Harmony Gardens
Inspection history, citations, penalties and survey trends for this long-term care facility in Maplewood, Minnesota.
- Location
- 1438 County Road C East, Maplewood, Minnesota 55109
- CMS Provider Number
- 245381
- Inspections on file
- 25
- Latest survey
- April 4, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Harmony Gardens during CMS and state inspections, most recent first.
The facility did not properly assess or document the use of bedrails as physical restraints for four residents, including those with cognitive and physical impairments. Bedrails were present and in use, but care plans and MDS assessments failed to reflect their use or classify them as restraints. Staff interviews revealed inconsistent practices, lack of provider orders, and absence of resident or representative consent, resulting in a failure to follow required assessment protocols.
The facility did not attempt alternative devices, assess for entrapment risk, review risks and benefits, or obtain informed consent before installing bed rails for four residents. Therapy evaluations and care plans did not document bed rail use, and staff were unaware of safety risks. Residents and families were not educated on the risks, and the facility did not follow its own policy requiring assessment and consent for bed rail installation.
A resident with significant cognitive and physical impairments was the subject of a family grievance alleging aggressive care by a nursing assistant, followed by the discovery of unexplained bruising resembling finger marks. Despite these events, staff did not report the allegations or the injury of unknown origin to the State Agency as required, and key staff were unaware of mandatory reporting protocols.
A resident with moderate cognitive impairment and significant physical limitations was found with unexplained bruising resembling finger marks after a family grievance about aggressive care. The facility did not document or investigate the injury as required, failed to notify the NP, and did not follow its own policy for investigating suspected abuse or injuries of unknown source. Key staff were not interviewed, and the incident was not logged or analyzed according to facility procedures.
The facility failed to adhere to transmission-based precautions and hand hygiene protocols, affecting multiple residents. Staff entered rooms without proper PPE, and there was confusion about the required precautions. Additionally, hand hygiene lapses were observed during medication administration, indicating systemic issues in the infection control program.
A resident with mild cognitive impairment and medical conditions experienced a 62-minute delay in receiving assistance for toileting, due to staff miscommunication and shift change challenges. The delay led to the resident's discomfort and missing an activity, highlighting a failure to adhere to the facility's policy on prompt response to resident needs.
A resident, who was cognitively intact and on high-risk medications, was not assessed for safe self-administration of medication. Despite lacking a SAM assessment and provider order, a nurse left Tylenol at the resident's bedside, contrary to facility policy. Interviews confirmed the oversight, highlighting a failure to follow procedures for self-administration of medications.
A resident with conditions such as diabetes and osteoarthritis was not consistently offered participation in their ambulation program, despite being cognitively intact and willing to participate. Documentation showed a decline in ambulation frequency, and staff interviews revealed confusion about program responsibilities after changes in the restorative nursing program.
A resident at risk for pressure injuries did not receive care planned interventions, such as heel elevation, despite complaints of heel pain. Observations showed the resident's heels resting on the bed, and staff failed to address the pain or elevate the heels. An LPN later found the resident's heel to be red and blanchable, indicating a risk for pressure injury.
A resident with mild cognitive impairment and muscle weakness was not provided with a prescribed hand splint to maintain range of motion, as observed in multiple instances. Despite care plan instructions and occupational therapy recommendations, the splint was not used, and staff were unaware of its necessity. The facility's policy for implementing therapy recommendations was not followed, leading to a deficiency in care.
A facility failed to properly assess and implement a toileting program for a resident with a history of stroke and edema, leading to frequent incontinence. Despite being cognitively intact, the resident experienced delays in staff response to call lights, resulting in incontinence episodes. The care plan inaccurately reflected the resident's continence status, and staff were unaware of any specific toileting plan, contrary to facility policy.
A resident with severe cognitive impairment and a history of weight loss was not weighed weekly as required, despite being on high-risk nutrition monitoring. The facility's staff failed to document and communicate missed weights, and the policy on obtaining resident weights was not provided, indicating a lapse in adherence to care protocols.
A facility failed to monitor and document a resident's dialysis fistula site, resulting in unaddressed bruising and swelling. The resident, requiring hemodialysis, experienced pain and swelling at the site, which was not properly assessed or documented by staff. Communication issues with the dialysis center were noted, and the DON confirmed the need for improved monitoring.
A resident with a history of gastric bypass surgery and malabsorption did not consistently receive their requested breakfast items, such as breakfast bars, despite these preferences being documented in their care plan and meal ticket. Interviews and observations revealed that the facility staff, including nursing assistants and the registered dietician, were aware of the resident's preferences but failed to consistently meet them, leading to dissatisfaction and potential nutritional risk.
A resident with a history of vascular dementia and other conditions required assistance for transfers. During a transfer, a nursing assistant failed to use a gait belt as required, resulting in the resident falling and sustaining a subarachnoid hemorrhage. The assistant was aware of the policy but chose not to use the belt, believing the resident could grab onto the chair. The incident led to noticeable changes in the resident's condition, including difficulty processing and following cues.
The facility failed to follow standard practice when CPR was initiated on a resident who displayed signs of rigor mortis. Despite the resident's POLST indicating a desire for full resuscitation, the staff performed CPR even though the resident exhibited clear signs of irreversible death. The incident involved delays and lack of clear documentation, and the nurse practitioner was not informed of the resident's full code status.
Failure to Accurately Assess and Document Bedrail Use as Physical Restraints
Penalty
Summary
The facility failed to accurately assess the use of physical restraints, specifically bedrails, for four residents who were observed to have bedrails in use. Despite the presence of bedrails, the residents' care plans and Minimum Data Set (MDS) assessments did not document the use of these devices, nor did they identify them as restraints. In several cases, residents were cognitively impaired and unable to remove the bedrails themselves, which meets the definition of a physical restraint according to the CMS Resident Assessment User Manual. Interviews with staff revealed that there was no consistent process for obtaining provider orders, documenting the intended purpose of the rails, educating residents or representatives on risks and benefits, or obtaining consent for their use. Observations and interviews indicated that residents with significant physical and cognitive impairments were using bedrails without proper assessment or documentation. For example, one resident with hemiplegia and moderate cognitive impairment was unable to remove the rails and relied on them for support during care, yet this was not reflected in her care plan or MDS. Another resident with moderate cognitive impairment and multiple comorbidities had a bedrail installed, but the assessment did not confirm her ability to remove the device or document consent. Similar issues were found with two other residents, including those who were cognitively intact but dependent on staff for mobility and transfers, with no documentation of bedrail use in their care plans or MDS. Staff interviews further revealed a lack of clarity and consistency regarding the classification and assessment of bedrails. The DON and physical therapist considered the rails as assistive devices rather than restraints and did not follow restraint assessment protocols. There was no evidence of a policy guiding the accurate assessment of such devices, and staff were not consistently obtaining provider orders or documenting the necessary information regarding the use of bedrails. This resulted in a systemic failure to accurately assess, document, and monitor the use of physical restraints for residents using bedrails.
Failure to Assess, Document, and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to follow required protocols regarding the use of bed rails for four residents. Specifically, the facility did not attempt alternative devices before installing bed rails, did not conduct or document comprehensive assessments for risk of entrapment, and did not review the risks and benefits of bed rail use with the residents or their representatives. Informed consent was not obtained, and there was no evidence that the facility ensured the bed rails were appropriate for the residents’ needs or that bed dimensions were suitable. These failures were identified through observation, interviews, and record reviews, which revealed that bed rails were in use without proper documentation or assessment. For each of the four residents reviewed, therapy evaluations and care plans did not indicate the presence or need for bed rails. Device assessments, when present, were incomplete and did not document attempts at less restrictive alternatives, the resident’s ability to remove the device, or the acquisition of informed consent. In several cases, residents and their families were not educated on the risks and benefits of bed rail use. Some residents were unaware of the purpose of the rails or how to remove them, and staff interviews revealed a lack of understanding regarding the safety risks associated with bed rails. Maintenance and nursing staff described a process for installing rails that did not include physician orders or consent, and the DON and other staff believed the rails were not considered restraints, relying on manufacturer documentation rather than regulatory requirements. Observations confirmed that residents had bed rails in place, sometimes in configurations that were not consistent or clearly documented. Residents reported using the rails for safety or mobility, but there was no evidence that the facility had assessed whether the rails posed a risk of entrapment or were the least restrictive option. The facility’s own policy required device assessments, orders, and consents for side rails, but these steps were not followed in practice. The lack of proper assessment, documentation, and education contributed to the deficiency identified by surveyors.
Failure to Timely Report Alleged Abuse and Injury of Unknown Origin
Penalty
Summary
The facility failed to immediately report allegations of abuse and an injury of unknown origin to the State Agency within the required timeframe for a resident who was moderately cognitively impaired and dependent on staff for most activities of daily living. The resident's family filed a grievance indicating that a nursing assistant was aggressive with the resident, and a nurse later discovered bruising on the resident's upper arm that resembled finger marks. Despite these events, neither the allegation of aggression nor the unexplained bruising was reported to the State Agency as required by facility policy and federal regulations. The resident had significant physical and cognitive limitations, including hemiplegia and polyneuropathy, making her particularly vulnerable. Documentation showed that the resident required maximum assistance and was always incontinent, with a history of stroke and related impairments. The care plan did not identify the resident as being at risk for abuse, and the event history did not document the bruising incident. Interviews with family members revealed ongoing concerns about aggressive care and changes in the resident's mental and physical state, including expressions of distress and a desire not to live if care continued to be painful. The family only learned of the bruising after inquiring, and the DON was unable to explain the cause, suggesting possible improper transfer techniques but not reporting the incident. Staff interviews indicated a lack of awareness and understanding regarding mandatory reporting requirements for abuse allegations and injuries of unknown origin. Nursing staff who observed or were informed of the bruising did not escalate the issue to management or report it externally, relying instead on documentation in the medical record. The DON and other staff did not recognize the need to report the incident, believing that internal interventions were sufficient. The facility's policy clearly outlined the obligation to report such events within two hours if abuse or serious injury was involved, but this protocol was not followed in this case.
Failure to Investigate Injury of Unknown Origin and Alleged Aggressive Care
Penalty
Summary
The facility failed to provide evidence of a thorough investigation into an allegation of injury of unknown origin for one resident. Staff discovered bruising resembling finger marks on the resident's upper arm, and the resident's family had filed a grievance about aggressive care the day before the bruising was found. Despite this, there was no documented grievance or investigation regarding the bruising, and the event was not recorded in the resident's event history. The resident, who was moderately cognitively impaired and dependent on staff for most activities of daily living, reported pain and showed the bruising to staff and family, but the cause was not determined or documented. Interviews revealed that the nurse practitioner was not notified of the bruising, and the direct care staff were not informed or questioned about the incident. The resident described feeling unsafe with a particular nursing assistant, reporting verbal aggression and rough care, but there was no evidence that these concerns were thoroughly investigated. The care plan did not reflect the resident's risk for abuse or require two staff for all care, despite staff awareness that this was needed. The facility's investigation into aggressive treatment did not include interviews with cognitively impaired residents or direct observation of care practices. Documentation and follow-up were lacking, as the facility did not log the incident as required by policy, nor did they conduct or document interviews with all relevant staff or witnesses. The facility's policy mandates prompt and thorough investigation of all suspected abuse or injuries of unknown source, including physical examination, interviews, and documentation, but these steps were not completed. The results of the investigation were not reported to the appropriate parties, and the incident was not analyzed for prevention of future occurrences.
Failure to Follow Infection Control Protocols
Penalty
Summary
The facility failed to adhere to transmission-based precautions (TBP) and hand hygiene protocols, as observed in multiple instances involving residents R29, R45, R17, and R14. For instance, R17 was on contact precautions due to vancomycin-resistant enterococci (VRE) in her urine, yet staff members, including a social worker and a physical therapy assistant, entered her room without donning the required personal protective equipment (PPE). The signage indicating contact precautions was not consistently followed, and there was confusion among staff regarding the type of precautions R17 was under, as evidenced by discrepancies between the signage and the electronic medical record (EMR). Similarly, R45, who exhibited flu-like symptoms, was placed on contact and droplet precautions. However, staff members, including activity staff and an occupational therapist, entered R45's room without the necessary PPE. The signage on R45's door was not consistently adhered to, and there was a lack of understanding among staff about the precautions required, as some believed PPE was only necessary for direct patient care. This inconsistency in following precautions was further highlighted by the fact that R45's door signage changed from indicating both contact and droplet precautions to only droplet precautions without clear communication to the staff. Additionally, the facility failed to ensure proper hand hygiene during medication administration for residents R14, R55, and R47. For example, a trained medication assistant (TMA) did not wash hands with soap and water after exiting R14's room, despite signage indicating the need for soap and water due to norovirus. The TMA also failed to perform hand hygiene upon entering R47's room and after completing a blood glucose test. These lapses in hand hygiene and PPE usage demonstrate a systemic issue in the facility's infection prevention and control program, potentially affecting all residents.
Delayed Response to Call Light Compromises Resident Care
Penalty
Summary
The facility failed to provide timely care to a resident, identified as R64, which compromised the resident's quality of life. R64, who had mild cognitive impairment and diagnoses of heart failure and sepsis, required extensive assistance for bed mobility and transfers. The resident's care plan indicated the need for maximum assistance with toileting due to weakness and sepsis. On the day of the incident, R64's call light was activated at 1:52 p.m. and was not addressed until 2:54 p.m., resulting in a 62-minute delay. During this time, the resident expressed discomfort and urgency to use the bedpan, which was not promptly addressed by the staff. The delay was attributed to a busy shift change and miscommunication among staff members. Nursing Assistant (NA)-G initially responded to the call light but did not provide immediate assistance, instead informing TMA-A, who was occupied with a medication pass. TMA-A acknowledged the delay and the challenge of finding additional help during shift changes. The Licensed Practical Nurse (LPN)-A and the Director of Nursing (DON) both acknowledged the delay in responding to the call light and the need for timely assistance. The facility's policy on resident dignity and prompt response to requests was not adhered to, resulting in the resident missing an activity and experiencing distress.
Failure to Assess Resident for Safe Self-Administration of Medication
Penalty
Summary
The facility failed to ensure a comprehensive assessment for safe self-administration of medication for a resident who was observed and reviewed for self-administration. The resident, who was cognitively intact and taking high-risk medications, had multiple diagnoses including type 2 diabetes, neuropathy, dysphagia, weakness, respiratory disease, and congestive heart failure. Despite these conditions, there was no evidence of a self-administration of medication (SAM) assessment or provider order in the resident's records. During an observation, the resident had a medicine cup with two caplets on her bedside table, which she identified as Tylenol due at 1:00 p.m. A registered nurse had left the medication at the bedside after the resident indicated she would take them later. The nurse acknowledged that the resident did not have a SAM assessment and should not have left the medication. Interviews with nursing staff and the director of nursing confirmed that the resident had not been assessed for SAM and did not have a provider order, which was against the facility's policy requiring an assessment and provider order for residents to self-administer medications.
Failure to Implement Resident Ambulation Program
Penalty
Summary
The facility failed to ensure that a resident, who was part of an ambulation program, received the necessary assistance to maintain their ability to walk. The resident, who was cognitively intact and had conditions such as type 2 diabetes, major depressive disorder, osteoarthritis, and muscle weakness, was supposed to participate in a restorative ambulation program at least five days per week. However, documentation showed a significant decline in the frequency of ambulation, with the resident walking only a few times over several months and not at all in December. Interviews with the resident revealed that they were not offered the opportunity to walk as expected, despite expressing a desire to maintain their strength and participate in the program. Staff interviews indicated a lack of clarity and communication regarding the responsibility for the ambulation program after the discontinuation of the restorative nursing program. Nursing assistants and nurses were aware of the resident's ambulation program but failed to consistently offer or document the ambulation activities. The director of nursing confirmed that the expectation was for staff to assist residents with ambulation daily and report any refusals to the nurse and physical therapy for re-evaluation. The facility's policy emphasized the importance of providing appropriate programs to help residents achieve their highest level of function, but this was not effectively implemented for the resident in question.
Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to implement care planned interventions for a resident (R64) who was at risk for pressure injuries. R64 had mild cognitive impairment and diagnoses of heart failure and sepsis, requiring extensive assistance for bed mobility and transfers. The care plan indicated that R64 was at risk for skin alterations and included interventions such as elevating heels off the bed with pillows. However, the nursing assistant care sheet did not indicate the need for heel elevation, and multiple observations showed R64's heels resting on the bed, contrary to the care plan. On several occasions, staff failed to address R64's complaints of heel pain or elevate the heels as required. A trained medication assistant (TMA-A) administered medication without addressing the heel pain or elevating the heels. Later, a licensed practical nurse (LPN-D) verified that R64's heels were not elevated and found the left heel to be red and blanchable, indicating a risk for pressure injury. Interviews with staff, including the Director of Nursing, revealed expectations for staff to notify nurses of heel pain and ensure interventions were in place, which were not followed in this case.
Failure to Implement Prescribed Splint Use for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as R30, used a prescribed hand splint to maintain or improve range of motion. R30, who has mild cognitive impairment and requires substantial assistance with daily activities, was observed multiple times without the splint or any palm protector, despite having a care plan that specified the use of a yellow splint for 2-3 hours daily. The resident's diagnoses include vascular dementia, muscle weakness, and neuralgia, which necessitate the use of the splint to prevent contractures and protect joint function. Documentation and interviews revealed that the splint was not used as prescribed. The resident's care plan and occupational therapy notes indicated the need for the splint, yet point of care documentation lacked evidence of its use throughout December and early January. Staff interviews revealed a lack of awareness and recall regarding the splint's use, with some staff unable to remember seeing the splint or any palm protector for the resident's contracted hand. Further investigation by the facility's director of nursing confirmed the absence of the splint, although a carrot was found in the resident's room. The facility's policy requires therapy recommendations to be communicated and incorporated into the care plan, but this was not effectively implemented. The occupational therapy team had recommended the splint's use, and the expectation was for staff to offer it daily and report any refusals or issues, which did not occur as required.
Failure to Implement Effective Toileting Program for Resident
Penalty
Summary
The facility failed to comprehensively assess and implement interventions necessary to maintain continence for a resident (R27) who was reviewed for bowel and bladder care. R27 was cognitively intact and had a history of cerebral infarction with left-sided hemiplegia and edema. The resident's Minimum Data Set (MDS) indicated occasional incontinence of bowel and bladder, yet no toileting program was in place. The comprehensive bowel and bladder assessment inaccurately stated R27 was fully continent, lacking a review of cognitive awareness, diuretic use, and toileting patterns. Despite the urinary incontinence care area assessment indicating frequent bladder incontinence and a need for maximum assistance with toileting, the care plan only included the use of incontinent briefs and peri care after episodes. Observations and interviews revealed that R27 often experienced delays in staff response to call lights, leading to incontinence episodes. The resident expressed frustration over not reaching the toilet in time, especially due to the urgency caused by diuretic medication. Nursing assistants and LPNs were unaware of any specific toileting plan, and the care sheets did not reflect an accurate assessment of R27's needs. The Director of Nursing acknowledged the discrepancy in assessments and the lack of a comprehensive review, emphasizing the importance of identifying and acting upon changes during quarterly assessments. The facility's policy required individualized toileting programs, which were not effectively implemented for R27.
Failure to Complete Weekly Weights for High-Risk Resident
Penalty
Summary
The facility failed to ensure weekly weights were completed for a resident (R32) who was at high nutritional risk. R32 had severe cognitive impairment, required substantial assistance with eating, and had a history of weight trending down. The care plan indicated that R32 should be weighed weekly as per the provider's order, but the December 2024 medication administration record showed weights were not administered on two occasions. Interviews with nursing assistants and licensed practical nurses revealed that weights were typically done on bath days, and if a weight was not taken, the nurse should be notified. However, there was a lack of documentation and communication regarding missed weights. The registered dietician confirmed that R32 was on high-risk nutrition monitoring and should have had weekly weights completed. The director of nursing stated that residents should be weighed according to the provider's order, and any refusals should be documented. Despite these expectations, the facility's policy on obtaining resident weights and nutrition high-risk monitoring was not provided, indicating a gap in policy adherence and documentation. This deficiency highlights a failure in the facility's process to ensure consistent monitoring of residents at nutritional risk.
Failure to Monitor Dialysis Fistula Site
Penalty
Summary
The facility failed to properly monitor and document the condition of a resident's dialysis fistula site, leading to unaddressed bruising and swelling. The resident, who was cognitively intact and diagnosed with end-stage kidney disease and hypertension, required hemodialysis three times a week. The care plan included monitoring the fistula site for signs of bleeding or infection and notifying the provider of any concerns. However, the facility's records lacked documentation of monitoring for bruit and thrill post-dialysis, and there were missed opportunities to document and address the resident's complaints of pain and swelling at the fistula site. Observations and interviews revealed that the resident experienced swelling and bruising at the fistula site, which was not documented by the nursing staff. The resident reported that the dialysis nurses had noted the bruising, but the facility staff did not assess or document these changes. The LPNs interviewed acknowledged issues with obtaining dialysis run sheets and the need for staff to assess and document any changes in the resident's condition. The Director of Nursing confirmed that there were communication problems with the dialysis center and that a new order was placed to ensure proper monitoring of the site.
Failure to Accommodate Resident's Dietary Preferences
Penalty
Summary
The facility failed to accommodate the dietary preferences of a resident, identified as R17, who was reviewed for food preferences. R17 had a history of gastric bypass surgery and malabsorption, which necessitated smaller meal portions and specific dietary requests. Despite these needs, the facility did not consistently provide the requested breakfast items, such as breakfast bars, which were noted as R17's preference on the meal ticket. This inconsistency was observed during multiple interviews and observations, where R17 expressed dissatisfaction with the meals provided, specifically noting the absence of breakfast bars. R17's care plan and physician's orders indicated a regular diet with specific requests for small portions and certain breakfast items. The resident's nutritional assessment highlighted inadequate oral intake and a risk for malnutrition, with a history of significant weight loss. Despite these documented needs and preferences, the facility's staff, including nursing assistants and the registered dietician, acknowledged that R17's meal preferences were not consistently met. The dietician had updated the meal ticket to reflect R17's preference for a lighter breakfast, yet the facility failed to adhere to these updates. Interviews with staff, including nursing assistants and the director of nursing, revealed a lack of consistent adherence to the meal tickets and resident preferences. The director of nursing acknowledged the importance of honoring resident preferences to encourage meal consumption but noted that nursing staff might not always have time to verify meal preferences. The facility's policy on resident dignity, choices, and preferences emphasized the importance of honoring resident choices, yet the failure to provide R17 with the requested breakfast items demonstrated a deficiency in this area.
Failure to Use Transfer Belt Results in Resident Injury
Penalty
Summary
The facility failed to ensure that care planned interventions were followed during a transfer for a resident, resulting in actual harm. The resident, who had a history of vascular dementia, cerebral infarction with left-sided weakness, anemia, and heart failure, required partial to moderate assistance for transfers. The care plan directed staff to provide contact guard assistance with transfers using a two-wheeled walker and to follow a toileting and repositioning schedule. However, during a transfer to a wheelchair for a shower, a nursing assistant did not use a gait belt as required by the facility's transfer policy. The nursing assistant, who was aware of the policy, chose not to use the gait belt because she believed the resident could grab onto the chair. During the transfer, the resident's legs gave out, and he fell, hitting his head on the floor. This resulted in a subarachnoid hemorrhage, a left front scalp hematoma, and a laceration that required repair. The resident was sent to the hospital for treatment and later readmitted to the facility with noticeable bruising and swelling. Interviews with staff, including the nursing assistant, director of nursing, and therapists, confirmed that the transfer belt was not used during the incident. The nursing assistant admitted to not using the belt, and the director of nursing confirmed that staff were educated to always use a transfer belt unless otherwise indicated by therapy. The occupational and physical therapists noted changes in the resident's condition following the fall, including difficulty processing and following cues, which were not present before the incident.
Inappropriate Initiation of CPR on Resident with Rigor Mortis
Penalty
Summary
The facility failed to follow standard practice when CPR was initiated on a resident who displayed signs of rigor mortis. The resident had a Provider Order for Life Sustaining Treatment (POLST) indicating a desire for full resuscitation if found with no pulse and not breathing. However, upon discovery, the resident exhibited clear signs of rigor mortis, including stiffness in the limbs and cold body temperature, which should have precluded the initiation of CPR according to both facility policy and the American Heart Association guidelines. Despite these signs, CPR was performed by the staff, and emergency medical services were called, but the resident was not revived. The incident began when a registered nurse (RN-A) found the resident unresponsive and cold to the touch, with stiff limbs indicating rigor mortis. RN-A called for assistance, and another nurse (RN-B) confirmed the absence of vital signs and the presence of rigor mortis. Despite recognizing these signs, the staff verified the resident's full code status and proceeded to move the resident to the floor to begin chest compressions. The timeline of events was not clearly documented in the progress notes, and there was a delay in initiating CPR as observed from the facility's camera system. The facility's CPR policy and the State Operations Manual both state that CPR should not be initiated if there are obvious signs of irreversible death, such as rigor mortis. The staff's actions were inconsistent with these guidelines, leading to the inappropriate initiation of CPR. The emergency medical technician (EMT) who arrived on the scene also noted that CPR was being performed despite the resident showing signs of rigor mortis. The nurse practitioner on call was not informed of the resident's full code status and gave an order to release the body after being notified of the resident's condition and the family's wishes.
Latest citations in Minnesota
A resident with dry eye syndrome and degenerative eye disease had orders for cyclosporine ophthalmic emulsion and Refresh Tears, both scheduled at the same time. Medication records and direct observation showed a TMA instilled cyclosporine drops in both eyes and immediately followed with Refresh Tears in both eyes without waiting between medications. This practice conflicted with referenced professional guidance recommending several minutes between multiple eye drops and with the medical provider’s recommendation to wait fifteen minutes between the two ophthalmic medications. No facility policy on ophthalmic medication administration was provided when requested.
A resident with severe cognitive impairment, impaired mobility, and high fall risk was care planned to have wheelchair footrests in place at all times, with staff ensuring proper positioning and monitoring for leaning during transport. A NA transported the resident in a manual wheelchair from the shower without the footrests, and while going through the doorway the wheelchair struck the door frame, causing the resident, who was leaning forward, to fall out. The resident sustained a T12 fracture, head injury with concussion, abrasions and contusions, and multiple right-hand lacerations requiring sutures, and the DON confirmed the care plan had not been followed.
A high‑risk, immobile resident with MS and prior heel DTI developed an avoidable unstageable coccygeal pressure ulcer after staff failed to consistently assess and document skin status, did not transfer or timely provide ordered pressure‑relieving mattresses, and did not reliably perform q2h repositioning. The resident was repeatedly left on a bedpan for prolonged periods despite early reports of this issue, and the toileting care plan was not revised to a bedside commode until after the coccygeal wound had significantly worsened. Wound assessments lacked complete measurements and staging, changes in wound size and color were not promptly recognized as deterioration or reported to providers, and recommended interventions from a wound NP (including an air mattress and offloading) were not promptly implemented. As a result, the coccygeal ulcer rapidly progressed to a large, necrotic, malodorous wound requiring hospital transfer and surgical debridement.
A resident with spastic hemiplegia, muscle weakness, and moderate cognitive impairment was observed using bilateral bed grab bars for bed mobility and transfers, but the care plan did not address grab bar or side rail use. Review of the EMR showed no completed bed mobility device or side rail assessment to determine the necessity or safety of the grab bars, and no documentation that risks and benefits were discussed or that informed consent was obtained. An LPN and the ADON stated that a bed mobility device assessment is required before grab bars are installed and confirmed that no such assessment existed for this resident.
A resident with bilateral heel pressure ulcers and multiple comorbidities received wound care during which an RN removed dressings from both heels, cleansed both wounds, and wiped each heel without changing gloves or performing hand hygiene between wounds or after disposing of soiled dressings. This practice conflicted with the facility’s written wound care procedure, which requires glove removal and hand hygiene after dressing removal and after wound cleansing. In interviews, the RN, NP, and DON/IP acknowledged that hand hygiene and glove changes are expected between dirty and clean tasks and between separate wounds to prevent infection.
A resident with MS, neurogenic bladder, mobility limitations, and existing pressure injuries was identified as dependent for toileting hygiene and at risk for pressure ulcers, yet the care plan lacked an individualized toileting/incontinence plan and a defined repositioning schedule. Despite a new coccyx pressure ulcer and documentation that interventions such as increased repositioning and incontinent care were needed, the care plan was not revised for a period of time to reflect these changes. During this time, the resident sometimes fell asleep on a bedpan and remained on it until staff removed it, and staff were not initially informed that the bedpan should no longer be used. The DON later acknowledged that the care plan revisions for turning, repositioning, and toileting were delayed until after the resident’s coccyx ulcer had significantly worsened.
A resident with diabetes, Crohn’s disease, bowel incontinence, and a history of MASD on the right gluteus developed an open, painful lesion on the right gluteal area that was documented over time without complete wound characteristics, clear etiology, or timely provider notification. Wound care orders were written for a stage 3 pressure ulcer on the left buttocks, while staff reported the wound was only on the right side and applied the left‑sided orders to the right gluteal wound in the absence of specific right‑side treatment orders. The DON acknowledged discomfort with staging the wound, lack of early physician notification, and confusion over wound classification, despite a facility policy requiring comprehensive wound assessment, consistent measurement, and provider notification when treatment orders are absent.
A resident with diabetes, chronic leg ulcer, kidney transplant, and a documented gluteal wound was care-planned for Enhanced Barrier Precautions (EBP), with posted instructions requiring gown and gloves for high-contact care such as transfers and wound care. During a telehealth wound assessment, the DON donned a gown and initially performed hand hygiene but then applied gloves without hand hygiene, removed a soiled dressing from the resident’s gluteal area, discarded it, removed gloves, and applied new gloves again without performing hand hygiene between glove changes. On another occasion, during use of a sit-to-stand lift, an NA wore gown and gloves, but the DON handled the lift harness, the resident’s clothing, and assisted with the transfer and repositioning while wearing a gown but no gloves, despite EBP requirements for transfers. The DON stated EBP was only needed for catheter or wound care and not for transfers, contradicting the posted EBP instructions and facility policy.
A resident with severe dementia, psychiatric disorders, and high dependence for ADLs was verbally abused during evening care when a NA, frustrated with the resident’s crying and resistance, loudly ridiculed her as acting like a two-year-old, threatened to hit her back if struck, told her she would be sent to a locked unit, and questioned who would want to care for her when she cried like a baby. Multiple staff witnessed the loud, stern, and intimidating tone and reported it to an LPN, who recognized it as verbal abuse but did not immediately remove the NA from duty or promptly report the allegation per policy, allowing the NA to continue working on the unit. Following this incident, the resident demonstrated increased crying, combativeness, resistance to care, wandering, self-isolation, and refusal of food, fluids, and medications above baseline, with documentation of significant emotional distress and subsequent ED evaluation for aggressive behaviors and poor intake.
A resident with dementia, bilateral above‑knee amputations, vascular disease, and severe protein‑calorie malnutrition developed a wound on an amputation stump that had a dressing dated several days before any documentation or treatment orders appeared in the record. Although bath audits and nursing notes initially reported no skin issues, a later assessment described a full‑thickness stage 4 ulcer/diabetic ulcer on the stump with exposed bone, erythema/edema, slough, and moderate serosanguineous drainage. Nursing staff interviews showed no one could identify who first discovered the wound or applied the initial dressing, and there was no evidence that the wound was assessed, the provider notified, or standing orders implemented when it was first present, despite facility expectations that new wounds be promptly evaluated and reported.
Failure to Follow Professional Standards for Ophthalmic Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice for administering ophthalmic medications to a resident with dry eye syndrome and degenerative eye disease. The resident was cognitively intact, required assistance with ADLs, and had physician orders for cyclosporine ophthalmic emulsion 0.05% one drop in both eyes twice daily and Refresh Tears ophthalmic solution one drop in both eyes four times daily for dry eyes. The administration summary showed that both eye medications were scheduled for the same time and were documented as being given at the same time on multiple dates. During a medication pass observation, a trained medication aide administered the ordered oral medications, then applied gloves and instilled one drop of cyclosporine in each eye, immediately followed by one drop of Refresh Tears in each eye, without any waiting period between the two medications. The surveyors referenced guidance from the American Academy of Allergy, Asthma, and Immunology stating that when more than one eye drop is ordered, three to four minutes should be allowed between drops in the same eye, and five to fifteen minutes should be allowed between different eye medications to prevent dilution. Interviews with the DON, pharmacy consultant, and medical provider confirmed that best practice and the provider’s recommendation were to wait between administration of cyclosporine and Refresh Tears, with the medical provider specifying a fifteen-minute interval. The facility did not provide a policy on ophthalmic medications when requested. The observed practice and documented administration times demonstrated that staff did not follow these professional standards or the medical provider’s recommended interval between the two eye medications.
Failure to Follow Wheelchair Transport Care Plan Leads to Fall With Injuries
Penalty
Summary
The deficiency involves the facility’s failure to implement care-planned fall prevention interventions for a resident at high risk for falls, resulting in a fall with injury. The resident had diagnoses including aphasia, dysphagia, muscle weakness, traumatic brain injury, and impaired mobility, with severe cognitive impairment documented on the MDS and dependence on staff for transfers and wheelchair transport. A care plan addressing wheelchair transport safety and positioning directed staff to ensure the resident was fully positioned and supported in the wheelchair prior to transport, verify footrests were in place prior to transport, and monitor for leaning, sliding, or unsafe positioning. An additional care-planned approach required wheelchair pedals to be on at all times. On the date of the incident, a nursing assistant transported the resident in a manual wheelchair from the shower room to the resident’s room without the foot pedals in place, contrary to the care plan. While being wheeled through the doorway, the wheelchair struck the door frame, causing the chair to stop and the resident, who had begun leaning forward, to fall out of the wheelchair onto the floor. Progress notes and ED documentation identified that the resident sustained a T12 vertebral fracture, a head injury with concussion, an abrasion and contusion to the head, a bruise to the left knee, and multiple lacerations to the right hand requiring sutures. The nursing assistant later acknowledged awareness that the foot pedals should have been on but did not apply them because the transport was only from the shower to the room. The DON confirmed that the resident’s care plan had not been followed when the fall occurred.
Failure to Implement and Update Pressure Ulcer Prevention and Treatment Led to Avoidable Unstageable Coccygeal Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, monitor, and implement individualized pressure ulcer prevention and treatment interventions for multiple high‑risk residents, resulting in an avoidable, unstageable coccygeal pressure ulcer for one resident that required surgical debridement and hospitalization. The resident had primary progressive multiple sclerosis, hereditary spastic paraplegia, obesity, and pre‑existing pressure‑related deep tissue injury to the left heel, and was identified as high risk for pressure ulcers on the Braden Scale due to constant moisture, chairfast status, very limited mobility, inadequate nutrition, and friction/shear risk. Hospital records on readmission documented irritant contact dermatitis of the bilateral gluteal cleft with specific cleansing and barrier cream orders, and facility documentation showed the resident could not reposition in bed or chair and required assist of two and a full‑body mechanical lift for transfers. Despite this, the admission/readmission skin assessment and weekly skin checks lacked measurements and detailed wound characteristics for the heel ulcer and gluteal dermatitis, and the care plan did not include comprehensive, individualized interventions beyond generic repositioning and wound care orders. After a new coccyx pressure ulcer was identified and documented as a stage 2 lesion, the facility failed to promptly and accurately update the care plan and implement recommended pressure‑relieving interventions. The wound nurse practitioner on 3/5 ordered coccyx wound care, an air mattress, pressure offloading, and a dietician consult, but the care plan was not revised and there was no evidence that an air mattress was placed on the bed for nearly two weeks. The environmental services director later confirmed that when the resident was moved to a new room, the gel mattress was not transferred, and the air mattress requested on 3/17 was not actually placed until the following day, despite being marked as completed. During this period, TAR documentation showed gaps in the every‑2‑hour repositioning order, and staff interviews revealed that CNAs were unaware of which residents were on repositioning programs, were not consistently repositioning residents, and had not received recent education on pressure ulcer prevention. The DON and RN case manager acknowledged that the coccyx wound increased in size and changed color between assessments, that the bed lacked the ordered gel mattress, and that the physician was not notified of the wound’s deterioration at that time. The facility also failed to timely modify toileting and incontinence care practices despite knowledge that the resident was being left on a bedpan for extended periods. The DON reported hearing before an IDT meeting that the resident had fallen asleep on a bedpan for an undetermined amount of time, but the care plan was not revised to discontinue bedpan use and implement a bedside commode until after the coccyx wound had significantly worsened. CNAs confirmed that the resident sometimes fell asleep on the bedpan and that they were not informed she should no longer use it until after the sore had worsened. Subsequent wound assessments documented rapid progression of the coccyx wound from a small stage 2 ulcer to a large, malodorous, necrotic wound with eschar, slough, erythema, and purulent drainage, ultimately classified as an unstageable pressure ulcer. The DON, NP, PA, and medical director all indicated that the lack of a pressure‑relieving mattress, failure to adjust pressure‑reducing interventions, and prolonged time on a bedpan likely contributed to the development and deterioration of the resident’s pressure ulcer, which was determined to be avoidable and resulted in hospitalization and surgical debridement. Additional documentation and interviews showed systemic assessment and communication failures related to pressure ulcer management. Weekly skin checks and wound assessments often omitted complete measurements, staging, and wound characteristics, and changes in wound size and appearance were not consistently recognized as deterioration or communicated to providers. The DON acknowledged that a 3/12 assessment showing increased wound size and purple discoloration should have been identified as a deep tissue injury and reported to the physician, but this did not occur. When nursing later documented foul odor, increased pain, and expanding necrotic tissue, telemedicine and PA responses deferred in‑person evaluation and ED transfer despite earlier recommendations that the resident be sent to the ED if an in‑person provider could not assess the wound. The NP ultimately found a large, malodorous, purulent wound with expanding eschar and ordered transfer to the hospital, where imaging and surgical findings confirmed a large necrotic sacral wound requiring extensive debridement. Throughout this sequence, the facility did not consistently follow its own pressure ulcer protocols, did not ensure ordered pressure‑relieving equipment was in place, and did not promptly revise care plans or interventions in response to known risk factors and documented wound changes. The report also notes that other residents reviewed for pressure ulcers were affected by similar failures in monitoring and individualized intervention, though detailed narratives focus primarily on this resident. Staff interviews revealed that CNAs relied on paper care guides that did not clearly identify residents on repositioning programs or at risk for skin breakdown, and that they were unaware of some residents’ special mattress orders or toileting restrictions. The DON and medical director stated that residents at risk for pressure ulcers should have immediate pressure‑relieving interventions and that existing ulcers require ongoing evaluation to prevent deterioration, but the documented practices for this resident did not align with those expectations. These combined actions and inactions—insufficient assessment detail, delayed or missing care plan revisions, failure to implement ordered support surfaces and repositioning, and delayed response to wound deterioration—constituted the deficiency in providing appropriate pressure ulcer care and preventing new ulcers from developing.
Failure to Assess, Care Plan, and Obtain Consent for Bed Grab Bar Use
Penalty
Summary
The deficiency involves the facility’s failure to follow required procedures before installing and using bed grab bars for a resident. The resident had diagnoses including spastic hemiplegia affecting the left side and muscle weakness, and an admission MDS indicating moderate cognitive impairment. During observation, the resident was seen in a power chair with bilateral grab bars on the bed and reported using them to roll in bed and for transfers. The resident’s care plan, dated 1/23/26, documented a need for assistance with bed mobility and independence with transfers but did not mention or address the use of grab bars or side rails. Review of the electronic medical record showed no completed grab bar/side rail or bed mobility device assessment to determine the necessity of the grab bars or whether the resident could safely use them. There was also no evidence that the resident or the resident’s representative had been educated on the risks of having a grab bar on the bed or that informed consent had been obtained. In interviews, an LPN and the ADON both stated that a bed mobility device assessment was required to determine need and safety prior to installing grab bars, and both confirmed that no such assessment was present in the resident’s record.
Failure to Perform Hand Hygiene and Change Gloves During Wound Care
Penalty
Summary
Surveyors observed that a registered nurse (RN) and a nurse practitioner (NP) did not follow the facility’s established infection control practices during wound care for one resident. During a wound treatment, the RN wore gloves while removing the dressing from the resident’s left heel, then removed the dressing from the right heel, sprayed both wounds with wound cleanser, wiped the left heel with gauze, and then used a clean gauze pad to wipe the right heel. The RN did not remove her gloves or perform hand hygiene after disposing of the soiled dressings or between cleaning the left and right heel wounds, contrary to the facility’s written wound care procedure, which requires glove removal and hand hygiene after removing the previous dressing and again after cleaning the wound. The resident’s admission MDS documented diagnoses including multiple rib fractures, heart failure, dementia, anxiety, and the presence of a pressure ulcer, and indicated the resident was cognitively intact and required staff assistance with care and transfers. The resident’s care plan identified pressure ulcers on both heels requiring wound care. In interviews, the RN, NP, and the DON/infection prevention nurse each stated that gloves should be changed when moving from dirty to clean areas and that hand hygiene is expected after glove removal and between wounds to prevent infection, confirming that the observed practice did not align with facility policy or expected infection control standards.
Failure to Timely Revise Care Plan for Toileting and Skin Integrity
Penalty
Summary
The deficiency involves the facility’s failure to timely revise and individualize a resident’s care plan to address toileting and incontinence needs in relation to impaired skin integrity. The resident had diagnoses including primary progressive multiple sclerosis, hereditary spastic paraplegia, obesity, and a pressure-induced deep tissue injury to the left heel. A Significant Change MDS identified the resident as dependent for toileting hygiene, with lower extremity range-of-motion limitations, wheelchair use, dependence for transfers, occasional urinary incontinence, intact cognition, and at risk for pressure ulcers with existing unhealed pressure injuries and MASD. The resident’s skin-focused care plan, revised on various dates, included skin inspections, wound care orders, weekly skin checks, pressure ulcer care to the left heel, nutritional supplements, and a gel mattress, but did not include an individualized toileting or incontinence plan. On a weekly skin check dated 3/3/26, nursing staff identified a new Stage 2 pressure ulcer on the coccyx and contact dermatitis on both gluteal folds. An IDT Final Post Review Follow Up dated 3/10/26 (signed 3/23/26) documented that a new skin issue had occurred and that interventions after the incident included wound care treatment orders, increased repositioning, and increased incontinent care. However, the resident’s care plan from 3/3/26 through 3/16/26 did not show revisions reflecting increased incontinence care or a repositioning schedule, and the care plan was not updated to include these elements until 3/17/26. During this period, the care plan still lacked an individualized toileting plan despite the resident’s identified incontinence and new coccyx pressure ulcer. Progress notes on 3/17/26 documented that the resident’s coccyx wound had declined, with an evaluation describing a deteriorating wound characterized as a Kennedy terminal ulcer/End of Life, staged as a Stage 4 pressure ulcer, in-house acquired, with increased size, exudate, odor, pain, and surrounding erythema. On that same date, the skin focus care plan was revised to include prompt incontinence care and keeping the skin clean and dry, and the elimination focus care plan was revised to address incontinence due to neurogenic bladder with use of a bedside commode offered every 2–3 hours. A nursing assistant reported that when working with the resident, the resident would sometimes fall asleep on the bedpan and forget to ask staff to remove it, and that she was not aware the resident was not supposed to use the bedpan until after the sore had worsened. The DON stated that the resident’s care plan had not been revised earlier to include a turning and repositioning schedule or toileting changes, and that it should have been revised as soon as staff learned the resident was falling asleep on the bedpan, rather than waiting until after the pressure ulcer worsened.
Failure to Assess and Notify Provider for Right Gluteal Wound
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess and appropriately manage a non‑pressure skin issue on a resident’s right gluteal area, and to notify the physician in a timely manner. The resident had diagnoses including diabetes, Crohn’s disease, and a kidney transplant, and the MDS indicated occasional bowel incontinence, no pressure ulcers, and no moisture‑associated skin damage at that time. Earlier documentation identified a resolved MASD to the right gluteus, and a progress note later described a sacral wound with creams applied, noting that sores were still open and painful during application, but without any measurements, wound characteristics, or evidence of physician notification. Subsequent wound assessments documented an open lesion on the right gluteus with specific measurements on multiple dates, but did not identify the wound type or other characteristics, and the record did not show physician notification or treatment orders for the right gluteal lesion. Provider orders in place initially addressed cleansing the buttocks and applying barrier cream, and later included a detailed wound care order for a stage 3 pressure ulcer documented on the left buttocks. However, the resident’s record did not contain a specific treatment order for the right gluteal wound, despite the ongoing documentation of an open lesion in that area. Interviews revealed confusion and inconsistency in wound identification and classification. The DON stated that the right gluteal wound was documented as an open lesion because she did not feel comfortable determining the wound type, and acknowledged that the physician should have been notified when the wound was first identified. The DON was unaware that the NP had documented the wound as being on the left buttocks and as a stage 3 pressure ulcer, while the RN reported that the wound had never been on the left buttocks and that she had been applying the left‑sided wound orders to the right gluteal area because there was no open area on the left. The resident reported a recurring painful area on the right buttocks and chronic stool leakage since prior anal fistula surgery. The facility’s own wound treatment policy required comprehensive assessment of wound etiology and characteristics, consistent measurement and documentation, and provider notification in the absence of treatment orders, which were not followed for this resident’s right gluteal wound. The deficiency centers on the lack of a comprehensive wound assessment for the right gluteal lesion, incomplete documentation of wound characteristics, failure to clearly determine and document the wound etiology, and failure to notify the physician and obtain appropriate treatment orders when the wound was identified and remained open. These actions and inactions resulted in a discrepancy between the documented wound location and type and the actual clinical presentation, as well as a period during which the right gluteal wound had no specific, clearly ordered treatment despite being open and painful.
Failure to Perform Hand Hygiene and Implement Enhanced Barrier Precautions During Wound Care and Transfers
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper hand hygiene during wound care and to consistently implement Enhanced Barrier Precautions (EBP) for a resident requiring such measures. The resident had diagnoses including diabetes, a non-pressure chronic ulcer of the right lower leg, and a kidney transplant, and a wound assessment documented an open lesion on the right gluteal area. The resident’s care plan and a sign posted outside the room specified that EBP, including gown and gloves, were required for high-contact care activities such as dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, catheter care, and wound care. During one observation, the DON performed hand hygiene and donned a gown before entering the resident’s room for a telehealth wound assessment. Inside the room, the DON went into the bathroom, applied gloves without performing hand hygiene, removed the resident’s brief, and removed a foam dressing from the right gluteal area that had stool on one corner. After discarding the soiled dressing, the DON removed gloves and then applied new gloves without performing hand hygiene between glove changes. When questioned, the DON stated that hand hygiene should be done when hands or gloves are visibly soiled and before and after removing or applying gloves, and acknowledged that hand hygiene had not been performed each time gloves were removed and reapplied. In a separate observation, the resident was transferred using a sit-to-stand mechanical lift while EBP requirements were not fully followed. An NA entered the room wearing a gown and gloves with the lift, and the DON applied the lift harness under the resident’s arms and cinched the waist strap, encountering the resident’s clothing, while not wearing gloves. After the transfer to bed, the DON pulled down the resident’s pants and removed the harness while touching the resident’s clothes. Following wound care by a CNP-WOC, the DON again assisted the resident by sitting the resident on the edge of the bed, applying the lift harness, and adjusting the resident’s pants and shirt while wearing a gown but no gloves. The DON stated that EBP was only needed for catheter or wound care and not for transfers, and only upon reading the posted EBP sign acknowledged that EBP was required for all high-contact resident care activities, including transfers.
Failure to Protect Resident From Verbal Abuse and Delay in Removing Alleged Perpetrator
Penalty
Summary
The deficiency involves the facility’s failure to protect a vulnerable resident from mental abuse and to respond appropriately to an allegation of abuse. The resident had severe cognitive impairment, Alzheimer’s disease, dementia, anxiety, depression, psychotic disorder, and significant functional dependence, including frequent incontinence and the need for extensive assistance with ADLs and transfers. Her care plan identified behavioral and mood issues such as wandering, yelling, combative behavior, and calling staff names, with interventions including calm approaches, emotional support, redirection, and monitoring for emotional distress and mood/behavior changes. She was identified as a vulnerable adult, with instructions to monitor for signs of emotional distress and to follow the facility’s abuse reporting policy. On the evening in question, while the resident was crying on the phone with her son and expressing a desire to leave, NA-A and NA-B entered to provide evening care using an EZ stand lift. After the resident ended the phone call, multiple staff reported that NA-A spoke to the resident in a loud, stern, and frustrated tone, telling her to stop crying and that she was acting like a two-year-old. When the resident swatted at NA-A, NA-A stated, “If you hit me, I’m going to hit you back,” and later told the resident she was “in trouble now.” Staff reported that NA-A told the resident she would be sent to a locked unit so she could not get out, and questioned who would want to care for her when she cried like a baby, and that nobody would want to keep working with her. NA-C described NA-A yelling commands such as “HOLD ON!” and “Stop crying! Where would you be if you were not here? Probably lying on the floor,” and felt NA-A was obviously upset and overwhelmed. These statements were made in the presence of the resident while she was already distressed and crying. Following this interaction, the resident exhibited crying, yelling, combativeness, resistance to care, wandering into other residents’ rooms, self-isolation, and refusal of food, fluids, and medications above her prior baseline, as documented in behavior charts, target behavior monitoring, and nursing progress notes. Staff documented that she cried most of the morning, was very restless, difficult to redirect, hit and pinched staff, called staff names, and refused care and meals. She required repeated redirection, 1:1 attention, and non-pharmacological interventions, and was ultimately sent to the ED for evaluation of combativeness and emotional distress, where she was treated for dementia with aggressive behavior and hypoglycemia related to poor intake. The report identifies that the resident’s actual response and the reasonable person concept showed serious psychosocial harm, including increased crying and combative behavior above baseline, fear/anxiety manifested as combativeness, resistance to care and social interaction, and self-isolation. The facility also failed to immediately remove the alleged perpetrator from resident care and to promptly report and investigate the allegation in accordance with its abuse policy. After NA-B and NA-C reported to LPN-A that NA-A had yelled at and threatened the resident, LPN-A acknowledged it as verbal abuse but did not initiate immediate protective measures or timely reporting. LPN-A stated she believed she had 24 hours to report because there was no injury, despite facility policy requiring reporting within two hours. NA-A remained on the unit and continued working until the end of her shift, including after staff had clearly communicated their concerns to LPN-A. TMA and NA staff described uncertainty about their authority to remove NA-A and reliance on the nurse to act, while the DON later informed LPN-A that NA-A should have been removed from the floor to prevent further danger to residents. The Immediate Jeopardy was determined to have begun when NA-A’s derogatory, intimidating, and threatening statements were made and continued while she remained on duty with access to the resident and other vulnerable residents.
Failure to Timely Assess and Treat Newly Discovered Stump Wound
Penalty
Summary
The deficiency involves the facility’s failure to provide timely treatment and care for a newly discovered wound on a resident’s above‑knee amputation stump. The resident was admitted with diagnoses including unspecified dementia with behavioral disturbances, vascular dementia, bilateral above‑knee amputations, vascular disease, reduced mobility, and severe protein‑calorie malnutrition, and had no documented ulcers or skin problems on admission or on the most recent MDS. A weekly bath audit on 3/17/26 documented only non‑tender lymph nodes on the right upper hip and did not identify any open areas. However, when the wound was later assessed, the dressing on the stump was dated 3/16/26, indicating that a wound and dressing existed at that time, even though no corresponding assessment, provider notification, or treatment orders were documented. On 3/23/26, nursing staff documented a new skin issue above the resident’s knee at the amputation site, describing a stage 4 pressure ulcer/injury with full‑thickness skin and tissue loss, exposed bone, erythema/edema, and moderate serosanguineous exudate. The wound measured 1.56 cm by 1.64 cm, with 20–29% granulation tissue and 80% slough. A progress note and skin issues assessment on that date confirmed the wound characteristics and staging, and the NP, after reviewing a picture, determined the wound to be a diabetic ulcer with peripheral vascular disease and severe protein‑calorie malnutrition as contributing factors. On that same date, the NP was notified, antibiotic therapy (doxycycline) was ordered for possible cellulitis, and specific wound care orders were initiated, with documentation on the MAR that these treatments were carried out beginning 3/23/26. Multiple interviews with nursing staff revealed that no one could identify who discovered the wound or who applied the initial dressing dated 3/16/26, and there was no documentation of a wound assessment, provider notification, or interim treatment between 3/16/26 and 3/22/26. Several RNs and LPNs who worked shifts from 3/16/26 through 3/20/26 stated they did not notice a wound on the stump and that, per their usual practice, they would have contacted the provider and initiated treatment if they had found one. One LPN recalled seeing a band‑aid with a date on the stump but could not recall the date, and another LPN stated she did not see the wound because she was not looking for one. The facility’s standing orders required staff to assess all wounds daily, change dressings every three days and as needed, treat with normal saline or non‑cytotoxic cleanser and appropriate dressings, and notify the provider the next business day when a new wound or injury was found. Despite these expectations, the wound identified by the dated dressing on 3/16/26 was not assessed, reported, or treated according to orders and facility policy until 3/23/26.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
