Hayes Residence
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Paul, Minnesota.
- Location
- 1620 Randolph Avenue, Saint Paul, Minnesota 55105
- CMS Provider Number
- 24E508
- Inspections on file
- 18
- Latest survey
- June 26, 2025
- Citations (last 12 mo.)
- 14 (1 serious)
Citation history
Health deficiencies cited at Hayes Residence during CMS and state inspections, most recent first.
A resident with intact cognition and chronic health conditions requested not to be resuscitated, but conflicting documentation in the EMR and paper chart indicated both CPR and DNR status. The resident's wishes were not promptly communicated to the provider for a verbal order, and staff relied on outdated records, creating a risk that CPR would be performed against the resident's wishes.
The facility did not ensure proper food storage and dish sanitization, as the resident snack refrigerator was repeatedly above safe temperatures and contained unlabeled, open food items, while expired milk was found in the main kitchen. Staff failed to consistently monitor and document refrigerator temperatures or remove unsafe items. Additionally, the high-temperature dishwasher did not reach required sanitization temperatures, and staff did not consistently report or address the issue as required by facility policy.
Several residents were unable to access hot water for showers, with reports of consistently cold water and restricted access to shower rooms and linens. Staff and administration were aware of ongoing boiler issues, and the facility lacked proper documentation and functioning equipment to monitor water temperature. As a result, residents' preferences and care plans for bathing were not met, and facility policy regarding hot water was not followed.
A resident with impaired cognition, upper extremity impairment, and incontinence was observed sitting in a recliner with the call light stuck and out of reach. A nursing assistant confirmed the issue and was unable to immediately resolve it, while both an LPN and the DON stated that call lights should be accessible to all residents for safety. The facility could not provide a call light policy when asked.
A resident with schizoaffective disorder and a history of self-injury developed a bruise under the left eye, which was reported as self-inflicted due to command hallucinations. Although a nursing assistant documented the injury and informed the charge nurse, there was no evidence of a licensed nurse's assessment, measurement, or ongoing monitoring of the bruise as required by facility policy and physician orders.
A resident with cognitive and physical impairments did not receive consistent weekly monitoring and measurement of pressure ulcers as ordered. Medical records showed multiple missed or incomplete wound assessments, and interviews with nursing staff and the DON confirmed that required documentation and skin checks were not consistently performed.
A resident with cognitive impairment and a history of falls experienced multiple unwitnessed falls without a documented root cause analysis or updates to their care plan. Staff failed to identify or implement new interventions, and required risk management forms were not completed or reviewed, despite facility policy mandating reassessment and intervention after each fall.
A resident with moderate cognitive impairment and schizophrenia used a bed rail that was found to be loose and incompatible with the bed frame. Staff confirmed the rail could not be properly secured, and manufacturer compatibility could not be verified due to missing information. The facility's policy required installation per manufacturer guidelines, but this was not followed, resulting in a safety deficiency.
The facility failed to properly label, date, and dispose of food items and maintain clean cooking equipment, potentially affecting all residents consuming food from the kitchen. Observations included uncovered and undated food items, and a KitchenAid mixer with residue, indicating non-compliance with facility policies on food safety and equipment cleaning.
The facility failed to cover linen carts during transport and storage, potentially impacting all 31 residents. Housekeeping staff were unaware of the requirement, and the facility's policy lacked guidance on this matter.
A facility failed to assess and document the need for grab bars for a resident, who was independent in bed mobility and had no documented requirement for such assistance. Despite the facility's policy requiring an assessment and education on risks, no such documentation was found, and staff confirmed the lack of a comprehensive assessment or provider order for the grab bars.
The facility failed to accurately assess and offer pneumococcal vaccinations to two residents according to CDC guidelines. One resident, with alcohol use and nicotine dependence, was not offered the vaccine despite no prior vaccinations. Another resident, with diabetes and lung disease, was not assessed for additional doses of newer vaccines, as required by shared clinical decision-making.
Failure to Accurately Document and Communicate Resident's DNR Wishes
Penalty
Summary
The facility failed to ensure that a resident's wishes regarding resuscitation were accurately and consistently documented across all areas of the medical record. The resident, who had intact cognition and diagnoses including delusional disorders and COPD, expressed a clear desire not to be resuscitated if found without a pulse or respirations. Despite this, the electronic medical record (EMR) and the paper chart contained conflicting information, with some documents indicating a full code (CPR) and others indicating Do Not Resuscitate (DNR). The resident had communicated his wishes to the health unit coordinator (HUC), who completed a new POLST form indicating DNR, but this form was awaiting a physician's signature and had not yet been reflected in the EMR or on the face sheet/banner. Staff interviews revealed inconsistent practices and communication regarding changes in code status. The HUC stated that the process was to update the EMR first and then the paper chart, but the code status would not officially change until the physician signed the POLST. The HUC did not notify nursing staff directly, relying instead on progress notes and the 24-hour report, which nurses were expected to review before each shift. Nursing staff, including LPNs, indicated that in an emergency, they would check the paper chart or the EMR for code status, and would perform CPR if the documentation indicated full code, regardless of any pending changes or verbal requests from the resident. The facility's policy required immediate notification of the physician and documentation of any verbal refusal of CPR, with the resident's wishes to be honored until a written order was obtained. However, in this case, the process was not followed, and the resident's verbal request for DNR was not promptly communicated to the provider for a verbal order, nor was it immediately updated in all relevant records. As a result, there was a significant risk that the resident would have received CPR against his wishes in the event of an emergency, due to the lack of accurate and timely documentation and communication among staff.
Failure to Maintain Safe Food Storage and Dish Sanitization Practices
Penalty
Summary
The facility failed to maintain proper food safety and storage practices, as evidenced by multiple observations and staff interviews. The resident snack refrigerator was repeatedly found to be operating above the required temperature, with recorded readings of 50°F and 48°F on several days, despite the facility's policy requiring temperatures to remain at or below 41°F. The refrigerator contained unlabeled and open food items, including pudding cups, a take-out container, pitchers of juice, and an open gallon of milk, all of which felt warm to the touch. Staff interviews confirmed that items were left open and unlabeled, and that temperature monitoring was inconsistent, with several days missing temperature logs. Nursing and dietary staff were not consistently aware of the temperature issues or the need to remove items or notify maintenance when temperatures were out of range. In the main kitchen, expired milk was found in the refrigerator, with a best-by date that had already passed. The cook acknowledged that expired items should be removed during routine checks but admitted that the expired milk had been missed. This indicates a lapse in the facility's process for monitoring and removing expired food items from storage areas. Additionally, the facility's high-temperature sanitization dishwasher was observed to be functioning improperly, with rinse temperatures consistently below the required 180°F, despite the wash temperature being adequate. Staff were aware of the issue with the temperature gauge but did not consistently report the problem to supervisors or maintenance. The Environmental Service Director and other staff confirmed that the machine had ongoing issues, and that procedures for verifying and documenting corrective actions were not always followed. The facility's policy required staff to notify supervisors and document corrective actions when temperatures were not adequate, but this was not consistently done.
Failure to Provide Hot Water for Resident Showers
Penalty
Summary
The facility failed to provide a comfortable and homelike environment by not ensuring the availability of hot water for resident showers. Multiple residents reported that the water in the showers was consistently cold, with some stating they had to take quick showers or wait extended periods for hot water to become available. Residents also described difficulties accessing shower rooms and linens, with staff either refusing to open shower rooms or requiring residents to seek towels from housekeeping. These issues were observed and corroborated through resident interviews and direct observation. The facility's environmental services director confirmed that the boiler system was old, had ongoing issues, and that the water temperature at the shower fixtures could not be measured due to a broken thermometer. Documentation of boiler temperature checks was not available, and the director was unaware of when a replacement thermometer would be obtained. The boiler system was known to overheat and trip a safety switch, resulting in only cold water being supplied to the showers. Staff and administration were aware of the problem, and maintenance staff had been trained to reset the system, but the issue persisted. Residents' care plans indicated preferences for shower times and the need for assistance, but these preferences were not consistently honored due to the lack of hot water and restricted access to shower facilities. The facility's hot water policy required water temperatures to be maintained within a specific range and for regular temperature logs to be kept, but these procedures were not followed. As a result, residents were unable to receive safe and comfortable bathing experiences as required.
Call Light Inaccessible for Resident with Impaired Mobility and Cognition
Penalty
Summary
The facility failed to ensure that a resident's call light was accessible, as required to reasonably accommodate the needs and preferences of each resident. The resident involved had moderately impaired cognition, diagnoses of paranoid schizophrenia and PTSD, upper extremity impairment on one side, required staff assistance with most activities of daily living and mobility, and was frequently incontinent of bladder and occasionally incontinent of bowel. During observation, the resident was found sitting in a recliner/lift chair with the call light stuck inside the bottom of the chair and not within reach. A nursing assistant confirmed the call light was not accessible and was unable to immediately fix the issue, stating it would be addressed later. Both an LPN and the DON confirmed that call lights should be within reach of residents for safety. The facility was unable to provide a policy regarding call lights when requested.
Failure to Assess and Monitor Bruising in Resident with Self-Injurious Behavior
Penalty
Summary
The facility failed to provide adequate assessment, monitoring, and documentation of a bruise observed under the left eye of a resident with schizoaffective disorder and a history of self-injurious behavior. The resident, who was cognitively intact and newly admitted for mental health and diabetes management, reported that the bruise was self-inflicted due to command hallucinations. Despite standing orders and care plan interventions requiring regular skin assessments, documentation of abnormal findings, and prompt follow-up for injuries, there was no evidence of a nurse's initial evaluation or ongoing monitoring of the bruise in the medical record. Nursing assistant documentation noted the presence of the bruise and communication to the charge nurse, but there was a lack of subsequent nursing assessment, measurement, or description of the injury in the progress notes or skin and wound documentation. The facility's policy and staff interviews confirmed that the expected process for non-pressure injuries included assessment, implementation of standing orders, provider notification, daily monitoring, and documentation until resolution. Additionally, an incident report and behavioral team notification were required if the injury was behaviorally related or of unknown origin. Despite these protocols, the only documentation related to the bruise was from the nursing assistant, with no follow-up by licensed nursing staff as required. The resident's care plan and physician orders emphasized the need for close monitoring due to his mental health condition and risk for self-harm, yet the facility did not ensure that the bruise was adequately assessed, monitored, or documented according to policy and physician orders.
Failure to Consistently Monitor and Document Pressure Ulcers
Penalty
Summary
The facility failed to ensure consistent weekly monitoring and measurement of pressure ulcers for a resident with significant cognitive and physical impairments. The resident had a history of moderately impaired cognition, delusions, paranoid schizophrenia, PTSD, upper extremity impairment, and required substantial assistance with mobility and hygiene. Physician orders and the care plan specified that wounds on the resident's buttocks were to be measured weekly and documented, with additional instructions for regular dressing changes and skin checks. Despite these orders, documentation in the resident's medical record showed multiple instances where wounds were not monitored or measured as required. Specific dates in May and June lacked evidence of wound assessment or measurement, and there were gaps in progress notes regarding the condition of the pressure ulcers. Interviews with nursing staff and the DON confirmed that nurses were responsible for weekly skin checks and documentation, and that these tasks were not consistently performed or recorded. The DON acknowledged that there was no formal wound care program and that documentation was missing for several weeks. The facility's own policy required appropriate staff to provide treatment and services to heal pressure ulcers and prevent further development, but the lack of consistent monitoring and documentation demonstrated a failure to follow these protocols. The deficiency was identified through interviews, document review, and direct observation of the resident's medical record, which showed a pattern of missed or incomplete wound care documentation.
Failure to Conduct Root Cause Analysis and Update Interventions After Resident Falls
Penalty
Summary
The facility failed to ensure a root cause analysis was conducted and appropriate interventions were implemented for a resident with a history of falls. The resident, who had moderately impaired cognition and diagnoses including paranoid schizophrenia, required substantial assistance for toileting and partial assistance for transfers. Despite being identified as high risk for falls due to intermittent confusion, recent falls, and being chair bound, the facility did not document a root cause for the falls or update the care plan with new interventions after two unwitnessed falls. On two separate occasions, the resident was found on the floor in their room, once while reaching for shoes and another time after attempting to use the bathroom. In both instances, documentation failed to indicate whether the resident had appropriate footwear, and the fall assessment forms lacked analysis of contributing factors or evidence that the care plan and treatment sheet were reviewed or revised. Observations showed the resident was assisted by staff with transfers and footwear, but staff interviews revealed a lack of awareness regarding specific fall prevention interventions for the resident. Interviews with nursing staff and the DON confirmed that risk management forms were either not completed or not accessible, and there was no evidence that a root cause analysis or new interventions were determined following the falls. The facility's policy required reassessment and review of the safety plan after any fall, but this process was not followed, resulting in a failure to address the resident's ongoing fall risk.
Failure to Ensure Bed Rail and Bed Frame Compatibility
Penalty
Summary
The facility failed to ensure that a separately purchased bed rail and bed frame were compatible for a resident who was reviewed for bed rail use. The resident, who had moderate cognitive impairment and a diagnosis of schizophrenia, used a grab bar on the bed to assist with independent bed mobility and transfer. During observation, the bed rail was found to be loose, moving back and forth and sliding up and down in its sleeve. The resident confirmed that the rail always moved and demonstrated its instability. Staff interviews revealed that the bed rail could not be tightened further and that the rail was not made for the bed in use. The Environmental Service Director acknowledged that some beds and rails were old, and there was no way to determine compatibility due to missing manufacturer information. The facility's policy required that bed rails be installed per manufacturer guidelines and that compatibility be ensured. However, the staff were unable to provide manufacturer recommendations for the bed rail and bed frame, and the Environmental Service Director admitted to using extra screws in an attempt to secure the rail. The Administrator confirmed that only universal rails were ordered for use with various beds, but acknowledged the loose rail as a safety risk. The facility's failure to ensure compatibility and proper installation of the bed rail and bed frame resulted in a deficiency related to resident safety.
Food Safety and Equipment Cleaning Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling, dating, and disposal of food items, as well as maintaining clean cooking equipment, which could potentially affect all residents consuming food from the kitchen. During an initial tour, several issues were observed: uncovered juices and milks in the refrigerator, undated and discolored lettuce, and a bottle of barbeque sauce with residue on the lid. In the freezers, a package of beef patties and a bag of fish were found undated. Additionally, a KitchenAid mixer was found with yellow particles and a powdery substance on the handle, indicating it had not been cleaned after use. Interviews with staff revealed that the certified dietary manager acknowledged the requirement for foods to be dated and labeled, and stated that she had placed dates on items the morning following the observation. The facility's policies on dating and labeling opened foods and equipment cleaning were not adhered to, as evidenced by the undated food items and unclean equipment. The policies specified that all opened food items should be dated and labeled, and equipment should be cleaned and sanitized after each use, which was not followed in this instance.
Failure to Cover Linen Carts During Transport
Penalty
Summary
The facility failed to ensure that clean linen was transported and stored in a manner that prevents the spread of infection, potentially impacting all 31 residents. On the morning of September 23, a housekeeper transported a cart of linens, including fitted sheets, flat sheets, pillowcases, and fabric incontinent protector/pads, without covering them. The cart was moved through resident areas and stored in the east hallway. Later that day, the same cart, still uncovered, was observed in the west hallway and then moved to the middle hallway near the dining room, where residents were passing by. Interviews with housekeeping staff revealed a lack of awareness regarding the requirement to cover linen carts during transport and storage in resident hallways. Housekeeper A acknowledged the need to cover the cart but noted that the task was taking longer than usual. The infection preventionist confirmed the expectation for linens to be covered to prevent infection. The facility's policy on laundry did not provide guidance on transporting clean linen or the necessity of covering it when stored on resident units.
Failure to Assess and Document Need for Grab Bars
Penalty
Summary
The facility failed to properly assess and document the need for grab bars for a resident, identified as R31, who was observed to have grab bars affixed to their bed. R31 was cognitively intact and had diagnoses of alcohol use and neuropathy, and was independent in bed mobility, as indicated by their admission Minimum Data Set (MDS) and care plan. Despite this, there was no documentation of an assessment or education regarding the risks and benefits of grab bars, nor any attempt to explore alternatives before their installation. During interviews, staff members, including a registered nurse (RN-A) and the Director of Nursing (DON), confirmed the lack of a comprehensive assessment and provider order for the grab bars. The facility's policy required an assessment to determine the need for grab bars, consideration of alternatives, and education of the resident about potential risks, none of which were documented for R31. The oversight was further highlighted by the fact that R31's care plan and provider orders did not indicate a requirement for a grab bar, and the grab bar had been in place since the resident's arrival without proper procedural adherence.
Failure to Accurately Assess and Offer Pneumococcal Vaccination
Penalty
Summary
The facility failed to ensure that two residents were accurately assessed and offered the pneumococcal vaccination according to CDC guidelines. One resident, who was cognitively intact and had diagnoses of alcohol use and nicotine dependence, was not offered the pneumococcal vaccination upon admission, despite having no prior pneumococcal vaccinations recorded. The resident's medical records lacked evidence of assessment or offer of the vaccination prior to the survey entrance. Another resident, with moderate cognitive impairment and diagnoses of diabetes and lung disease, was recorded as up to date for pneumococcal vaccination. However, the resident had not received the newer PCV15, PCV20, or PCV21 vaccines, and shared clinical decision-making was required to determine if an additional dose was necessary. The facility's Infection Preventionist confirmed that the resident had not been accurately assessed for the need for an additional dose, as the MIIC report indicated the vaccinations were complete.
Latest citations in Minnesota
A resident with dry eye syndrome and degenerative eye disease had orders for cyclosporine ophthalmic emulsion and Refresh Tears, both scheduled at the same time. Medication records and direct observation showed a TMA instilled cyclosporine drops in both eyes and immediately followed with Refresh Tears in both eyes without waiting between medications. This practice conflicted with referenced professional guidance recommending several minutes between multiple eye drops and with the medical provider’s recommendation to wait fifteen minutes between the two ophthalmic medications. No facility policy on ophthalmic medication administration was provided when requested.
A resident with severe cognitive impairment, impaired mobility, and high fall risk was care planned to have wheelchair footrests in place at all times, with staff ensuring proper positioning and monitoring for leaning during transport. A NA transported the resident in a manual wheelchair from the shower without the footrests, and while going through the doorway the wheelchair struck the door frame, causing the resident, who was leaning forward, to fall out. The resident sustained a T12 fracture, head injury with concussion, abrasions and contusions, and multiple right-hand lacerations requiring sutures, and the DON confirmed the care plan had not been followed.
A high‑risk, immobile resident with MS and prior heel DTI developed an avoidable unstageable coccygeal pressure ulcer after staff failed to consistently assess and document skin status, did not transfer or timely provide ordered pressure‑relieving mattresses, and did not reliably perform q2h repositioning. The resident was repeatedly left on a bedpan for prolonged periods despite early reports of this issue, and the toileting care plan was not revised to a bedside commode until after the coccygeal wound had significantly worsened. Wound assessments lacked complete measurements and staging, changes in wound size and color were not promptly recognized as deterioration or reported to providers, and recommended interventions from a wound NP (including an air mattress and offloading) were not promptly implemented. As a result, the coccygeal ulcer rapidly progressed to a large, necrotic, malodorous wound requiring hospital transfer and surgical debridement.
A resident with spastic hemiplegia, muscle weakness, and moderate cognitive impairment was observed using bilateral bed grab bars for bed mobility and transfers, but the care plan did not address grab bar or side rail use. Review of the EMR showed no completed bed mobility device or side rail assessment to determine the necessity or safety of the grab bars, and no documentation that risks and benefits were discussed or that informed consent was obtained. An LPN and the ADON stated that a bed mobility device assessment is required before grab bars are installed and confirmed that no such assessment existed for this resident.
A resident with bilateral heel pressure ulcers and multiple comorbidities received wound care during which an RN removed dressings from both heels, cleansed both wounds, and wiped each heel without changing gloves or performing hand hygiene between wounds or after disposing of soiled dressings. This practice conflicted with the facility’s written wound care procedure, which requires glove removal and hand hygiene after dressing removal and after wound cleansing. In interviews, the RN, NP, and DON/IP acknowledged that hand hygiene and glove changes are expected between dirty and clean tasks and between separate wounds to prevent infection.
A resident with MS, neurogenic bladder, mobility limitations, and existing pressure injuries was identified as dependent for toileting hygiene and at risk for pressure ulcers, yet the care plan lacked an individualized toileting/incontinence plan and a defined repositioning schedule. Despite a new coccyx pressure ulcer and documentation that interventions such as increased repositioning and incontinent care were needed, the care plan was not revised for a period of time to reflect these changes. During this time, the resident sometimes fell asleep on a bedpan and remained on it until staff removed it, and staff were not initially informed that the bedpan should no longer be used. The DON later acknowledged that the care plan revisions for turning, repositioning, and toileting were delayed until after the resident’s coccyx ulcer had significantly worsened.
A resident with diabetes, Crohn’s disease, bowel incontinence, and a history of MASD on the right gluteus developed an open, painful lesion on the right gluteal area that was documented over time without complete wound characteristics, clear etiology, or timely provider notification. Wound care orders were written for a stage 3 pressure ulcer on the left buttocks, while staff reported the wound was only on the right side and applied the left‑sided orders to the right gluteal wound in the absence of specific right‑side treatment orders. The DON acknowledged discomfort with staging the wound, lack of early physician notification, and confusion over wound classification, despite a facility policy requiring comprehensive wound assessment, consistent measurement, and provider notification when treatment orders are absent.
A resident with diabetes, chronic leg ulcer, kidney transplant, and a documented gluteal wound was care-planned for Enhanced Barrier Precautions (EBP), with posted instructions requiring gown and gloves for high-contact care such as transfers and wound care. During a telehealth wound assessment, the DON donned a gown and initially performed hand hygiene but then applied gloves without hand hygiene, removed a soiled dressing from the resident’s gluteal area, discarded it, removed gloves, and applied new gloves again without performing hand hygiene between glove changes. On another occasion, during use of a sit-to-stand lift, an NA wore gown and gloves, but the DON handled the lift harness, the resident’s clothing, and assisted with the transfer and repositioning while wearing a gown but no gloves, despite EBP requirements for transfers. The DON stated EBP was only needed for catheter or wound care and not for transfers, contradicting the posted EBP instructions and facility policy.
A resident with severe dementia, psychiatric disorders, and high dependence for ADLs was verbally abused during evening care when a NA, frustrated with the resident’s crying and resistance, loudly ridiculed her as acting like a two-year-old, threatened to hit her back if struck, told her she would be sent to a locked unit, and questioned who would want to care for her when she cried like a baby. Multiple staff witnessed the loud, stern, and intimidating tone and reported it to an LPN, who recognized it as verbal abuse but did not immediately remove the NA from duty or promptly report the allegation per policy, allowing the NA to continue working on the unit. Following this incident, the resident demonstrated increased crying, combativeness, resistance to care, wandering, self-isolation, and refusal of food, fluids, and medications above baseline, with documentation of significant emotional distress and subsequent ED evaluation for aggressive behaviors and poor intake.
A resident with dementia, bilateral above‑knee amputations, vascular disease, and severe protein‑calorie malnutrition developed a wound on an amputation stump that had a dressing dated several days before any documentation or treatment orders appeared in the record. Although bath audits and nursing notes initially reported no skin issues, a later assessment described a full‑thickness stage 4 ulcer/diabetic ulcer on the stump with exposed bone, erythema/edema, slough, and moderate serosanguineous drainage. Nursing staff interviews showed no one could identify who first discovered the wound or applied the initial dressing, and there was no evidence that the wound was assessed, the provider notified, or standing orders implemented when it was first present, despite facility expectations that new wounds be promptly evaluated and reported.
Failure to Follow Professional Standards for Ophthalmic Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice for administering ophthalmic medications to a resident with dry eye syndrome and degenerative eye disease. The resident was cognitively intact, required assistance with ADLs, and had physician orders for cyclosporine ophthalmic emulsion 0.05% one drop in both eyes twice daily and Refresh Tears ophthalmic solution one drop in both eyes four times daily for dry eyes. The administration summary showed that both eye medications were scheduled for the same time and were documented as being given at the same time on multiple dates. During a medication pass observation, a trained medication aide administered the ordered oral medications, then applied gloves and instilled one drop of cyclosporine in each eye, immediately followed by one drop of Refresh Tears in each eye, without any waiting period between the two medications. The surveyors referenced guidance from the American Academy of Allergy, Asthma, and Immunology stating that when more than one eye drop is ordered, three to four minutes should be allowed between drops in the same eye, and five to fifteen minutes should be allowed between different eye medications to prevent dilution. Interviews with the DON, pharmacy consultant, and medical provider confirmed that best practice and the provider’s recommendation were to wait between administration of cyclosporine and Refresh Tears, with the medical provider specifying a fifteen-minute interval. The facility did not provide a policy on ophthalmic medications when requested. The observed practice and documented administration times demonstrated that staff did not follow these professional standards or the medical provider’s recommended interval between the two eye medications.
Failure to Follow Wheelchair Transport Care Plan Leads to Fall With Injuries
Penalty
Summary
The deficiency involves the facility’s failure to implement care-planned fall prevention interventions for a resident at high risk for falls, resulting in a fall with injury. The resident had diagnoses including aphasia, dysphagia, muscle weakness, traumatic brain injury, and impaired mobility, with severe cognitive impairment documented on the MDS and dependence on staff for transfers and wheelchair transport. A care plan addressing wheelchair transport safety and positioning directed staff to ensure the resident was fully positioned and supported in the wheelchair prior to transport, verify footrests were in place prior to transport, and monitor for leaning, sliding, or unsafe positioning. An additional care-planned approach required wheelchair pedals to be on at all times. On the date of the incident, a nursing assistant transported the resident in a manual wheelchair from the shower room to the resident’s room without the foot pedals in place, contrary to the care plan. While being wheeled through the doorway, the wheelchair struck the door frame, causing the chair to stop and the resident, who had begun leaning forward, to fall out of the wheelchair onto the floor. Progress notes and ED documentation identified that the resident sustained a T12 vertebral fracture, a head injury with concussion, an abrasion and contusion to the head, a bruise to the left knee, and multiple lacerations to the right hand requiring sutures. The nursing assistant later acknowledged awareness that the foot pedals should have been on but did not apply them because the transport was only from the shower to the room. The DON confirmed that the resident’s care plan had not been followed when the fall occurred.
Failure to Implement and Update Pressure Ulcer Prevention and Treatment Led to Avoidable Unstageable Coccygeal Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, monitor, and implement individualized pressure ulcer prevention and treatment interventions for multiple high‑risk residents, resulting in an avoidable, unstageable coccygeal pressure ulcer for one resident that required surgical debridement and hospitalization. The resident had primary progressive multiple sclerosis, hereditary spastic paraplegia, obesity, and pre‑existing pressure‑related deep tissue injury to the left heel, and was identified as high risk for pressure ulcers on the Braden Scale due to constant moisture, chairfast status, very limited mobility, inadequate nutrition, and friction/shear risk. Hospital records on readmission documented irritant contact dermatitis of the bilateral gluteal cleft with specific cleansing and barrier cream orders, and facility documentation showed the resident could not reposition in bed or chair and required assist of two and a full‑body mechanical lift for transfers. Despite this, the admission/readmission skin assessment and weekly skin checks lacked measurements and detailed wound characteristics for the heel ulcer and gluteal dermatitis, and the care plan did not include comprehensive, individualized interventions beyond generic repositioning and wound care orders. After a new coccyx pressure ulcer was identified and documented as a stage 2 lesion, the facility failed to promptly and accurately update the care plan and implement recommended pressure‑relieving interventions. The wound nurse practitioner on 3/5 ordered coccyx wound care, an air mattress, pressure offloading, and a dietician consult, but the care plan was not revised and there was no evidence that an air mattress was placed on the bed for nearly two weeks. The environmental services director later confirmed that when the resident was moved to a new room, the gel mattress was not transferred, and the air mattress requested on 3/17 was not actually placed until the following day, despite being marked as completed. During this period, TAR documentation showed gaps in the every‑2‑hour repositioning order, and staff interviews revealed that CNAs were unaware of which residents were on repositioning programs, were not consistently repositioning residents, and had not received recent education on pressure ulcer prevention. The DON and RN case manager acknowledged that the coccyx wound increased in size and changed color between assessments, that the bed lacked the ordered gel mattress, and that the physician was not notified of the wound’s deterioration at that time. The facility also failed to timely modify toileting and incontinence care practices despite knowledge that the resident was being left on a bedpan for extended periods. The DON reported hearing before an IDT meeting that the resident had fallen asleep on a bedpan for an undetermined amount of time, but the care plan was not revised to discontinue bedpan use and implement a bedside commode until after the coccyx wound had significantly worsened. CNAs confirmed that the resident sometimes fell asleep on the bedpan and that they were not informed she should no longer use it until after the sore had worsened. Subsequent wound assessments documented rapid progression of the coccyx wound from a small stage 2 ulcer to a large, malodorous, necrotic wound with eschar, slough, erythema, and purulent drainage, ultimately classified as an unstageable pressure ulcer. The DON, NP, PA, and medical director all indicated that the lack of a pressure‑relieving mattress, failure to adjust pressure‑reducing interventions, and prolonged time on a bedpan likely contributed to the development and deterioration of the resident’s pressure ulcer, which was determined to be avoidable and resulted in hospitalization and surgical debridement. Additional documentation and interviews showed systemic assessment and communication failures related to pressure ulcer management. Weekly skin checks and wound assessments often omitted complete measurements, staging, and wound characteristics, and changes in wound size and appearance were not consistently recognized as deterioration or communicated to providers. The DON acknowledged that a 3/12 assessment showing increased wound size and purple discoloration should have been identified as a deep tissue injury and reported to the physician, but this did not occur. When nursing later documented foul odor, increased pain, and expanding necrotic tissue, telemedicine and PA responses deferred in‑person evaluation and ED transfer despite earlier recommendations that the resident be sent to the ED if an in‑person provider could not assess the wound. The NP ultimately found a large, malodorous, purulent wound with expanding eschar and ordered transfer to the hospital, where imaging and surgical findings confirmed a large necrotic sacral wound requiring extensive debridement. Throughout this sequence, the facility did not consistently follow its own pressure ulcer protocols, did not ensure ordered pressure‑relieving equipment was in place, and did not promptly revise care plans or interventions in response to known risk factors and documented wound changes. The report also notes that other residents reviewed for pressure ulcers were affected by similar failures in monitoring and individualized intervention, though detailed narratives focus primarily on this resident. Staff interviews revealed that CNAs relied on paper care guides that did not clearly identify residents on repositioning programs or at risk for skin breakdown, and that they were unaware of some residents’ special mattress orders or toileting restrictions. The DON and medical director stated that residents at risk for pressure ulcers should have immediate pressure‑relieving interventions and that existing ulcers require ongoing evaluation to prevent deterioration, but the documented practices for this resident did not align with those expectations. These combined actions and inactions—insufficient assessment detail, delayed or missing care plan revisions, failure to implement ordered support surfaces and repositioning, and delayed response to wound deterioration—constituted the deficiency in providing appropriate pressure ulcer care and preventing new ulcers from developing.
Failure to Assess, Care Plan, and Obtain Consent for Bed Grab Bar Use
Penalty
Summary
The deficiency involves the facility’s failure to follow required procedures before installing and using bed grab bars for a resident. The resident had diagnoses including spastic hemiplegia affecting the left side and muscle weakness, and an admission MDS indicating moderate cognitive impairment. During observation, the resident was seen in a power chair with bilateral grab bars on the bed and reported using them to roll in bed and for transfers. The resident’s care plan, dated 1/23/26, documented a need for assistance with bed mobility and independence with transfers but did not mention or address the use of grab bars or side rails. Review of the electronic medical record showed no completed grab bar/side rail or bed mobility device assessment to determine the necessity of the grab bars or whether the resident could safely use them. There was also no evidence that the resident or the resident’s representative had been educated on the risks of having a grab bar on the bed or that informed consent had been obtained. In interviews, an LPN and the ADON both stated that a bed mobility device assessment was required to determine need and safety prior to installing grab bars, and both confirmed that no such assessment was present in the resident’s record.
Failure to Perform Hand Hygiene and Change Gloves During Wound Care
Penalty
Summary
Surveyors observed that a registered nurse (RN) and a nurse practitioner (NP) did not follow the facility’s established infection control practices during wound care for one resident. During a wound treatment, the RN wore gloves while removing the dressing from the resident’s left heel, then removed the dressing from the right heel, sprayed both wounds with wound cleanser, wiped the left heel with gauze, and then used a clean gauze pad to wipe the right heel. The RN did not remove her gloves or perform hand hygiene after disposing of the soiled dressings or between cleaning the left and right heel wounds, contrary to the facility’s written wound care procedure, which requires glove removal and hand hygiene after removing the previous dressing and again after cleaning the wound. The resident’s admission MDS documented diagnoses including multiple rib fractures, heart failure, dementia, anxiety, and the presence of a pressure ulcer, and indicated the resident was cognitively intact and required staff assistance with care and transfers. The resident’s care plan identified pressure ulcers on both heels requiring wound care. In interviews, the RN, NP, and the DON/infection prevention nurse each stated that gloves should be changed when moving from dirty to clean areas and that hand hygiene is expected after glove removal and between wounds to prevent infection, confirming that the observed practice did not align with facility policy or expected infection control standards.
Failure to Timely Revise Care Plan for Toileting and Skin Integrity
Penalty
Summary
The deficiency involves the facility’s failure to timely revise and individualize a resident’s care plan to address toileting and incontinence needs in relation to impaired skin integrity. The resident had diagnoses including primary progressive multiple sclerosis, hereditary spastic paraplegia, obesity, and a pressure-induced deep tissue injury to the left heel. A Significant Change MDS identified the resident as dependent for toileting hygiene, with lower extremity range-of-motion limitations, wheelchair use, dependence for transfers, occasional urinary incontinence, intact cognition, and at risk for pressure ulcers with existing unhealed pressure injuries and MASD. The resident’s skin-focused care plan, revised on various dates, included skin inspections, wound care orders, weekly skin checks, pressure ulcer care to the left heel, nutritional supplements, and a gel mattress, but did not include an individualized toileting or incontinence plan. On a weekly skin check dated 3/3/26, nursing staff identified a new Stage 2 pressure ulcer on the coccyx and contact dermatitis on both gluteal folds. An IDT Final Post Review Follow Up dated 3/10/26 (signed 3/23/26) documented that a new skin issue had occurred and that interventions after the incident included wound care treatment orders, increased repositioning, and increased incontinent care. However, the resident’s care plan from 3/3/26 through 3/16/26 did not show revisions reflecting increased incontinence care or a repositioning schedule, and the care plan was not updated to include these elements until 3/17/26. During this period, the care plan still lacked an individualized toileting plan despite the resident’s identified incontinence and new coccyx pressure ulcer. Progress notes on 3/17/26 documented that the resident’s coccyx wound had declined, with an evaluation describing a deteriorating wound characterized as a Kennedy terminal ulcer/End of Life, staged as a Stage 4 pressure ulcer, in-house acquired, with increased size, exudate, odor, pain, and surrounding erythema. On that same date, the skin focus care plan was revised to include prompt incontinence care and keeping the skin clean and dry, and the elimination focus care plan was revised to address incontinence due to neurogenic bladder with use of a bedside commode offered every 2–3 hours. A nursing assistant reported that when working with the resident, the resident would sometimes fall asleep on the bedpan and forget to ask staff to remove it, and that she was not aware the resident was not supposed to use the bedpan until after the sore had worsened. The DON stated that the resident’s care plan had not been revised earlier to include a turning and repositioning schedule or toileting changes, and that it should have been revised as soon as staff learned the resident was falling asleep on the bedpan, rather than waiting until after the pressure ulcer worsened.
Failure to Assess and Notify Provider for Right Gluteal Wound
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess and appropriately manage a non‑pressure skin issue on a resident’s right gluteal area, and to notify the physician in a timely manner. The resident had diagnoses including diabetes, Crohn’s disease, and a kidney transplant, and the MDS indicated occasional bowel incontinence, no pressure ulcers, and no moisture‑associated skin damage at that time. Earlier documentation identified a resolved MASD to the right gluteus, and a progress note later described a sacral wound with creams applied, noting that sores were still open and painful during application, but without any measurements, wound characteristics, or evidence of physician notification. Subsequent wound assessments documented an open lesion on the right gluteus with specific measurements on multiple dates, but did not identify the wound type or other characteristics, and the record did not show physician notification or treatment orders for the right gluteal lesion. Provider orders in place initially addressed cleansing the buttocks and applying barrier cream, and later included a detailed wound care order for a stage 3 pressure ulcer documented on the left buttocks. However, the resident’s record did not contain a specific treatment order for the right gluteal wound, despite the ongoing documentation of an open lesion in that area. Interviews revealed confusion and inconsistency in wound identification and classification. The DON stated that the right gluteal wound was documented as an open lesion because she did not feel comfortable determining the wound type, and acknowledged that the physician should have been notified when the wound was first identified. The DON was unaware that the NP had documented the wound as being on the left buttocks and as a stage 3 pressure ulcer, while the RN reported that the wound had never been on the left buttocks and that she had been applying the left‑sided wound orders to the right gluteal area because there was no open area on the left. The resident reported a recurring painful area on the right buttocks and chronic stool leakage since prior anal fistula surgery. The facility’s own wound treatment policy required comprehensive assessment of wound etiology and characteristics, consistent measurement and documentation, and provider notification in the absence of treatment orders, which were not followed for this resident’s right gluteal wound. The deficiency centers on the lack of a comprehensive wound assessment for the right gluteal lesion, incomplete documentation of wound characteristics, failure to clearly determine and document the wound etiology, and failure to notify the physician and obtain appropriate treatment orders when the wound was identified and remained open. These actions and inactions resulted in a discrepancy between the documented wound location and type and the actual clinical presentation, as well as a period during which the right gluteal wound had no specific, clearly ordered treatment despite being open and painful.
Failure to Perform Hand Hygiene and Implement Enhanced Barrier Precautions During Wound Care and Transfers
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper hand hygiene during wound care and to consistently implement Enhanced Barrier Precautions (EBP) for a resident requiring such measures. The resident had diagnoses including diabetes, a non-pressure chronic ulcer of the right lower leg, and a kidney transplant, and a wound assessment documented an open lesion on the right gluteal area. The resident’s care plan and a sign posted outside the room specified that EBP, including gown and gloves, were required for high-contact care activities such as dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, catheter care, and wound care. During one observation, the DON performed hand hygiene and donned a gown before entering the resident’s room for a telehealth wound assessment. Inside the room, the DON went into the bathroom, applied gloves without performing hand hygiene, removed the resident’s brief, and removed a foam dressing from the right gluteal area that had stool on one corner. After discarding the soiled dressing, the DON removed gloves and then applied new gloves without performing hand hygiene between glove changes. When questioned, the DON stated that hand hygiene should be done when hands or gloves are visibly soiled and before and after removing or applying gloves, and acknowledged that hand hygiene had not been performed each time gloves were removed and reapplied. In a separate observation, the resident was transferred using a sit-to-stand mechanical lift while EBP requirements were not fully followed. An NA entered the room wearing a gown and gloves with the lift, and the DON applied the lift harness under the resident’s arms and cinched the waist strap, encountering the resident’s clothing, while not wearing gloves. After the transfer to bed, the DON pulled down the resident’s pants and removed the harness while touching the resident’s clothes. Following wound care by a CNP-WOC, the DON again assisted the resident by sitting the resident on the edge of the bed, applying the lift harness, and adjusting the resident’s pants and shirt while wearing a gown but no gloves. The DON stated that EBP was only needed for catheter or wound care and not for transfers, and only upon reading the posted EBP sign acknowledged that EBP was required for all high-contact resident care activities, including transfers.
Failure to Protect Resident From Verbal Abuse and Delay in Removing Alleged Perpetrator
Penalty
Summary
The deficiency involves the facility’s failure to protect a vulnerable resident from mental abuse and to respond appropriately to an allegation of abuse. The resident had severe cognitive impairment, Alzheimer’s disease, dementia, anxiety, depression, psychotic disorder, and significant functional dependence, including frequent incontinence and the need for extensive assistance with ADLs and transfers. Her care plan identified behavioral and mood issues such as wandering, yelling, combative behavior, and calling staff names, with interventions including calm approaches, emotional support, redirection, and monitoring for emotional distress and mood/behavior changes. She was identified as a vulnerable adult, with instructions to monitor for signs of emotional distress and to follow the facility’s abuse reporting policy. On the evening in question, while the resident was crying on the phone with her son and expressing a desire to leave, NA-A and NA-B entered to provide evening care using an EZ stand lift. After the resident ended the phone call, multiple staff reported that NA-A spoke to the resident in a loud, stern, and frustrated tone, telling her to stop crying and that she was acting like a two-year-old. When the resident swatted at NA-A, NA-A stated, “If you hit me, I’m going to hit you back,” and later told the resident she was “in trouble now.” Staff reported that NA-A told the resident she would be sent to a locked unit so she could not get out, and questioned who would want to care for her when she cried like a baby, and that nobody would want to keep working with her. NA-C described NA-A yelling commands such as “HOLD ON!” and “Stop crying! Where would you be if you were not here? Probably lying on the floor,” and felt NA-A was obviously upset and overwhelmed. These statements were made in the presence of the resident while she was already distressed and crying. Following this interaction, the resident exhibited crying, yelling, combativeness, resistance to care, wandering into other residents’ rooms, self-isolation, and refusal of food, fluids, and medications above her prior baseline, as documented in behavior charts, target behavior monitoring, and nursing progress notes. Staff documented that she cried most of the morning, was very restless, difficult to redirect, hit and pinched staff, called staff names, and refused care and meals. She required repeated redirection, 1:1 attention, and non-pharmacological interventions, and was ultimately sent to the ED for evaluation of combativeness and emotional distress, where she was treated for dementia with aggressive behavior and hypoglycemia related to poor intake. The report identifies that the resident’s actual response and the reasonable person concept showed serious psychosocial harm, including increased crying and combative behavior above baseline, fear/anxiety manifested as combativeness, resistance to care and social interaction, and self-isolation. The facility also failed to immediately remove the alleged perpetrator from resident care and to promptly report and investigate the allegation in accordance with its abuse policy. After NA-B and NA-C reported to LPN-A that NA-A had yelled at and threatened the resident, LPN-A acknowledged it as verbal abuse but did not initiate immediate protective measures or timely reporting. LPN-A stated she believed she had 24 hours to report because there was no injury, despite facility policy requiring reporting within two hours. NA-A remained on the unit and continued working until the end of her shift, including after staff had clearly communicated their concerns to LPN-A. TMA and NA staff described uncertainty about their authority to remove NA-A and reliance on the nurse to act, while the DON later informed LPN-A that NA-A should have been removed from the floor to prevent further danger to residents. The Immediate Jeopardy was determined to have begun when NA-A’s derogatory, intimidating, and threatening statements were made and continued while she remained on duty with access to the resident and other vulnerable residents.
Failure to Timely Assess and Treat Newly Discovered Stump Wound
Penalty
Summary
The deficiency involves the facility’s failure to provide timely treatment and care for a newly discovered wound on a resident’s above‑knee amputation stump. The resident was admitted with diagnoses including unspecified dementia with behavioral disturbances, vascular dementia, bilateral above‑knee amputations, vascular disease, reduced mobility, and severe protein‑calorie malnutrition, and had no documented ulcers or skin problems on admission or on the most recent MDS. A weekly bath audit on 3/17/26 documented only non‑tender lymph nodes on the right upper hip and did not identify any open areas. However, when the wound was later assessed, the dressing on the stump was dated 3/16/26, indicating that a wound and dressing existed at that time, even though no corresponding assessment, provider notification, or treatment orders were documented. On 3/23/26, nursing staff documented a new skin issue above the resident’s knee at the amputation site, describing a stage 4 pressure ulcer/injury with full‑thickness skin and tissue loss, exposed bone, erythema/edema, and moderate serosanguineous exudate. The wound measured 1.56 cm by 1.64 cm, with 20–29% granulation tissue and 80% slough. A progress note and skin issues assessment on that date confirmed the wound characteristics and staging, and the NP, after reviewing a picture, determined the wound to be a diabetic ulcer with peripheral vascular disease and severe protein‑calorie malnutrition as contributing factors. On that same date, the NP was notified, antibiotic therapy (doxycycline) was ordered for possible cellulitis, and specific wound care orders were initiated, with documentation on the MAR that these treatments were carried out beginning 3/23/26. Multiple interviews with nursing staff revealed that no one could identify who discovered the wound or who applied the initial dressing dated 3/16/26, and there was no documentation of a wound assessment, provider notification, or interim treatment between 3/16/26 and 3/22/26. Several RNs and LPNs who worked shifts from 3/16/26 through 3/20/26 stated they did not notice a wound on the stump and that, per their usual practice, they would have contacted the provider and initiated treatment if they had found one. One LPN recalled seeing a band‑aid with a date on the stump but could not recall the date, and another LPN stated she did not see the wound because she was not looking for one. The facility’s standing orders required staff to assess all wounds daily, change dressings every three days and as needed, treat with normal saline or non‑cytotoxic cleanser and appropriate dressings, and notify the provider the next business day when a new wound or injury was found. Despite these expectations, the wound identified by the dated dressing on 3/16/26 was not assessed, reported, or treated according to orders and facility policy until 3/23/26.
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