Highland Chateau Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Paul, Minnesota.
- Location
- 2319 West Seventh Street, Saint Paul, Minnesota 55116
- CMS Provider Number
- 245028
- Inspections on file
- 55
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 55 (2 serious)
Citation history
Health deficiencies cited at Highland Chateau Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with stroke-related expressive aphasia, cognitive impairment, and multiple comorbidities was allowed to leave independently for community outings without a documented assessment of community safety skills or corresponding care plan interventions. The MDS noted moderate cognitive impairment and did not assess community ambulation abilities, while the care plan addressed independence with ADLs and communication supports but not independent leave. Nursing notes showed repeated unsupervised outings, and staff interviews revealed no standardized process or clear criteria to determine which residents could safely go out alone, no provider order authorizing independent leave, and no consultation with therapy disciplines to evaluate communication and functional safety in the community, despite facility policies requiring comprehensive, person-centered assessment and care planning.
A resident with dementia, repeated falls, and documented exit-seeking and wandering behaviors was assessed as an elopement risk and placed on a wander guard with care plan interventions for wandering/elopement. In the days before the incident, staff notes described the resident attempting to elope, becoming aggressive when redirected, and requiring one-to-one supervision, with baseline confusion and chronic short-term memory loss. On the day of the event, the resident repeatedly approached an exit and triggered the wander guard alarm while waiting in a common area for transportation to another facility; during a busy shift change and staff handoff for supervision, staff lost track of the resident, who left the building undetected while still wearing the wander guard. Staff later reported they did not know whether the wander guard alarmed or how the resident exited, and camera footage only showed the resident outside talking with others and then moving away from the building, demonstrating a failure to provide adequate supervision and effective elopement prevention for a known high-risk resident.
Two residents with complex medical and behavioral histories received 30‑day discharge notices that lacked required contact information for the LTC ombudsman and the state agency appeals coordinator. One resident, a smoker with liver disease, COPD, and mental health diagnoses, was repeatedly observed smoking in his room despite education on facility policy and was issued a discharge notice with an incorrect transfer date and no ombudsman details; he believed he was being discharged for being mean to others and had to obtain the ombudsman’s number from staff. Another resident with DM, chronic pain, opioid dependence, depression, and anxiety, identified as a vulnerable adult due to substance abuse and trauma, was discharged after being found using illicit drugs and sent to the hospital, but his notice also omitted ombudsman and appeal contact information, leaving him thinking his only option was to beg the administrator to stay. The ADON acknowledged the omissions, and the LTC ombudsman reported that notices should include this information and that there was a delay in receiving copies of the notices.
The facility did not have a registered nurse designated as the full-time DON after the previous DON's departure. For two weeks, an LPN acted in the role, and staff interviews showed uncertainty about who was responsible for DON duties, with the facility relying on a team approach and awaiting corporate hiring decisions.
A resident experienced a significant decline in functional status, requiring increased assistance with ADLs and mechanical lift transfers following multiple hospitalizations and new diagnoses. Despite these changes and new therapy orders, the care plan was not updated to reflect her current needs, and staff were inconsistent in their understanding and implementation of required interventions.
A resident with multiple fractures, trauma, and diabetes experienced severe pain that was not promptly managed, waiting approximately nine hours for prescribed narcotic pain medication after admission. The resident's blood glucose and vital signs were not monitored as ordered, and the facility's emergency medication kit was out of the required medication, leading to the resident calling 911 and returning to the hospital for pain management.
A resident with multiple fractures and trauma did not receive oxycodone HCl according to physician orders, with records showing administration of doses more frequently and in greater quantities than prescribed. Staff interviews revealed medication errors due to lack of medication availability, improper documentation in the narcotic count book, and failure to transcribe or follow updated orders. The pharmacy and DON confirmed that the facility was not adhering to the most current prescription, and errors were not reported as required.
Multiple residents with complex medical needs experienced significant delays in receiving assistance with toileting, repositioning, and other ADLs due to insufficient staffing and lack of oversight. Call light response times frequently exceeded the facility's policy, with some residents waiting over an hour or more for help. Agency nursing assistants were observed using cell phones while on duty, and there was inadequate supervision and training. Facility leadership acknowledged the delays but did not consistently review or address call light response data, resulting in unmet resident needs.
The facility did not provide adequate orientation, training, or competency verification for both employed and agency NAs, as evidenced by incomplete documentation, lack of job-specific training materials, and resident reports of unprepared staff. Two NAs lacked required skill competencies and in-service trainings, and residents reported that agency NAs were unfamiliar with facility procedures and equipment.
The facility did not employ a full-time RD or a qualified DM to manage food and nutrition services, as required. The DM could not provide evidence of necessary certifications, and her personnel file was incomplete. The RD was a part-time consultant, and the facility could not verify the qualifications of either staff member, potentially affecting all residents receiving meals.
The facility did not maintain an effective pest control program, as evidenced by repeated mouse sightings, droppings in the kitchen and storage areas, improper food storage, and unsanitary conditions. Staff frequently left doors propped open and dumpsters uncovered, failed to consistently log pest sightings, and did not ensure food was stored in sealed containers, leading to ongoing pest activity throughout the facility.
Surveyors identified multiple deficiencies in food storage and labeling, including unlabeled and undated food items, improper storage of opened foods, food containers with residue, and kitchen equipment with visible debris. Facility staff and management confirmed these lapses, which were not in accordance with established food safety and sanitation policies.
Two residents were not provided with appropriate clothing, with one left wearing only a robe and slippers for an extended period due to lack of personal belongings and discontinued facility gowns, and another resident was spoken to in an undignified manner by a staff member after an incident involving soiled clothing. Staff and leadership interviews confirmed awareness of these issues, and facility policy requires residents to be treated with dignity and respect, including support for preferred clothing and respectful communication.
A resident with severe cognitive impairment and multiple medical conditions experienced a change in health status, resulting in a hospital transfer. The facility did not notify the resident's family about the change in condition or the transfer, and the family only learned of the hospitalization from a hospital physician. The DON confirmed that family notification should have occurred but did not.
A resident who required staff assistance for dressing reported missing clothing to nursing staff, but no grievance form was completed and no investigation was initiated. Key facility staff were unaware of the issue until it was brought up during the survey, despite facility policy requiring prompt investigation of such complaints.
A resident's MDS assessment was inaccurately coded, failing to document the use of an anticoagulant medication despite the resident receiving it during the review period. The DON confirmed the omission and acknowledged the need for accurate MDS coding, as the assessment forms the basis for payment and care planning.
A resident admitted with an infection and inflammatory reaction related to a joint prosthesis did not receive a summary of the baseline care plan within the required timeframe. Documentation was lacking in the EMR, and staff interviews confirmed that the care conference and provision of the baseline care plan summary did not occur as required by facility policy.
Two residents with significant medical needs did not have comprehensive care plans addressing their risks for pressure ulcers and respiratory impairment. One resident at moderate risk for pressure ulcers lacked documented preventive interventions, while another using oxygen and a non-invasive ventilator had no care plan for respiratory care. Staff and the DON confirmed these omissions, which were not in line with facility policy requiring individualized, updated care plans.
The facility did not consistently conduct required care conferences for three residents, including those with cognitive impairment, recent admission, and complex medical needs. In some cases, care conferences were canceled and not rescheduled, or not held with the full interdisciplinary team, and residents sometimes did not recall participating. Facility staff misunderstood requirements, leading to missed or incomplete care planning meetings.
A resident with severe cognitive impairment and quadriplegia, fully dependent on staff for ADLs, was repeatedly observed with long, dirty fingernails despite care plans and facility policy requiring regular nail care. Staff interviews revealed confusion about responsibility for nail trimming, and a family member's request for nail care was not addressed, resulting in ongoing neglect of the resident's personal hygiene.
A resident with a history of joint infection, heart failure, and recent knee surgery did not receive prescribed compression stockings or wound care due to improper transcription of physician orders into the electronic health record. Nursing staff were unaware of the active orders, leading the resident to manage his own wound care and compression therapy. The care plan was not updated to address edema or the use of ted stockings, and documentation of required treatments was missing.
A resident with multiple risk factors, including immobility and incontinence, was not consistently repositioned or provided with appropriate heel protection, despite being at high risk for pressure ulcers. The care plan lacked specific interventions for skin breakdown prevention, and staff did not follow recommended repositioning schedules. As a result, the resident developed new pressure ulcers while under care.
A resident with a medical marijuana card and chronic pain was observed vaping THC in bed without the facility's knowledge or assessment for safe vaping practices. Although the DON and ADON were aware of the resident's marijuana use, there was no documentation in the care plan or physician orders, and no assessment for safe self-administration or supervision was conducted. The facility's policies prohibited vaping indoors and required care plan updates and assessments, but these were not followed, resulting in unaddressed accident hazards.
A resident with mixed incontinence and mobility limitations did not have a comprehensive incontinence care plan and experienced significant delays in receiving assistance with toileting and changing, often waiting over two hours despite repeated requests. Staff interviews confirmed delays due to limited staffing, and the DON acknowledged that the care provided did not meet facility policy requirements.
A resident with severe malnutrition and ongoing weight loss did not receive ice cream as recommended by the RD to increase calorie intake, because the recommendation was not transcribed into a physician's order or added to the MAR. Nursing and dietary staff were unaware of the need to provide ice cream, and the resident continued to experience weight loss as a result.
A resident receiving gastrostomy tube feeding was observed lying flat in bed while the feeding was infusing, despite care plan and facility policy requiring the head of bed to be elevated to at least 30-45 degrees during and after tube feeding. Staff interviews confirmed the expectation for HOB elevation to prevent aspiration, but this standard was not followed at the time of observation.
A resident with obstructive sleep apnea and other complex conditions did not receive respiratory care in accordance with physician orders, as the non-invasive ventilator was not used due to missing supplies and there was no physician order for continuous oxygen use. Staff failed to document respiratory treatments and did not communicate the resident's refusal or inability to use the NIV to the provider, resulting in incomplete care planning and lack of adherence to facility policy.
Staff failed to secure OTC medications, including acetaminophen, vitamins, and lidocaine patches, which were left unattended and unlocked in an office near a resident hallway. The Medical Records Director, responsible for central supply, left the office door open or unlocked on multiple occasions while medications were present. The DON confirmed that all medications should be stored in locked rooms, and no medication storage policy was provided.
A resident with multiple chronic conditions did not receive meals that matched his stated preferences and dietary needs, repeatedly being served items like white rice and milk despite requesting alternatives. Staff interviews and observations confirmed ongoing complaints from the resident about his meals, with dietary staff failing to update his meal card or address his dislikes as required by facility policy.
A resident with multiple health conditions, along with two other residents, did not receive fresh water or clean water mugs as required. Residents reported having to obtain and refill their own water, and staff interviews revealed confusion and inconsistency regarding water pass procedures. Facility policy required daily provision of fresh water and clean mugs, but this was not being followed.
Staff did not follow enhanced barrier precautions or proper glove use and hand hygiene while providing personal care to a resident with significant infection risks, despite clear signage and available PPE. Nursing assistants provided care without gowns and failed to wash hands between glove changes, contrary to facility policy and expectations.
A resident who was dependent on staff for toileting and hygiene was unable to use her call light system, as it was not functioning. Despite being given a tap bell as an alternative, staff did not always hear it, and the resident had to call out for help. Another resident confirmed that this was a recurring issue. The facility's policy required a working call system at all times, but the malfunction was not addressed until identified by a surveyor.
Mail was not delivered to residents on Saturdays because no staff member was assigned to this task when the business office manager was off. Several cognitively intact residents confirmed they did not receive mail on Saturdays, and staff interviews verified this practice, which was not in accordance with facility policy requiring timely delivery of mail, including on weekends.
Two nursing assistants did not have documented annual performance reviews in their employee files, despite being employed for over a year. The human resources manager was unsure of the review process, and the DON confirmed that required evaluations had not been completed, with the facility's policy lacking a specified time frame for ongoing reviews.
Two residents' care plans in an LTC facility failed to include bathing preferences and required assistance levels. One resident, with morbid obesity and weakness, and another with quadriplegia and blindness, had incomplete care plans. Staff interviews confirmed that care plans should have included these details, as per facility policy.
The facility failed to provide weekly baths for two residents, one with morbid obesity and another with dementia and hemiplegia. Documentation was missing for several bathing dates, and staff interviews confirmed the lack of adherence to the facility's policy requiring documentation of bathing activities and refusals.
Several residents in a facility experienced neglect due to inadequate equipment and staff training, resulting in their prolonged confinement to bed. These residents, who were dependent on staff for mobility, suffered mental anguish and emotional distress as they were unable to participate in activities or attend medical appointments. The facility's failure to provide appropriate care and safety measures led to significant deficiencies in meeting the residents' needs.
The facility failed to update its assessment to reflect the discontinuation of restorative nursing services, affecting all 56 residents. Two residents, who were cognitively intact and had specific care needs, could have benefited from these services. Interviews revealed a lack of awareness and documentation regarding the cessation of restorative nursing, with staff uncertain about its status. The facility's policy required regular updates to the assessment, which was not followed.
The facility failed to involve the Medical Director in the care coordination for three bariatric residents, leading to inadequate care and mobility issues. These residents, with significant medical needs and high body weights, were admitted without proper planning or equipment, resulting in them being bedridden. Staff were unsure of how to safely transfer the residents, and the Medical Director was not informed of the immediate jeopardy situation.
The facility failed to assess and document the use of bed rails for five residents, neglecting to attempt alternative devices and provide ongoing assessments. Residents had bed rails installed without proper documentation or assessment, and in some cases, without the residents' or physicians' signatures on the evaluation forms. The facility's policy on bed safety and bed rails was not followed, leading to potential risks for the residents.
The facility failed to provide comprehensive care plans for three residents, leading to deficiencies in their transfer procedures. Care plans lacked specific instructions on mechanical lifts and slings, resulting in staff uncertainty and residents not being mobilized. Interviews revealed confusion among staff, and the director of nursing acknowledged the absence of detailed care plan instructions.
A resident dependent on staff for bathing did not receive assistance as ordered, with no documentation of bathing from February 1 to March 4. The resident complained about poor hygiene, and the PA confirmed an order for every other day bathing, which was not reflected in the care plan. The DON was unaware of the issue, and no policy on ADLs for bathing was provided.
The facility failed to meet the activity needs of three residents who were dependent on staff for engagement, impacting their well-being. One resident, with significant medical conditions, felt isolated and had not participated in activities since admission. Another resident, using a wheelchair, expressed interest in group activities but had not been engaged due to lack of staff assistance. A third resident, unable to leave bed, created their own activities due to lack of facility support. The activity director and administrator were unaware of the residents' lack of engagement.
The facility failed to monitor weights for two residents as per protocol. One resident was not weighed due to mechanical lift limitations and lack of a bed scale, while another had inconsistent weight documentation and was not weighed as required. Interviews confirmed the lack of adherence to the facility's weight assessment policy.
A resident in a LTC facility was self-administering Keppra, an antiseizure medication, without proper assessment or IDT review. The resident kept the medication in her bedside drawer and took it independently, contrary to the physician's order requiring staff to witness administration. The facility's policy required an IDT determination for safe self-administration, which was not documented in the resident's care plan or medical record.
The facility failed to provide adequate staffing, resulting in significant delays in responding to call lights and providing necessary care. Residents experienced prolonged wait times for assistance, with call light response times ranging from 15 minutes to over three hours. Staffing shortages left only one NA to care for up to 22 residents, leading to missed baths and delayed responses, compromising residents' dignity and care.
A resident with a swallowing problem was not assessed for self-administration of medication, yet their medication was left unsupervised in their room. The resident's records lacked an order for self-administration, and staff interviews confirmed the absence of necessary assessments and orders, leading to the assumption of self-administration.
The facility failed to develop baseline care plans for two residents within 48 hours of admission. One resident, post-knee replacement, had unmanaged pain and respiratory needs not addressed in the care plan. Another resident with a cholecystostomy tube had no specific wound care interventions. Staff interviews confirmed the care plans were incomplete.
The facility failed to properly assess and monitor two residents, leading to deficiencies in care. One resident, with a knee replacement, lacked comprehensive skin assessment and wound documentation, while another, diagnosed with hypotension, did not have complete vital sign monitoring. Additionally, wound care orders for a cholecystostomy tube were not documented as completed. Interviews with staff revealed non-adherence to protocols for monitoring and documentation, resulting in missed opportunities to identify changes in residents' conditions.
A resident with chronic congestive heart failure and emphysema was admitted to the facility without proper orders for oxygen therapy, despite using it prior to admission. The facility's staff failed to obtain a physician's order for the oxygen, which was noted in the resident's electronic medical record. Interviews with staff revealed a lack of adherence to the facility's policy requiring verification of a physician order for oxygen administration.
Failure to Assess and Care Plan Resident’s Safety for Independent Community Outings
Penalty
Summary
The deficiency involves the facility’s failure to assess and implement individualized interventions to ensure safe independent community access for a resident with expressive aphasia and cognitive impairment. The resident had multiple diagnoses including stroke, bipolar disorder, aphasia, diabetes type II, anxiety disorder, cognitive symptoms, and encephalopathy. The admission MDS documented moderate cognitive impairment and noted that community ambulation abilities (such as navigating uneven surfaces, managing curbs/steps, and car transfers) were not assessed. The resident’s care plan identified independence with ADLs, transfers, and ambulation, and noted vulnerability due to communication impairment with interventions such as clear, simple instructions and visual prompts, but it did not address community outings or independent leave. Nursing notes documented multiple occasions when the resident left the facility independently for outings, with staff noting expected return times, but there was no documentation between the admission date and the survey period of any assessment of the resident’s ability to safely navigate community environments, manage emergencies, or obtain assistance while outside the facility. During observation and interview, the resident was seen ambulating independently and demonstrated use of a cell phone to call family members, but the contact list did not include the facility’s phone number or address. Staff interviews revealed inconsistent understanding and lack of clear criteria regarding which residents were safe to leave independently; CNAs and RNs relied on factors such as ability to walk, absence of a WanderGuard, or checking the care plan or provider orders, but they did not reference any standardized assessment tool. Clinical staff, including a speech therapist and occupational therapist, reported they had not been consulted to assess the resident’s safety for independent community access, despite the speech therapist expressing concerns related to communication and suggesting that written word lists could assist the resident. The vice president of clinical services described an informal approach using hospital history, elopement assessment, and cognition to determine safety, and stated she would document in the care plan if a resident was not safe to leave alone, but there was no such documentation for this resident. The nurse practitioner stated she would expect an assessment of cognition, mobility, and functional abilities such as crossing the street, using a bus, or handling money before a resident went out independently. Facility policies on resident leave of absence and comprehensive person-centered care planning did not include protocols or criteria for determining when residents could leave independently, contributing to the lack of a formal assessment and care plan interventions for this resident’s unsupervised community outings.
Failure to Prevent Elopement of High-Risk Resident Despite Wander Guard and Known Exit-Seeking Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to implement appropriate, individualized interventions to prevent elopement for a resident who had been assessed as an elopement risk. The resident was admitted with diagnoses including repeated falls, dizziness and giddiness, unspecified mental disorder, and dementia with behavioral disturbance, and used a wheelchair. An elopement risk assessment identified the resident as an elopement risk due to verbal expressions of wanting to go home, wandering behavior, recent admission, and not accepting the situation. Suggested clinical actions included notifying staff of wandering and elopement risk, using exit alarms, and frequently monitoring the resident’s location. The care plan included a focus on wandering/elopement with goals that the resident would not leave the facility unattended and would remain safe, and interventions such as identifying de-escalation behaviors and providing reorientation. A nursing order directed staff to check the resident’s wander guard on the wrist daily and its function weekly. In the days leading up to the elopement, multiple progress notes documented escalating exit-seeking and behavioral issues. Notes indicated the resident wanted to go back to a prior place, was wandering, attempting to elope, hitting staff, and looking for her husband. The resident was described as alert and oriented to self with confusion at baseline, with chronic disorientation, some confusion, and chronic short-term memory loss. Staff documented that the resident had been on one-to-one supervision on a previous shift after attempting to leave the facility and becoming aggressive when redirected. On the morning of the elopement, a progress note recorded that the resident came into the hallway undressed, kicking and cursing at staff. Staff interviews confirmed that the resident had previous exit-seeking behaviors, was not easy to redirect, would refuse care, and was often kept at the nursing station for increased supervision. On the day of the elopement, staff assigned to the resident reported difficulty keeping track of residents during shift change and could not explain how the resident left the building while under their assignment. One NA stated the resident kept approaching the exit and setting off the wander guard alarm and that he had been assigned to watch the resident in the common area for a period before taking a break. At shift change, responsibility for watching the resident was to be handed off to other staff, but when the NA returned from break, the resident was missing. Another nurse reported that the resident had packed belongings and was waiting in the common area for transportation to another facility, and that around shift change staff left to find a replacement to supervise the resident; when they returned, the resident could not be located. Staff were unsure whether the wander guard alarm sounded, whether someone assisted the resident out the door, or how the resident exited the building, and the resident was still wearing the wander guard when later found. The facility’s location near several bus stations and the lack of camera coverage on the inside of the exit door were noted, and camera footage from outside showed the resident talking with other residents who were smoking and then following turkeys down a hill away from the building. The facility’s own policies required staff to attempt to prevent a resident’s departure if observed leaving and allowed use of a wander management system for residents at risk of elopement, but the events show that despite the resident’s known risk and documented behaviors, supervision and monitoring were not effectively maintained at the time of the elopement.
Removal Plan
- Facility began an investigation.
- Transferred R1 to a sister nursing facility with the capacity to keep her in a secured memory unit.
- Completed mandatory staff education on elopement, missing residents, facility policies and procedures, and the specific elopement event.
- Re-educated nursing staff on completing the elopement risk assessment accurately and completely.
- Checked the wander guard system and confirmed it was in working order for all residents identified as an elopement risk.
- Reviewed charts and care plans for other at-risk residents and added interventions as needed.
Failure to Include Required Appeal and Ombudsman Information on 30‑Day Discharge Notices
Penalty
Summary
The deficiency involves the facility’s failure to ensure that 30‑day discharge notices contained all required information related to residents’ needs, appeal rights, and ombudsman contact information for two residents. One resident had multiple diagnoses including alcoholic cirrhosis, chronic hepatitis C, COPD, left above‑knee amputation, anxiety disorder, and depression, and was cognitively intact and independent with transfers. This resident had a smoking care plan identifying him as a smoker with interventions to instruct him on facility smoking policies and safety. Progress notes documented that he was observed smoking in his room on one evening, was reminded of the policy and risks, and stated he did not care and would continue due to the cold weather. A subsequent note indicated he continued to smoke in his room despite multiple staff requests to stop. A 30‑day notice was then issued, but the progress note did not specify the reasons for the notice, and the discharge form contained an incorrect transfer date and lacked required contact information for the state agency appeals coordinator and the LTC ombudsman. The same resident later produced two discharge notices from his drawer, one older notice and a second dated later with a list of homeless shelters stapled to the back. He stated he believed he was being discharged for being mean to other residents, was unaware that the notice was related to smoking policy violations, and reported that ombudsman contact information was not listed on the form. He indicated he had to obtain the ombudsman’s number from a staff member and that the facility only provided him with a list of homeless shelters, which he did not want to use. The ADON reported she had been instructed by the administrator in training to give this resident a 30‑day discharge notice due to repeated smoking policy violations and acknowledged she did not notice that the ombudsman contact section on the form was blank. A second resident, with diagnoses including diabetes mellitus, chronic pain syndrome, opioid dependence, depression, and anxiety, was also cognitively intact and independent with transfers and ADLs. This resident’s care plan identified him as a vulnerable adult due to alcohol/substance abuse and traumatic life events, with interventions to notify the provider if he posed a potential threat to self or others. His discharge form, signed by the ADON, stated he would be transferred and cited endangerment to the safety and health of individuals in the facility as the reason, but similarly omitted the email address for the state agency appeals coordinator and the contact information for the LTC ombudsman. The ADON stated this resident was given a 30‑day notice because he was found using illicit drugs in the facility and required 911 transport to the hospital. The resident reported that the ombudsman contact information was not on his notice and that he initially believed his only option was to plead with the administrator to stay because the facility had not helped him find another placement. The LTC ombudsman stated that 30‑day notices should include ombudsman contact information to allow assistance with the appeal process and reported a delay in receiving copies of the discharge notices from the facility, despite an earlier request.
Failure to Designate a Full-Time Registered Nurse as DON
Penalty
Summary
The facility failed to designate a registered nurse to serve as the director of nursing (DON) on a full-time basis after the previous DON was terminated. For approximately two weeks, an LPN was the only administrative staff on duty and had been acting as the DON, despite not being a registered nurse. Interviews with facility staff, including the Director of Human Resources and the Administrator, revealed uncertainty about who was currently fulfilling the DON role, with the corporate office handling the hiring process for a new DON. The facility was relying on a team approach involving the assistant director of nursing, nursing staff, and the President of Clinical Services to cover the responsibilities of the DON, but no one was officially designated or able to assume the role full-time. No facility policy regarding required nursing services was provided upon request.
Failure to Revise Care Plan After Resident's Decline and Change in Condition
Penalty
Summary
The facility failed to revise the care plan for a resident after significant changes in her condition and care needs, as required by regulation and facility policy. Initially, the resident was assessed as independent in most activities of daily living (ADLs), including dressing, eating, personal hygiene, toilet use, and transfers. However, over the course of her stay, the resident experienced multiple hospitalizations, falls, and a decline in functional status, resulting in increased dependence on staff for ADLs and the need for mechanical lift assistance for transfers. Despite these changes, the care plan was not updated to reflect her increased care needs, new therapy orders, or the implementation of a home exercise program recommended by physical therapy. Medical records and staff interviews revealed that the resident's condition deteriorated significantly, with new diagnoses including metabolic encephalopathy, heart failure, neuropathy, and essential tremor. She became dependent on staff for toileting, bathing, dressing, and transfers, and required maximum assistance or mechanical lift for mobility. Orders for rehabilitation services and therapy were not processed or incorporated into the care plan, and goals related to pain management and functional improvement were not added. Staff members were inconsistent in their understanding and implementation of the resident's care needs, with some unaware of her current status or the interventions required. Interviews with nursing staff, therapy staff, and administration confirmed that the care plan had not been revised since the resident's admission, despite multiple significant changes in her condition and care requirements. The RAI coordinator acknowledged not updating the care plan after completing the MDS assessment, citing inexperience. Other staff members were unaware of therapy orders or failed to document education and interventions related to the resident's noncompliance and deconditioning. The facility's policy required care plans to be updated after significant changes, but this was not followed in the resident's case.
Failure to Timely Assess and Manage Pain and Blood Glucose
Penalty
Summary
The facility failed to appropriately monitor and comprehensively assess complaints of pain and failed to assess or monitor blood glucose levels for a resident with multiple complex medical conditions, including multiple fractures, trauma, respiratory failure, and diabetes. Upon admission, the resident repeatedly reported severe pain rated as 9/10 on four separate assessments, but was not administered pain medication as ordered and waited approximately nine hours before receiving the prescribed narcotic pain medication. During this period, the resident was only given acetaminophen, which was ineffective, and no further interventions or escalation to the provider were documented. The resident ultimately called 911 due to unrelieved pain and was transported back to the hospital for pain management and assessment. Documentation and interviews revealed that the resident's vital signs were not reassessed after admission until two days later, and blood glucose monitoring was not initiated until two days after admission, despite orders for regular monitoring and the resident's insulin-dependent diabetes. Staff interviews confirmed that blood glucose checks and vital sign assessments were not performed as required by physician orders and facility protocols. The resident expressed concern about the lack of assessment and monitoring, questioning how staff would know if his condition deteriorated. Further investigation found that the facility's emergency medication kit (e-kit) was out of the prescribed pain medication, and the pharmacy did not deliver the medication promptly. The process for obtaining narcotic pain medications was delayed, and staff did not request a stat order or notify the provider in a timely manner. Facility policies required immediate interventions for pain and regular monitoring for diabetic residents, but these were not followed. The director of nursing acknowledged that immediate interventions and assessments should have occurred, and that the resident's blood glucose should have been checked on admission.
Failure to Administer Oxycodone per Physician Orders
Penalty
Summary
The facility failed to ensure that oxycodone hydrochloride (HCl), a narcotic pain medication, was administered according to physician orders for a resident admitted with multiple fractures and trauma. The resident's care plan lacked information related to pain management, and provider orders specified maximum dosing and frequency for oxycodone HCl. However, medication administration records and progress notes showed that the resident received oxycodone HCl more frequently than every four hours and in greater quantities than the maximum four doses per day as ordered. There were also instances where the resident received both 5 mg and 10 mg doses close together, resulting in a total dose that was not prescribed. Interviews with staff revealed that the facility ran out of medications in the emergency kit due to failure to reorder, leading to medication errors when the drugs were not available for administration. Staff also acknowledged that the narcotic count book did not contain proper dosing instructions, and orders were not consistently transcribed or recorded as required. Discrepancies were noted between the number of doses administered according to the medication administration record and the narcotic count book, with staff unable to account for the differences. Further, the pharmacy confirmed that the administration of both 5 mg and 10 mg doses together was a medication error, and the most current prescription for oxycodone HCl was not being followed by the facility. The director of nursing was unaware of the new order and acknowledged that errors occurred when doses were given more frequently than ordered and that these errors were not reported to the provider. The facility's policy required drug orders to be recorded and reviewed, but this was not consistently done.
Failure to Provide Sufficient Staffing and Timely Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff and oversight to meet the needs of all residents, resulting in multiple instances where residents did not receive timely care and assistance. Observations and interviews revealed that several residents, including those with significant mobility limitations, incontinence, and other complex medical conditions, experienced prolonged wait times for assistance with toileting, repositioning, and other activities of daily living (ADLs). For example, one resident with morbid obesity and reduced mobility waited over an hour to be assisted onto a bedpan, despite repeated requests and calls for help. Another resident reported being left in a wet pad for over two hours, with staff failing to respond to call lights in a timely manner. Call light response logs and resident interviews indicated a pattern of delayed responses, with numerous instances of call lights going unanswered for 20 minutes or more, and in some cases, up to several hours. Residents and staff reported that agency nursing assistants were often observed using cell phones while on duty, and there was a lack of accountability and supervision to ensure prompt response to resident needs. The facility's own policy required call lights to be answered within five minutes, but this standard was not met, as evidenced by both documented response times and resident grievances. Further review showed that the facility did not provide adequate orientation, training, or supervision for agency nursing assistants, and failed to ensure comprehensive care planning for residents with incontinence. The Director of Nursing and Assistant Director of Nursing acknowledged awareness of delayed call light responses but did not consistently review or act upon call light response data. The lack of effective communication and coordination among staff, as well as insufficient staffing levels and oversight, contributed to residents not receiving timely and appropriate care.
Failure to Ensure Nursing Assistant Competency and Orientation
Penalty
Summary
The facility failed to ensure that both employed and agency nursing assistants (NAs) received appropriate orientation, training, and supervision, as well as to verify and document their competency in providing resident care. Interviews with residents revealed concerns about agency staff lacking motivation, accountability, and knowledge of their job duties. Residents reported that agency NAs were unfamiliar with facility procedures, did not know how to use mechanical lifts, and sometimes asked residents for guidance on basic tasks and the location of supplies. Additionally, not all staff wore name tags, making it difficult for residents to distinguish between agency and employed staff. A review of the facility's orientation materials showed that the binder used for new employee and agency orientation was primarily focused on topics relevant to licensed nursing staff, with little job-specific information for NAs. There were no orientation checklists or documentation tools to ensure that NAs were trained in essential areas such as the use of mechanical lifts, location of supplies, resident preferences, transfer status, call light response times, or expectations regarding personal cell phone use. The assistant director of nursing (ADON) and director of nursing (DON) both confirmed that there was no documentation to verify that NAs had received or demonstrated required competencies, and that agency NAs did not have a specific orientation checklist. The only individualized resident care orientation provided to NAs was a single screenshot showing how to access the Kardex in the electronic medical record, and there was no follow-up to ensure agency NAs could access or use it. Employee files for two NAs showed missing or incomplete documentation of skill competencies and required in-service trainings. One NA had no skill competencies completed within the past year, while another had undated competency exams and incomplete Relias online training. The facility's own assessment and orientation policy described a comprehensive educational program and the use of checklists to ensure staff competency, but these practices were not reflected in the actual documentation or processes observed during the survey. The lack of proper orientation, training, and competency verification had the potential to affect all residents in the facility.
Failure to Employ Qualified Dietary Staff
Penalty
Summary
The facility failed to employ either a full-time registered dietician (RD) or a qualified dietary manager (DM) to oversee the food and nutrition service, potentially affecting all 44 residents who received food from the kitchen. Interviews revealed that the DM could not provide evidence of required certifications or qualifications, and her personnel file was incomplete. The DM stated she had a food safety certification and experience as a manager at another facility, but did not possess a certified dietary manager certificate or an associate's degree. The human resources director confirmed that the DM's personnel file was missing and that there were broader issues with incomplete employee files. The contracted RD reported working only 10 to 12 hours per week, typically on Mondays, and was not a full-time employee. The administrator acknowledged that the RD was a consultant and not full-time, and believed the DM was a certified dietary manager, though this could not be verified. The facility was unable to provide documentation of the DM's or RD's qualifications or certifications upon request, and the job description for the dietary manager position required at least a certified dietary manager or comparable certification, which was not substantiated by available records.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to implement and maintain an effective pest control program to eliminate mice, as evidenced by multiple documented sightings and the presence of mouse droppings in various areas, including the kitchen and dry storage. Pest control inspection reports over several months indicated repeated mouse activity, with staff often failing to log sightings or take consistent action. Observations revealed mouse droppings near traps, improperly stored food items, and unsanitary conditions such as spilled molasses, dried salsa, and unsecured bags of chips in the kitchen and storage areas. Staff interviews confirmed that doors to the outside were frequently propped open, which pest control personnel identified as a significant factor in allowing pests to enter the facility. The dumpster outside the kitchen was routinely left uncovered, and food waste was visible, further attracting pests. Housekeeping and dietary staff described inconsistent cleaning routines, with tables and floors often left with crumbs and food debris, especially overnight when housekeeping was not present. Nursing assistants were expected to clean tables after dinner, but observations showed food residue remained on surfaces into the morning. Staff also reported that residents sometimes kept food in their rooms without proper containers, and clutter in some rooms could conceal pest activity. Despite the facility's policy requiring all food to be stored in covered containers and for staff to report all pest sightings, there were lapses in both food storage and reporting. For example, a dead mouse found by an LPN was not logged, and the pest sighting log had not been updated for several months despite ongoing activity. Interviews with the administrator and maintenance staff revealed a lack of awareness of recent mouse sightings and inconsistent communication regarding pest control measures. The pest control company reduced its inspection frequency due to perceived decreased activity, but staff and pest control personnel acknowledged that mice were still present, particularly at night. The facility's own pest control policy outlined preventive measures such as keeping doors closed, using self-closing doors, and ensuring proper food storage, but these measures were not consistently followed. The combination of propped open doors, uncovered dumpsters, improper food storage, and inadequate reporting and cleaning contributed to the ongoing pest problem affecting all residents in the facility.
Deficient Food Storage, Labeling, and Sanitation Practices Identified
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food storage, preparation, and labeling practices. In the kitchen refrigerator, an opened sponge cake was found unlabeled and undated, and a container of dried milk was kept beyond its recommended use period. The kitchen freezer contained several food items, including gluten-free pasta shells stored on the floor, undated and unlabeled packages of waffles and egg omelets, and opened bags of chicken and chicken strips that were not properly sealed, labeled, or dated. In dry storage, an opened jug of molasses with residue on the outside and a jar of salsa with dried salsa and an unsecured lid were found. Multiple opened bags of tortilla chips were not properly closed, and scoops were stored inside a sugar bin, contrary to facility policy. The lids of sugar and flour bins were also found to be soiled with food debris. Additionally, the coffee machine had visible debris and buildup, and a salad brought from outside was found in the kitchenette refrigerator without a label or date. Interviews with the dietary manager and administrator confirmed awareness of the improper food storage and labeling practices, as well as the potential for pest attraction due to these lapses. Facility policies require that all food items be labeled, dated, and stored in clean, sealed containers, with scoops kept outside of food bins and all foods stored off the floor. The observed failures to follow these procedures were verified by both staff and management during the survey.
Failure to Ensure Resident Dignity and Access to Appropriate Clothing
Penalty
Summary
The facility failed to provide a dignified experience for two residents by not ensuring they had appropriate clothing and by allowing staff to speak to a resident in an undignified manner. One resident, with diagnoses including weakness, morbid obesity, and bipolar disorder, required assistance with dressing and reported being scolded by a nursing assistant after accidentally soiling her shirt. The resident stated she felt she was treated like a child and had reported the incident to a nurse, who was supposed to notify the assistant director of nursing (ADON). However, the ADON did not recall receiving the grievance form and had not followed up on the report until the resident brought it up again. Another resident, with chronic medical conditions and moderately impaired cognition, was observed without clothing except for a robe and slippers. The resident stated she had no other clothing at the facility, as her belongings remained at her previous group home and the facility no longer provided gowns. Staff interviews confirmed the resident's lack of clothing and indicated that attempts to retrieve her belongings had been unsuccessful. The social services staff and ADON acknowledged the dignity concern of the resident not having appropriate clothing for an extended period. Facility policy requires residents to be treated with dignity and respect, including being encouraged to dress in their preferred clothing and being spoken to respectfully at all times. Despite this, the facility did not ensure that the residents had access to appropriate clothing or that staff consistently interacted with residents in a dignified manner, resulting in a failure to honor the residents' rights to dignity and self-determination.
Failure to Notify Family of Resident's Change in Condition and Hospitalization
Penalty
Summary
The facility failed to provide timely notification to a family member regarding a resident's change in condition and subsequent hospitalization. The resident in question was severely cognitively impaired and had diagnoses including cerebral infarction, quadriplegia, hypertension, and seizure disorders. Progress notes indicated that the resident experienced increased coughing and bleeding from the mouth, which led to a nurse practitioner being updated and new medication ordered. The following day, the resident's condition changed further, and the nurse practitioner ordered a transfer to the hospital for evaluation. Despite these significant changes, there was no documentation in the progress notes that the resident's family was notified about the change in condition, new orders, or the hospital transfer. During interviews, a family member confirmed she was not informed by the facility and only learned of the hospitalization from a hospital physician. The DON acknowledged that the family should have been notified prior to the transfer and confirmed that this did not occur. The facility was unable to provide a policy regarding notification of change in condition and transfer.
Failure to Investigate Resident's Report of Missing Clothing
Penalty
Summary
A resident with diagnoses including weakness, adult failure to thrive, morbid obesity, and bipolar disorder with psychotic features reported missing clothing items to nursing staff. The resident, who required substantial assistance with dressing and was dependent on staff for lower body dressing, stated she informed a nurse about the missing items but did not recall the nurse's name and did not complete a formal grievance form. The resident reported that the nurse said she would look into the matter, but no further follow-up occurred, and the resident had not received any updates regarding her missing clothing. Interviews with social services, the assistant director of nursing, and the director of nursing revealed that none were aware of the missing clothing until the week of the survey. All agreed that a grievance form should have been completed by the nurse who received the report, in accordance with facility policy, which requires prompt investigation of complaints regarding resident property. The failure to document and investigate the resident's report of missing clothing resulted in the deficiency.
Inaccurate MDS Coding for Medication Administration
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was accurately coded for a resident during their annual assessment. The assessment indicated the resident had limited upper extremity range of motion, was cognitively intact, and had diagnoses including renal insufficiency, amputation, diabetes, heart failure, and atrial fibrillation. The MDS section N0415 documented that the resident was taking an antidepressant and an antibiotic, but did not indicate that the resident was also receiving an anticoagulant, despite this being the case during the assessment period. During an interview, the DON confirmed that the resident did receive an anticoagulant during the MDS review period, but this was not reflected in the assessment. The DON acknowledged the importance of MDS accuracy for both payment and care planning. The facility's policy on MDS error correction outlines procedures for correcting both minor and major errors, depending on the impact on the resident's clinical status and care plan.
Failure to Provide Baseline Care Plan Summary Upon Admission
Penalty
Summary
The facility failed to provide a summary of the baseline care plan to a resident and/or the resident's representative within the required timeframe after admission. The resident, who was admitted with an infection and inflammatory reaction due to an internal joint prosthesis, was cognitively intact and receiving pain management, wound care, oxygen, and therapy services. Documentation in the electronic medical record did not show evidence that a baseline care plan was given to the resident. Interviews with the resident and staff confirmed that the resident did not recall receiving a care plan or participating in a care conference, and staff were unable to provide documentation that the care conference or baseline care plan had been completed or provided. Facility policy required that a baseline plan of care be developed within forty-eight hours of admission and that a written summary be provided to the resident or representative, with documentation of this provision in the medical record. However, staff interviews revealed that the initial care conference, where the baseline care plan is typically provided, may not have occurred within the required timeframe, and no documentation could be produced to show that the baseline care plan summary was given to the resident. This resulted in a failure to meet the resident's immediate needs as outlined by facility policy and regulatory requirements.
Failure to Develop and Maintain Comprehensive Care Plans for Residents with Pressure Ulcer and Respiratory Risks
Penalty
Summary
The facility failed to develop and maintain comprehensive care plans for two residents with significant medical needs. One resident, who had diagnoses including a right tibia fracture, type 2 diabetes, morbid obesity, and pulmonary embolism, was assessed as being at moderate risk for pressure ulcers according to multiple Braden Scale assessments. Despite this, the resident's care plan did not include a risk for skin breakdown or specific interventions to prevent pressure ulcers, even though the nurse practitioner had recommended a repositioning program and heel protectors. Nursing staff believed that repositioning was part of the care plan, but documentation did not reflect this, and the director of nursing confirmed the absence of a preventive care plan for skin breakdown. Another resident with morbid obesity, chronic pain, reduced mobility, and obstructive sleep apnea was observed using an oxygen concentrator and a non-invasive mechanical ventilator. The care plan for this resident did not address the risk or potential for respiratory system impairment, despite the presence of respiratory equipment and physician orders for a non-invasive ventilator. Additionally, there was no physician order for oxygen, even though the resident had been on oxygen since admission, and the care plan did not address the use of oxygen or other respiratory interventions. The LPN and DON both confirmed the lack of a respiratory care plan for this resident. Facility policy requires that comprehensive, person-centered care plans include measurable objectives, timeframes, and services to maintain residents' highest practicable well-being, and that care plans be revised as residents' conditions change. In both cases, the facility did not ensure that care plans reflected the residents' current needs and risks, as evidenced by the lack of documented interventions for pressure ulcer prevention and respiratory care.
Failure to Conduct Required Care Conferences for Residents
Penalty
Summary
The facility failed to ensure that care conferences were conducted as required for three residents reviewed for care planning. For one resident with moderate cognitive impairment and multiple diagnoses, a care conference was scheduled but canceled at the family's request. The family requested to reschedule, but the social services staff did not follow up, and the care conference was never rescheduled. The director of nursing acknowledged that the facility should accommodate care conferences to facilitate resident and family participation. Another resident, who was cognitively intact and admitted with a surgical wound and on a pain management program, did not have evidence of a care conference after admission, despite documentation indicating that one should have occurred. The resident reported not recalling any care conference involving the interdisciplinary team, and the social services staff confirmed that the resident did not meet with the full team to discuss care planning or rehabilitation goals. The director of nursing stated that care conferences should be scheduled shortly after admission and rescheduled promptly if missed. A third resident, also cognitively intact and with a history of amputation and other medical conditions, did not recall having a care conference. Social services staff indicated that care conferences were sometimes not conducted if the resident declined, and the interdisciplinary team did not always meet without the resident to review care areas. The director of nursing clarified that care conferences should occur every 92 days regardless of resident attendance. The facility's policy required care conferences to develop and review care plans with the interdisciplinary team, but this was not consistently followed.
Failure to Provide Routine Nail Care for Dependent Resident
Penalty
Summary
A resident who was severely cognitively impaired and diagnosed with cerebral infarction, quadriplegia, essential hypertension, and seizure disorders was found to be dependent on staff for all activities of daily living, including personal hygiene. The resident's care plan specified the need for total assistance with personal hygiene, and facility policy required regular cleaning and trimming of fingernails to prevent infection. Despite these directives, multiple observations over several days revealed that the resident's fingernails were about half an inch long and had black debris underneath. Staff interviews confirmed that the resident's nails had not been trimmed or cleaned as required, and there was uncertainty among staff regarding responsibility for nail care, especially since the resident was diabetic and required a nurse to perform this task. A family member also reported observing the resident's long and dirty fingernails and left a voicemail for the charge nurse requesting nail care, but the issue persisted in subsequent observations. Nursing assistants and an LPN acknowledged the condition of the resident's nails and described the process for nail care, but the care was not provided in a timely manner. The DON stated that nails should be cut on bath days or weekly, and recognized the risk of infection and dignity issues associated with untrimmed nails, particularly for residents with contractures. The facility's failure to provide routine nail care as outlined in the care plan and policy resulted in the resident having long, dirty fingernails over multiple days.
Failure to Transcribe and Implement Physician Orders for Compression Stockings and Wound Care
Penalty
Summary
The facility failed to properly transcribe and implement physician orders for a resident who required monitoring and care for edema and a surgical incision. The resident had multiple complex diagnoses, including infection and inflammatory reaction due to a joint prosthesis, heart failure, cellulitis, and respiratory failure. Physician orders included the use of compression stockings (ted hose) and specific wound care instructions, but these were not consistently transcribed into the treatment administration record (TAR) or medication administration record (MAR), resulting in a lack of documentation and implementation by nursing staff. Observations and interviews revealed that the resident was not wearing the prescribed ted stockings and was managing wound care independently, as staff were unaware of the current orders. The resident reported that staff never assisted with the ted stockings or wound care, and he had to perform these tasks himself. Documentation for wound care orders was either missing or not completed, and the order for ted stockings was not visible to nurses in their daily assignments due to improper transcription in the electronic health record system. Interviews with facility staff, including the ADON, LPN, and DON, confirmed that the orders for ted stockings and wound care were not properly processed or carried over into the nurses' daily assignments, making them inaccessible for routine care. The resident's care plan was not updated to reflect the need for ted stockings or address edema, and there were no reviews or updates to the wound management care plan after the initial entry. This resulted in the resident not receiving care as ordered and required by his condition.
Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
A deficiency occurred when the facility failed to implement interventions to prevent the development of new pressure ulcers for a resident with multiple risk factors. The resident had a history of right tibia fracture, type 2 diabetes, morbid obesity, and was incontinent of stool. Upon admission, the resident was assessed as cognitively intact and at moderate risk for pressure ulcers according to the Braden Scale, with subsequent assessments indicating high risk. Despite these risk factors and recommendations from wound care specialists, the resident's care plan did not include specific interventions for the prevention of skin breakdown. Observations and interviews revealed that the resident was not consistently repositioned according to the recommended schedule. The resident was observed lying in the same position for extended periods, and staff interviews confirmed that repositioning was not performed every two hours as required. Additionally, heel protectors were not consistently applied to both heels, and the resident's right heel was found resting on the bed without protection. The facility's own policy required individualized repositioning schedules and the use of support devices for residents at risk, but these measures were not fully implemented for this resident. Documentation showed that the resident developed new pressure ulcers, including an unstageable ulcer on the left heel and a stage 3 ulcer on the left gluteus, while under the facility's care. Wound care notes and staff interviews confirmed that the resident required assistance with mobility and repositioning, yet these interventions were not reliably provided. The director of nursing acknowledged the absence of a care plan for skin breakdown prevention and confirmed that the resident should have had heel protectors on both feet and been repositioned every 1-2 hours.
Failure to Assess and Supervise Safe Vaping Practices for Medical Marijuana
Penalty
Summary
The facility failed to comprehensively assess and ensure safe vaping practices for a resident with a medical marijuana card who was observed vaping THC in his room. The resident, who had diagnoses including malignant cancer of the bladder, chronic pain, anxiety, and insomnia, was dependent on staff for some activities of daily living and experienced constant pain. Despite the resident's use of medical marijuana being known to some staff, there was no documentation in the physician orders or care plan regarding the use or method of administration of medical marijuana, nor was there an assessment for safe vaping practices. Smoking assessments conducted at various intervals indicated the resident was a non-smoker, and the option for vaping was not selected in the electronic assessment tool, resulting in the absence of a safe vaping assessment. The facility's director of nursing (DON) and assistant director of nursing (ADON) were unaware that the resident was vaping, and the DON stated that while the resident was provided a locked box for marijuana supplies, the facility did not inquire about the method of ingestion or monitor the use. The facility's medical cannabis policy required physician support, documentation, and care plan updates for medical cannabis use, and specifically prohibited vaporizing or smoking cannabis within the facility or on its grounds. Despite these policies, the resident was observed vaping in bed, and documentation in the medical record by a physician assistant indicated prior awareness of the resident's use of a vape pen for THC. The facility did not assess the resident for safe self-administration of vaping, did not update the care plan to reflect the use of medical marijuana, and did not monitor or supervise the resident's vaping activities, resulting in a failure to prevent potential accident hazards related to vaping within the facility.
Failure to Provide Timely Incontinence Care and Comprehensive Care Planning
Penalty
Summary
The facility failed to provide a comprehensive incontinence care plan and timely assistance with toileting for a resident with a history of mixed incontinence, orthopedic aftercare following hip replacement, pressure ulcer, and muscle weakness. The resident was identified as always incontinent of urine and bowel, requiring substantial to maximum assistance for lower body dressing and supervision or touching assistance for toilet transfers. Despite these needs, the resident's care plan did not include an incontinence care plan, and no bladder/bowel incontinence assessment was found in the medical record. Multiple observations revealed that the resident repeatedly activated the call light requesting assistance to be changed out of a wet pad and to get dressed, but staff responses were delayed. On one occasion, the resident waited over two hours before being assisted by an LPN, after initially being told by a nursing assistant that help would arrive soon. The resident expressed frustration about being left in a wet pad for extended periods and reported that this occurred almost daily, with staff often providing excuses or not entering the room promptly. Interviews with staff confirmed that the resident's requests for assistance were delayed due to staffing limitations, with only one nursing assistant assigned to the hallway at the time. The DON acknowledged that staff should enter the room when a call light is activated and that residents should not have to wait over an hour for toileting or dressing assistance, nor be left in a wet pad for two hours. The facility's own policy requires timely assessment and individualized management of incontinence, which was not followed in this case.
Failure to Implement Dietician's Order for Nutritional Intervention
Penalty
Summary
A resident with diagnoses including severe protein-calorie malnutrition, chronic kidney disease, depression, and repeated falls experienced significant weight loss over several months. The resident's care plan identified a nutritional problem and set goals for weight maintenance or gain, with interventions to provide diet as ordered. The registered dietician (RD) recommended offering ice cream three times daily between meals to increase calorie intake, as the resident declined other supplements but agreed to eat ice cream. However, this recommendation was not transcribed into a physician's order or added to the medication administration record (MAR), and staff were unaware of the need to provide ice cream. Multiple interviews with the resident, nursing staff, and dietary staff confirmed that the resident had not received the recommended ice cream, and there was no order in place for it. The assistant director of nursing (ADON) and director of nursing (DON) were unaware of the process for implementing RD recommendations, and the RD stated he had communicated the recommendation via email but expected it to be implemented promptly. Facility policy requires dietary supplement orders to specify type, amount, and frequency, and to be maintained in the clinical record, but this was not followed, resulting in the resident not receiving the prescribed nutritional intervention.
Failure to Maintain Head of Bed Elevation During Tube Feeding
Penalty
Summary
Staff failed to follow standard practice for gastrostomy tube care for a resident with severe cognitive impairment, quadriplegia, and multiple medical diagnoses, including a history of recurrent pneumonia and sepsis. The resident was ordered to receive Jevity 1.5 tube feeding at 65 ml per hour for 22 hours daily and was care planned as NPO, with instructions to keep the head of bed (HOB) elevated to 45 degrees during and for thirty minutes after tube feeding to prevent aspiration. Facility policy required the HOB to be elevated at least 30-45 degrees during tube feeding and for at least one hour after. On observation, the resident was found lying flat in bed while tube feeding was infusing, contrary to care plan and facility policy. Staff interviews confirmed that the HOB should have been elevated to at least 30 degrees during tube feeding. The failure to maintain the required HOB elevation was acknowledged by both nursing assistants and licensed staff, and the facility's policy was consistent with this standard of care.
Failure to Ensure Safe and Appropriate Respiratory Care and Documentation
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident with complex respiratory needs, specifically by not ensuring the use of a non-invasive ventilator (NIV) in accordance with physician orders and by not having a physician order for continuous oxygen administration. The resident had diagnoses including morbid obesity, chronic pain, reduced mobility, and obstructive sleep apnea, and required total assistance for mobility and personal care. The care plan did not address the resident's risk or potential for respiratory impairment, and there was no documented plan of care for respiratory treatments such as oxygen use, NIV, or inhaler use. Observations revealed that the resident was using a nasal cannula for oxygen, but the tubing was not connected to the concentrator, resulting in an oxygen saturation of 87%. Staff connected the tubing only after this was pointed out. The resident reported not using the NIV for several nights due to a lack of fluid for the machine, and staff confirmed that the necessary supplies were not available. Documentation of NIV use was incomplete, and there was no documentation of oxygen use in the medical record. The physician assistant was unaware of the resident's refusal to use the NIV and the lack of supplies, and there was no physician order for oxygen despite its ongoing use. Interviews with staff indicated a lack of communication with the provider regarding the resident's refusal or inability to use the NIV and the absence of necessary supplies. The DON confirmed that oxygen could be started per standing orders but required a provider order within 72 hours, which was not obtained. Facility policies required verification of physician orders and documentation for both oxygen administration and mechanical ventilation, but these procedures were not followed, resulting in the identified deficiencies.
Unsecured Storage of OTC Medications in Unlocked Office
Penalty
Summary
Facility staff failed to ensure the safe storage of over-the-counter (OTC) medications, as required by professional standards. Multiple bottles and containers of OTC medications, including vitamins, acetaminophen, probiotics, lidocaine patches, and ibuprofen, were observed left unattended and unlocked on a table in an office located at the end of a resident hallway. The Medical Records Director, who also managed central supply, stated she was unpacking medications to refill the medication closet and typically locked the office door when leaving. However, on several occasions, the office door was found open or closed but not locked, with medications still present and unattended. The Medical Records Director admitted to leaving the door unlocked when stepping away for short periods, and the administrator confirmed this was a potential safety issue. Further observations revealed that the only medication room in the building was crowded with tube feeding solutions and other non-medication supplies, limiting available storage space. The Director of Nursing stated that medications, including OTC stock, should not be stored in an unlocked room and expected the Medical Records Director to secure the office when medications were present. No policy on medication storage was provided when requested.
Failure to Honor Resident Food Preferences and Dietary Needs
Penalty
Summary
A resident with end stage renal disease, diabetes, and other chronic conditions was not provided with meals that accommodated his stated preferences and dietary needs. Despite being cognitively intact and able to communicate his preferences, the resident repeatedly received white rice and milk, which he had specifically requested to avoid, and was not given preferred alternatives such as strawberries. The resident also expressed a desire for larger portion sizes, which was communicated to the dietician and dietary manager, but his meal card and actual meals did not reflect these preferences for an extended period. Multiple staff interviews confirmed that the resident had complained for weeks about receiving rice and that his concerns were not addressed by the dietary staff or the registered dietician, who did not recall discussing these issues with him. Observations showed that the resident continued to receive meals inconsistent with his preferences and dietary orders, including being served white rice and cake instead of requested items. The dietary manager and registered dietician were unaware or did not recall the resident's dislikes, and the meal card was not updated in a timely manner to reflect the resident's current diet and preferences. The facility's policy required assessment and communication of food preferences upon admission and care planning if a resident was dissatisfied, but these procedures were not followed, resulting in the resident's preferences not being honored.
Failure to Provide Fresh Water and Clean Mugs to Residents
Penalty
Summary
The facility failed to provide water consistent with resident needs and preferences, and did not ensure sufficient hydration for residents. One resident with a history of left below the knee amputation, diabetes, and protein calorie malnutrition, who was cognitively intact and independent in mobility, reported that staff did not provide fresh water and that she had to obtain it herself. Observations confirmed that no water mug or cup was present in her room on multiple occasions. She also noted the removal of ice machines, limiting her access to ice water. Two additional residents, both cognitively intact and independent, stated they did not receive fresh water or clean water mugs from staff, instead refilling their own cups from the bathroom sink and reusing the same mug without cleaning. Staff interviews revealed a lack of clarity and consistency regarding the process for providing fresh water and clean mugs to residents. The dietary manager was unaware of any process to ensure daily provision of clean water mugs and fresh water. Nursing staff, including an LPN and a nursing assistant, indicated that water was not routinely passed to residents and that previous methods, such as pitchers of water or ice near the nurses' station, had recently been discontinued without explanation. The assistant director of nursing acknowledged that water pass was not happening consistently, and the director of nursing stated that staff were expected to provide fresh water and clean mugs daily. Facility policy required daily provision of fresh water and clean containers, but observations and interviews indicated this was not being followed.
Failure to Follow Enhanced Barrier Precautions and Proper Glove Use
Penalty
Summary
Staff failed to follow enhanced barrier precautions (EBP) for a resident with significant medical needs, including quadriplegia, a gastrostomy tube, and wounds. The resident was identified as requiring EBP due to infection risks, with clear signage and personal protective equipment (PPE) available at the room entrance. Despite these measures, nursing assistants provided personal care, including a sponge bath and pericare, without wearing gowns as required. One nursing assistant acknowledged awareness of the EBP requirements but stated she forgot to don a gown due to being rushed by a nurse. Additionally, during personal care, staff did not adhere to proper glove use and hand hygiene protocols. While one nursing assistant changed gloves between different care tasks, neither she nor her colleague washed their hands after removing dirty gloves and before putting on clean ones, as required by facility policy. Both staff members admitted forgetting to perform hand hygiene. Interviews with nursing and administrative staff confirmed the expectation for PPE use and hand hygiene, and facility policies directed staff to follow these infection control measures.
Failure to Maintain Functional Call Light System in Resident Room
Penalty
Summary
The facility failed to ensure that a resident's call light system was functioning, resulting in the resident being unable to summon assistance when needed. The resident, who had a diagnosis of left below the knee amputation and was dependent on staff for toileting and hygiene, was found to have a non-functioning call light in her room. Both the resident and a surveyor attempted to activate the call light without success, as the indicator light did not illuminate and the room number did not appear on the hallway display. The resident reported being given a tap bell as an alternative, but stated that staff did not always hear it, requiring her to call out for help. Another resident in the same hallway confirmed that the affected resident had called out for help on multiple occasions due to the malfunctioning call light. The facility's policy required that each resident be provided with a functional call system at all times, with calls for assistance to be answered promptly. Despite this policy, the call light in the resident's room remained non-functional, and the issue had not been addressed prior to the surveyor's observation. The administrator was unaware of the ongoing problem until it was brought to her attention during the survey, at which point maintenance was notified. Documentation and interviews confirmed that the call system was not routinely maintained or tested as required, leading to the deficiency.
Failure to Deliver Resident Mail on Saturdays
Penalty
Summary
The facility failed to ensure that residents received their mail on Saturdays, as required by facility policy. Four residents with intact cognition reported during a resident council meeting that mail was not delivered on Saturdays. Interviews with the business office manager and the DON confirmed that no staff member was assigned to deliver mail on Saturdays, and the business office manager, who typically handled mail delivery during the week, did not work on Saturdays. Facility policy stated that mail and packages should be delivered to residents within 24 hours of arrival, including on Saturdays, but this was not followed, affecting all residents in the facility.
Failure to Complete Annual Performance Reviews for Nursing Assistants
Penalty
Summary
The facility failed to complete annual performance reviews for two of five nursing assistants whose employee files were reviewed. Review of the employee files for these nursing assistants showed that, although counseling forms with verbal and written warnings were present, there was no documentation of an annual performance review within the last year. One nursing assistant had been employed since May 2021 and the other since December 2023, yet neither had a documented performance review in the past year. During interviews, the human resources manager indicated uncertainty about the performance review process and stated that a process for timely reviews was not yet in place. The director of nursing confirmed that performance reviews had not been completed for these staff members in the past year, despite referencing the facility's policy, which did not specify a required time frame for ongoing reviews.
Deficiency in Resident Care Plans for Bathing Preferences and Assistance
Penalty
Summary
The facility failed to include bathing preferences and assistance levels in the care plans for two residents, leading to a deficiency. Resident 1, diagnosed with morbid obesity and weakness, required substantial assistance for bathing and dressing. However, their care plan did not specify their bathing preferences or the level of assistance needed for bathing. Similarly, Resident 3, who had quadriplegia, legal blindness, and an inability to communicate or make cognitive decisions, also lacked a care plan detailing their bathing preferences and required assistance. Interviews with facility staff, including a nursing assistant, registered nurse, and the director of nursing, revealed that the care plans should have included these details. The facility's policies required comprehensive, person-centered care plans with measurable objectives and timetables to meet residents' needs. Despite this, the care plans for the two residents were incomplete, lacking essential information about their bathing preferences and assistance requirements.
Failure to Provide Weekly Baths for Residents
Penalty
Summary
The facility failed to ensure that residents received at least weekly baths or showers, as required. Resident 1, who had diagnoses of morbid obesity and weakness, required substantial assistance for bathing and was dependent on staff for dressing. However, the care plan did not specify bathing preferences or the level of assistance needed. Documentation showed that Resident 1 was not bathed on several occasions, with no records of bathing on specific dates in February. Interviews with staff confirmed the lack of documentation and the expectation that bathing should occur weekly. Resident 2, diagnosed with dementia and hemiplegia, was dependent on staff for showering and preferred to shower twice a week. Despite this, there were missing records of bathing on certain dates in January and February. Staff interviews revealed that nursing assistants were responsible for documenting bathing activities and notifying nurses of any refusals. The facility's policy required documentation of bathing activities, including any refusals and interventions taken, but this was not consistently followed.
Neglect of Residents Due to Inadequate Equipment and Staff Training
Penalty
Summary
The facility failed to protect the rights of several residents by not providing necessary care, comfort, and safety, resulting in neglect. Three residents, who were dependent on staff for mobility, experienced mental anguish and emotional distress due to the facility's inability to assist them in getting out of bed. The facility lacked the appropriate equipment and staff training to safely transfer these residents, leading to their prolonged confinement to bed. One resident, who was non-weight bearing and required a full body lift for transfers, had not been out of bed since admission due to the facility's failure to provide a suitable lift and sling. This resident expressed feelings of isolation and anxiety, exacerbated by the inability to attend medical appointments due to transportation issues related to their size. Another resident, also dependent on staff for mobility, had not been out of bed since a hospital transfer, citing obesity as a barrier to receiving adequate care. This resident expressed a desire to participate in activities and experience fresh air but was unable to do so due to the facility's shortcomings. A third resident, who required a full body lift and two staff members for transfers, had not been out of bed since the previous year. This resident expressed frustration and a lack of safety, fearing they would be unable to evacuate in an emergency. The facility's failure to provide appropriate equipment and staff training resulted in these residents experiencing significant emotional distress and a lack of basic care, highlighting a severe deficiency in the facility's ability to meet the needs of its residents.
Removal Plan
- Had Physical therapy reassess R1, R2 and R3 on their transfer status
- Updated R1, R2, and R3's care plans
- Educated staff about the need to follow the care plan
- Ensured the facility had the proper equipment in working order
Failure to Update Facility Assessment for Restorative Nursing Services
Penalty
Summary
The facility failed to update their facility-wide assessment to reflect the discontinuation of restorative nursing services, which had the potential to affect all 56 residents. The facility assessment still indicated that restorative nursing was offered, despite the service no longer being available. This oversight was discovered during interviews and record reviews, where it was noted that two residents, R1 and R2, who were cognitively intact and had specific care needs, could have benefited from restorative nursing. Both residents had significant mobility and incontinence issues, with R1 also dealing with a chronic ulcer and diabetes, and R2 experiencing chronic pain and prediabetes. Interviews with facility staff, including the physical therapist, physician assistant, director of nursing, medical director, and administrator, revealed a lack of awareness and documentation regarding the cessation of restorative nursing services. The physical therapist confirmed that both residents would have benefited from such services, and the physician assistant noted the potential for improved outcomes with restorative nursing. The director of nursing and medical director were uncertain about the status of restorative nursing, while the administrator mentioned a functional maintenance program that lacked documentation and utilization. The facility's policy required regular updates to the facility assessment, which was not adhered to in this case.
Failure in Bariatric Resident Care Coordination
Penalty
Summary
The facility failed to ensure the Medical Director was involved in the implementation and guidance of resident care policies, particularly for the admission and care of three bariatric residents. These residents, each with significant medical needs and high body weights, were admitted without proper planning or equipment to manage their care safely. The Medical Director was not involved in the admission process, and the facility did not have the necessary equipment, such as appropriately sized slings for mechanical lifts, to safely transfer these residents. Resident 1, with a weight of 547 lbs, was admitted with a care plan that lacked specific instructions for the type of lift and sling size required. Despite being cognitively intact and expressing a desire to get out of bed, Resident 1 remained bedridden due to the facility's inability to safely transfer him. Attempts to use a 600 lb mechanical lift resulted in pain and distress for the resident, highlighting the facility's lack of preparedness and coordination in managing his care. Similarly, Resident 2, weighing 435 lbs, and Resident 3, also with significant weight and mobility issues, were not provided with adequate care plans or equipment to facilitate their mobility. Both residents remained in bed for extended periods, with staff unsure of how to safely transfer them. The Physician Assistant was unaware of the residents' conditions and lack of mobility, and the Medical Director was not informed of the immediate jeopardy situation involving these residents. The facility's failure to involve the Medical Director in admissions and care planning contributed to the neglect of these residents' needs.
Failure to Assess and Document Bed Rail Use
Penalty
Summary
The facility failed to attempt alternative devices before using bed rails on the beds of five residents. The facility did not accurately assess the residents for the risk of entrapment by evaluating their medical diagnoses, height and weight, cognition, communication, mobility, and risk of falling. Additionally, the facility did not provide ongoing assessments to ensure the bed rails met the residents' needs. This deficiency was observed in residents who had bed rails installed without proper documentation or assessment, and in some cases, without the residents' or physicians' signatures on the evaluation forms. One resident, who was cognitively impaired and dependent on staff for various activities, had bed rails that were not indicated in their care plan. The resident stated that they used the rails when staff turned them during care but did not recall a formal assessment for the use of the bed rails. Another resident, who was cognitively intact and used a wheelchair, had a bed rail on one side of the bed and expressed the need for the other rail to be replaced for assistance with bed mobility. This resident also did not recall a formal assessment for the bed rails. The facility's policy on bed safety and bed rails required an interdisciplinary evaluation and informed consent before the use of bed rails, which was not followed. The policy also outlined the need for regular inspections and assessments to prevent risks such as entrapment and restricted mobility. However, the facility did not adhere to these guidelines, as evidenced by the lack of completed evaluations and the absence of informed consent for the use of bed rails.
Deficient Care Planning for Resident Transfers
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for three residents, leading to deficiencies in their care. For Resident 1, the care plan did not specify which mechanical lift and sling should be used during transfers, despite the resident's significant weight and medical conditions such as chronic ulcer, diabetes, and morbid obesity. Nursing staff were uncertain about the appropriate equipment to use, and the resident was not being transferred out of bed due to perceived non-weight-bearing status. Similarly, Resident 2's care plan lacked details on the weight limit and sling size for transfers, and the resident was not being mobilized due to the absence of a suitable wheelchair and uncertainty about the resident's weight. Resident 3's care plan contained conflicting information regarding transfer methods, with discrepancies between the use of a mechanical lift and a stand pivot transfer, leading to confusion among staff and the resident remaining in bed for an extended period. Interviews with staff revealed a lack of clarity and consistency in the care plans, with nursing assistants and licensed practical nurses unsure of the correct procedures for transferring residents. The director of nursing acknowledged the absence of specific instructions in the care plans regarding the use of lifts and slings, which contributed to the deficiencies observed. The facility did not provide a comprehensive care plan policy when requested, indicating a systemic issue in care planning and implementation for residents requiring mechanical assistance for transfers.
Failure to Assist Resident with Bathing as Ordered
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for a resident who was dependent on staff for bathing. The resident, identified as R3, had a provider order dated February 25, 2025, indicating the need for assistance with bathing every other day. However, the electronic Medication Administration Record (eMAR) from February 1 to February 28, 2025, showed no documentation that R3 received the required assistance. During an observation and interview on February 28, 2025, R3 was found in bed with unwashed hair and stated that he had not had his hair washed since being hospitalized in December 2024. R3 also mentioned that he had never been in the shower at the facility and only received a bed bath weekly without hair washing. The Physician Assistant (PA) confirmed that R3 had complained about not being cleaned and had issued an order for every other day bathing. Despite this, the care plan dated March 4, 2024, did not reflect the updated frequency for bathing. The eMAR from March 1 to March 4, 2025, also lacked documentation of bathing assistance. The Director of Nursing (DON) was unaware of the issue until March 4, 2025, when it was confirmed that R3 had a specialized order for bathing that was not being followed. Additionally, the facility did not provide a policy on ADLs related to bathing upon request.
Failure to Support Resident Activity Needs
Penalty
Summary
The facility failed to support the activity needs of three residents who were dependent on staff for activities, impacting their physical, mental, and psychosocial well-being. Resident 1, who was cognitively intact and had significant medical conditions including chronic ulcer, diabetes, and morbid obesity, expressed a desire for social interaction and outdoor activities. Despite an activity assessment indicating these preferences, Resident 1 had not participated in any activities since admission and felt isolated, having only had one one-on-one activity early in their stay. Resident 2, also cognitively intact and using a wheelchair, had a care plan that noted a preference for self-initiated activities like reading spiritual books. However, no facility-initiated group activities were identified for them. Resident 2 reported that their days were monotonous and expressed interest in participating in group activities like Bingo and a Bible class, but had not been engaged in any one-on-one visits or group activities due to staff not assisting them out of bed. Resident 3, who had been at the facility for about a year, was also cognitively intact and had diagnoses including muscle weakness and morbid obesity. Their care plan required one-to-one bedside activities if unable to attend group events. Despite this, Resident 3 had not been out of bed since December and had to create their own activities, such as playing video games remotely with a family member. The activity director acknowledged the lack of engagement and noted that nursing staff were unable to assist residents out of bed to attend activities. The facility's policy required documentation of all activities, but the administrator was unaware of the lack of activity engagement for these residents.
Failure to Monitor Resident Weights as Per Protocol
Penalty
Summary
The facility failed to adhere to standing orders for weekly weight monitoring for two residents, R1 and R2. R1's records indicated that weights were not consistently documented as required by the standing orders and care plan. Despite being scheduled for weekly weigh-ins, R1's electronic medication administration record (eMAR) showed multiple instances where weights were either not recorded or marked with chart codes such as 'drug refused' or 'other / see progress notes.' Interviews revealed that R1 had not been weighed since admission due to the mechanical lift's weight limit being exceeded, and the bed lacked a built-in scale. Similarly, R2's weight monitoring was inconsistent with the facility's protocol. R2's eMAR indicated missed weigh-ins and incorrect documentation, with one instance of hospitalization noted instead of a weight. Interviews with R2 and staff confirmed that R2 had not been weighed, and the mechanical lift used did not have a scale. The facility's policy on weight assessment and intervention was not followed, leading to a failure in monitoring for undesirable weight changes.
Failure to Assess and Review Self-Administration of Medication
Penalty
Summary
The facility failed to conduct a proper assessment for self-administration of medications (SAM) and did not perform an Interdisciplinary Team (IDT) review for a resident who was self-administering an antiseizure medication, Keppra, without staff oversight. The resident, who was cognitively intact, had been taking Keppra independently, storing it in her bedside drawer, and self-administering it twice daily without being witnessed by staff, contrary to the physician's order. The resident's medical record lacked a SAM assessment and IDT review, and her care plan did not indicate she was authorized to self-administer the medication. The Licensed Practical Nurse (LPN) and the Director of Nursing (DON) were aware that the resident kept Keppra in her bedside table, but neither ensured that the medication was given to staff or that the resident was assessed for SAM. The LPN acknowledged not witnessing the resident taking Keppra as required, and the Medical Doctor (MD) was unaware of the need for a SAM assessment and IDT review. The facility's policy stated that residents could self-administer medications only if deemed clinically appropriate and safe by the IDT, and this decision should be documented in the medical record and care plan, which was not done in this case.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to ensure adequate staffing to meet the needs of residents, resulting in significant delays in responding to call lights and providing necessary care. Residents R2, R3, and R4 experienced prolonged wait times for assistance, with call light response times ranging from 15 minutes to over three hours. These delays were particularly concerning given the residents' dependence on staff for activities of daily living, such as toileting and bathing. R2, for instance, was cognitively intact but required maximum assistance for bathing and toileting, and reported waiting over an hour for a brief change after soiling himself. R3, who was also cognitively intact and fully dependent on staff for personal hygiene, experienced similar delays. On multiple occasions, R3's call light went unanswered for extended periods, leaving her feeling uncared for and unclean. R3's brief was improperly positioned, and her hair was uncombed and greasy, indicating a lack of adequate personal care. R4, with a right below-knee amputation and requiring a wheelchair, also faced long wait times for assistance, including a two-hour wait for a brief change after a bowel movement. R4 expressed frustration over not receiving regular showers and hair care, which contributed to feelings of discomfort and neglect. The facility's staffing issues were exacerbated by staff call-ins, leaving only one nursing assistant to care for up to 22 residents at times. This understaffing led to missed baths and delayed responses to call lights, as confirmed by staff interviews. The facility's policy required call lights to be answered promptly, but the staffing shortages made it impossible to meet this standard, resulting in residents' needs being unmet and their dignity compromised.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to assess and determine the safety of a resident for self-administration of medication. The resident, who had a care plan indicating a swallowing problem and was on a dysphagia diet, did not have an order for self-administration of medications. Despite this, the resident's medication was left in their room unsupervised, leading to the assumption that the resident self-administered the medication. The resident's electronic medical record did not include an order for self-administration, and the medication administration record indicated that the medication was given without the necessary blood pressure check. Interviews with staff revealed that the licensed practical nurse left the resident's pills in the room to retrieve another medication, and upon return, the medications were gone. The nurse practitioner confirmed that the resident would need an assessment and an order to self-administer medications, which was not present. The director of nursing stated that leaving medication in a resident's room without supervision constituted self-administration and confirmed that an interdisciplinary team assessment and provider order were necessary for self-administration, which were not in place for this resident.
Failure to Develop Baseline Care Plans for Residents
Penalty
Summary
The facility failed to develop a baseline care plan for two residents within 48 hours of admission, as required by their policy. One resident, who had undergone a total knee replacement, was experiencing significant pain and had respiratory issues requiring oxygen and multiple medications. Despite these needs, the care plan did not adequately address pain management strategies or the resident's respiratory needs, including the use of oxygen and inhalers. Additionally, the care plan did not cover the surgical incision site, which was a critical aspect of the resident's post-operative care. Another resident had a cholecystostomy tube and was experiencing pain at the tube site and a previous chest tube site. The care plan for this resident failed to include specific interventions for wound care, monitoring, and infection risk related to the cholecystostomy tube. Interviews with facility staff, including a registered nurse, an LPN, and the DON, revealed that the care plans were incomplete and did not meet the facility's standards for addressing the residents' immediate needs upon admission.
Deficiencies in Resident Monitoring and Documentation
Penalty
Summary
The facility failed to adequately assess and monitor two residents, R1 and R3, leading to deficiencies in their care. R1 was admitted with a right total knee replacement and required oxygen therapy. However, the facility did not conduct a comprehensive skin assessment or document the surgical incision and wound care. R1's oxygen saturation and pulse were only recorded twice during the stay, and there was a lack of documentation regarding the condition of the surgical site until it became erythematous and hot to the touch on 6/12/24. The facility's failure to document and monitor R1's condition adequately was confirmed by the Director of Nursing (DON) and other staff members. R3 was diagnosed with hypotension and had orders for vital signs to be checked every four hours for 48 hours. Despite this, the facility did not document a complete set of vital signs, including temperature, pulse, respiration rate, or oxygen saturation, after 6/24/24. Additionally, R3 had a cholecystostomy tube with orders for daily dressing changes, but there was no documentation of wound care being completed as ordered. The DON confirmed that the facility did not follow through with the necessary wound care and vital sign monitoring, which was crucial for establishing a baseline and monitoring changes in R3's condition. Interviews with facility staff, including the nurse practitioner, registered nurse, licensed practical nurse, assistant director of nursing, and director of nursing, revealed a lack of adherence to protocols for monitoring and documenting vital signs and wound care. The facility's policies required daily vital sign checks for transitional care unit residents and documentation of wound assessments, which were not followed in these cases. The failure to document and monitor these residents' conditions adequately resulted in missed opportunities to identify changes in their health status.
Failure to Obtain Oxygen Therapy Orders for Resident
Penalty
Summary
The facility failed to properly assess and obtain orders for a resident receiving oxygen therapy. The resident, who was admitted with diagnoses of chronic congestive heart failure and emphysema, had been using oxygen therapy prior to admission. However, the hospital discharge orders did not include any orders for oxygen. Despite this, the resident's electronic medical record noted that the resident arrived at the facility with oxygen on via nasal cannula at 2.5 liters, and an oxygen concentrator was set up in the resident's room. The resident's care plan did not address oxygen use or respiratory problems, and the provider visit note failed to include orders or indications for the use of oxygen. Interviews with facility staff, including a nurse practitioner, registered nurse, licensed practical nurses, and the director of nursing, revealed that there was a lack of proper procedure in obtaining a physician's order for oxygen administration. Staff members acknowledged that oxygen is considered a medication and requires a prescription. The facility's policy on oxygen administration required verification of a physician order before administering oxygen, which was not followed in this case. The director of nursing confirmed the absence of an order for oxygen in the resident's electronic medical record and emphasized the importance of obtaining such orders to ensure appropriate care.
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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