication order and care plan. Family members also reported that staff did not stay with the resident during treatments and noted instances where used nebulizer equipment was left unattended for hours. Another resident, admitted with a fracture, hyperthyroidism, and recent orthopedic surgery, was also not assessed for self-administration of medications. The care plan did not indicate the resident could self-administer, and there was no provider order for SAM. However, the resident was observed with a cup of medications left at the bedside by a nurse, and the resident stated the nurse had left them there. The medication administration record confirmed multiple medications were given that morning, but there was no documentation of a SAM assessment. Interviews with staff, including the LPN and DON, confirmed that neither resident had been assessed for self-administration of medications prior to being left alone with their treatments or medications. The facility's policy required a SAM assessment and interdisciplinary team review before allowing residents to self-administer medications, including evaluation of cognitive and physical status, medication appropriateness, storage, monitoring, and documentation. These procedures were not followed for the two residents involved.
Failure to Timely Update Care Plans After Significant Changes
Penalty
Summary
The facility failed to ensure timely review and revision of care plans for two residents following significant changes in their conditions and treatments. For one resident with a history of stroke, dysphagia, muscle weakness, and epilepsy, the care plan was not updated after a fall from a recliner, despite a post-fall assessment and identification of the root cause and new intervention. The care plan had last been revised prior to the fall, and staff confirmed that the necessary updates to fall prevention interventions were not made after the incident and interdisciplinary review. For another resident with multiple chronic conditions, including congestive heart failure, diabetes, chronic kidney disease, and severe depression, the care plan did not reflect recent medication changes, such as the initiation of new antidepressant and anticoagulant therapies. The care plan was last revised before these medication orders were implemented. Facility policy requires care plans to be updated on an ongoing basis as needed, especially following significant changes, but this was not done for either resident.
Untrained Nurse Aides Managed Tube Feeding, Breaching Facility Policy
Penalty
Summary
The facility failed to ensure that only competent, trained staff managed tube feeding pumps and tubing for a resident who was dependent on enteral nutrition. The resident, who had a history of stroke, dysphagia, muscle weakness, and epilepsy, was dependent for activities of daily living and received more than half of their nutrition through tube feeding. During morning care, two nurse aides (NAs) paused and disconnected the resident's tube feeding, leaving the uncapped end of the tubing hanging over the pole and later allowing it to touch the floor. One NA wiped the tubing with a tissue before reconnecting it to the resident and restarting the pump, despite not having received formal training on tube feeding management or pump operation. The NA expressed uncertainty about proper infection control procedures and indicated that nurses had only shown them how to pause the pump. Interviews with multiple staff members, including NAs, LPNs, an RN, and the DON, confirmed that NAs were not trained or authorized to operate tube feeding pumps or to connect/disconnect tube feeding tubing. Facility policy specified that only licensed staff should perform these tasks, and there was no record of NAs receiving education or competency checks related to tube feeding management. The deficiency was identified through observation, interview, and record review, demonstrating a lack of adherence to facility policy and proper staff training regarding tube feeding care.
Failure to Offer and Document Flu and Pneumonia Vaccinations Upon Admission
Penalty
Summary
The facility failed to ensure that residents were educated on and offered pneumococcal and influenza vaccinations upon admission, as required by policy. Specifically, one resident admitted prior to 3/31/25 with diagnoses including kidney failure, heart disease, and urinary tract infection did not have any documented vaccination history or evidence of being offered or educated about pneumococcal and influenza vaccines. Another resident admitted after 3/31/25 with a history of kidney transplant, chronic kidney disease, and immunodeficiency also lacked documentation of vaccination history or evidence of being offered or educated about pneumococcal vaccination. During interviews and document reviews, it was confirmed that the facility's process included vaccination reconciliation within 48 hours of admission and checking the Minnesota Immunization Information Connection (MIIC) for immunization history. However, for both residents, there was no vaccine data present in their records. The facility's policy required obtaining immunization history upon admission, sharing unknown or incomplete histories with the attending physician, and documenting this information in the electronic medical record, but these steps were not completed for the residents in question.
Failure to Educate and Offer COVID-19 Vaccination Upon Admission
Penalty
Summary
The facility failed to ensure that residents were educated on and offered COVID-19 vaccinations upon admission, as required by policy. Specifically, two residents with significant medical histories, including kidney failure, heart disease, urinary tract infection, status post-kidney transplant, chronic kidney disease, and immunodeficiency, were admitted without documentation of their COVID-19 vaccination status. Immunization Audit Reports for both residents did not identify any vaccination history, and there was no evidence that the required education or vaccine offer was provided at admission. During an interview, a registered nurse confirmed that vaccination reconciliation, including checking the Minnesota Immunization Information Connection (MIIC) and documenting immunization history, was part of the admission process. However, upon review, the nurse acknowledged that there was no vaccine data for the two residents in question. The facility's policy required that immunization history be obtained and documented in the electronic medical record, and that any unknown or incomplete vaccination histories be communicated to the attending physician for appropriate orders, which was not done in these cases.
Inaccessible and Damaged Bathroom Call Lights
Penalty
Summary
The facility failed to ensure that a working call system was available and accessible in each resident's bathroom and bathing area. Specifically, one resident's bathroom call light was found to be missing a cord, making it unusable from the bathroom floor, while another resident's bathroom call light cord was frayed and visibly damaged. Maintenance staff confirmed these issues, acknowledging that the missing and damaged cords posed a safety concern, as residents would be unable to call for help if needed. The facility's call light policy required staff to position call lights within reach and orient residents to their use, but did not address the condition or presence of call light cords.
Failure in Timely Pain Management for Resident
Penalty
Summary
The facility failed to provide appropriate pain management for a resident with chronic pain syndrome, leading to unmanaged severe pain and disturbed sleep. The resident, who was cognitively intact, had a care plan that included administering medications as ordered and using non-pharmacological interventions like applying cold or heat and repositioning. Despite having orders for hydrocodone-acetaminophen to be given as needed every six hours, the resident experienced a significant delay in receiving pain medication on a particular evening. On the evening in question, the resident activated the call light multiple times over several hours, requesting pain medication for severe flank pain. Nursing staff, including a nursing assistant and two LPNs, were informed of the resident's request, but the medication was not administered until five hours later. During this time, the resident reported escalating pain, describing it as feeling like someone was ripping his side open and rating it a 13/10 on the pain scale. The delay in administering the medication resulted in the resident needing two doses to manage the pain effectively. Interviews with staff revealed communication breakdowns and a lack of timely response to the resident's pain management needs. The nursing assistant informed one LPN of the resident's request, but did not follow up when the medication was not provided. Another LPN was also informed but did not ensure the medication was administered promptly. The director of nursing acknowledged that staff should follow provider orders and care plans when a resident requests assistance, highlighting the deficiency in pain management practices.
Removal Plan
- Facility investigation was coordinated with interviews of staff and residents on unit.
- Pain management policy was reviewed.
- Staff was educated on the pain management policy and expectations if a resident was in pain.
- Audits monitoring pain management practices started.
- LPN-A was provided education for pain management, resident rights, and customer service.
Improper Use of Toileting Sling Leads to Resident Injury
Penalty
Summary
The facility failed to safely use a toileting sling according to the manufacturer's recommendations, resulting in a resident falling from a mechanical lift and sustaining serious injuries, including subarachnoid and subdural brain bleeds. The resident, who had diagnoses of hemiplegia, abnormal involuntary movements, epilepsy, and a malignant neoplasm of the frontal lobe, required total assistance from two staff members for transfers using a mechanical lift with a medium toileting sling. On the day of the incident, a nursing assistant instructed the resident to place her arms inside the sling, contrary to proper procedure, and did not buckle the sling around the resident's waist. As a result, the resident fell from the sling during the transfer, hitting her head on the lift and the floor. The nursing assistants involved in the incident admitted to not having received proper training on the use of mechanical lifts and sling placements prior to the event. One of the nursing assistants acknowledged that she was aware the procedure was incorrect but did not intervene. The mechanical lift company representative confirmed that improper use of the sling, such as not buckling it or having the resident's arms inside, increased the risk of falling. The facility's medical director attributed the resident's injuries to the incorrect application of the toileting sling.
Removal Plan
- Reviewed policies on use of mechanical lifts, including proper placement and size of the slings.
- Re-assessed all residents who utilize a mechanical lift to ensure they have the proper size sling.
- Re-educated all staff who use the mechanical lift on the policy and procedure and did competency testing.
- Completed audits observing staff transferring residents with mechanical lifts results will then be brought to QAPI committee.
Unauthorized Access to Medication Storage Area
Penalty
Summary
The facility failed to ensure that unauthorized staff, visitors, and residents did not have access to the medication storage area, which had the potential to affect all residents on the 400 hallway. During observations, the medication storage area door was found open on multiple occasions without any staff present to monitor access. At 7:18 a.m. and 8:33 a.m. on 7/16/24, the door was open with no staff around, and the nurse manager was in her office with her back to the door. This lack of supervision allowed for potential unauthorized access to medications. Interviews with staff revealed a misunderstanding of responsibility regarding securing the medication storage area. RN-C confirmed the room was open and stated it was the responsibility of the nurse working the cart to secure the room. LPN-B admitted to leaving the door open while administering medications, believing the presence of the nurse manager nearby was sufficient security. However, the assistant director of nursing clarified that the expectation was for all medication storage area doors to remain shut and secured when not attended by a licensed nurse. The facility's policy, last reviewed on 4/11/23, required the medication room to be locked and the door closed at all times when unattended.
Failure to Document Resident's Contracture
Penalty
Summary
The facility failed to comprehensively assess and document a resident's contracture in the right hand upon admission and during subsequent assessments. The resident, identified as R8, was admitted with diagnoses including bilateral lower extremity amputations, anemia, and renal insufficiency, and was noted to have minimal cognitive impairment. The admission Minimal Data Set (MDS) and assessment indicated no functional limitations or impairments in the upper extremities, including the shoulder, elbow, wrist, or hand. However, during an observation, R8 was found to have a contracture in the right hand and fingers, which the resident stated had been present for over two years. Interviews with facility staff, including a registered nurse and the MDS coordinator, revealed that the contracture was not documented in R8's medical records at the time of admission. The registered nurse confirmed the presence of the contracture upon visiting R8's room, and the MDS coordinator acknowledged the lack of documentation regarding the contracture. The assistant director of nursing emphasized the importance of complete and accurate assessments to ensure the MDS is filled out correctly. The facility's policy on MDS 3.0 Assessment, last reviewed in October 2021, mandates comprehensive, accurate, and standardized assessments of each resident.
Inaccurate Care Plans for Hospice and Continence
Penalty
Summary
The facility failed to comprehensively assess and care plan services for two residents, leading to inaccuracies in their care plans. Resident R162, who was admitted on 7/3/24 with impaired cognition and diagnoses of lung and colon cancer, was receiving hospice services. However, the care plan dated 7/3/24 did not include a focus on hospice care and coordination, despite the resident being on hospice services since 2/1/24. This omission was confirmed by RN-A and acknowledged by the Director of Nursing, who stated that hospice care should have been included in the care plan for proper coordination of care. Resident R8, who had minimal cognitive impairment and was always continent of bowel and bladder, was inaccurately documented in the care plan dated 6/4/24 as being always incontinent of bowel. This discrepancy was noted despite the admission assessments and MDS indicating the resident's continence. RN-C acknowledged the error upon reviewing R8's medical record, and the Assistant Director of Nursing emphasized the importance of building care plans based on accurate assessments and resident needs. The facility's policy on Person Centered Care Planning, last reviewed on 4/20/23, mandates that care plans include accurate assessments of resident needs.
Failure to Follow Weight Monitoring Orders
Penalty
Summary
The facility failed to adhere to provider orders for weight monitoring for two residents, R42 and R33, who were under review for unnecessary medications. Resident R42, with impaired cognition and multiple diagnoses including Alzheimer's dementia and diabetes, had a care plan that did not address weight monitoring despite provider orders for weekly weights starting in May 2024. The electronic medical record showed no weight entries from late June to mid-July 2024. Interviews revealed that the nursing assistants were responsible for weighing residents and recording the data, which was then supposed to be entered into the electronic medical record by the nurse. However, there were lapses in this process, partly due to the dietician's absence on vacation and the resident's occasional refusal to be weighed. Resident R33, also with impaired cognition and diagnosed with diabetes and Parkinson's disease, had a care plan indicating weekly weight monitoring due to congestive heart failure. However, the provider orders lacked specific instructions for weights, and the electronic medical record showed missing weights for several weeks between April and July 2024. Interviews with staff confirmed that weights were supposed to be recorded weekly on the resident's bath day, but there were acknowledged gaps in documentation. The facility's Weight Monitoring Program policy required weekly weight tracking, which was not consistently followed, leading to the deficiency.
Failure to Document Rationale for Extended PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to document a rationale for the continuation of a PRN psychotropic medication beyond 14 days for a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease and dementia. The resident had a physician order for Ativan, a psychotropic medication, to be administered as needed for anxiety and hallucinations, with no specified end date. The medication was administered 14 times over a two-week period. During an interview, the assistant director of nursing acknowledged that the interdisciplinary team should have discussed the PRN order in their monthly pharmacy review meeting. The order lacked a documented rationale from the provider for its extended use, which is required by the State Operations Manual from the Centers for Medicare & Medicaid Services.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for residents with indwelling catheters and a chronic wound, as observed during a survey. One resident with an indwelling urinary catheter was not provided with the required personal protective equipment (PPE) by a nursing assistant during personal care activities, despite clear signage indicating the need for EBP. The nursing assistant admitted to not wearing a gown and gloves, acknowledging the importance of these precautions for infection control. Another resident with an indwelling urinary catheter also did not receive the necessary EBP during repositioning by a nursing assistant. Although PPE supplies were available outside the room, the nursing assistant initially failed to don a gown and gloves. It was only after observing another nursing assistant wearing PPE that the first assistant corrected her actions, confirming the requirement for PPE during such activities. Additionally, a resident with a stage 3 pressure ulcer did not have EBP implemented, as evidenced by the absence of signage and PPE outside the room. The registered nurse and assistant director of nursing were uncertain about the necessity of EBP for this resident, despite the facility's policy indicating that chronic wounds require such precautions. The assistant director confirmed the resident's pressure ulcer and the lack of EBP orders, acknowledging the oversight.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that required nurse staffing data was posted daily before each shift, including over the weekend, which had the potential to affect all 61 residents, staff, and visitors who wished to review this information. During an observation on 7/14/24, it was noted that the nurse staffing data posting was dated 7/11/24, indicating that the information had not been updated for several days. The administrator confirmed that the updated nurse staff data sheets were not posted at the beginning of the shifts on 7/12/24, 7/13/24, or 7/14/24. The responsibility for posting the data sheets was assigned to the scheduler, who was not present at the facility on those dates. Interviews revealed that the scheduler typically leaves completed nurse staff data sheets in the supervisors' book when not at the facility, with the expectation that the director or assistant director of nursing would post them on weekdays and the charge nurse on weekends. However, it was acknowledged by both the scheduler and the assistant director of nursing that the sheets were sometimes not posted on weekends, remaining in the supervisors' book until Monday mornings. The facility's policy, dated 12/18, requires daily posting of staffing levels for review by residents and families, which was not adhered to in this instance.
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A resident with dry eye syndrome and degenerative eye disease had orders for cyclosporine ophthalmic emulsion and Refresh Tears, both scheduled at the same time. Medication records and direct observation showed a TMA instilled cyclosporine drops in both eyes and immediately followed with Refresh Tears in both eyes without waiting between medications. This practice conflicted with referenced professional guidance recommending several minutes between multiple eye drops and with the medical provider’s recommendation to wait fifteen minutes between the two ophthalmic medications. No facility policy on ophthalmic medication administration was provided when requested.
A resident with severe cognitive impairment, impaired mobility, and high fall risk was care planned to have wheelchair footrests in place at all times, with staff ensuring proper positioning and monitoring for leaning during transport. A NA transported the resident in a manual wheelchair from the shower without the footrests, and while going through the doorway the wheelchair struck the door frame, causing the resident, who was leaning forward, to fall out. The resident sustained a T12 fracture, head injury with concussion, abrasions and contusions, and multiple right-hand lacerations requiring sutures, and the DON confirmed the care plan had not been followed.
A high‑risk, immobile resident with MS and prior heel DTI developed an avoidable unstageable coccygeal pressure ulcer after staff failed to consistently assess and document skin status, did not transfer or timely provide ordered pressure‑relieving mattresses, and did not reliably perform q2h repositioning. The resident was repeatedly left on a bedpan for prolonged periods despite early reports of this issue, and the toileting care plan was not revised to a bedside commode until after the coccygeal wound had significantly worsened. Wound assessments lacked complete measurements and staging, changes in wound size and color were not promptly recognized as deterioration or reported to providers, and recommended interventions from a wound NP (including an air mattress and offloading) were not promptly implemented. As a result, the coccygeal ulcer rapidly progressed to a large, necrotic, malodorous wound requiring hospital transfer and surgical debridement.
A resident with spastic hemiplegia, muscle weakness, and moderate cognitive impairment was observed using bilateral bed grab bars for bed mobility and transfers, but the care plan did not address grab bar or side rail use. Review of the EMR showed no completed bed mobility device or side rail assessment to determine the necessity or safety of the grab bars, and no documentation that risks and benefits were discussed or that informed consent was obtained. An LPN and the ADON stated that a bed mobility device assessment is required before grab bars are installed and confirmed that no such assessment existed for this resident.
A resident with bilateral heel pressure ulcers and multiple comorbidities received wound care during which an RN removed dressings from both heels, cleansed both wounds, and wiped each heel without changing gloves or performing hand hygiene between wounds or after disposing of soiled dressings. This practice conflicted with the facility’s written wound care procedure, which requires glove removal and hand hygiene after dressing removal and after wound cleansing. In interviews, the RN, NP, and DON/IP acknowledged that hand hygiene and glove changes are expected between dirty and clean tasks and between separate wounds to prevent infection.
A resident with MS, neurogenic bladder, mobility limitations, and existing pressure injuries was identified as dependent for toileting hygiene and at risk for pressure ulcers, yet the care plan lacked an individualized toileting/incontinence plan and a defined repositioning schedule. Despite a new coccyx pressure ulcer and documentation that interventions such as increased repositioning and incontinent care were needed, the care plan was not revised for a period of time to reflect these changes. During this time, the resident sometimes fell asleep on a bedpan and remained on it until staff removed it, and staff were not initially informed that the bedpan should no longer be used. The DON later acknowledged that the care plan revisions for turning, repositioning, and toileting were delayed until after the resident’s coccyx ulcer had significantly worsened.
A resident with diabetes, Crohn’s disease, bowel incontinence, and a history of MASD on the right gluteus developed an open, painful lesion on the right gluteal area that was documented over time without complete wound characteristics, clear etiology, or timely provider notification. Wound care orders were written for a stage 3 pressure ulcer on the left buttocks, while staff reported the wound was only on the right side and applied the left‑sided orders to the right gluteal wound in the absence of specific right‑side treatment orders. The DON acknowledged discomfort with staging the wound, lack of early physician notification, and confusion over wound classification, despite a facility policy requiring comprehensive wound assessment, consistent measurement, and provider notification when treatment orders are absent.
A resident with diabetes, chronic leg ulcer, kidney transplant, and a documented gluteal wound was care-planned for Enhanced Barrier Precautions (EBP), with posted instructions requiring gown and gloves for high-contact care such as transfers and wound care. During a telehealth wound assessment, the DON donned a gown and initially performed hand hygiene but then applied gloves without hand hygiene, removed a soiled dressing from the resident’s gluteal area, discarded it, removed gloves, and applied new gloves again without performing hand hygiene between glove changes. On another occasion, during use of a sit-to-stand lift, an NA wore gown and gloves, but the DON handled the lift harness, the resident’s clothing, and assisted with the transfer and repositioning while wearing a gown but no gloves, despite EBP requirements for transfers. The DON stated EBP was only needed for catheter or wound care and not for transfers, contradicting the posted EBP instructions and facility policy.
A resident with severe dementia, psychiatric disorders, and high dependence for ADLs was verbally abused during evening care when a NA, frustrated with the resident’s crying and resistance, loudly ridiculed her as acting like a two-year-old, threatened to hit her back if struck, told her she would be sent to a locked unit, and questioned who would want to care for her when she cried like a baby. Multiple staff witnessed the loud, stern, and intimidating tone and reported it to an LPN, who recognized it as verbal abuse but did not immediately remove the NA from duty or promptly report the allegation per policy, allowing the NA to continue working on the unit. Following this incident, the resident demonstrated increased crying, combativeness, resistance to care, wandering, self-isolation, and refusal of food, fluids, and medications above baseline, with documentation of significant emotional distress and subsequent ED evaluation for aggressive behaviors and poor intake.
A resident with dementia, bilateral above‑knee amputations, vascular disease, and severe protein‑calorie malnutrition developed a wound on an amputation stump that had a dressing dated several days before any documentation or treatment orders appeared in the record. Although bath audits and nursing notes initially reported no skin issues, a later assessment described a full‑thickness stage 4 ulcer/diabetic ulcer on the stump with exposed bone, erythema/edema, slough, and moderate serosanguineous drainage. Nursing staff interviews showed no one could identify who first discovered the wound or applied the initial dressing, and there was no evidence that the wound was assessed, the provider notified, or standing orders implemented when it was first present, despite facility expectations that new wounds be promptly evaluated and reported.
Failure to Follow Professional Standards for Ophthalmic Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice for administering ophthalmic medications to a resident with dry eye syndrome and degenerative eye disease. The resident was cognitively intact, required assistance with ADLs, and had physician orders for cyclosporine ophthalmic emulsion 0.05% one drop in both eyes twice daily and Refresh Tears ophthalmic solution one drop in both eyes four times daily for dry eyes. The administration summary showed that both eye medications were scheduled for the same time and were documented as being given at the same time on multiple dates. During a medication pass observation, a trained medication aide administered the ordered oral medications, then applied gloves and instilled one drop of cyclosporine in each eye, immediately followed by one drop of Refresh Tears in each eye, without any waiting period between the two medications. The surveyors referenced guidance from the American Academy of Allergy, Asthma, and Immunology stating that when more than one eye drop is ordered, three to four minutes should be allowed between drops in the same eye, and five to fifteen minutes should be allowed between different eye medications to prevent dilution. Interviews with the DON, pharmacy consultant, and medical provider confirmed that best practice and the provider’s recommendation were to wait between administration of cyclosporine and Refresh Tears, with the medical provider specifying a fifteen-minute interval. The facility did not provide a policy on ophthalmic medications when requested. The observed practice and documented administration times demonstrated that staff did not follow these professional standards or the medical provider’s recommended interval between the two eye medications.
Failure to Follow Wheelchair Transport Care Plan Leads to Fall With Injuries
Penalty
Summary
The deficiency involves the facility’s failure to implement care-planned fall prevention interventions for a resident at high risk for falls, resulting in a fall with injury. The resident had diagnoses including aphasia, dysphagia, muscle weakness, traumatic brain injury, and impaired mobility, with severe cognitive impairment documented on the MDS and dependence on staff for transfers and wheelchair transport. A care plan addressing wheelchair transport safety and positioning directed staff to ensure the resident was fully positioned and supported in the wheelchair prior to transport, verify footrests were in place prior to transport, and monitor for leaning, sliding, or unsafe positioning. An additional care-planned approach required wheelchair pedals to be on at all times. On the date of the incident, a nursing assistant transported the resident in a manual wheelchair from the shower room to the resident’s room without the foot pedals in place, contrary to the care plan. While being wheeled through the doorway, the wheelchair struck the door frame, causing the chair to stop and the resident, who had begun leaning forward, to fall out of the wheelchair onto the floor. Progress notes and ED documentation identified that the resident sustained a T12 vertebral fracture, a head injury with concussion, an abrasion and contusion to the head, a bruise to the left knee, and multiple lacerations to the right hand requiring sutures. The nursing assistant later acknowledged awareness that the foot pedals should have been on but did not apply them because the transport was only from the shower to the room. The DON confirmed that the resident’s care plan had not been followed when the fall occurred.
Failure to Implement and Update Pressure Ulcer Prevention and Treatment Led to Avoidable Unstageable Coccygeal Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, monitor, and implement individualized pressure ulcer prevention and treatment interventions for multiple high‑risk residents, resulting in an avoidable, unstageable coccygeal pressure ulcer for one resident that required surgical debridement and hospitalization. The resident had primary progressive multiple sclerosis, hereditary spastic paraplegia, obesity, and pre‑existing pressure‑related deep tissue injury to the left heel, and was identified as high risk for pressure ulcers on the Braden Scale due to constant moisture, chairfast status, very limited mobility, inadequate nutrition, and friction/shear risk. Hospital records on readmission documented irritant contact dermatitis of the bilateral gluteal cleft with specific cleansing and barrier cream orders, and facility documentation showed the resident could not reposition in bed or chair and required assist of two and a full‑body mechanical lift for transfers. Despite this, the admission/readmission skin assessment and weekly skin checks lacked measurements and detailed wound characteristics for the heel ulcer and gluteal dermatitis, and the care plan did not include comprehensive, individualized interventions beyond generic repositioning and wound care orders. After a new coccyx pressure ulcer was identified and documented as a stage 2 lesion, the facility failed to promptly and accurately update the care plan and implement recommended pressure‑relieving interventions. The wound nurse practitioner on 3/5 ordered coccyx wound care, an air mattress, pressure offloading, and a dietician consult, but the care plan was not revised and there was no evidence that an air mattress was placed on the bed for nearly two weeks. The environmental services director later confirmed that when the resident was moved to a new room, the gel mattress was not transferred, and the air mattress requested on 3/17 was not actually placed until the following day, despite being marked as completed. During this period, TAR documentation showed gaps in the every‑2‑hour repositioning order, and staff interviews revealed that CNAs were unaware of which residents were on repositioning programs, were not consistently repositioning residents, and had not received recent education on pressure ulcer prevention. The DON and RN case manager acknowledged that the coccyx wound increased in size and changed color between assessments, that the bed lacked the ordered gel mattress, and that the physician was not notified of the wound’s deterioration at that time. The facility also failed to timely modify toileting and incontinence care practices despite knowledge that the resident was being left on a bedpan for extended periods. The DON reported hearing before an IDT meeting that the resident had fallen asleep on a bedpan for an undetermined amount of time, but the care plan was not revised to discontinue bedpan use and implement a bedside commode until after the coccyx wound had significantly worsened. CNAs confirmed that the resident sometimes fell asleep on the bedpan and that they were not informed she should no longer use it until after the sore had worsened. Subsequent wound assessments documented rapid progression of the coccyx wound from a small stage 2 ulcer to a large, malodorous, necrotic wound with eschar, slough, erythema, and purulent drainage, ultimately classified as an unstageable pressure ulcer. The DON, NP, PA, and medical director all indicated that the lack of a pressure‑relieving mattress, failure to adjust pressure‑reducing interventions, and prolonged time on a bedpan likely contributed to the development and deterioration of the resident’s pressure ulcer, which was determined to be avoidable and resulted in hospitalization and surgical debridement. Additional documentation and interviews showed systemic assessment and communication failures related to pressure ulcer management. Weekly skin checks and wound assessments often omitted complete measurements, staging, and wound characteristics, and changes in wound size and appearance were not consistently recognized as deterioration or communicated to providers. The DON acknowledged that a 3/12 assessment showing increased wound size and purple discoloration should have been identified as a deep tissue injury and reported to the physician, but this did not occur. When nursing later documented foul odor, increased pain, and expanding necrotic tissue, telemedicine and PA responses deferred in‑person evaluation and ED transfer despite earlier recommendations that the resident be sent to the ED if an in‑person provider could not assess the wound. The NP ultimately found a large, malodorous, purulent wound with expanding eschar and ordered transfer to the hospital, where imaging and surgical findings confirmed a large necrotic sacral wound requiring extensive debridement. Throughout this sequence, the facility did not consistently follow its own pressure ulcer protocols, did not ensure ordered pressure‑relieving equipment was in place, and did not promptly revise care plans or interventions in response to known risk factors and documented wound changes. The report also notes that other residents reviewed for pressure ulcers were affected by similar failures in monitoring and individualized intervention, though detailed narratives focus primarily on this resident. Staff interviews revealed that CNAs relied on paper care guides that did not clearly identify residents on repositioning programs or at risk for skin breakdown, and that they were unaware of some residents’ special mattress orders or toileting restrictions. The DON and medical director stated that residents at risk for pressure ulcers should have immediate pressure‑relieving interventions and that existing ulcers require ongoing evaluation to prevent deterioration, but the documented practices for this resident did not align with those expectations. These combined actions and inactions—insufficient assessment detail, delayed or missing care plan revisions, failure to implement ordered support surfaces and repositioning, and delayed response to wound deterioration—constituted the deficiency in providing appropriate pressure ulcer care and preventing new ulcers from developing.
Failure to Assess, Care Plan, and Obtain Consent for Bed Grab Bar Use
Penalty
Summary
The deficiency involves the facility’s failure to follow required procedures before installing and using bed grab bars for a resident. The resident had diagnoses including spastic hemiplegia affecting the left side and muscle weakness, and an admission MDS indicating moderate cognitive impairment. During observation, the resident was seen in a power chair with bilateral grab bars on the bed and reported using them to roll in bed and for transfers. The resident’s care plan, dated 1/23/26, documented a need for assistance with bed mobility and independence with transfers but did not mention or address the use of grab bars or side rails. Review of the electronic medical record showed no completed grab bar/side rail or bed mobility device assessment to determine the necessity of the grab bars or whether the resident could safely use them. There was also no evidence that the resident or the resident’s representative had been educated on the risks of having a grab bar on the bed or that informed consent had been obtained. In interviews, an LPN and the ADON both stated that a bed mobility device assessment was required to determine need and safety prior to installing grab bars, and both confirmed that no such assessment was present in the resident’s record.
Failure to Perform Hand Hygiene and Change Gloves During Wound Care
Penalty
Summary
Surveyors observed that a registered nurse (RN) and a nurse practitioner (NP) did not follow the facility’s established infection control practices during wound care for one resident. During a wound treatment, the RN wore gloves while removing the dressing from the resident’s left heel, then removed the dressing from the right heel, sprayed both wounds with wound cleanser, wiped the left heel with gauze, and then used a clean gauze pad to wipe the right heel. The RN did not remove her gloves or perform hand hygiene after disposing of the soiled dressings or between cleaning the left and right heel wounds, contrary to the facility’s written wound care procedure, which requires glove removal and hand hygiene after removing the previous dressing and again after cleaning the wound. The resident’s admission MDS documented diagnoses including multiple rib fractures, heart failure, dementia, anxiety, and the presence of a pressure ulcer, and indicated the resident was cognitively intact and required staff assistance with care and transfers. The resident’s care plan identified pressure ulcers on both heels requiring wound care. In interviews, the RN, NP, and the DON/infection prevention nurse each stated that gloves should be changed when moving from dirty to clean areas and that hand hygiene is expected after glove removal and between wounds to prevent infection, confirming that the observed practice did not align with facility policy or expected infection control standards.
Failure to Timely Revise Care Plan for Toileting and Skin Integrity
Penalty
Summary
The deficiency involves the facility’s failure to timely revise and individualize a resident’s care plan to address toileting and incontinence needs in relation to impaired skin integrity. The resident had diagnoses including primary progressive multiple sclerosis, hereditary spastic paraplegia, obesity, and a pressure-induced deep tissue injury to the left heel. A Significant Change MDS identified the resident as dependent for toileting hygiene, with lower extremity range-of-motion limitations, wheelchair use, dependence for transfers, occasional urinary incontinence, intact cognition, and at risk for pressure ulcers with existing unhealed pressure injuries and MASD. The resident’s skin-focused care plan, revised on various dates, included skin inspections, wound care orders, weekly skin checks, pressure ulcer care to the left heel, nutritional supplements, and a gel mattress, but did not include an individualized toileting or incontinence plan. On a weekly skin check dated 3/3/26, nursing staff identified a new Stage 2 pressure ulcer on the coccyx and contact dermatitis on both gluteal folds. An IDT Final Post Review Follow Up dated 3/10/26 (signed 3/23/26) documented that a new skin issue had occurred and that interventions after the incident included wound care treatment orders, increased repositioning, and increased incontinent care. However, the resident’s care plan from 3/3/26 through 3/16/26 did not show revisions reflecting increased incontinence care or a repositioning schedule, and the care plan was not updated to include these elements until 3/17/26. During this period, the care plan still lacked an individualized toileting plan despite the resident’s identified incontinence and new coccyx pressure ulcer. Progress notes on 3/17/26 documented that the resident’s coccyx wound had declined, with an evaluation describing a deteriorating wound characterized as a Kennedy terminal ulcer/End of Life, staged as a Stage 4 pressure ulcer, in-house acquired, with increased size, exudate, odor, pain, and surrounding erythema. On that same date, the skin focus care plan was revised to include prompt incontinence care and keeping the skin clean and dry, and the elimination focus care plan was revised to address incontinence due to neurogenic bladder with use of a bedside commode offered every 2–3 hours. A nursing assistant reported that when working with the resident, the resident would sometimes fall asleep on the bedpan and forget to ask staff to remove it, and that she was not aware the resident was not supposed to use the bedpan until after the sore had worsened. The DON stated that the resident’s care plan had not been revised earlier to include a turning and repositioning schedule or toileting changes, and that it should have been revised as soon as staff learned the resident was falling asleep on the bedpan, rather than waiting until after the pressure ulcer worsened.
Failure to Assess and Notify Provider for Right Gluteal Wound
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess and appropriately manage a non‑pressure skin issue on a resident’s right gluteal area, and to notify the physician in a timely manner. The resident had diagnoses including diabetes, Crohn’s disease, and a kidney transplant, and the MDS indicated occasional bowel incontinence, no pressure ulcers, and no moisture‑associated skin damage at that time. Earlier documentation identified a resolved MASD to the right gluteus, and a progress note later described a sacral wound with creams applied, noting that sores were still open and painful during application, but without any measurements, wound characteristics, or evidence of physician notification. Subsequent wound assessments documented an open lesion on the right gluteus with specific measurements on multiple dates, but did not identify the wound type or other characteristics, and the record did not show physician notification or treatment orders for the right gluteal lesion. Provider orders in place initially addressed cleansing the buttocks and applying barrier cream, and later included a detailed wound care order for a stage 3 pressure ulcer documented on the left buttocks. However, the resident’s record did not contain a specific treatment order for the right gluteal wound, despite the ongoing documentation of an open lesion in that area. Interviews revealed confusion and inconsistency in wound identification and classification. The DON stated that the right gluteal wound was documented as an open lesion because she did not feel comfortable determining the wound type, and acknowledged that the physician should have been notified when the wound was first identified. The DON was unaware that the NP had documented the wound as being on the left buttocks and as a stage 3 pressure ulcer, while the RN reported that the wound had never been on the left buttocks and that she had been applying the left‑sided wound orders to the right gluteal area because there was no open area on the left. The resident reported a recurring painful area on the right buttocks and chronic stool leakage since prior anal fistula surgery. The facility’s own wound treatment policy required comprehensive assessment of wound etiology and characteristics, consistent measurement and documentation, and provider notification in the absence of treatment orders, which were not followed for this resident’s right gluteal wound. The deficiency centers on the lack of a comprehensive wound assessment for the right gluteal lesion, incomplete documentation of wound characteristics, failure to clearly determine and document the wound etiology, and failure to notify the physician and obtain appropriate treatment orders when the wound was identified and remained open. These actions and inactions resulted in a discrepancy between the documented wound location and type and the actual clinical presentation, as well as a period during which the right gluteal wound had no specific, clearly ordered treatment despite being open and painful.
Failure to Perform Hand Hygiene and Implement Enhanced Barrier Precautions During Wound Care and Transfers
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper hand hygiene during wound care and to consistently implement Enhanced Barrier Precautions (EBP) for a resident requiring such measures. The resident had diagnoses including diabetes, a non-pressure chronic ulcer of the right lower leg, and a kidney transplant, and a wound assessment documented an open lesion on the right gluteal area. The resident’s care plan and a sign posted outside the room specified that EBP, including gown and gloves, were required for high-contact care activities such as dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, catheter care, and wound care. During one observation, the DON performed hand hygiene and donned a gown before entering the resident’s room for a telehealth wound assessment. Inside the room, the DON went into the bathroom, applied gloves without performing hand hygiene, removed the resident’s brief, and removed a foam dressing from the right gluteal area that had stool on one corner. After discarding the soiled dressing, the DON removed gloves and then applied new gloves without performing hand hygiene between glove changes. When questioned, the DON stated that hand hygiene should be done when hands or gloves are visibly soiled and before and after removing or applying gloves, and acknowledged that hand hygiene had not been performed each time gloves were removed and reapplied. In a separate observation, the resident was transferred using a sit-to-stand mechanical lift while EBP requirements were not fully followed. An NA entered the room wearing a gown and gloves with the lift, and the DON applied the lift harness under the resident’s arms and cinched the waist strap, encountering the resident’s clothing, while not wearing gloves. After the transfer to bed, the DON pulled down the resident’s pants and removed the harness while touching the resident’s clothes. Following wound care by a CNP-WOC, the DON again assisted the resident by sitting the resident on the edge of the bed, applying the lift harness, and adjusting the resident’s pants and shirt while wearing a gown but no gloves. The DON stated that EBP was only needed for catheter or wound care and not for transfers, and only upon reading the posted EBP sign acknowledged that EBP was required for all high-contact resident care activities, including transfers.
Failure to Protect Resident From Verbal Abuse and Delay in Removing Alleged Perpetrator
Penalty
Summary
The deficiency involves the facility’s failure to protect a vulnerable resident from mental abuse and to respond appropriately to an allegation of abuse. The resident had severe cognitive impairment, Alzheimer’s disease, dementia, anxiety, depression, psychotic disorder, and significant functional dependence, including frequent incontinence and the need for extensive assistance with ADLs and transfers. Her care plan identified behavioral and mood issues such as wandering, yelling, combative behavior, and calling staff names, with interventions including calm approaches, emotional support, redirection, and monitoring for emotional distress and mood/behavior changes. She was identified as a vulnerable adult, with instructions to monitor for signs of emotional distress and to follow the facility’s abuse reporting policy. On the evening in question, while the resident was crying on the phone with her son and expressing a desire to leave, NA-A and NA-B entered to provide evening care using an EZ stand lift. After the resident ended the phone call, multiple staff reported that NA-A spoke to the resident in a loud, stern, and frustrated tone, telling her to stop crying and that she was acting like a two-year-old. When the resident swatted at NA-A, NA-A stated, “If you hit me, I’m going to hit you back,” and later told the resident she was “in trouble now.” Staff reported that NA-A told the resident she would be sent to a locked unit so she could not get out, and questioned who would want to care for her when she cried like a baby, and that nobody would want to keep working with her. NA-C described NA-A yelling commands such as “HOLD ON!” and “Stop crying! Where would you be if you were not here? Probably lying on the floor,” and felt NA-A was obviously upset and overwhelmed. These statements were made in the presence of the resident while she was already distressed and crying. Following this interaction, the resident exhibited crying, yelling, combativeness, resistance to care, wandering into other residents’ rooms, self-isolation, and refusal of food, fluids, and medications above her prior baseline, as documented in behavior charts, target behavior monitoring, and nursing progress notes. Staff documented that she cried most of the morning, was very restless, difficult to redirect, hit and pinched staff, called staff names, and refused care and meals. She required repeated redirection, 1:1 attention, and non-pharmacological interventions, and was ultimately sent to the ED for evaluation of combativeness and emotional distress, where she was treated for dementia with aggressive behavior and hypoglycemia related to poor intake. The report identifies that the resident’s actual response and the reasonable person concept showed serious psychosocial harm, including increased crying and combative behavior above baseline, fear/anxiety manifested as combativeness, resistance to care and social interaction, and self-isolation. The facility also failed to immediately remove the alleged perpetrator from resident care and to promptly report and investigate the allegation in accordance with its abuse policy. After NA-B and NA-C reported to LPN-A that NA-A had yelled at and threatened the resident, LPN-A acknowledged it as verbal abuse but did not initiate immediate protective measures or timely reporting. LPN-A stated she believed she had 24 hours to report because there was no injury, despite facility policy requiring reporting within two hours. NA-A remained on the unit and continued working until the end of her shift, including after staff had clearly communicated their concerns to LPN-A. TMA and NA staff described uncertainty about their authority to remove NA-A and reliance on the nurse to act, while the DON later informed LPN-A that NA-A should have been removed from the floor to prevent further danger to residents. The Immediate Jeopardy was determined to have begun when NA-A’s derogatory, intimidating, and threatening statements were made and continued while she remained on duty with access to the resident and other vulnerable residents.
Failure to Timely Assess and Treat Newly Discovered Stump Wound
Penalty
Summary
The deficiency involves the facility’s failure to provide timely treatment and care for a newly discovered wound on a resident’s above‑knee amputation stump. The resident was admitted with diagnoses including unspecified dementia with behavioral disturbances, vascular dementia, bilateral above‑knee amputations, vascular disease, reduced mobility, and severe protein‑calorie malnutrition, and had no documented ulcers or skin problems on admission or on the most recent MDS. A weekly bath audit on 3/17/26 documented only non‑tender lymph nodes on the right upper hip and did not identify any open areas. However, when the wound was later assessed, the dressing on the stump was dated 3/16/26, indicating that a wound and dressing existed at that time, even though no corresponding assessment, provider notification, or treatment orders were documented. On 3/23/26, nursing staff documented a new skin issue above the resident’s knee at the amputation site, describing a stage 4 pressure ulcer/injury with full‑thickness skin and tissue loss, exposed bone, erythema/edema, and moderate serosanguineous exudate. The wound measured 1.56 cm by 1.64 cm, with 20–29% granulation tissue and 80% slough. A progress note and skin issues assessment on that date confirmed the wound characteristics and staging, and the NP, after reviewing a picture, determined the wound to be a diabetic ulcer with peripheral vascular disease and severe protein‑calorie malnutrition as contributing factors. On that same date, the NP was notified, antibiotic therapy (doxycycline) was ordered for possible cellulitis, and specific wound care orders were initiated, with documentation on the MAR that these treatments were carried out beginning 3/23/26. Multiple interviews with nursing staff revealed that no one could identify who discovered the wound or who applied the initial dressing dated 3/16/26, and there was no documentation of a wound assessment, provider notification, or interim treatment between 3/16/26 and 3/22/26. Several RNs and LPNs who worked shifts from 3/16/26 through 3/20/26 stated they did not notice a wound on the stump and that, per their usual practice, they would have contacted the provider and initiated treatment if they had found one. One LPN recalled seeing a band‑aid with a date on the stump but could not recall the date, and another LPN stated she did not see the wound because she was not looking for one. The facility’s standing orders required staff to assess all wounds daily, change dressings every three days and as needed, treat with normal saline or non‑cytotoxic cleanser and appropriate dressings, and notify the provider the next business day when a new wound or injury was found. Despite these expectations, the wound identified by the dated dressing on 3/16/26 was not assessed, reported, or treated according to orders and facility policy until 3/23/26.
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