Hopkins Restorative Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Hopkins, Minnesota.
- Location
- 725 Second Avenue South, Hopkins, Minnesota 55343
- CMS Provider Number
- 245293
- Inspections on file
- 29
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Hopkins Restorative Care Center during CMS and state inspections, most recent first.
The facility failed to complete annual performance reviews for five nursing assistants, potentially affecting all 37 residents. Employee records lacked documentation of these reviews, and interviews revealed that the previous DON was believed to have completed them, but no documentation was found. The facility's assessment indicated that annual reviews were part of the training program to meet regulatory requirements, but no policy was provided.
The facility failed to ensure proper hand hygiene during medication administration, implement Enhanced Barrier Precautions (EBP) for residents with wounds or indwelling devices, and develop a Legionella risk assessment and mitigation plan. An LPN did not perform hand hygiene between handling medications for different residents, and the facility lacked signage and PPE for EBP. Additionally, the facility could not provide documentation of a Legionella water management plan.
The facility failed to provide adequate nursing staff, resulting in delayed care for residents. Observations showed call lights going unanswered for extended periods, with residents left unattended. Staff interviews confirmed understaffing, with some working double shifts and being interrupted during critical tasks. The facility's assessment noted a high need for two-person assistance, yet staffing levels were insufficient to meet these demands.
The facility failed to maintain a clean and safe environment, with structural issues and disrepair noted throughout. Residents and staff reported poor conditions, including unclean kitchen areas, a tired memory care dining area, and a malfunctioning ice machine. The facility lacked a maintenance director, leading to inadequate upkeep and cleanliness.
The facility failed to act on pharmacist recommendations for four residents, leading to deficiencies in medication management. One resident lacked side effect monitoring for psychotropic medications, while another had no follow-up on pharmacy recommendations for psychotropic orders. Two residents had incomplete lab tests and unaddressed medication clarifications. Staff interviews revealed inconsistent follow-up on pharmacist recommendations.
The facility failed to complete required in-service training based on annual performance reviews for five nursing assistants, potentially affecting all 37 residents. Employee records lacked documentation of completed reviews and training addressing identified weaknesses. Interviews revealed an assumption that the previous DON completed these tasks, but no documentation was found. The facility plans to restart reviews, as indicated by the DON.
A facility failed to document a resident's resuscitation wishes clearly in both the EMR and paper chart. The resident, with cognitive impairments and multiple medical conditions, had no clear code status documented, leading staff to potentially initiate CPR contrary to the resident's wishes. Interviews revealed inconsistencies in verifying and documenting code status, and the facility lacked a POLST policy, relying on state guidance.
A facility failed to notify healthcare providers about a resident's weight status while on a diuretic for edema. The resident, with severe cognitive impairment and multiple diagnoses, was on hospice care. Despite significant weight loss and refusals to be weighed, there was no documentation of provider notification. Staff interviews confirmed the lack of communication, and the facility's policy required immediate notification of changes in treatment needs.
A facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) within the required timeframe for a resident with moderate cognitive impairment and dementia. The resident's POA discussed discharge plans with the facility two days prior, but the NOMNC was not presented to the POA. Instead, the resident signed the NOMNC on the day of discharge. A nurse confirmed she sometimes allowed residents to sign if she believed they were cognitively intact, based on observation. The facility lacked a specific policy on NOMNC and stated they follow Medicare regulations.
A facility failed to complete a Level II PASARR for a resident with mental health needs, including schizophrenia and other disorders. Despite a preadmission screening indicating the need for a Level II assessment, the social services staff did not recognize this requirement. The oversight was confirmed during interviews, highlighting the importance of identifying mental health disorders for appropriate care. The facility's policy was requested but not provided.
A resident with cognitive impairments and a need for substantial assistance was not offered or documented as having received a shower for over 30 days, despite his care plan indicating the importance of bathing preferences. Staff interviews revealed inconsistencies in documentation and communication regarding his shower schedule and refusals. The facility's policies on resident rights and ADLs were not followed, leading to a deficiency in care.
A resident with severely impaired cognition and a preference for outdoor activities was not offered opportunities to go outside, despite this being documented as important in her care plan. Observations showed the resident spent most of her time in bed, and staff did not consistently facilitate or document attempts to meet her preferences. The facility's activities policy was not followed, and there was a lack of communication and documentation regarding the resident's requests and refusals.
A facility failed to comprehensively assess and provide appropriate treatment to prevent UTIs and restore continence for a resident. The resident, dependent on staff for toileting and transfers, experienced frequent incontinence and significant delays in receiving assistance after activating her call light. Despite a history of UTIs and risk for skin breakdown, the facility did not implement a toileting program, and staffing levels were insufficient to meet resident needs. The DON acknowledged the staffing issues and the potential benefits of a toileting program, but the facility lacked an occupational therapist to guide such a program.
A facility failed to ensure proper administration and documentation of prescription topical medications for a resident with impaired cognition. The resident's MAR lacked documentation for Nystatin powder application, which was observed being applied by a nursing assistant instead of a nurse. Facility policy requires medications to be administered by authorized personnel and documented immediately, but the Nystatin powder was kept at the resident's bedside and applied without proper oversight.
A facility failed to monitor side effects and obtain informed consent for a resident's psychotropic medication use. The resident, with severe cognitive impairment and multiple diagnoses, was prescribed several psychotropic medications without proper monitoring of vital signs and orthostatic blood pressure. The care plan lacked necessary monitoring, and there was no consent for gabapentin use. PRN trazodone was administered without an end date, contrary to policy. Interviews revealed inconsistencies in monitoring practices and documentation, confirmed by the DON and consulting pharmacist.
A resident with severe cognitive impairment was found using a bed remote control with exposed wires, posing a risk of electrical shock. Despite staff awareness of reporting protocols, no maintenance request was recorded. Maintenance records showed a history of inadequate bed conditions and inconsistent oversight, contributing to the deficiency.
The facility failed to maintain a safe and homelike environment, with issues such as missing baseboards, gouged walls, and unstable cabinetry in resident rooms and dining areas. Residents reported unsanitary conditions and environmental hazards, but the facility's understaffed maintenance department did not address these concerns. Staff confirmed the lack of a dedicated maintenance team, leading to delays in resolving safety issues.
The facility failed to provide Ombudsman contact information to residents, as confirmed by interviews and observations. Residents were unaware of the Ombudsman and their services, with one resident having to search online for the information. Staff confirmed the information was not accessible to residents, contrary to the facility's policy on Resident Rights.
The facility did not ensure that State survey results were accessible to residents, particularly those on the second floor. The results were only available in a binder on the first floor, and residents were unaware of their right to view them. An LPN confirmed the lack of accessibility, contrary to the facility's policy requiring survey results to be posted in an accessible location.
A resident with dementia reported being pinched and having her hair grabbed by a nursing assistant. The incident was not reported to the State Agency within the required two-hour timeframe due to delays in communication among staff and a busy schedule. The facility's policy mandates immediate reporting of abuse allegations, which was not adhered to, resulting in a deficiency.
A resident with dementia and personality disorder reported being physically abused by a nursing assistant (NA) during care. The facility failed to immediately remove the NA from the building after the allegation, as she completed her shift before being suspended. The resident felt unsafe until assured of the NA's suspension, highlighting a delay in protective measures as per facility policy.
Failure to Complete Annual Performance Reviews for Nursing Assistants
Penalty
Summary
The facility failed to complete annual performance reviews for five nursing assistants, which had the potential to affect all 37 residents residing at the facility. During a review of employee records, it was found that there was a lack of documentation for completed annual performance reviews for these nursing assistants, all of whom had been employed at the facility for more than a year. Interviews with the administrator and the Director of Nursing (DON) revealed that the previous DON was believed to have completed these reviews, but no documentation could be found to confirm this. The facility's assessment, last reviewed in August, indicated that the training program was based on the resident population and included ongoing training for all staff. This assessment also identified that annual reviews were part of the training sessions and were necessary to meet regulatory requirements. The assessment further stated that skills and competencies were to be completed upon hire and annually to ensure continued competence in various areas such as assessment, safe patient handling, and infection control. Despite these requirements, the facility was unable to provide a policy pertaining to annual reviews when requested.
Deficiencies in Hand Hygiene, EBP, and Legionella Management
Penalty
Summary
The facility failed to ensure proper hand hygiene practices during medication administration for two residents. An LPN was observed not performing hand hygiene between handling medications for different residents, despite the facility's policy requiring hand hygiene before preparing or handling medications. This lapse in protocol was confirmed by both the LPN and the Director of Nursing (DON), who acknowledged the importance of hand hygiene in preventing the spread of germs between residents. The facility also failed to implement Enhanced Barrier Precautions (EBP) for six residents who had either open wounds or indwelling medical devices. Observations revealed a lack of signage or personal protective equipment in the rooms of these residents, and their care plans did not include necessary interventions for EBP. Interviews with staff, including a nursing assistant and the DON, indicated a lack of understanding and implementation of EBP, despite the facility's policy and CDC guidelines requiring such precautions for residents with wounds or indwelling devices. Additionally, the facility did not have a Legionella risk assessment or a plan to mitigate the growth of Legionella, which is required to prevent potential infections. Despite multiple requests, the facility's administrator and DON were unable to provide documentation of a Legionella water management plan or a schematic of the water system. The facility's policy stated the need for strategies to prevent and control Legionella infections, but no evidence of such a plan was provided.
Insufficient Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by multiple observations and interviews. Residents were left unattended for extended periods, with call lights going unanswered for significant lengths of time. For instance, one resident's call light was activated at 10:48 a.m., but assistance did not arrive until 11:42 a.m., nearly an hour later. This delay in care was observed repeatedly, with staff being unavailable or occupied with other tasks, leaving residents without necessary assistance. The report highlights specific instances where residents were not provided timely care, such as a resident who was left wet for 2.5 hours and another who was not changed after a bowel movement for three hours. These incidents were compounded by grievances from residents about long wait times for call lights to be answered, particularly during evening and night shifts. Interviews with staff revealed that the facility was understaffed, with some staff members working double shifts and others being interrupted during critical tasks like medication passes and meal services. The facility's assessment indicated that a significant portion of the resident population required two-person assistance for transfers and other care needs, yet staffing levels were insufficient to meet these demands. The Director of Nursing and other staff members acknowledged the staffing shortages and the impact on resident care, noting that the facility did not utilize agency or pool staff to fill gaps. The lack of adequate staffing was further exacerbated by the absence of a maintenance director, leading to additional operational challenges within the facility.
Facility Maintenance and Cleanliness Deficiencies
Penalty
Summary
The facility failed to maintain a functional, sanitary, and safe environment, as evidenced by structural issues and items in disrepair throughout the facility. Residents reported during a council meeting that the facility was in poor condition, with no maintenance staff available to address problems in resident rooms, dining rooms, and hallways. Observations revealed multiple areas with blackish-brownish speckles, crumbs, and streaks of tannish substances in the main kitchen, indicating a lack of cleanliness and maintenance. In the memory care dining area, family members and staff noted missing appliances, mismatched items, and a generally tired appearance. Observations confirmed the presence of orange-yellow splotches, grayish-blackish fuzzy substances on air vents, and brownish-black speckles on walls and valances. Missing cabinet pieces and scuff marks on walls further highlighted the disrepair. Staff confirmed these conditions, acknowledging that the dining area had not been maintained to a homelike standard for an extended period. The ice and water dispensing machine in the second-floor dining room was also found to be malfunctioning and unclean, with excess mineral buildup and sediment around the spout. Family members and staff reported issues with the machine spraying water erratically, and the dietary manager confirmed the need for a deep cleaning due to hard water. The facility had been without a maintenance director since September, and the administrator admitted to being unsure about the comprehensiveness of maintenance reports, relying on corporate assistance every two weeks.
Failure to Act on Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure timely action on consultant pharmacist recommendations for four residents reviewed for unnecessary medications. For one resident, the facility did not implement side effect monitoring for psychotropic medications and failed to establish an end date for trazodone, despite repeated recommendations from the consulting pharmacist. The resident had severe cognitive impairment and was on multiple medications, including antipsychotics and antidepressants, without proper monitoring or documentation of follow-up on pharmacy recommendations. Another resident, who was receiving hospice care, had multiple medication orders, including psychotropic medications, without proper documentation of medication regimen review (MRR) follow-up. The facility did not provide a signed order summary or documentation of follow-up on pharmacy recommendations, which included concerns about duplicative therapy and the need for clinical rationale for PRN psychotropic orders. The consulting pharmacist's recommendations were not acted upon, and there was no evidence of provider or nursing staff follow-up. For two other residents, the facility failed to complete recommended lab tests and did not document follow-up on pharmacy recommendations. One resident had a history of schizophrenia and other mental health disorders, and the facility did not complete labs ordered months prior. The other resident, with multiple chronic conditions, had recommendations for medication clarifications and adjustments that were not documented as followed up by the facility. Interviews with staff revealed a lack of consistent follow-up on pharmacist recommendations, contributing to the deficiencies identified.
Deficiency in Annual Performance Reviews and In-Service Training
Penalty
Summary
The facility failed to ensure that required in-service training based on annual performance reviews was completed for five nursing assistants whose employee files were reviewed. This deficiency had the potential to affect all 37 residents residing at the facility. During a review of employee records, it was found that there was a lack of documentation for completed annual performance reviews and in-service training addressing areas of weakness identified by these reviews. All five sampled employees had been employed at the facility for more than one year. Interviews with the administrator and the Director of Nursing (DON) revealed that there was an assumption that the previous DON had completed the competencies with annual reviews, but no documentation could be found to support this. The DON confirmed that the facility would restart these reviews at the beginning of the next year, emphasizing the importance of staff being aware of their strengths and areas for improvement. The facility's assessment indicated that annual reviews were part of the training sessions to meet regulatory requirements, but no policy regarding annual reviews or in-service training was provided upon request.
Failure to Document Resident's Resuscitation Wishes
Penalty
Summary
The facility failed to ensure that a resident's resuscitation wishes were clearly documented and accessible in both the electronic medical record (EMR) and physical paper chart. The resident, identified as R22, had significant cognitive impairments and multiple medical conditions, including Alzheimer's disease and dementia. Despite these conditions, there was no clear documentation of R22's code status in the EMR or paper chart, and the POLST (Physician Orders for Life-Sustaining Treatment) was not uploaded or available. Interviews with various staff members, including nursing assistants, licensed practical nurses (LPNs), and the director of nursing (DON), revealed inconsistencies in the process of verifying and documenting code status. Staff members indicated they would initiate CPR if a resident's code status was unclear or not documented, as was the case with R22. The facility's process for confirming and entering code status during admission was not followed for R22, and there was no admission checklist in place to ensure all necessary documentation was completed. The facility's social worker and DON acknowledged the lack of a POLST policy and procedure, relying instead on state guidance. The absence of a clear and consistent process for documenting and verifying code status led to confusion among staff and the potential for actions contrary to the resident's wishes. The facility's CPR policy directed staff to provide life support in accordance with advance directives, but the failure to have these directives clearly documented for R22 highlighted a significant deficiency in the facility's procedures.
Failure to Notify Providers of Resident's Weight Status
Penalty
Summary
The facility failed to notify healthcare providers about a resident's weight status while the resident was on a prescribed diuretic for edema management. The resident, who had severe cognitive impairment and multiple diagnoses including heart failure, kidney failure, and lymphedema, was receiving hospice care. The care plan required staff to report signs of dehydration, hypotension, and weight changes, but there was a lack of documentation regarding the resident's weight and refusals to be weighed. The resident's treatment administration record showed inconsistent documentation of weights, with several instances where weights were not recorded or the resident refused to be weighed. Despite a significant weight loss over several months, there was no documentation of provider notification about these refusals or the weight loss. Interviews with staff, including the registered dietitian and hospice nurse, confirmed the lack of communication with the primary care provider regarding the resident's weight status and refusals. The facility's policy required immediate notification of the resident's physician and representative when there was a need to alter treatment significantly. However, interviews with the primary care provider and nursing staff revealed that the provider was not informed about the resident's weight refusals and lack of documentation. The director of nursing expected staff to report such refusals to the interdisciplinary team and the resident's care providers, but this was not done, leading to a deficiency in care management.
Failure to Provide Timely NOMNC to POA
Penalty
Summary
The facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) within the required timeframe for a resident with moderate cognitive impairment and a diagnosis of dementia. The resident's power of attorney (POA) discussed discharge plans with the facility two days prior to the resident's discharge, but the NOMNC was not presented to the POA at that time. Instead, the NOMNC was signed by the resident on the day of discharge, despite the presence of a POA. A registered nurse confirmed that she sometimes allowed residents to sign the form if she believed they were cognitively intact, based on her observation rather than a formal assessment. The facility administrator acknowledged that there are no exceptions to the requirement for the NOMNC to be given two days prior to discharge and that the POA should have been given the notice to sign. The facility did not have a specific policy on NOMNC and stated they follow Medicare regulations.
Failure to Complete Level II PASARR for Resident with Mental Health Needs
Penalty
Summary
The facility failed to ensure a Level II Pre-Admission Screening and Resident Review (PASARR) was completed for a resident with mental health needs. The resident, identified as R8, had a documented diagnosis of schizophrenia and other mental health disorders, including schizoaffective disorder, depression, bipolar disorder, and hoarding disorder. The preadmission screening results indicated that a Level II assessment was necessary for mental illness. However, the social services staff member, SS-A, did not realize the requirement for a Level II assessment despite conducting an audit of PAS results. This oversight was confirmed during interviews, where SS-A acknowledged the importance of identifying mental health or developmental disorders to provide appropriate care. The facility's policy was requested but not provided, indicating a lack of documentation to support compliance with PASARR requirements.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as R30, was offered or provided a shower as per his care plan and preferences. R30, who had moderately impaired cognition, memory deficits, and required substantial assistance for activities of daily living (ADLs), was not documented as having received a shower for the past 30 days. His care plan indicated that bathing preferences were very important to him, and he was scheduled for showers on Tuesday mornings. However, there was no documentation of showers or refusals in the PointOfCare (POC) system or progress notes. Interviews with staff, including nursing assistants and licensed practical nurses, revealed inconsistencies in documentation and communication regarding R30's shower schedule and refusals. Staff members were unable to find records of R30's last shower, and there was no documentation of any refusals. The Director of Nursing (DON) confirmed the lack of documentation and acknowledged that staff might not be diligent in documenting when a bed bath was performed. The DON emphasized the importance of offering showers to residents to promote dignity and overall health. The facility's policies on resident rights and activities of daily living (ADLs) were not adhered to, as they require that residents be treated with respect and dignity, and that their abilities in ADLs do not deteriorate unless unavoidable. The policies also mandate that care and services for ADLs, including bathing, be provided based on the resident's comprehensive assessment and consistent with their needs and choices. The failure to offer or document showers for R30 represents a deficiency in meeting these standards.
Failure to Provide Preferred Activities for Resident
Penalty
Summary
The facility failed to ensure that a resident's preferred activities for individual entertainment were offered, specifically for a resident with severely impaired cognition and a primary language of Russian. The resident's care plan and activity participation review indicated a preference for 1:1 activities, reading Russian books, watching Russian television, and going outside for fresh air. However, the care plan and documentation lacked evidence of the resident being offered the opportunity to go outside, despite this being identified as important in the resident's significant change Minimum Data Set (MDS). Observations and interviews revealed that the resident spent much of her time in bed, with limited engagement in activities. The resident expressed a desire to go outside more often, but staff did not consistently offer or document attempts to facilitate this preference. The activities staff, who was the only one in the facility, acknowledged the challenge of meeting all residents' preferences and noted that the language barrier could be an issue. The staff also mentioned that the resident's family sometimes took her outside, but there was no consistent effort from the facility to ensure this preference was met. The facility's policy on activities emphasized the importance of supporting residents' choices based on their assessments and care plans, including indoor and outdoor activities. However, the facility did not adhere to this policy, as evidenced by the lack of documentation and effort to accommodate the resident's preference for outdoor activities. Interviews with the nursing assistant and the Director of Nursing (DON) highlighted a lack of awareness and documentation regarding the resident's requests and refusals, indicating a gap in communication and implementation of the care plan.
Failure to Provide Comprehensive Assessment and Timely Care for Resident
Penalty
Summary
The facility failed to comprehensively assess and provide appropriate treatment and services to prevent urinary tract infections (UTIs) and restore continence for a resident. The resident, who had intact cognition and was dependent on staff for toileting and transfers, was frequently incontinent of urine and bowel. Despite having a history of UTIs and being at risk for skin breakdown, the facility did not implement a urinary or bowel toileting training program. The resident's care plan lacked interventions to promote continence or improve her current level of function, and the facility did not conduct a thorough bladder/incontinence evaluation. Observations and interviews revealed that the resident experienced significant delays in receiving assistance after activating her call light. On one occasion, the resident waited nearly an hour for assistance, during which time no staff were present on the unit to address her needs. The resident's family member expressed concerns about understaffing and long wait times for assistance, particularly during evenings and mealtimes. The resident herself reported that call light wait times were particularly bad on weekends, and she was not aware of her urge to void. Interviews with facility staff, including the Director of Nursing (DON) and a nurse practitioner, highlighted issues with staffing levels and the lack of a toileting program for the resident. The DON acknowledged that the facility's staffing was not meeting the needs of the residents and that the resident could potentially benefit from a toileting program. However, the facility did not have an occupational therapist to guide such a program, and the resident's cognitive issues and unawareness of her urge to void were cited as reasons for not initiating a toileting program. The facility's assessment tool indicated that it provided bowel and bladder care, but the lack of a toileting program and delayed response to call lights contributed to the resident's risk of UTIs and skin breakdown.
Failure to Properly Administer and Document Topical Medications
Penalty
Summary
The facility failed to ensure that prescription topical medications were applied and documented according to professional standards of practice for a resident with severely impaired cognition and a self-care deficit. The resident, identified as R26, had active physician orders for Nystatin powder to be applied to skin folds and the groin area as needed. However, the medication administration records (MAR) for October, November, and December 2024 lacked documentation of the administration of the Nystatin powder, indicating a failure to record the use of the medication as required. During an observation, a nursing assistant (NA) was seen applying the Nystatin powder to the resident's skin without proper documentation or oversight from a licensed nurse. The NA stated that they applied the powder for the resident's dry skin and monitored the skin condition, reporting any changes to the nurses. However, the licensed practical nurse (LPN) and director of nursing (DON) interviews revealed that prescription medications, including topical powders, should be applied by nurses, who are responsible for assessing the resident's condition and ensuring proper medication administration. The facility's policy on medication administration requires that medications be administered by authorized personnel and documented immediately after administration. The policy also mandates that prescription medications be kept in a locked medication cart. The failure to adhere to these protocols resulted in the Nystatin powder being kept at the resident's bedside and applied by an unauthorized staff member, leading to a deficiency in the facility's pharmaceutical services.
Inadequate Monitoring and Consent for Psychotropic Medication Use
Penalty
Summary
The facility failed to provide appropriate side effect monitoring and obtain informed consent for psychotropic medication use for a resident with severe cognitive impairment and multiple diagnoses, including heart failure and adjustment disorder with mixed anxiety and depressed mood. The resident was prescribed several psychotropic medications, including Depakote, trazodone, Seroquel, and Neurontin, without proper monitoring of vital signs and orthostatic blood pressure. The care plan did not include necessary monitoring, and there was no evidence of informed consent for the use of gabapentin. The facility's medication administration records indicated that the resident received trazodone PRN on multiple occasions without an end date, contrary to the facility's policy requiring a 14-day limit for PRN psychotropic medications. Interviews with nursing staff revealed inconsistencies in monitoring practices and a lack of documentation for vital signs and orthostatic blood pressure. The staff also failed to obtain consent for gabapentin, which was used for anxiety and pain, and did not adequately monitor for side effects of psychotropic medications. The Director of Nursing and consulting pharmacist confirmed the deficiencies, emphasizing the importance of obtaining informed consent and monitoring for side effects. The facility's policy required education on the risks and benefits of psychotropic drugs and limited PRN orders to a specific duration. However, the facility did not adhere to these guidelines, resulting in inadequate monitoring and documentation for the resident's psychotropic medication use.
Failure to Maintain Safe Bed Remote Control
Penalty
Summary
The facility failed to ensure the safety and proper maintenance of a bed remote control for a resident with severely impaired cognition and multiple diagnoses, including heart failure and dementia. The resident was observed using a bed controller with exposed wires, although the wires were not frayed. Despite the resident's ability to use the controller independently, the potential risk of electrical shock was present. Interviews with staff revealed that while the nursing assistant and LPNs were aware of the protocol to report such issues through the TELS system, no maintenance request had been recorded for the resident's bed controller. The facility's maintenance records indicated a history of inadequate bed conditions and a lack of consistent maintenance oversight, as evidenced by skipped tasks and unrecorded actions in the TELS system. The absence of a maintenance director during certain periods contributed to the failure to address the bed controller's condition. The facility's policy required routine inspection and maintenance of electrical equipment, but this was not effectively implemented, leading to the deficiency observed in the resident's bed controller.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by multiple maintenance issues that were not addressed. Observations revealed significant environmental concerns in the dining areas and resident rooms, including missing baseboards, gouged walls, stained ceiling tiles, and web-like material on blinds. These issues were reported by residents and staff, but there was a lack of timely response from the facility's maintenance department, which was noted to be understaffed. Resident R30, who had been admitted to the facility, reported several complaints about the unsanitary conditions and environmental hazards, including fire and electrical hazards. Despite these complaints, the facility did not take adequate action to rectify the issues. Observations confirmed the presence of gouge marks, missing baseboards, and scuff marks in the dining room, as well as an electrical outlet coming out of the wall in R30's room. Interviews with staff and residents indicated that these conditions had persisted for some time without resolution. Resident R36 also experienced a lack of a homelike environment, with issues such as unstable cabinetry, a lack of heat in the bathroom, and a privacy curtain that could not fully close. The resident expressed dissatisfaction with the living conditions, describing the facility as "falling down." Staff interviews confirmed that there was no dedicated maintenance department, and concerns were to be reported to the administrator. However, the absence of a maintenance team led to delays in addressing these safety and environmental concerns.
Failure to Provide Ombudsman Contact Information
Penalty
Summary
The facility failed to provide contact information for the Ombudsman to three residents who attended a resident council group meeting. During the meeting, two residents stated they were unaware of the Ombudsman, their telephone number, or the advocacy services provided. Another resident mentioned that they had to search the Internet to obtain this information, as it was not posted in the facility. An observation confirmed that the Ombudsman information was not visible in the facility. Interviews with facility staff revealed that the Ombudsman contact information was not accessible to residents. An LPN mentioned that the information was located in the copier room, which residents could not access. Another LPN confirmed that the information was not posted in the facility. The Director of Nursing stated that the Ombudsman contact information was in the administrator's office and confirmed it was not posted in a place accessible to residents and families. The facility's policy on Resident Rights emphasized the importance of informing residents of their rights and providing an environment where they can exercise them, which includes providing a list of pertinent contact information.
Inaccessible State Survey Results for Residents
Penalty
Summary
The facility failed to ensure that the most recent State agency survey results were accessible for review by residents, particularly those residing on the second floor. During an observation, it was noted that the survey results were placed in a red three-ring binder attached to the wall near the main entrance on the first floor. However, there was no indication or posting of these results on the second floor, where all 37 residents resided, nor any signage to inform them that the results were available elsewhere in the building. During a resident group meeting, three residents expressed that they were unaware of the location of the State Survey results and did not know they had the right to view them. An LPN confirmed that the survey results were not easily accessible to all residents, as they were only available on the first floor by the business office. The facility's policy stated that survey results should be posted in an accessible location where individuals do not have to ask to see them, which was not adhered to in this case.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of physical abuse involving a resident with dementia and personality disorder in a timely manner, as required by regulations. The resident, who had unimpaired cognition, reported that a nursing assistant became angry during care, pinched her leg, and grabbed her hair with wet hands. The incident was reported to the State Agency (SA) and the administrator later than the mandated two-hour timeframe. The report was submitted to the SA at 5:41 p.m., despite the incident being known to staff earlier in the day. Interviews with staff revealed that the allegation was first reported to an LPN at approximately 11:30 a.m., but was not escalated to the administrator until 2:00 p.m. due to other duties such as medication administration and meal service. The administrator acknowledged the delay in reporting to the SA, citing a busy schedule and lack of immediate follow-up. The facility's policy required immediate reporting of abuse allegations to the administrator and the SA within two hours, but this protocol was not followed, leading to the deficiency.
Failure to Immediately Protect Resident After Abuse Allegation
Penalty
Summary
The facility failed to immediately implement an intervention to protect a resident following an allegation of physical abuse by a staff member. The resident, who had diagnoses of dementia and personality disorder but whose cognition was not impaired, reported that a nursing assistant (NA) became angry during care, pinched her leg, and grabbed her hair with wet hands. The incident was reported to social services and the administrator at approximately 2:00 p.m. on the day of the alleged abuse, but the NA was not immediately removed from the building, as she had already completed her shift. The facility's policy on abuse, neglect, and exploitation requires immediate action to protect residents from harm during and after an investigation, including removing the alleged perpetrator from direct care. However, the NA continued to work her shift until its completion, and the resident expressed feeling unsafe until assured that the NA would be suspended. Interviews with staff confirmed that the NA was suspended for three days during the investigation, but there was a delay in implementing protective measures immediately after the allegation was made.
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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