Hope Springs At Minnetonka
Inspection history, citations, penalties and survey trends for this long-term care facility in Minnetonka, Minnesota.
- Location
- 16913 Highway 7, Minnetonka, Minnesota 55345
- CMS Provider Number
- 245606
- Inspections on file
- 18
- Latest survey
- February 14, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Hope Springs At Minnetonka during CMS and state inspections, most recent first.
The facility failed to provide a registered nurse (RN) for a minimum of eight consecutive hours per day, as required. This deficiency was identified through the PBJ Staffing Data Report, which showed gaps in RN coverage on multiple days. The Director of Nursing acknowledged the issue but highlighted the competence of the LPNs in maintaining continuity of care. A resident reported no concerns, and the facility's staffing policy was not provided.
The facility failed to ensure proper food storage and labeling, with items found unlabeled and undated. Staff did not consistently follow hygiene practices, such as wearing hair nets and performing hand hygiene between glove changes. Observations included condensation on stacked dishes and improper temperature checks of food items. The administrator confirmed expectations for these practices, which were not met by the staff.
The facility failed to maintain a comprehensive, data-driven QAPI program, affecting all 21 residents. The QA committee, including the DON, administrator, and medical director, met quarterly but lacked a system to collect and use data from all departments. No opportunities for improvement or performance projects were identified, and no meeting minutes or documentation were recorded, despite a policy emphasizing QAPI's importance.
The facility's QA committee, consisting of the DON, administrator, and medical director, failed to identify and implement performance improvement projects due to a lack of a system for data collection and utilization. Despite having a policy for conducting PIPs, the facility did not initiate any projects to address identified concerns, potentially affecting all 21 residents.
The facility's QA committee did not include the minimum required members, consisting only of the DON, administrator, and medical director. The DON confirmed the absence of at least two additional staff members, despite the facility's policy requiring broader representation, including key staff from other departments and potentially a resident and family members.
The facility failed to accurately code MDS assessments for medication use for several residents, misclassifying Melatonin as a hypnotic and omitting prescribed anticonvulsant and anticoagulant medications. The DON confirmed these inaccuracies, which were contrary to the RAI Manual guidelines.
Two residents in a facility were allowed to self-administer topical medications without proper assessments for safe use. One resident, despite being visually impaired, used a steroid cream unsupervised on areas not originally prescribed. Another resident self-administered multiple topical medications without a formal assessment. The facility's policy required assessments by an interdisciplinary team, but these were not conducted, leading to a deficiency.
A resident with intact cognition and mental health issues expressed a preference for vegetarian options, but the facility failed to consistently honor these preferences. Despite being aware of the resident's dietary likes and dislikes, the facility's staff did not document or provide meals that aligned with the resident's choices. The resident reported insufficient vegetarian options and received regular entrees if alternative options were not selected in time. Observations showed the resident was served unwanted meat, which was discarded without offering alternatives.
A resident's code status was inconsistently documented in their medical records, with discrepancies between their Health Care Directive and hospital orders. The facility failed to ensure provider involvement in the resident's DNR status, as required by policy.
The facility failed to follow a process for missing clothing, affecting three residents who reported missing items without receiving appropriate follow-up. Despite being informed, the facility's Missing Item Report lacked documentation of these concerns. The DON acknowledged the lack of follow-up and inadequate labeling of clothing, contributing to unresolved issues and dissatisfaction among residents and their families.
A facility failed to adequately monitor and assess skin alterations for a resident at risk of skin breakdown and did not effectively manage another resident's recurring UTIs, leading to hospitalizations. The facility did not adhere to care plans or conduct timely assessments, resulting in inadequate treatment of residents' health conditions.
A facility failed to assess a resident's safety for off-campus smoking and did not implement interventions for residents at risk of falls. One resident, who wished to smoke off-campus, was not provided with a safe smoking assessment or interventions. Another resident experienced multiple falls after ECT, but the facility did not update the care plan with new interventions. A third resident's care plan was not updated after a fall, lacking a root cause analysis and new interventions.
A resident experienced constant pain affecting daily activities, yet the facility failed to assess pain comprehensively or attempt non-pharmacological interventions. Despite receiving multiple pain medications, the care plan lacked specific non-pharmacological strategies, and no pain assessments were documented for seven months. Interviews revealed staff did not inquire about pain levels or implement non-pharmacological interventions unless ordered by a doctor. The facility's pain management policy was unavailable during the survey.
The facility failed to assess alternative interventions and obtain informed consent for bed assist devices for two residents. One resident's care plan and risk assessment indicated no need for bed rails, yet staff tied the call light to the siderail. Another resident's assessment showed bed rails were unnecessary, but the device remained in place without re-evaluation or consent. Staff interviews revealed a lack of clarity and communication regarding device assessments and use.
A resident with dysphagia and a history of coughing during meals did not consistently receive the prescribed mechanical soft diet. Despite orders for soft foods and ground meat, the resident often received meals not cut into bite-sized pieces, leading to multiple coughing episodes. Staff interviews revealed a lack of communication about the risks of the resident's food choices, and the DON had not discussed these risks with the resident.
The facility failed to deliver mail to residents on Saturdays and opened personal mail without proper authorization, affecting residents' privacy. Two residents reported their mail was opened despite requests for unopened delivery. The administrative assistant could not provide documentation of authorization for opening mail, leading to a deficiency.
The facility failed to schedule a registered nurse (RN) for a minimum of eight consecutive hours per day, as required. This deficiency was identified through a review of staffing data, which showed multiple dates without RN coverage. Interviews with staff confirmed gaps in coverage due to vacation time and limited RN staff. The facility preferred using licensed practical nurses (LPNs) familiar with residents over hiring agency RNs. The Facility Assessment Tool lacked identification of the need for eight consecutive hours of RN coverage daily.
The facility failed to properly store, label, and date food items, and did not ensure dishware was sanitized effectively, posing potential health risks. Observations revealed unlabeled and improperly stored food, as well as fluctuating dish machine temperatures that did not meet sanitization standards. The cook and administrator acknowledged these issues, which were not in compliance with the facility's policies.
The facility failed to submit accurate staffing data to CMS, with discrepancies noted between the PBJ Staffing Data Report and the facility's payroll sheets. The report indicated missing RN coverage and gaps in 24-hour licensed nursing coverage, which the payroll sheets contradicted. The administrator was unsure why the data was inaccurate, and no policy on PBJ data submission was provided.
The facility failed to implement a QAPI plan to maintain acceptable care levels and did not conduct ongoing quality assessment activities. Despite holding quarterly QAPI meetings, no performance improvement projects or formal documentation were developed to address repeated quality deficiencies. The focus had been on settling into a new building, with plans to address these issues in the future.
The facility's infection prevention and control program was found lacking in comprehensive policies and procedures, including those for TBP, EBP, and hand hygiene. The antibiotic stewardship protocol also lacked a system for monitoring antibiotic use. Interviews revealed informal monitoring practices without documentation, and the DON acknowledged the need for policy improvements.
The facility failed to ensure staff were educated on infection control standards, potentially affecting all 20 residents. An LPN was unsure about monitoring infections, and the DON acknowledged issues with providing education. The infection control policy lacked staff education requirements.
The facility failed to conduct regular resident council meetings due to the absence of the activity director, who was on medical leave. No one was assigned to organize the meetings during this period, affecting all 12 residents involved in the council. The facility's policy required monthly meetings, but this was not followed, leading to the deficiency.
The facility failed to provide residents with adequate access to their personal funds, limiting access to Wednesdays only, which affected their ability to manage financial affairs independently. Despite a policy allowing for emergency access, residents were not effectively informed or able to access funds on weekends or other days.
The facility failed to develop comprehensive care plans for two residents, lacking specific interventions for their identified needs. One resident's care plan missed goals for areas like pain management and ADLs, while another's lacked interventions for cognitive and behavioral concerns. Staff interviews revealed gaps in addressing chronic pain and anxiety, with the DON acknowledging the care plans were incomplete.
A resident with a right leg amputation was not provided with necessary assistance and coordination for their prosthetic care. Despite a provider's order to reassess the prosthesis due to skin irritation, the facility failed to contact the prosthetic company for six months. The resident expressed a desire to use the prosthesis, but it caused blisters, and staff were unaware of the need for a walking program. The care plan lacked details on prosthetic use, and no policy on prosthetic care was provided.
The facility did not act on pharmacist recommendations for two residents regarding unnecessary medications, including an opioid and liothyronine sodium. Additionally, the pharmacist failed to identify duplicative acetaminophen orders for a third resident. The DON was unaware of some recommendations, and the facility's process for communicating these to providers was inadequate.
A resident with schizoaffective disorder and chronic pain was prescribed multiple acetaminophen orders without clear administration parameters, leading to potential overuse. Facility staff, including an LPN and the DON, acknowledged the issue, noting that duplicate PRN orders for the same medication were not standard practice. The clinical pharmacist confirmed the oversight and the lack of guidance on safe dosage limits.
A facility failed to ensure a resident's dental status was accurately assessed and routine dental services were provided. The resident, who was cognitively intact and had multiple health issues, expressed a desire to see a dentist due to infrequent visits and dentures that occasionally fell out. Staff interviews revealed a lack of awareness and action regarding the resident's dental needs, with no specific policy on dental assessments in place.
The facility failed to offer influenza vaccinations to two residents, one with bipolar disorder and depression, and another with schizoaffective disorder and depression. The medical records lacked documentation of offers or declinations, and interviews revealed that the DON, responsible for vaccination oversight, may have overlooked obtaining necessary signatures. The facility's policy required consent but lacked a clear process for assessing vaccination status.
The facility did not ensure survey results were visible and accessible, as they were stored at the second-floor nurse's station, affecting all 20 residents and their visitors. During a resident council meeting, several residents expressed unawareness of the survey results' location. The administrative assistant confirmed the results should have been placed in a more accessible area.
Deficiency in RN Staffing Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was scheduled for a minimum of eight consecutive hours per day, which is a requirement for staffing in long-term care facilities. This deficiency was identified through the Payroll Based Journal (PBJ) Staffing Data Report, which indicated that there was no continuous 8-hour RN coverage for several days within the 4th quarter. Specific dates of non-compliance included multiple days in July, September, November, December, and January. During interviews, the Director of Nursing (DON) acknowledged the lack of continuous RN coverage but emphasized that the facility was staffed with competent licensed practical nurses (LPNs) who provided continuity of care. Despite the deficiency, a resident reported no concerns during a resident council meeting, and the facility's policy on staffing was requested but not received.
Deficiencies in Food Storage, Labeling, and Hygiene Practices
Penalty
Summary
The facility failed to ensure proper food storage and labeling practices, as observed during a kitchen tour. Sliced cheese and a half of Smithfield boneless ham were found without opened dates, and several items in the freezer, including bratwurst, tortillas, and a cheese omelet, were unlabeled and undated. Additionally, clean cups and bowls were stacked with condensation between them, indicating they were not completely dry before storage. Dietary aid (DA)-A confirmed these observations and admitted uncertainty about the duration of storage for some items. In terms of personal hygiene and food handling, DA-A was observed not wearing a hair net and failed to perform hand hygiene between glove changes while preparing and serving food. DA-A also did not check the temperature of all food items, such as the beef and pizza cooked in the microwave, relying instead on package instructions and personal judgment. DA-A acknowledged not washing hands between glove changes unless visibly dirty, citing time management as a reason. Another dietary aid, DA-B, was observed wearing a stocking cap without a beard net, despite having a longer loose hair on their chin. DA-B stated they took food temperatures and labeled food when opened, but their understanding of beard net requirements was incorrect. The facility administrator confirmed expectations for food temperature checks, proper labeling, and hand hygiene practices, which were not consistently followed by the staff. Facility policies required food to be labeled and dated, dishes to be air-dried, and staff to wear appropriate hair coverings and perform hand hygiene between tasks.
Lack of Comprehensive QAPI Program and Documentation
Penalty
Summary
The facility failed to maintain documentation and demonstrate evidence of a comprehensive, data-driven Quality Assurance and Performance Improvement (QAPI) program, potentially affecting all 21 residents. During an interview, the Director of Nursing (DON) revealed that the Quality Assurance (QA) committee, which included the DON, the administrator, and the medical director, met quarterly to review adverse events. However, the committee lacked a system to identify, collect, and utilize data from all departments and had not identified any opportunities for improvement or performance improvement projects to implement. Additionally, the facility did not record any meeting minutes or documentation of their ongoing QA meetings, despite having a policy that outlined the importance of QAPI as a comprehensive approach to ensuring high-quality care.
Failure to Implement Effective Quality Assurance Measures
Penalty
Summary
The facility failed to ensure that its Quality Assurance (QA) committee effectively identified and implemented performance improvement projects to address identified concerns. During an interview, the Director of Nursing (DON) revealed that the QA committee, which included herself, the administrator, and the medical director, met quarterly to review adverse events. However, the committee lacked a system to identify, collect, and utilize data from all departments, and had not identified any opportunities for improvement or initiated any performance improvement projects. The facility's policy on Quality Assurance and Performance Improvement (QAPI) outlined that a Performance Improvement Project (PIP) should be a concentrated effort on a specific problem within the facility, involving data collection and intervention for improvements. Despite this policy, the facility had not conducted any PIPs to examine and improve care or services in areas needing attention. This deficiency had the potential to affect all 21 residents residing within the facility.
QA Committee Lacks Required Members
Penalty
Summary
The facility failed to ensure that the Quality Assurance (QA) committee included the minimum required members, which had the potential to affect all 21 residents residing within the facility. During an interview, the Director of Nursing (DON) confirmed that the committee, which consisted of herself (also serving as the infection preventionist), the administrator, and the medical director, met quarterly to review adverse events. However, the DON acknowledged that the QA committee did not include at least two additional staff members as required. The facility's policy on Quality Assurance and Performance Improvement (QAPI) indicated that the team should include the Administrator, DON, medical director, other key staff members from various departments, a designated resident if they wish to participate, and family or guardians if they wish to participate. Despite this policy, the committee had not yet included additional staff members, although there was a discussion about having a nursing assistant join the committee.
Inaccurate MDS Coding for Medication Use
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments were accurately coded to reflect the correct medication use for five residents. The inaccuracies involved misclassification of medications, such as coding Melatonin, a dietary supplement, as a hypnotic medication, contrary to the guidelines in the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual. Additionally, the MDS assessments for several residents did not accurately reflect the use of prescribed anticonvulsant and anticoagulant medications. For instance, one resident was recorded as taking a hypnotic medication without a prescription for such, and another resident's MDS did not mention the use of prescribed anticonvulsant and anticoagulant medications. The Director of Nursing (DON), who was responsible for completing the MDS, confirmed the inaccuracies during interviews. The DON acknowledged that medications should be coded based on their pharmacological classification rather than their intended use, as per the RAI Manual. Despite this, the DON incorrectly classified Melatonin as a hypnotic. The facility's MDS policy indicated that staff chart in the electronic medical record on various aspects of resident care, with a licensed practical nurse assisting the DON in interviewing residents and completing assessments. However, the deficiencies in the MDS coding were evident across multiple residents, indicating a systemic issue in accurately reflecting medication use.
Failure to Assess Residents for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents who self-administered topical medications were assessed for safe and appropriate use. Resident R11, who was cognitively intact, had an order for Betamethasone Valerate External Cream for a rash, which she self-administered unsupervised. However, there was no evidence in her electronic medical record (EMR) that she had been assessed for safe self-administration of the medication. Despite being visually impaired, R11 continued to self-administer the cream without staff assistance or assessment, and she used it on a different area of her body than originally prescribed. Resident R15, also cognitively intact, had multiple topical medications for self-administration, including hydrocortisone cream, antifungal powder, and Voltaren Gel. Similar to R11, R15's EMR lacked evidence of an assessment for safe self-administration of these medications. R15 self-applied the creams and powders as needed, and although staff were aware of the medications, there was no formal assessment conducted to ensure safe use. The facility's policy required an interdisciplinary team to assess residents' cognitive, physical, and visual abilities to self-administer medications. However, both R11 and R15 were not assessed according to this policy, leading to a deficiency in ensuring safe self-administration of medications. The Director of Nursing confirmed the lack of assessments for both residents, acknowledging the need for proper evaluation beyond just having a doctor's order.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor a resident's food preferences, which is a violation of the resident's right to self-determination. The resident, who had intact cognition and a history of mental health issues, expressed a preference for vegetarian options and a dislike for certain meats. Despite this, the facility did not consistently provide meals that aligned with the resident's preferences. The resident reported that the facility lacked sufficient vegetarian options and that they received the regular entree if they did not sign up for an alternative option in time. Observations and interviews revealed that the facility's dietary staff and nursing assistants were aware of the resident's food preferences but did not consistently document or honor them. The dietary aid and nursing assistant noted that the resident sometimes requested no meat and other times ate meat, but the kitchen's whiteboard and dietary book did not reflect any special instructions for the resident. During a meal observation, the resident was served barbequed pork, which they did not eat, and the meat was discarded without checking if the resident wanted anything else. The facility's policy required the cook and dietician to assess and document residents' food preferences, but this was not effectively implemented for the resident in question. The director of nursing acknowledged the resident's inconsistent preferences and the importance of providing food they liked, but the facility's practices did not ensure the resident's dietary needs and preferences were consistently met. This deficiency highlights a failure in the facility's processes to support resident choice and self-determination regarding food preferences.
Inconsistent Code Status Documentation for Resident
Penalty
Summary
The facility failed to ensure that a resident's code status was updated, consistent, and accurate throughout their medical record. The resident, who had intact cognition and diagnoses including orthostatic hypotension, dementia, and schizophrenia, had a Health Care Directive indicating they did not want CPR and preferred a natural death. However, the resident's Transfer and Discharge Orders from Regions Hospital indicated a full code status, creating a discrepancy in their medical records. Additionally, the resident's care plan lacked documentation of their code status, and their orders did not indicate their code status. Interviews with facility staff revealed that code statuses were reviewed at care conferences and during admission, but there was no provider order or involvement in the resident's DNR status. The Director of Nursing confirmed the absence of a provider's signature on the resident's Health Care Directive and Admission Record. The facility's policies required staff to assist residents in completing a POLST form and to ensure provider involvement, but these procedures were not followed for the resident in question.
Failure to Address Missing Clothing Concerns
Penalty
Summary
The facility failed to ensure a process for missing clothing was followed and residents received appropriate follow-up after reporting concerns of missing clothing. Three residents, identified as R1, R5, and R9, reported missing clothing items, but their concerns were not adequately addressed. R1, who was cognitively intact, reported a missing blue hoody and stated that missing clothing was a common occurrence. Despite informing the nursing assistants, R1 did not receive any follow-up. Similarly, R5, also cognitively intact, reported missing jeans, socks, and underwear, and although the director of nursing (DON) was informed, no follow-up was conducted. The facility's Missing Item Report lacked evidence of these reports, indicating a failure in the documentation process. R9, who had moderately impaired cognition and a history of paranoia, reported a missing expensive jacket. Despite the facility's process for handling missing items, R9's missing jacket was not documented in the missing items log. Interviews with staff revealed inconsistencies in the process of reporting and searching for missing items. NA-A and RN-A were unaware of R9's missing jacket, and the DON acknowledged that the facility did not find the jacket, leading to dissatisfaction from R9's family. The facility's labeling process for clothing was also inadequate, as the use of a sharpie that washed off after a few washes contributed to the issue of missing clothing. The facility's policy related to resident missing items was requested but not available at the time of the survey, further highlighting the lack of a structured process for addressing missing personal property. The DON admitted that the facility lacked follow-up on the missing items report and with missing items in general. The absence of a clear and effective procedure for managing and documenting missing clothing items resulted in unresolved concerns for the residents involved, impacting their right to a safe, clean, comfortable, and homelike environment.
Deficiencies in Skin and UTI Management
Penalty
Summary
The facility failed to adequately assess and monitor skin alterations for a resident, R8, who was at risk for skin breakdown due to various health conditions and the use of compression stockings. Despite having a care plan in place to prevent skin breakdown, the facility did not conduct regular skin assessments as required. R8 had a sore in the buttock area that was not properly documented or monitored, and staff failed to follow the facility's policy on skin monitoring, which required weekly assessments by a registered nurse and documentation of any skin alterations. Additionally, the facility did not effectively manage another resident, R3, who experienced multiple urinary tract infections (UTIs) leading to hospitalizations. R3, who was cognitively intact and mostly independent, reported symptoms of UTIs multiple times over several months. However, the facility did not conduct timely assessments or interventions, such as bladder scanning or proactive UTI assessments, to address these symptoms. The facility also failed to follow up with urology as previously recommended, and R3's care plan lacked updated interventions despite recurring UTIs. The facility's inaction in both cases highlights a lack of adherence to established care plans and policies, resulting in inadequate monitoring and treatment of residents' health conditions. The deficiencies in care for R3 and R8 were identified through observations, interviews, and document reviews, revealing significant gaps in the facility's processes for managing skin integrity and urinary health.
Failure to Assess Smoking and Fall Risks
Penalty
Summary
The facility failed to ensure a resident who wished to smoke off facility grounds was properly assessed for safety. The resident, who was cognitively intact and used a walker, expressed a desire to smoke off-campus. Despite being informed that the facility was non-smoking, the resident was not provided with a safe smoking assessment or any interventions to ensure her safety while smoking off-campus. The facility's staff, including the DON and RN, acknowledged the resident's desire to smoke but did not complete a safe smoking assessment or implement any safety measures. The facility also failed to adequately assess and implement new interventions for residents at risk of falls. One resident, with moderate cognitive impairment and a history of falls, experienced multiple falls, particularly after receiving ECT. Despite the pattern of falls occurring on Thursdays following ECT, the facility did not update the resident's care plan with new interventions or conduct a root cause analysis. The resident's care plan and Kardex lacked updated interventions, and orthostatic blood pressure monitoring was not conducted as required. Another resident, who had intact cognition and a history of falls, experienced a fall while trying to pick up a blanket from the floor. The facility's fall care plan for this resident was not updated following the incident, and there was no evidence of a root cause analysis or new fall prevention interventions. The DON confirmed that the resident's care plan was not updated after the fall, and the facility's fall book had not been fully implemented to analyze resident falls and create effective interventions.
Deficiency in Comprehensive Pain Management for Resident
Penalty
Summary
The facility failed to comprehensively assess and manage pain for a resident, identified as R11, who was receiving multiple medications for pain management. R11's quarterly Minimum Data Set (MDS) indicated that the resident was cognitively intact and experienced almost constant pain, which frequently affected sleep and daily activities. Despite receiving several medications for pain, including Ajovy, alpha-lipoic acid, Gabapentin, diclofenac sodium gel, Humira, and Nurtec, there were no documented non-pharmacological pain interventions attempted. The care plan for R11 lacked specific non-pharmacological pain interventions, and the electronic medical record (EMR) did not include any pain assessments over the past seven months, such as pain goals or what alleviated or exacerbated the pain. Interviews with R11 and facility staff revealed further deficiencies in pain management practices. R11 reported experiencing constant pain and expressed a desire to avoid additional medication, noting that staff did not attempt non-pharmacological interventions or inquire about pain levels. Licensed Practical Nurse (LPN)-A acknowledged that pain assessments should occur at least quarterly and whenever pain medication is administered, but noted that non-pharmacological interventions were not implemented unless ordered by a doctor. Nursing Assistant (NA)-C was unaware of any non-pharmacological interventions for R11 and had not attempted any herself. The Director of Nursing (DON) confirmed the absence of non-pharmacological interventions and noted that pain assessments were not conducted when R11 self-administered diclofenac sodium gel. Additionally, the facility's pain management policy was requested but unavailable during the survey.
Failure to Assess and Obtain Consent for Bed Assist Devices
Penalty
Summary
The facility failed to ensure that alternative interventions were assessed or attempted before using bed assist devices for two residents. For one resident, identified as R9, the facility did not document any assessment or education regarding the risks and benefits of bed assist devices, nor did they obtain informed consent. Despite the resident's care plan and risk assessment indicating that bed rails were not needed, staff tied the resident's call light to the bed siderail on multiple occasions. During an interview, the resident stated they did not use the device and were not informed about it upon admission. For another resident, identified as R14, the facility did not re-evaluate the need for a bed assist device after an assessment indicated it was no longer necessary. Initially, the resident's assessment suggested that bed rails were beneficial, but a later assessment showed they were not needed. Despite this, the bed assist device remained in place, and the resident did not recall being educated about its risks and benefits or providing consent. Staff continued to secure the call light to the siderail, and the resident stated they did not use the device. Interviews with facility staff, including nursing assistants and the director of nursing, revealed a lack of clarity and communication regarding the assessment and use of bed assist devices. The director of nursing acknowledged that assessments were supposed to be conducted upon admission and quarterly, but there was no evidence of follow-up or removal of devices when no longer needed. The facility's policy required informed consent and education about the risks and benefits of bed rails, which was not adhered to in these cases.
Failure to Provide Appropriate Modified Diet for Resident with Dysphagia
Penalty
Summary
The facility failed to ensure that a resident with dysphagia and a history of coughing during meals received the appropriate modified diet. The resident, who was cognitively intact, had been admitted with diagnoses including dysphagia and moderate protein-calorie malnutrition. Despite orders for a mechanical soft texture diet, the resident often requested not to have their meat ground, and the facility did not consistently provide food in the prescribed form. The resident's care plan and Kardex indicated the need for soft foods and ground meat, but the resident sometimes received meals that were not cut into bite-sized pieces, leading to multiple coughing episodes during meals. Interviews and observations revealed that the staff did not consistently follow the dietary instructions, and there was a lack of communication regarding the risks and benefits of the resident's food choices. The resident reported not having discussions with staff about the risks of aspiration or choking. The Director of Nursing acknowledged the resident's refusal of the prescribed diet but had not discussed the associated risks with the resident. The facility's policy on modified diets was requested but not provided, indicating a potential gap in policy adherence or availability.
Failure to Ensure Privacy and Timely Delivery of Resident Mail
Penalty
Summary
The facility failed to ensure that residents had reasonable access to and privacy in their use of communication methods, specifically regarding the delivery and handling of personal mail. Observations and interviews revealed that the facility did not deliver mail to residents on Saturdays because the front office was locked and weekend staff did not have access. Additionally, the facility was opening residents' mail to process medical and financial items before delivering it to them, which was against the wishes of some residents. Two residents, R5 and R6, reported that their mail was being opened by the facility despite their requests for it to be delivered unopened. The administrative assistant explained that residents or their representatives were asked to sign a form authorizing the facility to open and manage business mail. However, there was no documentation to show that R5 had signed such an authorization, and R6's request to receive unopened mail had not been addressed. The facility's policy indicated that business mail was handled by the business office unless otherwise communicated, but the lack of proper documentation and failure to respect residents' requests led to the deficiency.
Failure to Ensure RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was scheduled for a minimum of eight consecutive hours per day, as required. This deficiency was identified through a review of the facility's Payroll Based Journal (PBJ) Staffing Data Report, which showed multiple dates between October 1, 2023, and December 23, 2023, where RN coverage was not provided. Interviews with facility staff, including the Director of Nursing (DON) and the administrator, confirmed the gaps in RN coverage. The DON attributed these gaps to vacation time and a limited number of RNs on staff, preferring to use licensed practical nurses (LPNs) who were familiar with the residents over hiring agency RNs. The facility's Staffing Contingency Plan and Facility Assessment Tool were reviewed, revealing that the facility had a plan to ask staff to pick up shifts in the event of a staffing shortage. However, the Facility Assessment Tool did not specify the need for eight consecutive hours of RN coverage daily. Interviews with the administrative assistant and the administrator indicated awareness of staffing requirements, but the administrator was unaware of the extent of the RN coverage gaps. The facility had the option to use agency nurses to fill RN hours but chose to rely on their own LPN staff, who were considered more knowledgeable about the residents.
Deficiencies in Food Storage and Dishware Sanitization
Penalty
Summary
The facility failed to ensure proper storage, labeling, and dating of food items in the kitchen, which could potentially affect all residents and staff consuming meals from the main kitchen. During an initial kitchen observation, it was noted that several refrigerated, frozen, and dry food items were not labeled with opened dates or identifying information. For instance, opened milk containers, slices of meat, and packages of roast beef lacked opened dates. Additionally, frozen items such as spring rolls and brats were found with freezer burn and without proper labeling. The facility's cook acknowledged these issues, stating that some items were not labeled due to rapid usage, while others were improperly stored or labeled. The facility also failed to maintain proper dishware sanitation practices, increasing the risk of foodborne illness. Observations revealed that the dish machine's temperature fluctuated and did not consistently reach the required levels for effective sanitization. The cook admitted to using a manual sanitization process with a bucket and test strips, but the test strips did not indicate appropriate sanitization levels when diluted in the sink. The administrator confirmed that the dish machine was a chemical sanitizer and that test strips were used to test the pH level of the standing water, but there was no alternative method to verify the dish machine's temperature. The facility's policies on food storage and dish machine sanitization were not adhered to, as evidenced by the improper storage of food items and the inadequate sanitization process. The administrator acknowledged that opened items should be dated and labeled, and food should not be stored on the floor. The dish machine was expected to operate at specific temperatures, but the observed practices did not align with these requirements, leading to potential health risks for residents and staff.
Inaccurate Staffing Data Submission to CMS
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) for the first quarter of the year. The Payroll-Based Journal (PBJ) Staffing Data Report indicated that the facility lacked Registered Nurse (RN) coverage on multiple specified dates and did not maintain 24-hour licensed nursing coverage on certain days. Additionally, the report flagged the facility for low weekend staffing. However, a review of the facility's payroll sheets contradicted these findings, showing RN coverage on several of the dates in question and no gaps in 24-hour licensed nursing coverage. During an interview, the facility administrator stated that the PBJ data was submitted by the business office and was unsure why it did not accurately reflect staffing hours. The facility did not provide a policy regarding the submission of PBJ data to CMS when requested.
Failure to Implement QAPI Plan and Address Quality Deficiencies
Penalty
Summary
The facility failed to implement a Quality Assurance and Performance Improvement (QAPI) plan to ensure care and services were maintained at acceptable levels and continually improved. The facility did not conduct ongoing quality assessment and assurance activities, nor did it develop and implement appropriate plans of action to correct repeated quality deficiencies. These deficiencies were identified during the survey and were issues the facility was aware of or should have been aware of, potentially affecting all 20 residents residing in the facility. The facility's QAPI meeting minutes, attendance records, and evidence of ongoing performance improvement projects (PIPs) were requested but not provided. During an interview, the administrator stated that the facility held quarterly QAPI meetings but had not developed any PIPs or formal documentation to address previous and repeated quality deficiencies. The focus over the past year had been on settling into a new building, and plans to start addressing these issues were mentioned for the future. The QAPI plan dated 11/10/23 indicated intentions to establish a committee, conduct a facility assessment, identify areas of concern, and begin working on a PIP.
Inadequate Infection Control Program and Antibiotic Stewardship
Penalty
Summary
The facility failed to develop a comprehensive infection prevention and control program, which included written standards, policies, and procedures for reporting communicable diseases or infections, implementing transmission-based precautions (TBP) and enhanced barrier precautions (EBP), and ensuring proper hand hygiene practices. The existing policies lacked specific guidance on when and how to implement TBP, the required personal protective equipment (PPE) for different types of precautions, and staff education requirements. Additionally, there was no process for monitoring infection control practices among staff, and the antibiotic stewardship protocol did not include a system to monitor antibiotic use or assess residents' responses to antibiotics. Interviews with staff revealed that there was no specific method for monitoring residents with infections or those on antibiotics. The Director of Nursing (DON), who also served as the infection preventionist, acknowledged the deficiencies in the infection control policies and the lack of a structured monitoring process. The DON admitted that infection control practices were informally observed through cameras and personal observation without documentation. The antibiotic stewardship program was also found lacking in specific monitoring and data collection, with no structured discussion on antibiotic use in the quality committee. The DON, who had multiple responsibilities, recognized the need for improvement in the infection control policies.
Inadequate Staff Education on Infection Control
Penalty
Summary
The facility failed to ensure that staff were adequately educated on the standards, policies, and procedures of their infection control program, potentially impacting all 20 residents. During an interview, an LPN stated that they would alert the DON and the provider if a resident showed signs of infection, but there was no specific protocol for monitoring infections or antibiotic use. The LPN mentioned a recent in-service on enhanced barrier precautions but was unsure about education on policies and procedures. The DON confirmed that on-the-spot training was conducted when infection control concerns arose and acknowledged issues with providing education through an online platform. The facility's infection control policy, revised in June 2023, lacked direction on staff education requirements.
Failure to Conduct Regular Resident Council Meetings
Penalty
Summary
The facility failed to assist the resident council in setting up regular meetings, which affected all 12 residents who participated in the council. The deficiency was identified through interviews and document reviews, revealing that the resident council meetings were not held consistently. The activity director, who was responsible for organizing these meetings, was on medical leave from November 2023 to March 2024, and no one else was assigned to arrange the meetings during this period. As a result, the meetings were not conducted monthly as required by the facility's policy. During a resident council meeting with the surveyor, the residents confirmed that the meetings were not held consistently and expressed their desire for regular monthly meetings even during the activity director's absence. The facility's policy, updated in January 2023, stated that meetings should occur on the third Wednesday of each month, with the activity director or a designee responsible for facilitating them. However, this policy was not adhered to during the activity director's leave, leading to the deficiency.
Facility Fails to Provide Adequate Access to Resident Personal Funds
Penalty
Summary
The facility failed to ensure that residents had adequate access to their personal funds, which were deposited with the facility. This deficiency affected three residents who reported that they could only access their funds on Wednesdays, designated as 'money pass day.' The residents expressed that they were unable to access their funds on weekends or other days of the week, which limited their ability to manage their financial affairs independently. Interviews with the residents confirmed that they were informed by the facility staff that Wednesday was the only day they could access their funds. The facility's policy on resident personal accounts, dated July 2021, stated that while residents were encouraged to manage their money independently, access to funds was typically limited to Wednesday afternoons. The policy also mentioned that money pass was not available on weekends or holidays, although a small amount of cash was kept at the nursing station for emergencies. However, the administrative assistant clarified that residents were made aware of the designated money pass day, and it was implied that access could be granted on other days, including weekends, although this was not effectively communicated or implemented.
Incomplete Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, R11 and R19, which did not include resident-specific interventions for their identified needs. R11's care plan lacked desired goals and person-centered interventions for several areas, including visual function, communication, indwelling catheter, activities, dehydration/fluid maintenance, pressure ulcer/injury, and pain. Additionally, the care plan did not address R11's constipation diagnosis or provide instructions for activities of daily living (ADL) such as bathing, bed mobility, dressing, eating, oral care, personal hygiene, toilet use, or transfers. Interviews with staff revealed that R11 experienced chronic pain and anxiety, but non-pharmacological interventions were not offered, and the care plan was not updated to reflect these needs. Similarly, R19's care plan was incomplete, lacking person-centered interventions for identified concerns such as cognitive loss/dementia, behavioral symptoms, nutritional status, pressure ulcer/injury, and psychotropic drug use. The care plan only included a focus on COVID-19 and nutrition, failing to address other significant areas of concern. The Director of Nursing acknowledged responsibility for creating and updating care plans and admitted that the care plans for R11 and R19 were incomplete and not up to the desired standard. The facility's policy emphasized the need for comprehensive, resident-centered care plans that address all identified concerns and are updated as needed.
Failure to Coordinate Prosthetic Care for Resident
Penalty
Summary
The facility failed to provide necessary assistance and coordination of services for a resident with a prosthesis, leading to a deficiency in care. The resident, who was cognitively intact and had a right lower leg amputation, was supposed to use a prosthetic leg for mobility. However, due to complaints of itchy skin and irritation, the resident had not been using the prosthesis. Despite a provider's order to follow up with the prosthetic company for reassessment, the facility did not contact the company for six months after the resident's admission. The resident expressed a desire to use the prosthesis again, but it caused blisters, indicating a need for refitting. Observations and interviews revealed that the resident's prosthetic leg was not being used and was left standing in their room. Nursing staff, including a nursing assistant and a registered nurse, were unaware of the resident's prosthetic leg and the need for a walking program. The director of nursing acknowledged the need to contact the prosthetic company but admitted that no action had been taken. The resident's care plan lacked information on the fitting or use of the prosthesis, and a policy on prostheses and coordination of care was requested but not provided.
Failure to Act on Pharmacist Recommendations and Identify Medication Duplications
Penalty
Summary
The facility failed to act upon the consultant pharmacist's recommendations for two residents regarding unnecessary medications. One resident, who was cognitively intact and had a history of chronic pain and mental health disorders, was prescribed hydromorphone, an opioid pain medication, which they had not taken since December of the previous year. Despite the consultant pharmacist's recommendation to discontinue the medication in January, the order remained active, and the facility did not address the recommendation in a timely manner. The Director of Nursing (DON) was unaware of the recommendation until it was brought to their attention during the survey. Another resident, also cognitively intact, was prescribed liothyronine sodium for major depressive disorder. The consultant pharmacist questioned the continued need for this medication in March, but the recommendation was not communicated to the resident's provider. The DON confirmed that the pharmacy recommendations were kept in a folder in their office, which was not always accessible to providers, leading to a delay in addressing the pharmacist's concerns. Additionally, the consultant pharmacist failed to identify duplicative medication orders for a third resident, who had multiple orders for acetaminophen with no parameters for administration. The resident was using all prescribed orders, and the consultant pharmacist did not note any irregularities in their reviews. The DON acknowledged the oversight and expected the pharmacist to identify such issues during the monthly medication review.
Failure to Prevent Duplicative Medication Orders
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically duplicative prescriptions of acetaminophen. The resident, who was cognitively intact and diagnosed with schizoaffective disorder and chronic pain, had multiple orders for acetaminophen: 325 mg and 650 mg as needed (PRN), and 1000 mg three times a day for chronic pain. These orders lacked parameters for administration, leading to the potential for excessive acetaminophen intake. The medication administration record indicated that the resident had been using all prescribed Tylenol orders concurrently. Interviews with facility staff, including an LPN and the Director of Nursing (DON), revealed that the presence of two PRN orders for the same medication was not standard practice and could result in excessive dosing. The DON expected nursing staff to identify and clarify duplicate orders with the provider, and the clinical pharmacist (CP) to note such issues during monthly medication reviews. However, the CP acknowledged that the duplicate orders were easy to overlook due to different naming conventions and confirmed the absence of guidance on safe dosage limits. The facility did not provide a policy related to medication reconciliation and unnecessary medications when requested.
Failure to Provide Routine Dental Care and Assessments
Penalty
Summary
The facility failed to ensure that a resident's dental status was accurately assessed and that routine dental services were provided. The resident, who was cognitively intact and had multiple diagnoses including renal insufficiency, diabetes mellitus, hemiplegia, and hemiparesis, was independent with oral hygiene but had no natural teeth. The resident's Minimum Data Set (MDS) did not indicate any issues with dentures, yet the resident expressed a desire to see a dentist, stating that it had been a long time since their last visit and that their dentures occasionally fell out. Despite this, the resident's dental care area assessment was triggered but not provided, and their care plan did not mention dentures. Interviews with staff revealed a lack of awareness and action regarding the resident's dental needs. A nursing assistant was unaware of any concerns with the resident's dentures, and a licensed practical nurse admitted to not conducting many oral assessments unless a resident complained of a sore. The administrative assistant acknowledged the resident's request for a dental appointment but found no record of a dental visit in the resident's chart. The Director of Nursing stated that dental services were offered as needed and encouraged regular dental visits, but there was no specific policy on dental assessments. The facility's policy on physician visits indicated that other provider services could be scheduled as needed, but there was no documentation of a dental assessment policy.
Failure to Offer Influenza Vaccinations
Penalty
Summary
The facility failed to ensure that influenza immunizations were offered to two residents, R20 and R11, as part of their immunization protocol. R20, who was cognitively intact and had diagnoses of bipolar disorder and depression, was not offered the influenza vaccine for the 2023-2024 season, as indicated by both the Minimum Data Set (MDS) and the Minnesota Immunization Information Connection Report. R20's medical record did not show any evidence of the vaccine being offered, received, or declined, and a request for R20's declination was not fulfilled. Similarly, R11, who was also cognitively intact with diagnoses of schizoaffective disorder and depression, was noted in the MDS to have been offered and refused the vaccine, but the medical record lacked documentation of this offer or declination. Interviews with facility staff revealed gaps in the vaccination process. An LPN stated that floor nurses did not determine vaccination needs, which was the responsibility of the Director of Nursing (DON), who also served as the infection preventionist. The DON explained that vaccines were provided either by the facility or through clinic providers, who would check vaccination status and make recommendations. However, the DON admitted to possibly overlooking obtaining declination signatures for residents who refused the vaccine, including R11, and acknowledged that R20's admission during a busy period might have led to the oversight. The facility's policy on vaccinations required education and consent before administration but lacked a clear process for assessing vaccination status, contributing to the deficiency.
Survey Results Not Accessible to Residents and Visitors
Penalty
Summary
The facility failed to ensure that survey results were posted in a location visible and easily accessible to residents and visitors. On May 15, 2024, the survey results were observed at the second-floor nurse's station, stored in a folder among several binders on the counter, making them not visible or accessible to residents or visitors. This deficiency had the potential to affect all 20 residents residing in the facility and their visitors, as they were unable to view the survey results without assistance. During a resident council meeting on the same day, several residents expressed that they were unaware of the location of the survey results and were interested in reading them. The administrative assistant, responsible for posting the survey results, acknowledged that the binder should have been placed in a more accessible location, such as the designated public viewing area on the first floor across from the business office. The administrator was not available for an interview regarding this issue.
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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