Hilltop Healthcare Rehabilitation And Skilled Nurs
Inspection history, citations, penalties and survey trends for this long-term care facility in Duluth, Minnesota.
- Location
- 2501 Rice Lake Road, Duluth, Minnesota 55811
- CMS Provider Number
- 245366
- Inspections on file
- 42
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Hilltop Healthcare Rehabilitation And Skilled Nurs during CMS and state inspections, most recent first.
The facility did not consistently offer or provide substantial bedtime snacks to residents, resulting in a prolonged period between dinner and breakfast. Several residents reported that snacks were not delivered or were insufficient, and staff interviews confirmed that snacks were only available upon request, with no routine snack cart service. This practice did not align with the facility's policy and had the potential to affect all residents.
A resident with multiple medical conditions was prescribed duloxetine and pristiq without any documented indication for use. Both an RN and the DON confirmed that these psychotropic medication orders did not include the required indication, which was inconsistent with facility policy.
The facility failed to ensure accurate MDS coding for three residents, including errors in documenting hospice services, colostomy status, and use of mobility devices. Staff interviews and record reviews confirmed that the assessments did not accurately reflect the residents' actual conditions at the time.
A resident with multiple mental health diagnoses was admitted for post-hospital rehabilitation with a Level II PASARR assessment limited to 30 days. When the resident's stay exceeded this period, facility staff failed to conduct or document the required reassessment, as they were unaware of the 30-day limitation and the need for further evaluation, resulting in unmet requirements for addressing the resident's mental health needs.
Two residents with complex pain and wound care needs did not have individualized or comprehensive care plans. One resident's plan lacked specific details on pain assessment, goals, and non-pharmacologic interventions, while another's plan did not address actual wound conditions, individualized positioning, or coordination with outside wound care providers, despite relevant provider orders and staff acknowledgment of these needs.
A resident with COPD, depression, and pressure ulcers did not receive required quarterly care conferences, with documentation showing only two conferences and no further records. The resident recalled only one care conference, and staff confirmed that additional conferences were missed, possibly due to hospitalizations. Facility policy requires quarterly interdisciplinary care plan reviews, which were not completed for this resident.
A resident with heart failure and other chronic conditions did not have daily weights completed as ordered, with only a few weights documented for the month and no record of refusals. Additionally, there was no assessment or documentation prior to the resident being sent to the ER for leg pain and edema, despite staff expectations for such documentation.
A resident with chronic kidney disease and other comorbidities did not have vital signs assessed before or after dialysis sessions. Staff interviews confirmed that vital sign assessments were not routinely performed upon the resident's return from dialysis, and the facility's care plan and policy did not address this requirement.
A nurse administered insulin to a resident with diabetes by drawing doses from insulin pens into a syringe, rather than using the pens as intended, while failing to change gloves or perform hand hygiene and leaving the medication cart and medications unattended. The resident expressed concern about the accuracy of the dose and the method used, and facility policies did not support the nurse's actions.
Two residents were found to have medication orders without proper indications or diagnoses attached, including multiple medications for a resident with severe cognitive impairment and a valacyclovir order for another resident with psychiatric and medical conditions. Both nursing staff and the DON confirmed that all medication orders are expected to have an associated diagnosis or indication, in line with facility policy.
Staff failed to keep medication carts locked and medications secured, leaving narcotics and other prescription drugs unattended and accessible in resident areas. On multiple occasions, medication carts were left unlocked, and medications such as insulin pens were left unattended at the desk, contrary to facility policy requiring locked storage.
A resident with moderate cognitive impairment and a history of falls was injured during a transfer when staff failed to use a gait belt as required by the care plan. The resident fell, resulting in multiple rib fractures, a pneumothorax, and a hemothorax, requiring emergency medical treatment. Staff interviews confirmed awareness of the resident's tendency to lean backwards, which increased fall risk, but the care plan was not followed, leading to the incident.
A resident's POLST indicating full CPR was not followed when the resident was found unresponsive without a pulse. An LPN failed to initiate CPR or verify the resuscitation status promptly, leading to a delay in life-saving measures. The resident was pronounced deceased by EMS upon their arrival.
Two residents requiring 1:1 supervision during meals were left unsupervised, leading to choking risks. One resident with dysphagia experienced multiple coughing episodes and a severe choking incident, while another was found asleep with food in his mouth. Staff failed to follow care plans and therapy recommendations, resulting in immediate jeopardy.
The facility did not ensure that two nursing assistants completed the required 12 hours of annual in-service training. One assistant completed 8.57 hours, and another completed 3.5 hours. Despite daily reminders, one assistant forgot to complete the necessary modules. The DON and administrator expected all assistants to fulfill their training requirements annually.
The facility did not provide mandatory QAPI training to staff, as confirmed by interviews with a nursing assistant, an LPN, and an RN, who were unaware of the QAPI plan. The DON acknowledged the need for staff education, and the administrator admitted the lack of formal training. A review of the Relias training program showed no QAPI training for employees.
Failure to Routinely Offer and Provide Substantive Bedtime Snacks
Penalty
Summary
The facility failed to consistently offer and provide a substantive, nutrient- and calorie-rich snack to residents after the dinner meal and before bedtime, resulting in a gap of up to 15 hours between the evening and morning meals. Multiple residents with intact cognition reported during interviews and a resident council meeting that staff did not deliver bedtime snacks, snacks were not substantial, and there was insufficient variety or quantity. Staff interviews revealed that snacks were available on the unit, but residents had to request them, and there was no routine snack cart service. Some staff were unaware of the existence of snack carts, and the DON stated that the expectation was for snacks to be offered before bedtime. Meal delivery times for each unit were documented, showing dinner was served in the early evening and breakfast the following morning, confirming the extended period without food. The facility's Snack Availability policy stated that residents should have access to nourishing snacks, defined as verbal offerings from basic food groups, but the practice did not align with this policy. The deficiency had the potential to affect all 107 residents in the facility.
Psychotropic Medication Orders Lacked Indication for Use
Penalty
Summary
The facility failed to ensure that psychotropic medication orders included an indication for use for one resident. Record review showed that a cognitively intact resident with multiple diagnoses, including depression, anxiety, polyneuropathy, hypertension, and amputation, had active orders for duloxetine and pristiq without any listed indication for use. During interviews, both a registered nurse and the director of nursing confirmed that these medication orders lacked an indication, which was contrary to facility policy requiring every medication order to have an associated indication or diagnosis. The facility's medication administration policy also specified that staff should be able to state the indication for each medication administered.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for three residents, resulting in assessments that did not reflect the residents' actual status at the time of completion. For one resident, the admission MDS was incorrectly coded to indicate the resident was not receiving hospice services, despite census documentation and the care plan confirming hospice care at admission. Both the RN and DON acknowledged that the MDS should have reflected hospice services. Another resident's quarterly MDS was marked as having a colostomy in Section H, but interviews with nursing staff confirmed the resident did not have a colostomy, and the MDS nurse admitted this was an error. A third resident's quarterly MDS indicated no use of mobility devices, despite the resident having a history of lower limb amputation and being observed with a wheelchair and prosthetic leg in the room. The resident confirmed using these devices when out of bed, and the MDS coordinator acknowledged the MDS was inaccurate. The DON confirmed the expectation that MDS reports should accurately reflect the resident's status and that the MDS in question was not accurate regarding mobility devices. These findings were based on record review, staff interviews, and direct observation.
Failure to Complete Required PASARR Reassessment After 30 Days
Penalty
Summary
A deficiency occurred when the facility failed to ensure a required Level II Pre-Admission Screening and Resident Review (PASARR) reassessment was conducted, documented, and retained for a resident with multiple mental health diagnoses. The resident, who had severely impaired cognition and required substantial assistance with most activities of daily living, was admitted with diagnoses including dementia with agitation, delusional disorder, bipolar disorder, depression, and schizophrenia. The initial PASARR Level II assessment approved admission for post-hospital rehabilitative services for 30 days, with instructions that further assessment and service plan changes must be documented if the resident's stay exceeded 30 days or if there was a change in condition. Despite these requirements, the facility did not complete or document a PASARR reassessment after the resident remained in the facility beyond the approved 30-day period. Interviews with the admissions clerk, social services director, and director of nursing revealed that none were aware of the 30-day limitation on the Level II assessment or the need to notify the appropriate agency for reassessment. As a result, the resident's mental health needs may not have been appropriately addressed or provided for during their extended stay.
Failure to Develop Individualized and Comprehensive Care Plans for Pain and Wound Management
Penalty
Summary
The facility failed to develop individualized and comprehensive care plans for two residents with needs related to pain and wound management. For one resident with diagnoses including malignant neoplasm of the prostate, chronic pain syndrome, and anxiety, the care plan did not clearly identify the presence of pain, lacked individualized details on pain assessment, did not specify a goal for pain tolerance, and omitted how pain impacted sleep, activities of daily living, leisure activities, mood, or behavior. Provider orders included scheduled and as-needed morphine, but there were no documented non-pharmacologic interventions. Interviews revealed that non-pharmacologic strategies were not consistently implemented or documented, and the care plan was not updated to reflect the resident's specific pain symptoms and interventions. For another resident with bilateral lower extremity cellulitis, thoracic spine pain, and chronic pulmonary edema, the care plan identified a general problem with skin integrity but did not specify the presence of venous stasis or pressure ulcers. The interventions listed were generic and did not include individualized instructions for positioning, a turning and repositioning program, or coordination with the outside wound care provider, despite provider orders and documentation indicating the need for these measures. Interviews with nursing staff confirmed the importance of individualized positioning and turning for this resident, but the care plan did not reflect these needs.
Missed Quarterly Care Conferences for Resident
Penalty
Summary
The facility failed to ensure that quarterly care conferences were completed for a resident with diagnoses of COPD, depression, and pressure ulcers. Documentation showed that the resident had care conferences on two occasions, but no further conferences were documented as required. The resident reported only recalling one care conference since admission. The social services director confirmed that the last care conference occurred several months prior and acknowledged that subsequent conferences were missed, possibly due to the resident's hospitalizations. The director of nursing stated that care conferences should occur quarterly and after a change in condition, emphasizing their importance in developing individualized care plans. Facility policy requires quarterly interdisciplinary care plan reviews and conferences, but this was not followed for the resident in question.
Failure to Complete Ordered Weights and Document Assessment Prior to ER Transfer
Penalty
Summary
The facility failed to ensure that a resident with multiple chronic conditions, including congestive heart failure, chronic obstructive pulmonary disease, morbid obesity, obstructive sleep apnea, hypertension, and chronic kidney disease, received care and treatment according to physician orders and care plan interventions. Specifically, the resident had provider orders for daily weights and fluid restriction, as well as multiple diuretic medications. However, the electronic medical record for April did not show that weights were taken as ordered, with only three weights documented for the entire month. There was no documentation of the resident refusing weights or any progress notes explaining missed weights. Additionally, prior to the resident being sent to the emergency department for leg pain and edema, there was no assessment or documentation in the medical record regarding the resident's symptoms or the decision to transfer. Observations noted the resident had significant lower extremity edema and pain, and interviews with staff confirmed that documentation and assessment were expected but not completed. The director of nursing and registered nurse both acknowledged that daily weights and documentation of refusals or assessments prior to ER transfer should have occurred.
Failure to Assess Pre- and Post-Dialysis Vital Signs
Penalty
Summary
The facility failed to ensure that vital signs were assessed before and after dialysis for a resident with multiple chronic conditions, including chronic kidney disease, atrial fibrillation, coronary artery disease, diabetes mellitus, and hypertension. The resident's care plan included interventions for monitoring the dialysis access site but did not address the need for pre- and post-dialysis vital sign assessments. Documentation for April 2025 did not show any record of vital sign assessments before or after dialysis sessions. Interviews with the resident and staff revealed that vital signs were not routinely taken upon the resident's return from dialysis, and staff were unaware of any requirement to do so. The trained medication aide confirmed that no assessment was performed after dialysis, and the registered nurse stated that only the dialysis site was checked, with vital signs being taken at the dialysis facility. The director of nursing acknowledged that pre- and post-dialysis vital signs should be taken to monitor for complications, but this was not reflected in practice or in the facility's dialysis policy, which did not address vital sign assessments.
Improper Insulin Administration and Infection Control Lapses
Penalty
Summary
A nurse failed to competently administer insulin to a resident with diabetes, as evidenced by video footage and interviews. The nurse, while wearing the same pair of gloves throughout the process, handled multiple surfaces, medication drawers, and insulin pens without changing gloves or performing hand hygiene. The nurse drew insulin from two different insulin pens into a syringe and administered two injections to the resident, rather than using the insulin pens as intended. The medication cart and insulin pens were left open and unattended during the process, contrary to facility policy. The resident, who was cognitively intact and had a diagnosis of type II diabetes, expressed concern about the insulin administration, specifically suspecting that the nurse may have miscalculated the dose and administered too much insulin. The resident reported experiencing a low blood sugar episode that night, although this was not documented in the vitals summary. The resident also noted that the nurse appeared unsure during the administration and that the method used—drawing insulin from pens into a syringe—was not appropriate. Interviews with the nurse, the DON, and the consulting pharmacist confirmed that drawing insulin from an insulin pen with a syringe is not an acceptable practice and is not included in the facility's competency checklist or policy. The nurse acknowledged the improper technique and infection control lapses, and the DON confirmed that the medication cart and medications should not be left unlocked or unattended. Facility policies reviewed did not support the actions taken by the nurse during the insulin administration.
Failure to Document Indications for Medication Orders
Penalty
Summary
The facility failed to ensure that all medication orders for two residents included a proper indication or diagnosis for use, as required. For one resident with severe cognitive impairment and multiple diagnoses including cerebrovascular disease, dementia, hypertension, depression, hyperlipidemia, and a history of transient ischemic attack, provider orders for several medications such as aspirin, atorvastatin, clopidogrel, losartan, and pantoprazole did not have an associated indication or diagnosis. This was confirmed during a review of the resident's chart by a registered nurse, who acknowledged the absence of proper indications for these medications. For another resident with diagnoses of bipolar disorder, PTSD, and chronic pancreatitis, a provider order for valacyclovir also lacked a documented diagnosis or indication for use. The DON confirmed the expectation that all medication orders should have a diagnosis or indication attached. The facility's medication administration policy requires staff to be able to state the indication for all medications, but this was not followed in these cases.
Medications Left Unsecured and Medication Carts Unlocked
Penalty
Summary
Facility staff failed to ensure that medications and biologicals were securely stored in accordance with professional standards and facility policy. On multiple occasions, medication carts containing narcotics and other prescription medications were observed to be left unlocked and unattended in resident-accessible areas. Specifically, a medication cart was found unlocked and unattended by the DON, who confirmed the incident with the trained medication administrator (TMA). The TMA acknowledged leaving the cart unsecured, which contained medications such as gabapentin and muscle relaxants. Additionally, video footage reviewed by the DON showed a nurse leaving the medication cart open and unlocked while administering insulin to a resident, and also leaving insulin pens unattended at the desk. The facility's policy required all medications to be stored in locked compartments, with controlled substances requiring two locks. These observations and interviews confirmed that staff did not consistently follow procedures for securing medications, resulting in medications being left accessible to unauthorized individuals.
Failure to Implement Care Plan Leads to Resident Injury
Penalty
Summary
The facility failed to implement care plan interventions for a resident who required the use of a transfer belt during transfers, resulting in a fall and significant injuries. The resident, who had moderate cognitive impairment and required assistance with various activities of daily living, was being assisted to the bathroom by a nursing assistant. During the transfer, the nursing assistant held onto the resident's pants instead of using a gait belt, as specified in the care plan. This led to the resident falling backwards and sustaining multiple rib fractures, a pneumothorax, and a hemothorax, necessitating emergency medical treatment. The resident's care plan clearly indicated the need for a gait belt during transfers due to the resident's tendency to lean backwards, which increased the risk of falls. Despite this, the nursing assistant did not use the gait belt, resulting in the resident's fall. The physical therapy assistant and registered nurse confirmed that the resident's backward lean was a known issue, and the use of a gait belt was emphasized to provide better control during transfers. Interviews with staff revealed that the nursing assistant was aware of the resident's tendency to lean backwards but failed to follow the care plan by not using the gait belt. The director of nursing confirmed that the care plan was not followed, which contributed to the fall and subsequent injuries. The facility's gait belt and care plan policies were requested but not provided, indicating a lack of documentation to support proper procedures.
Failure to Follow POLST and Initiate CPR
Penalty
Summary
The facility failed to follow a Physician Orders for Life-Sustaining Treatment (POLST) for a resident who wished to have cardiopulmonary resuscitation (CPR) in the event of cardiopulmonary arrest. The resident was found unresponsive, without a pulse or respirations, by an LPN who did not initiate CPR as per the resident's POLST. The LPN left the room multiple times and communicated with other staff members but did not take action to start CPR or call for emergency assistance. The resident was eventually pronounced deceased by emergency medical services. The incident was further compounded by the LPN's failure to verify the resident's resuscitation status promptly, despite being advised by other staff members to do so. The Director of Nursing was informed of the situation and upon arrival, confirmed the resident's full code status and initiated CPR with the assistance of another RN. However, by the time CPR was started, the resident was already deceased. The facility's CPR procedure was not followed, leading to a delay in providing life-saving measures to the resident.
Removal Plan
- Reviewed their policy and procedure on CPR, and re-educated all staff on the CPR policy and procedure.
- Assessed all residents to ensure their POLST were completed and accurate.
- Conducted a mock CPR drill during morning and evening shift to ensure staff respond correctly.
- Reviewed the daily schedule to ensure each shift had at least three staff of nurses or TMAs who were CPR certified.
- Completed audits to ensure all crash carts had all essential equipment and supplies, and the AED was functional and will bring the results of the audits to the Quality Assurance and Performance Improvement (QAPI) committee.
Failure to Provide 1:1 Supervision During Meals
Penalty
Summary
The facility failed to provide proper supervision during meals for two residents who required 1:1 supervision to prevent choking. Resident 1 had a history of dysphagia and required close supervision during meals to prevent choking. Despite this, there were multiple instances where Resident 1 was left unsupervised during meals, leading to coughing episodes and a severe choking incident on medications. The staff failed to adhere to the care plan and therapy recommendations, which required 1:1 supervision and cues to ensure safe eating practices. Resident 2, who had aphasia and required 1:1 supervision during meals, was also left unsupervised. On one occasion, Resident 2 was found asleep at the dining table with food in his mouth, unresponsive to initial attempts to wake him. Despite therapy recommendations for 1:1 supervision, staff did not consistently provide the necessary oversight, leaving Resident 2 at risk of choking and aspiration. The facility's failure to provide adequate supervision during meals for these residents resulted in immediate jeopardy. Staff were aware of the supervision requirements but did not consistently implement them, leading to potentially dangerous situations for both residents. The lack of documentation and communication among staff further contributed to the deficiency, as incidents were not properly recorded or addressed in a timely manner.
Removal Plan
- The facility reviewed and revised their current policy on meal assistance.
- The facility reviewed all resident care plans/Kardex to reflect current ST recommendations.
- The facility implemented a new system for therapy recommendations.
- The facility completed staff education on the meal assistance policy with post quiz.
- The facility completed audits on all residents who needed assistance or supervision with meals to ensure they were being assisted or supervised.
Deficiency in Annual Training for Nursing Assistants
Penalty
Summary
The facility failed to ensure the completion of 12 hours of annual in-service training for two of the five nursing assistants reviewed. NA-A had completed only 8.57 hours, while NA-D had completed 3.5 hours of the required training within the last 12 months. Despite being reminded almost daily by the facility, NA-A forgot to complete the necessary modules, resulting in overdue training. The Director of Nursing and the administrator both stated that all nursing assistants were expected to complete their 12 hours of training each year by the due date.
Lack of QAPI Training for Staff
Penalty
Summary
The facility failed to provide mandatory training on its Quality Assurance and Performance Improvement (QAPI) program to all staff. During interviews, a nursing assistant, a licensed practical nurse, and a registered nurse all stated they did not recall receiving any QAPI training and were unaware of the facility's QAPI plan or how to communicate concerns related to it. The director of nursing acknowledged that all staff should be educated on QAPI, while the administrator admitted that although QAPI is often discussed, there has been no formal education provided to staff. A review of the facility's Relias training program confirmed the absence of QAPI training for employees.
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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