Lakehouse Healthcare & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Minneapolis, Minnesota.
- Location
- 3737 Bryant Avenue South, Minneapolis, Minnesota 55409
- CMS Provider Number
- 245055
- Inspections on file
- 46
- Latest survey
- March 10, 2026
- Citations (last 12 mo.)
- 37 (1 serious)
Citation history
Health deficiencies cited at Lakehouse Healthcare & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with a POLST indicating DNR/DNI and comfort care developed a cough and declining O2 saturation, leading an RN to obtain vital signs, start 2 LPM oxygen, and notify an NP, who ordered a chest X‑ray and flu test. During the following night, an LPN reported the resident slept and was checked every two hours, but no further significant reassessment or documented vital signs were recorded despite ongoing respiratory concerns and the X‑ray service not responding. Later that morning, the resident received routine medications, was found with worsening chest congestion, O2 saturation below 81% on 4 LPM, hypotension, tachycardia, cough, and shortness of breath, and was transferred to the hospital after 911 was called, while a family member reported the resident appeared severely ill and confused. The deficiency is the facility’s failure to reassess and document the resident’s condition after the initial change, despite progressive respiratory symptoms.
A resident with full code status and clear POLST orders for CPR was found unresponsive and not breathing. Staff, including an LPN and a hospice nurse, did not check the resident's code status or initiate CPR, despite facility policy and the resident's documented wishes. The resident was pronounced dead without resuscitation efforts, and the incident was confirmed through interviews and record review.
A deficiency was identified due to the absence of a pest control program to prevent or manage mice, insects, or other pests within the facility.
Staff did not consistently knock, introduce themselves, or wait for permission before entering resident rooms, resulting in multiple residents experiencing a lack of privacy and dignity. Both residents and staff acknowledged the importance of these actions, but observations showed repeated failures to follow protocol, contrary to facility policy.
Staff left care sheets containing residents' personal and medical information unattended on medication carts across multiple units, exposing sensitive details such as names, diagnoses, and care preferences. Several staff acknowledged the expectation to secure this information and referenced HIPAA and facility policy, but the information remained accessible in public areas, affecting residents on three floors.
A resident's MDS assessment was inaccurately coded to indicate receipt of insulin injections, although medication records and physician orders confirmed no insulin was administered. The resident, who has diabetes, was treated with oral diabetic medications, and the error was attributed to misclassification of an oral agent as insulin. The facility lacked a specific MDS policy.
The facility did not ensure that required PASARR screenings were completed for three residents with significant mental health diagnoses, resulting in missing or incomplete documentation of Level I and, when indicated, Level II screenings prior to admission. Staff interviews revealed confusion and lack of documentation regarding responsibility for obtaining final determinations, and one screening was missed due to staff training issues.
A resident with severe cognitive impairment and right-sided weakness following a stroke required a right AFO brace when out of bed, but the facility failed to include instructions for the brace's use in the care plan, order report, or task documentation. Although staff received education on the brace's application, they could not find written guidance, and therapy recommendations were not integrated into the care plan.
The facility did not update care plans for two residents: one continued to have a left leg brace listed as an intervention despite no clinical indication or provider order, and another had outdated behavioral interventions that were not followed by staff. Staff interviews revealed inconsistent knowledge of care plan requirements, and observations showed care was not aligned with current assessments or resident needs.
A resident with cognitive impairment and dependence on staff for ADLs was observed with long, unclean fingernails, indicating a lack of routine nail care. Staff interviews revealed that nail care was expected to be performed during showers but was not documented, and there was no evidence in the medical record of nail care being offered or refused. Facility policy required assistance with personal hygiene for residents unable to perform these tasks, but this was not consistently followed or recorded.
A resident who was cognitively intact and expressed a strong preference for music did not have a completed therapeutic recreation assessment in the EMR, and their care plan lacked an activities section. Despite repeated requests for a radio and documented preferences, the resident was observed multiple times without any music, television, or engagement, and there was no evidence that life enrichment activities were offered or provided.
A resident with severe hearing loss did not receive daily access to required hearing aids due to staff failing to apply them, communicate their location, or document their status. The hearing aids were held by an LPN for several weeks without informing the resident or other staff, and the EMR lacked updates about their whereabouts. The DON confirmed the absence of documentation or communication regarding the hearing aids.
A resident did not receive enough food and fluids to maintain their health, as identified by surveyors through observations and records showing unmet nutritional and hydration needs.
A resident with PTSD and a history of sexual abuse had a care plan specifying a preference for female caregivers, but male staff continued to enter the resident's room alone, causing distress. Staff were largely unaware of the resident's care preferences, and care documentation did not reflect the need for female-only caregivers, despite this being documented in the care plan.
Two residents experienced medication administration errors when an LPN crushed an extended-release potassium chloride tablet for a resident with a PEG-tube, contrary to provider orders, and an RN administered tamsulosin hydrochloride to another resident during a meal instead of after, as ordered. These actions resulted in a medication error rate above the acceptable threshold, with staff not following provider orders or manufacturer guidelines.
The facility did not ensure that a resident received necessary dental services or referrals, resulting in unmet dental care needs.
Therapeutic diets were not prescribed by the attending physician or properly delegated to a registered or licensed dietitian, resulting in noncompliance with regulatory requirements for dietary orders.
Staff did not consistently use gowns and gloves during high-contact care activities for two residents on enhanced barrier precautions, including those with pressure ulcers and indwelling urinary catheters. Despite clear signage, care plans, and available PPE, staff assisted with transferring, changing briefs, and catheter care without donning gowns, contrary to facility policy and infection control protocols.
A resident with CHF experienced a significant weight gain after admission, but staff did not notify the physician or clarify orders regarding weight monitoring and notification parameters. Facility records lacked evidence of communication with the physician about the weight changes, and the DON confirmed that no protocol was in place for such situations.
A resident admitted with CHF did not have a baseline care plan developed and implemented within 48 hours as required. The care plan lacked specific parameters for weight monitoring and physician notification, despite the resident experiencing significant weight gain. Facility staff confirmed the care plan was incomplete and not timely, and weight monitoring was inconsistent.
The facility did not ensure that its services met professional standards of quality, as required by regulations. This was identified through observations and review of facility practices, which did not align with established professional guidelines.
A resident with severe cognitive impairment and multiple health conditions had a new POLST form indicating DNR and comfort-focused care submitted by their legal guardian, but the facility did not obtain the required provider signature or update the medical record in a timely manner. As a result, the resident's code status remained full code, and the resident was transferred to the hospital and treated as a full code when found unresponsive, contrary to the updated wishes.
Two residents experienced medication errors due to the facility's failure to accurately document and process medication orders. One resident received duplicate doses of Levetiracetam due to a failure to discontinue the tablet form when switching to an oral solution. Another resident missed doses of critical medications for liver disease and diabetes after returning from a hospital stay, as the orders were not processed in time. The facility had recently changed its verification process, eliminating the requirement for a second nurse to verify new orders, contributing to these errors.
A resident returned from the hospital with leg sores and did not receive wound care for three days, despite a history of conditions that increased the risk of skin integrity issues. The facility failed to document and initiate treatment orders promptly, leading to a delay in care. Interviews revealed a lack of communication and adherence to procedures, contributing to the resident's worsening condition.
A resident was observed self-administering medications without proper assessment or supervision, contrary to facility policy. The resident's medical record lacked evidence of an assessment for self-administration, and staff interviews confirmed that medications should not be left unattended. The resident was only assessed to self-administer a nebulization inhaler, not the other medications observed.
The facility failed to maintain a clean environment in the laundry room, with dusty fans facing clean linens, and did not consistently implement transmission-based precautions for COVID-19. Staff were observed not wearing required PPE, and soiled linen carts were left uncovered in hallways, posing infection control risks.
The facility failed to ensure clean and safe conditions, with sticky floors observed in two dining rooms and a resident's room. Staff confirmed inadequate cleaning, and improper waxing practices were identified. A resident's family member reported the room was not cleaned adequately, contributing to an unpleasant environment.
The facility failed to provide adequate personal care and hygiene for several residents requiring assistance with ADLs. Observations revealed residents with long, soiled nails, unshaved facial hair, and greasy hair. Care plans lacked specific instructions for nail care, and there was no documentation of care being offered or provided. Staff interviews confirmed inconsistent practices and a lack of documentation, contributing to the deficiency.
The facility failed to secure medication carts, leaving them unlocked and unattended on multiple floors, accessible to residents, staff, and guests. Observations showed unlocked carts on the seventh, fifth, and second floors, with staff acknowledging the oversight. Interviews confirmed the expectation to lock carts when not in use, aligning with the facility's medication administration policy.
The facility failed to deliver and serve meals in a timely manner, resulting in cold food being served to residents. Observations showed meal carts arriving late and food not being served promptly, with scrambled eggs recorded at 113°F, below the required temperature. Residents and family members expressed dissatisfaction with the meal service, citing cold and unpalatable food. Staff interviews revealed a lack of adherence to the meal delivery schedule, and the facility's regional director confirmed that meal carts were not insulated, contributing to the issue.
The facility failed to cover food and beverages during transport to resident rooms, risking foodborne illness. Observations showed nursing assistants delivering uncovered trays, despite staff acknowledging the need for coverings to prevent contamination. The facility's policy on this practice was not provided.
A resident in a LTC facility experienced a bed bug infestation in her room, leading to distress and discomfort. Despite being moved to a new room, the resident was returned to her original room where bed bugs were still present. Observations confirmed unsanitary conditions, and staff interviews revealed a lack of coordination in pest control efforts. The facility's bed bug protocol was not fully followed, contributing to the ongoing issue.
The facility failed to provide a dignified dining experience, with residents waiting long periods for meals and one resident brought to the dining room ungroomed. Additionally, a resident was left in bed without pants against their preferences. Staff confirmed that residents needing assistance were served last, leading to delays.
The facility failed to notify the Ombudsman of two residents' hospital transfers. One resident with dementia and multiple health issues was transferred without a documented bed hold discussion, while another cognitively intact resident with several conditions was also transferred without notification. Staff interviews revealed a lack of adherence to procedures for notifying the Ombudsman, and a technical glitch in the EMR system contributed to the oversight.
A facility failed to complete a final PASARR for a resident with mental health disorders, including generalized anxiety disorder, major depressive disorder, and schizoaffective disorder. The resident's medical record lacked a final determination from the lead agency, as required. Staff interviews revealed a misunderstanding of the PASARR process, with the director of social services initially believing the screening was final. A senior linkage line representative clarified the need for a final determination from the lead agency, but the facility's administrator maintained the incomplete document was sufficient. No policy on PASARR completion was provided.
The facility failed to conduct timely care conferences for three residents, leading to a deficiency in care planning. A resident with no cognitive deficits did not have a care conference after February, despite needing one in May. Another resident, cognitively intact with multiple diagnoses, lacked care conferences from January to August. A third resident with severe cognitive impairment also missed conferences from January to June. Staff turnover contributed to the backlog, as acknowledged by the social services director and DON.
The facility failed to develop proactive interventions for a resident's bowel management, leading to discomfort and potential complications. Despite having a care plan, the facility did not establish a toileting schedule or update the care plan to reflect the resident's usual bowel movement pattern. Additionally, the facility failed to transcribe prescription orders for another resident who returned from a hospital admission with new orders for skin treatment, delaying the resident's treatment.
A resident with moderate cognitive impairment reported worsening hearing and believed an audiology appointment was set up but not confirmed. Despite a diagnosis of bilateral hearing loss and an order for an audiology consult, the facility failed to act on the referral. Staff interviews revealed a lack of communication about the resident's complaints, and the director of nursing acknowledged the oversight, noting a staff resignation might have contributed to the missed appointment.
A resident with a history of falls and significant medical conditions did not receive a prescribed perimeter mattress to prevent falls, despite a physician order and assessment indicating its necessity. Observations showed the resident using a standard air mattress, and interviews with staff confirmed the failure to implement the required intervention.
The facility failed to reassess and determine additional interventions for a resident with chronic pain, despite medication adjustments. Two other residents with chronic pain were not offered non-pharmacological interventions, and their care plans lacked documentation of such interventions. Interviews revealed inconsistencies in offering and documenting non-pharmacological interventions, and the director of nursing confirmed the need for such practices.
A facility failed to address consulting pharmacist recommendations for a resident's medications. The resident, with impaired cognition, was prescribed quetiapine for agitation and lorazepam as needed. The pharmacist recommended a 14-day stop date for lorazepam and a proper diagnosis for quetiapine use, but these were not addressed. The nurse practitioner did not add a stop date or clarify the diagnosis, and the pharmacist's recommendations were reissued monthly without resolution. Interviews revealed misunderstandings and lack of communication regarding the recommendations.
The facility failed to provide specific indications and target behaviors for antipsychotic medication use for two residents. One resident received Olanzapine without a clear indication, while another received quetiapine for agitation, an inappropriate use, and lorazepam without a specific duration. Staff interviews and pharmacy recommendations highlighted ongoing issues with medication management and response to recommendations.
The facility failed to provide or offer routine dental services to four residents, leading to unmet dental needs and frustration among residents. One resident had been without dentures for a long time, another had broken dentures, and a third reported tooth pain. Despite these issues, there was no evidence of dental visits being offered or documented in their medical records. Staff interviews revealed inconsistencies in the process of offering dental services, highlighting a failure to adhere to the facility's Dental Services policy.
A resident with moderate cognitive impairment and multiple medical conditions was observed self-administering a nebulizer treatment without a required assessment or physician's order. Interviews with staff confirmed the absence of necessary documentation, and the facility's policy on self-administration was not provided.
A resident with significant respiratory disease used a Respironics Trilogy 100 ventilator machine overnight, but the facility failed to ensure nursing staff were trained and competent in its use. Interviews revealed that staff had not received training on the device, and there was no user manual available at the nurses' station. The director of nursing confirmed the absence of education on the device, highlighting a deficiency in staff competency for managing the resident's respiratory care.
Two residents experienced a 64.52% medication error rate due to improper administration via gastric tubes without appropriate provider orders. Medications were crushed and mixed together, contrary to facility policy requiring separate administration. Staff interviews revealed a lack of understanding and adherence to proper procedures.
A resident with moderate cognitive impairment expressed dissatisfaction with the meal service due to not receiving their preferred drink, milk, despite repeated requests. During meal service, a nursing assistant failed to provide milk, opting for a red-colored drink instead, despite the menu slip indicating a preference for milk. Staff interviews revealed a lack of clarity regarding the significance of starred items on menu slips, which were meant to indicate resident preferences, and the facility lacked a policy on resident drink preferences.
The facility failed to offer timely pneumococcal vaccinations to two residents, despite their medical conditions and CDC recommendations. One resident, a smoker with chronic lung disease, had not been offered additional vaccinations since admission, while another with heart and respiratory failure had not been asked about newer vaccines. The lack of documentation and oversight in the infection control program contributed to this deficiency.
A resident with a primary language of Somali and cognitive impairments was not provided with adequate interpretive services, leading to a lack of understanding about his health status and treatment plan. Despite documented needs for an interpreter, the facility relied on inconsistent methods for communication, resulting in the resident's frustration and refusal of care.
A facility failed to use an interpreter during the admission process for a resident whose preferred language was Somali, impacting their understanding of rights and care decisions. The resident, with cognitive impairments and a complex medical history, was not provided communication interventions. Staff misunderstood the resident's right to refuse care based on code status, leading to inappropriate actions like removing sweets from the resident's room. The facility's policy stated residents have the right to refuse treatment regardless of code status.
Failure to Reassess Resident After Respiratory Decline and Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to reassess a resident after a documented change in condition. The resident had a POLST specifying DNR/DNI status with a focus on comfort care, including use of oxygen and medications, and authorization for oral and IV/IM antibiotics. Prior assessments showed the resident had normal cognition, no behaviors, minimal depression, and was ambulatory with assistance for ADLs. On the evening in question, the resident developed a cough, and an RN documented that initial vital signs showed normal temperature, BP 100/63, RR 20, HR 94, but oxygen saturation at 89–90% on room air. By the end of that shift, the resident’s oxygen saturation had dropped further to 85–90% on room air, prompting initiation of 2 LPM oxygen and notification of the on‑call NP, who ordered a chest X‑ray and influenza testing. During the subsequent night shift, the LPN reported that the resident slept and was monitored every two hours for incontinence care and repositioning, and that oxygen saturation remained above 90% on oxygen. The portable X‑ray company did not respond despite four calls, and no X‑ray was obtained. The night shift nurse documented that the resident slept all night and did not document any reassessment indicating a significant change in condition or any additional vital signs beyond the initial assessment. The facility’s administrator stated that night shift protocol was to check and turn residents every two hours and that staff documented by exception, with the expectation that staff would notify the provider and family if the resident’s condition worsened. Later that morning, the resident received scheduled morning medications, and a progress note documented transfer to the hospital due to increased chest congestion and oxygen saturation less than 81% on 4 LPM, with the X‑ray still not completed. A late entry note recorded that the resident had cough and shortness of breath, oxygen saturation less than 80% on 4 LPM, BP 71/45, HR 108, and that 911 was called. A family member, who was the resident’s POA, reported that upon arrival that morning the resident appeared febrile, was struggling to breathe, was delusional, and did not recognize her, and that a nursing assistant had given him a bed bath and made him comfortable before the head nurse assessed him and called 911. Interviews with nursing staff and the medical director showed they understood the POLST as directing comfort care at the facility, but there was no facility policy defining comfort care, and the regional DCS could not locate such a policy. The deficiency centers on the lack of reassessment and documentation of the resident’s changing condition between the initial decline in oxygen saturation and the later, more severe deterioration that led to hospital transfer.
Failure to Initiate CPR for Full Code Resident
Penalty
Summary
The facility failed to follow the Provider Orders for Life Sustaining Treatment (POLST) for a resident who had elected to be a full code, meaning they wished to receive cardiopulmonary resuscitation (CPR) in the event of cardiopulmonary arrest. The resident, who had diagnoses including metabolic encephalopathy, type 2 diabetes, and end stage renal disease, was also on hospice care but had clearly documented wishes and provider orders for full resuscitation efforts. When the resident was found unresponsive and not breathing, staff did not check the resident's code status and did not initiate CPR, despite the absence of a pulse and respirations. Multiple staff interviews confirmed that the standard procedure was to check a resident's code status and initiate CPR if consistent with the resident's wishes, regardless of hospice status. However, in this incident, both the LPN and the hospice nurse present failed to verify the code status or begin resuscitation efforts. The time of death was called without any attempt at CPR, and the resident's body was prepared for the mortuary without further intervention. Documentation in the resident's progress notes also lacked any reference to checking code status or attempting CPR. The facility's policy required staff to provide basic life support, including CPR, in accordance with the resident's advance directives unless there were obvious signs of clinical death, which were not present in this case. The DON confirmed that the resident's code status was not checked and that CPR was not performed, which was inconsistent with both facility policy and the resident's documented wishes.
Removal Plan
- LPN-A was immediately suspended and communication with hospice company occurred.
- House-wide nurse education started including the importance of checking a resident's code status when they were found unresponsive and not breathing, including residents who had elected hospice care. Education completed.
- Nurse STAT (Code Blue) drills started. Drills included residents who were full code, DNR, and hospice residents.
Lack of Pest Control Program
Penalty
Summary
The facility did not have a pest control program in place to prevent or address the presence of mice, insects, or other pests. This deficiency was identified based on the lack of measures or systems to manage and control pests within the facility environment.
Failure to Ensure Resident Dignity and Privacy During Room Entry
Penalty
Summary
Staff at the facility failed to consistently honor residents' rights to dignity and privacy by not following established protocols when entering resident rooms. Observations and interviews revealed that staff frequently entered rooms without knocking, introducing themselves, or waiting for permission to enter. Specific incidents included staff entering rooms after only a single knock without waiting for a response, entering without any knock or introduction, and failing to announce their presence or purpose. Residents with both intact and impaired cognition expressed discomfort and dissatisfaction with these actions, citing feelings of disrespect and loss of privacy, especially during personal care activities. Multiple staff members, including nursing assistants and LPNs, acknowledged during interviews that the expectation is to knock, introduce themselves, and wait for permission before entering a resident's room, in accordance with facility policy and resident rights. Despite this, direct observations showed repeated lapses in this practice across several residents. The facility's own policy emphasizes the right to personal privacy, including accommodations and personal care, but these standards were not consistently upheld during the survey period.
Failure to Secure Resident Care Information on Unattended Medication Carts
Penalty
Summary
Staff failed to secure residents' personal and medical information on three of seven facility units, resulting in care sheets containing sensitive data being left unattended on mobile medication and treatment carts. These care sheets included resident names, room numbers, medication administration details, diagnoses, information on pressure ulcers, assistance required for transfers, adaptive equipment needs, infection control precautions, and personal care preferences. Multiple observations documented that these sheets were left visible and accessible in public areas, such as hallways, while staff were absent from the carts. Several staff members, including LPNs and RNs, acknowledged during interviews that the information should have been secured and not left out, referencing HIPAA and facility policy requirements for privacy. The deficiency affected residents on the 2nd, 5th, and 7th floors, with a total of 28 residents' information exposed on unattended care sheets. Staff interviews confirmed an understanding of the expectation to keep such information private, with some staff noting that computers should be used instead of paper to protect privacy. Facility policy dated July 2025 states that residents have the right to personal privacy and confidentiality of their records, which was not upheld in these instances.
Inaccurate MDS Coding for Insulin Administration
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was accurately coded for one resident. During a quarterly MDS assessment, the resident was incorrectly documented as having received seven insulin injections during the look-back period, despite a review of physician orders and medication administration records showing no insulin was ordered or administered before or after the look-back period. The resident, who has diabetes, was instead being treated with two oral diabetic agents. The MDS coordinator confirmed that the error likely occurred when an oral diabetic medication was mistakenly coded as insulin. The facility did not have a specific MDS policy and followed the RAI manual.
Failure to Complete Required PASARR Screenings for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that required Level I Pre-admission Screening (PAS) and, when indicated, Level II Pre-admission Screening and Resident Review (PASARR) were completed for three out of four residents reviewed for PAS. For one resident with diagnoses including schizophrenia, post-traumatic stress disorder, and a psychotic disorder, the medical record lacked evidence of a final PAS determination, and the director of admissions was unable to provide documentation of attempts to obtain it. The director of admissions and the director of social services gave conflicting accounts regarding responsibility for obtaining the final PAS, and no documentation was found in the resident's record. Another resident with major depressive disorder with severe psychotic symptoms, post-traumatic stress disorder, and generalized anxiety disorder also lacked evidence of a final PAS determination in the medical record. The director of admissions and the social worker director both confirmed the absence of this documentation. For a third resident with multiple psychiatric diagnoses, including anxiety, major depressive disorder, bipolar disorder, post-traumatic stress disorder, schizophrenia, and traumatic brain injury, there was no evidence that a Level I PAS or, if needed, a Level II PASARR was completed prior to admission. The director of admissions confirmed that the PAS was missed due to a new admission coordinator being trained. The facility's policy required Level I screening for all applicants before admission, but this was not followed in these cases.
Failure to Develop Comprehensive Care Plan for AFO Brace Use
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with severely impaired cognition, functional limitations in both lower extremities, and a diagnosis of right-sided weakness following a stroke. Although the resident was prescribed a right ankle foot orthosis (AFO) brace to be worn when out of bed and in a wheelchair, the care plan, order report, and task documentation did not include instructions for the use of the brace. Staff interviews confirmed that while nursing assistants and LPNs had received education on the application of the brace, they were unable to locate written instructions or documentation in the resident's care plan regarding when and how the brace should be applied. Further review revealed that therapy staff had communicated the need for the resident to wear the AFO brace for more than four hours a day when in a wheelchair, with skin checks to be performed during application and removal. However, this information was not incorporated into the resident's care plan. The director of therapy acknowledged that it was her responsibility to ensure new therapy orders were added to the care plan, but this had not occurred. The lack of documented instructions and integration of therapy recommendations into the care plan resulted in a failure to provide a complete and measurable plan of care for the resident's needs.
Failure to Update and Revise Care Plans for Positioning and Behavioral Interventions
Penalty
Summary
The facility failed to update and revise the care plans for two residents, resulting in deficiencies related to position, mobility, and behavioral management. For one resident with a history of stroke, hemiplegia, and foot drop, the care plan included the use of a left leg brace (AFO) for positioning and protection. However, there was no provider order for the brace, and therapy assessments determined the brace was not clinically indicated since the resident was no longer ambulatory. Despite this, the care plan continued to list the brace as an intervention, and staff interviews revealed inconsistent knowledge and application of the intervention. The resident reported discomfort and refusal to wear the brace, and therapy staff were unaware of its continued use, indicating a lack of communication and care plan updates based on current assessments and resident needs. For another resident with moderate cognitive impairment and a history of resident-to-resident aggression, the care plan included interventions to prevent physical aggression, such as specific seating arrangements during meals and activities. Observations showed the resident was seated within arm's reach of other residents, contrary to the care plan interventions. Staff interviews revealed a lack of awareness of the care plan's specific interventions, and the DON was not aware of the resident's history of aggressive incidents or the care plan requirements. The care plan was not updated to reflect the resident's current behavior status or to discontinue interventions that were no longer appropriate. The facility's policy required care plans to be developed, reviewed, and revised based on comprehensive assessments and to be updated when problems, goals, or approaches were no longer appropriate. In both cases, the facility did not ensure care plans were accurately updated to reflect current clinical indications, resident preferences, and behavioral status, leading to discrepancies between care provided and documented interventions.
Failure to Provide and Document Routine Nail Care for Dependent Resident
Penalty
Summary
The facility failed to ensure that routine personal hygiene, specifically nail care, was provided to a resident who was dependent on staff for activities of daily living (ADLs). The resident had moderately impaired cognition, exhibited some physical behavioral symptoms, and was noted to be dependent on staff for bathing and required assistance for personal hygiene. The care plan specified that nail care should be performed on bath days and as needed, with staff instructed to report any changes to the nurse. Despite this, observations revealed that the resident had long fingernails with dark debris underneath, and the resident reported that nail care had not been performed for some time. Staff interviews confirmed that nail care was expected to be done during showers, but there was no documentation of nail care being offered or completed, nor of any refusals by the resident. Progress notes reviewed over a one-month period did not contain any evidence of nail care being provided or refused. Staff, including an LPN and a nursing assistant, acknowledged that nail care was not documented in the electronic medical record and that it was considered a routine practice. The DON stated that nail care would be documented only if there were continual refusals. The facility's policy required that residents unable to perform ADLs receive necessary services to maintain grooming and personal hygiene, but this was not consistently implemented or documented for the resident in question.
Failure to Complete and Implement Therapeutic Recreation Assessment
Penalty
Summary
The facility failed to ensure that a therapeutic recreation assessment was completed and documented in the electronic medical record (EMR) for a cognitively intact resident who expressed a strong preference for music and individual activities. The resident's initial Activity Interview indicated that listening to music was very important, but the corresponding Therapeutic Recreation/Life Enrichment Assessment in the EMR was left blank, with only a note stating information would be entered at a later date. Although a completed paper assessment was later produced, the resident's care plan lacked an activities section to inform staff of preferences and goals, and there was no evidence in the EMR that life enrichment activities were offered or provided. Observations over several days showed the resident sitting alone in a quiet room, asleep in a wheelchair, without any music, television, or other forms of stimulation. The resident reported having requested a radio from multiple staff members but never received one or any follow-up. The Director of Therapeutic Recreation confirmed that the assessment was incomplete in the EMR and that the care plan did not include an activities section, attributing the lapse to staffing shortages and division of responsibilities within the department. Facility policy required completion of the therapeutic recreation assessment within 14 days of admission and identified the activities department as integral to interdisciplinary care planning.
Failure to Ensure Resident Access to Hearing Aids Due to Poor Communication and Documentation
Penalty
Summary
The facility failed to implement interventions to ensure that hearing aids were routinely applied or offered daily for a resident with severe bilateral hearing loss. The resident, who had intact cognition and did not reject care, was identified in the care plan as requiring staff assistance with placement of hearing aids. During observation and interview, the resident was found without hearing aids, was unable to locate them, and reported not being informed of their whereabouts. The resident expressed a need for the hearing aids to hear and required the surveyor to speak louder during the interview. Interviews with staff revealed a lack of communication and documentation regarding the location and application of the resident's hearing aids. A nursing assistant stated she had not applied the hearing aids and was unaware of their location, while a registered nurse confirmed the absence of the hearing aids and lack of information in the electronic medical record. The nurse manager disclosed that she had possession of the hearing aids for several weeks but had not documented this or communicated it to staff or the resident. The Director of Nursing verified that the electronic medical record did not reflect the location of the hearing aids or any communication about their status. The facility's policy on quality of care was requested but not provided.
Failure to Provide Adequate Food and Fluids
Penalty
Summary
The facility failed to provide sufficient food and fluids to maintain a resident's health. This deficiency was identified by surveyors based on observations and records indicating that the nutritional and hydration needs of at least one resident were not adequately met. The report specifically notes the lack of provision of adequate food and fluids necessary for the resident's health maintenance.
Failure to Follow Trauma-Informed Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to follow care planned interventions to prevent re-traumatization for a resident diagnosed with post-traumatic stress disorder (PTSD) and a history of sexual abuse. The resident's care plan and trauma history assessment clearly indicated a preference for female caregivers and an inability to tolerate male staff in his room, due to past trauma involving male perpetrators. Despite these documented interventions, male staff continued to enter the resident's room alone, including an observed incident where a male staff member entered with a lunch tray and closed the door. The resident reported ongoing distress and anger related to these incidents, stating he did not feel safe and that his PTSD was not being taken seriously by staff. Interviews with facility staff revealed a lack of awareness regarding the resident's preference for female caregivers, with several staff members and a registered nurse referencing care sheets and stating that only one other resident (not the resident in question) had such a preference. The care sheets and aide care plan lacked information about the resident's need for female-only caregivers, despite this being documented in the care plan. The nurse manager confirmed that staff should have been aware of and following the resident's preferences. Additionally, the facility was unable to provide a policy on behavioral management and trauma informed care when requested.
Medication Administration Errors Involving Extended-Release and Meal-Timed Medications
Penalty
Summary
The facility failed to prevent medication errors during medication administration for two residents, resulting in a medication error rate of 7.14%. For one resident with a history of anemia, atrial fibrillation, heart failure, hypertension, hyponatremia, hyperlipidemia, non-Alzheimer's dementia, and malnutrition, and who had a feeding tube, a licensed practical nurse crushed all tablets, including potassium chloride extended-release, before administering them via PEG-tube. The provider order specified that the potassium chloride extended-release should be dissolved in water, not crushed. The nurse confirmed knowledge of which medications could or could not be crushed but still crushed the extended-release tablet. The director of nursing and consultant pharmacist both confirmed that crushing extended-release potassium chloride was not appropriate, as it compromised the medication's intended release mechanism. For another resident with benign prostatic hyperplasia and kidney disease, a registered nurse administered tamsulosin hydrochloride capsules while the resident was still eating breakfast, despite provider orders specifying the medication should be given after a meal. The nurse stated that the resident preferred to take all medications at the same time and planned to update the provider and care plan accordingly. The consultant pharmacist explained that administering tamsulosin during a meal, rather than after, could decrease the medication's effectiveness. The facility's medication administration policy required staff to follow provider orders and manufacturer specifications, which was not done in these instances.
Failure to Provide or Obtain Dental Services
Penalty
Summary
The facility failed to provide or obtain necessary dental services for each resident as required. This deficiency was identified through surveyor observation and review of facility practices, indicating that residents did not receive appropriate dental care or referrals for dental services when needed. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Therapeutic Diets Not Properly Prescribed or Delegated
Penalty
Summary
Therapeutic diets were not consistently prescribed by the attending physician, nor was there documentation that the responsibility for prescribing these diets was appropriately delegated to a registered or licensed dietitian as permitted by State law. This resulted in a failure to ensure that residents requiring therapeutic diets received orders from the proper medical professional, as required by regulation.
Failure to Use Required PPE During Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that personal protective equipment (PPE), specifically gowns and gloves, was consistently used by staff during high-contact care activities for residents under enhanced barrier precautions (EBP). Observations revealed that staff members assisted residents with pressure ulcers and indwelling urinary catheters in activities such as transferring, changing briefs, and providing perineal hygiene without donning gowns, despite clear signage and facility policy requiring both gown and glove use for these activities. Staff interviews confirmed a lack of understanding or adherence to the EBP requirements, with some staff believing gowns were only necessary during morning care or for residents on isolation, and others indicating they could decide whether to use a gown during catheter care. The residents involved included one with diabetes and multiple unstageable pressure ulcers requiring dressing changes, and another with severe cognitive impairment, multiple chronic conditions, and an indwelling urinary catheter. Both residents had care plans and signage indicating the need for EBP, and PPE carts were available outside their rooms. Despite these measures, staff did not follow the required infection control protocols during observed care activities, as confirmed by interviews with the infection preventionist, LPN, and DON, all of whom stated that both gowns and gloves should be used for high-contact care under EBP.
Failure to Notify Physician of Rapid Weight Gain in CHF Resident
Penalty
Summary
The facility failed to notify a physician of a rapid weight gain in a resident with a diagnosis of Congestive Heart Failure (CHF), and did not seek clarification on physician orders regarding weight monitoring and notification parameters. The resident was admitted with CHF and had a hospital discharge weight of 188 lbs. Facility records show the resident's weight increased to 207 lbs. over a period of days, but there was no evidence that the primary physician was contacted about this significant weight gain or to clarify orders for weight monitoring and notification parameters, despite the absence of such parameters in the initial orders. Progress notes from the facility between admission and a cardiovascular appointment did not document any communication with the primary physician regarding the resident's weight changes or CHF management. The DON confirmed that staff did not clarify orders or notify the physician about the weight gain, and that there was no established protocol for staff to follow in such situations, aside from general best practice. The deficiency was identified through interview and document review, which revealed incomplete weight monitoring and lack of physician notification for a resident at risk due to CHF.
Failure to Timely Develop and Implement Person-Centered Baseline Care Plan for CHF Management
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident with a diagnosis of congestive heart failure (CHF). Upon admission, the resident's Minimum Data Set (MDS) assessment and physician orders indicated the need for weight monitoring due to CHF, with specific instructions to weigh the resident daily, then weekly, and then monthly. However, the baseline care plan created did not include specific parameters for when to notify a physician about weight changes, which is critical for CHF management. The care plan only directed staff to take daily weights without providing guidance on thresholds for physician notification regarding weight gain, a key indicator of fluid retention in CHF patients. Additionally, the baseline care plan was not developed and implemented within the required 48-hour timeframe after admission. Documentation showed inconsistent weight monitoring, and there was no evidence that the physician was contacted when the resident experienced significant weight gain. Interviews with the resident, nurse manager, and director of nursing confirmed that the baseline care plan lacked necessary weight parameters and was not completed on time. The facility's own policy required the development of a baseline care plan within 48 hours, including instructions necessary to provide effective and resident-centered care, but this was not followed in the resident's case.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The nursing facility failed to ensure that services provided met professional standards of quality. This deficiency was identified based on observations and review of facility practices, which did not align with established professional guidelines for care delivery. The report notes that the facility did not maintain the expected level of quality in the provision of services, as required by regulatory standards. No specific details about individual residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Timely Update and Honor Resident's Advanced Directive
Penalty
Summary
The facility failed to timely update a resident's end-of-life wishes in the medical record, resulting in the advanced directive not being followed. The resident, who had severe cognitive impairment and multiple diagnoses including acute respiratory failure, diabetes, malnutrition, intellectual disabilities, and adult failure to thrive, required assistance with all decision-making. The legal guardian provided a new Provider Orders for Life Sustaining Treatment (POLST) form indicating do not attempt resuscitation (DNR) and comfort-focused treatment, and sent it to the facility's social worker. However, the facility's process required the provider to sign the POLST for it to be valid, and this signature was not obtained in a timely manner. As a result, the resident's medical record and provider orders continued to indicate full code status, and the resident was transferred to the hospital and treated as a full code when found unresponsive. Staff interviews confirmed that the new POLST was received but not processed due to the lack of a provider signature, and the code status in the medical record was not updated. The facility's policy required support and facilitation of residents' rights to request or refuse treatment and to formulate advanced directives, but this was not carried out in this instance.
Medication Order Processing Errors Lead to Missed and Duplicate Doses
Penalty
Summary
The facility failed to accurately document and process medication orders for two residents, leading to medication errors. For one resident, identified as R1, the medication Levetiracetam was changed from tablet form to an oral solution. However, the tablet form was not discontinued, resulting in the resident receiving both forms of the medication simultaneously. This error occurred over several days and was not identified by the facility until after the resident was discharged. Another resident, identified as R2, returned from a hospital stay with new medication orders that were not processed in a timely manner. As a result, the resident missed several doses of critical medications for liver disease and diabetes, including Rifaximin, Glargine insulin, and Metformin. These medications were not administered because the orders were not entered into the medication administration record until after the resident was readmitted to the hospital. Interviews with nursing staff revealed that the facility had recently changed its process for verifying new medication orders, eliminating the requirement for a second nurse to verify the accuracy of the orders. This change contributed to the errors, as staff did not catch the discrepancies in the medication orders. The facility's policy required discontinuation of previous orders before entering new ones, but this was not followed, leading to the deficiencies noted in the report.
Failure to Provide Timely Wound Care for Resident
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident (R1) who was discharged from the hospital with sores on his lower legs. Upon returning to the facility, R1 did not receive any wound care for three days, despite having been hospitalized for septic shock related to a leg wound. The resident's care plan indicated a potential for impaired skin integrity due to various health conditions, yet no immediate action was taken to address the leg wounds upon readmission. R1's medical history included cerebral infarction, cardiogenic shock, atrial fibrillation, cellulitis of both lower limbs, and dysphagia. Upon readmission to the facility, R1's nursing progress notes and assessments failed to document the condition of his leg wounds accurately. The initial assessment noted dark dry scabs on both legs, but no treatment orders were initiated until three days later, when the wounds were identified as venous ulcers. During this period, there was a lack of documentation and communication regarding the resident's wound care needs. Interviews with facility staff revealed a breakdown in communication and procedure. The RN responsible for the readmission assessment did not document skin concerns or initiate treatment orders, leading to a delay in care. The facility's Director of Nursing acknowledged the absence of wound care orders upon R1's return and attributed part of the issue to the hospital's failure to provide discharge orders. Despite the facility's policy requiring a body check upon admission, the necessary wound care was not provided in a timely manner, contributing to the resident's deteriorating condition.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure an assessment for self-administration of medications (SAM) was completed for a resident, identified as R2, who was observed self-administering medications without proper assessment or supervision. R2's medical record lacked evidence of an assessment for self-administration for all current medications, despite having a care plan that required such assessments. R2 was observed taking medications from a cup on her table without nursing staff present, and she was unable to swallow them properly due to shaking hands. R2 was not aware of all the medications she had self-administered and did not recall being assessed for self-administration. The facility's policy required that a resident may only self-administer medications after the interdisciplinary team determined it was safe, considering the resident's cognitive status and ability to correctly name their medications. However, R2's physician orders only indicated she was assessed to self-administer a nebulization inhaler, not the other medications. Staff interviews revealed that medications should not be left unattended and that residents must be assessed and have a physician order to self-administer medications. The therapy director expressed concern about the medications being left with R2 and discussed it with the assistant director of nursing.
Infection Control Deficiencies in Laundry and PPE Practices
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in the laundry room, which posed a risk of contamination to laundered linens. During a tour, it was observed that the grates of multiple fans and a mobile air conditioner, which were facing clean linens, had significant dust and debris build-up. The laundry aide confirmed that these devices were not on a routine cleaning schedule, and the director of engineering acknowledged that the cleaning of these devices fell under their department. However, no documented tracking or cleaning schedule was provided during the survey. The facility also failed to consistently implement transmission-based precautions for residents with COVID-19. For instance, a nursing assistant was observed exiting a COVID-positive resident's room without wearing the required eye protection, and another staff member was seen wearing a surgical mask below their nose in a unit with an active COVID outbreak. Interviews with staff revealed a lack of adherence to the facility's policy on personal protective equipment, which required the use of gowns, N95 masks, gloves, and eye protection when entering rooms of COVID-positive residents. Additionally, the facility did not ensure that soiled linen and garbage carts were covered in the hallways, which is a concern for infection control. Observations showed uncovered bins with soiled linens and garbage visible in the hallways. Staff interviews confirmed that these bins should be covered to prevent the spread of infection. The facility's failure to adhere to its own policies and procedures regarding infection control and personal protective equipment contributed to these deficiencies.
Failure to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean and safe environment, as evidenced by the condition of the floors in two resident dining rooms and one resident's room. Observations revealed that the floors were tacky and sticky, causing shoes to stick, which was confirmed by multiple staff members. The resident's room, occupied by a resident with severe cognitive impairment and multiple medical conditions, was reported by a family member to be smelly and not cleaned adequately. Staff interviews indicated that the housekeeping department was responsible for cleaning the floors after meals, but the floors remained sticky, suggesting inadequate cleaning practices. Further investigation revealed that the facility's maintenance practices were insufficient, as the floors were not stripped before waxing, leading to a buildup of old wax. The associate administrator confirmed that the floors in the memory care and third-floor dining rooms, as well as the resident's room, were improperly waxed. Despite requests, the facility's policy on environmental cleaning and maintenance of floors was not provided, indicating a lack of documented procedures to ensure proper floor care.
Deficiencies in Personal Care and Hygiene for Residents
Penalty
Summary
The facility failed to ensure routine personal care and hygiene for several residents who required assistance with activities of daily living (ADLs). Observations and interviews revealed that residents were not receiving adequate bathing, nail care, and hair grooming. For instance, one resident with moderate cognitive impairment was observed with long, soiled fingernails and expressed dissatisfaction with the bathing assistance provided, stating it was inadequate. The resident's care plan did not include specific instructions for nail care, and there was no documentation of nail care being offered or provided. Another resident with moderate cognitive impairment and a hand contracture was observed with long, soiled fingernails. The resident stated that staff had not offered to clip his nails, although he desired them to be shorter. The care plan for this resident also lacked specific instructions for nail care, and there was no evidence in the medical record that nail care had been offered or provided. Staff interviews confirmed that nail care was typically done with bathing but was not documented unless refused. Additional deficiencies were noted for other residents, including one with severe cognitive impairment who was observed with unshaved facial hair and greasy, uncombed hair. The resident's care plan required assistance with personal hygiene, but there was no documentation of refusal or completion of these tasks. Another resident with diabetes was told by staff that they could not cut her nails, although the facility's policy allowed nurses to perform this task. The lack of documentation and inconsistent practices contributed to the failure to provide necessary personal care and hygiene for these residents.
Unsecured Medication Carts in Facility
Penalty
Summary
The facility failed to ensure that medications were kept locked or under direct observation of authorized staff, leading to multiple instances of unattended and unlocked medication carts on three of the five resident floors. On several occasions, medication carts were observed unlocked and unattended in areas accessible to residents, staff, and guests. For example, on the seventh floor, a registered nurse verified that a medication cart was left unlocked during mealtime. Similarly, on the fifth floor, a licensed practical nurse acknowledged responsibility for an unlocked cart, noting the potential for resident access. Further observations revealed additional unlocked medication carts on the second floor, where the Director of Nursing eventually secured the cart. Interviews with nursing staff, including nurse managers and the Director of Nursing, confirmed the expectation that medication carts should be locked when not in direct use. The facility's policy on medication administration, dated May 2024, specifies that medications are to be administered by licensed nurses or other legally authorized staff, underscoring the importance of securing medication carts to prevent unauthorized access.
Delayed Meal Service Leads to Cold Food
Penalty
Summary
The facility failed to ensure that food was delivered and served in a timely manner, resulting in meals being served at undesired temperatures. During the survey, it was observed that meal carts were not arriving on time, and even when they did, the food was not served promptly to the residents. For instance, on the 7G unit, the meal cart was supposed to arrive at 8:00 AM, but food was not served until 8:57 AM. This delay in serving meals led to food being served cold, as evidenced by the temperature of scrambled eggs being 113 degrees Fahrenheit, which was below the required temperature. Residents expressed dissatisfaction with the meal service, citing that food was often cold and not palatable. One resident with intact cognition reported that the food was consistently cold when it should be warm. Another resident with moderate cognitive impairment complained about the poor service and mentioned that the food trays sat out for half an hour before being served. A third resident, who typically ate meals in his room, indicated that the food was bland and not warm when served. Family members also expressed concern about the nutritional intake of their loved ones due to the poor quality of meals. Interviews with staff revealed a lack of awareness and adherence to the meal delivery schedule. A nursing assistant mentioned that they believed the meal cart was brought up at a different time than scheduled, and dietary aides acknowledged that they were late in serving meals. The facility's regional director of dietary services confirmed that the meal carts were not insulated, and food should not be left sitting on the counter, as it leads to further cooling. Despite the facility's policy on food temperatures and timing of serving food being requested, it was not provided during the survey.
Failure to Cover Food and Beverages During Transport
Penalty
Summary
The facility failed to ensure that all food items were properly covered when served to residents, which could potentially lead to foodborne illness. During multiple observations, nursing assistants were seen transporting meal trays with uncovered beverages and desserts on uncovered carts. These trays were delivered to residents' rooms without any coverings, despite the beverages being initially transported in covered pitchers. Staff members, including nursing assistants and dietary aides, were either unaware or did not adhere to the requirement of covering food and beverages during transport. Interviews with various staff members, including the Director of Nursing, Kitchen Supervisor, and Regional Director of Dietary Services, confirmed that liquids and food items should be covered when transported to resident rooms to prevent cross-contamination and ensure infection control. Despite this understanding, the facility's policy on covering food during transport was not provided upon request, indicating a possible lack of clear guidelines or enforcement of existing protocols.
Ineffective Pest Control Program Leads to Bed Bug Infestation
Penalty
Summary
The facility failed to implement an effective pest control program to eliminate bed bugs, affecting a resident and potentially other residents on the same floor. The resident, who required moderate assistance with daily activities, was moved from her original room due to a bed bug infestation. Despite being moved back to her original room, the resident reported seeing bed bugs again, which caused distress and discomfort. Observations confirmed the presence of bed bugs and unsanitary conditions in the room, including stained sheets and clutter. Interviews with staff revealed a lack of coordination and communication regarding the pest control measures. The nurse manager was unaware of the specific actions taken to manage the bed bug issue, and the director of engineering admitted to not having addressed the clutter that hindered effective treatment. Maintenance staff used a heating device to treat the infestation but did not inspect adjacent rooms for potential spread. The district manager for environmental services noted that the cleaning process might not have been thorough, as evidenced by grime on the bed frame. The facility's bed bug protocol outlined steps for managing infestations, including moving residents and deep cleaning affected areas. However, the protocol was not fully followed, as personal items were left in the room, and there was no documentation of audits or treatments. The associate administrator confirmed that bed bugs were still present when the resident was moved back, and a pest control company was only called after the issue persisted. The lack of a comprehensive and documented approach to pest control contributed to the ongoing infestation problem.
Deficiencies in Resident Dignity and Meal Service
Penalty
Summary
The facility failed to provide a dignified dining experience for several residents, as observed during multiple instances. Residents were left waiting for their meals while their tablemates were served, leading to delays in meal service. For example, residents were observed sitting without food or drinks for extended periods, with some waiting up to 1.5 hours for breakfast. Additionally, a resident was brought to the dining room ungroomed, wearing a hospital gown with unbrushed hair, which was acknowledged by the nursing staff as inappropriate. The report also highlights the facility's failure to maintain dignity for a resident who was left in bed without pants, despite the resident's representative expressing that this was against the resident's preferences. The representative noted that the issue was not communicated effectively to the staff, many of whom were agency workers unfamiliar with the resident's needs. An agency nursing assistant admitted to leaving the resident without pants to prevent soiling, indicating a lack of personalized care. Interviews with staff revealed a systematic issue where residents requiring assistance with meals were served last, causing them to wait longer than those who could eat independently. This practice was confirmed by multiple staff members, including nursing assistants and registered nurses, who stated that the order of meal service was based on the level of assistance required. The director of nursing acknowledged the need for improvement in providing a home-like, dignified dining experience for residents.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to ensure that a written notice of transfer was sent to the Office of the Ombudsman for Long-Term Care for two residents who were hospitalized. Resident R60, who had multiple diagnoses including stroke, renal insufficiency, and dementia, was transferred to the emergency room without a documented bed hold discussion or written notice of transfer. Similarly, Resident R27, who was cognitively intact and had several health conditions including coronary artery disease and schizophrenia, was also transferred to the hospital without evidence of a written notification to the ombudsman. Interviews with facility staff revealed that the nursing staff did not follow the expected procedure of providing a paper copy of the Transfer Notice to the resident or their power of attorney and documenting it in the resident's electronic medical record. The director of social services confirmed that the reports faxed to the ombudsman did not include the hospitalizations of R60 and R27 due to a technical glitch in the electronic medical record system. The facility lacked a policy for notifying the ombudsman of transfers, and the administrator acknowledged the issue with the report faxed to the ombudsman.
Failure to Complete Final PASARR for Resident with Mental Health Disorders
Penalty
Summary
The facility failed to ensure a Level I Pre-Admission Screening and Resident Review (PASARR) was completed prior to the admission of a resident diagnosed with generalized anxiety disorder, major depressive disorder, and schizoaffective disorder. The resident's medical record lacked evidence of a final determination from the lead agency, as required by the PASARR process. The initial PASARR document dated 10/12/23 indicated that the screening was not final until the lead agency sent the documentation to the nursing facility, but no such final determination was found in the resident's records. Interviews with facility staff revealed a misunderstanding regarding the completion of the PASARR process. The director of social services initially believed the preadmission screening was final and did not require additional screening. However, a senior linkage line representative clarified that the document on file was not the final PASARR and advised the facility to contact the lead agency, Hennepin County, for the final determination. Despite this guidance, the facility's administrator maintained that the PASARR on file did not trigger a Level II assessment, yet it was the same incomplete document dated 10/12/23. Additionally, the facility did not provide a policy regarding PASARR completion or maintenance when requested.
Deficiency in Timely Care Conferences
Penalty
Summary
The facility failed to ensure timely person-centered care conferences for three residents, leading to a deficiency in care planning. Resident R9, who had no cognitive deficits, did not have a care conference after February 1, 2024, despite the requirement for one to align with her Minimum Data Set (MDS) in May. R9 expressed a desire to be more involved in her care. The social worker acknowledged a backlog of care conferences due to departmental turnover. Resident R103, who was cognitively intact and had multiple diagnoses, did not have any care conferences documented between January 25, 2024, and August 1, 2024, despite MDS submissions in March and June. Resident R134, with severe cognitive impairment and multiple health issues, also lacked evidence of care conferences between January 25, 2024, and June 26, 2024, despite an MDS submission in April. The director of social services and the director of nursing both acknowledged the lapse in care conferences, attributing it to staff turnover and emphasizing the importance of timely conferences for communication and care planning.
Deficiencies in Bowel Management and Prescription Order Transcription
Penalty
Summary
The facility failed to develop proactive interventions for a resident's bowel management, leading to discomfort and potential complications. The resident, who had no cognitive deficits and required moderate assistance with daily activities, was diagnosed with multiple medical conditions, including diabetes and chronic pain syndrome. Despite having a care plan that included checking the resident every two hours and assisting with toileting, the facility did not establish a toileting schedule or update the care plan to reflect the resident's usual bowel movement pattern. The resident experienced multiple days without bowel movements, and the facility did not implement new interventions or notify the provider of the ongoing constipation issues. Interviews with the resident and nursing staff revealed that the resident had been receiving a medication for constipation that was no longer effective, and the nursing staff had not assessed the resident's bowel movement status daily. The registered nurse in charge was unaware of the resident's usual bowel pattern and did not initiate standing bowel management orders until three days without a bowel movement. The unit nurse manager acknowledged the resident's risk for constipation due to narcotic use and lack of activity but was unsure if the provider had been updated on the resident's symptoms. The director of nursing emphasized the importance of reviewing bowel movement records and updating the provider if the current regimen was ineffective. Additionally, the facility failed to transcribe prescription orders for another resident who returned from a hospital admission with new orders for skin treatment. The health unit coordinator and a nurse were responsible for processing and verifying new orders, but the nurse missed the order for the prescribed creams. The director of nursing confirmed that the orders were not transcribed within the expected timeframe, delaying the resident's treatment for a skin condition.
Failure to Act on Audiology Referral for Resident
Penalty
Summary
The facility failed to ensure timely action on an audiology referral for a resident, identified as R39, who expressed difficulty with hearing. Despite a significant change Minimum Data Set (MDS) indicating moderate cognitive impairment and no use of hearing aids, R39 reported worsening hearing and a need for earwax removal. The resident believed an audiology appointment was set up with the Veterans Administration but was not confirmed. The initial nursing assessment and care plan lacked evidence of a physical ear inspection or an offer for a hearing appointment. A medical provider's progress note from April indicated a diagnosis of bilateral hearing loss and included an order for an audiology consult, which was not acted upon. Interviews with staff revealed that the nursing assistant had heard the resident complain about hearing difficulties but did not report it to the nurses. The registered nurse manager and the director of nursing confirmed that in-house audiology services were available but had not been scheduled for the resident due to a lack of awareness of the complaints. The director of nursing acknowledged the oversight and noted that the health unit coordinator's abrupt resignation might have contributed to the missed appointment. The facility's policy on audiology services was requested but not provided.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement necessary interventions to prevent falls for a resident with a history of repeated falls. The resident, who had diagnoses including cerebral infarct, hemiplegia, hemiparesis, and a history of falling with injuries, required extensive assistance with bed mobility, transfers, and toileting. The resident's care plan identified them as at risk for falls due to an unsteady gait, cognitive deficits, and syncope, and included interventions such as keeping the call light within reach and providing a safe environment. A physical device assessment indicated the need for a perimeter mattress to decrease the risk of falls from bed, and a physician order was issued for its use. Despite the physician order and assessment, the resident was observed on multiple occasions with a standard air mattress instead of the prescribed perimeter mattress. Interviews with the RN and DON revealed that the order for the perimeter mattress was not implemented, and no requisition for the mattress was found. The DON acknowledged the importance of implementing interventions and physician orders to reduce fall risks and confirmed that the perimeter mattress had not been put in place as required by the facility's Fall Mitigation Program policy.
Deficiencies in Pain Management and Documentation
Penalty
Summary
The facility failed to comprehensively reassess and determine additional interventions for pain management for a resident, identified as R39, who had moderate cognitive impairment and chronic pain. Despite receiving scheduled pain medication, R39 reported constant pain that occasionally affected sleep, with pain levels often recorded at 5 or higher. The facility did not conduct a comprehensive reassessment after a medication adjustment, and there was a lack of documentation to show whether the pain management plan was effective or sufficient for R39's needs. Additionally, the facility did not assess and develop non-pharmacological interventions for two other residents, R69 and R131, who were reviewed for pain management. R69, with severely impaired cognition, reported frequent pain affecting daily activities and expressed a desire for non-medication interventions, which were not offered. The care plan for R69 lacked evidence of non-pharmacological interventions being tried or documented. Similarly, R131, who had intact cognition and chronic pain, was not offered any non-pharmacological interventions, and the care plan did not specify what interventions should be used. Interviews with nursing staff revealed that non-pharmacological interventions were not consistently documented or offered, and there was a lack of follow-up assessments after medication adjustments. The director of nursing confirmed that residents should be offered non-pharmacological interventions, but the facility did not provide a policy on their use. The report highlights deficiencies in pain management practices, including inadequate reassessment and documentation, and a failure to offer non-pharmacological interventions to residents experiencing chronic pain.
Failure to Address Pharmacist Recommendations for Resident Medications
Penalty
Summary
The facility failed to ensure that consulting pharmacist recommendations were fully addressed or acted upon for a resident reviewed for unnecessary medications. The resident, who had severely impaired cognition and was dependent on staff for various activities, was prescribed quetiapine for agitation and lorazepam as needed. The consulting pharmacist recommended that the as-needed lorazepam should have a 14-day stop date unless a longer duration was justified by the physician, and that the use of quetiapine for agitation was not appropriate without a proper diagnosis. However, the physician's responses did not address these recommendations adequately, and the pharmacist's recommendations were reissued monthly without resolution. The nurse practitioner responsible for reviewing the pharmacist's recommendations did not add a stop date for the lorazepam, as she was unaware it was necessary, and did not clarify the appropriate diagnosis for the quetiapine use. Despite the pharmacist's repeated recommendations, the facility did not establish a specific duration for the lorazepam or provide an appropriate diagnosis for the quetiapine. The nurse practitioner did not reach out to the pharmacist for clarification, and the pharmacist did not further communicate with the facility staff to explain the repeated recommendations. Interviews with the consulting pharmacist and the director of nursing revealed that there was a misunderstanding regarding the requirement for a stop date for as-needed psychotropic medication, and the order for quetiapine should have been updated to include an appropriate indication. The facility did not have a policy regarding pharmacist medication regimen reviews available, which further contributed to the deficiency.
Deficiencies in Antipsychotic Medication Management
Penalty
Summary
The facility failed to provide an indication for use and resident-specific target behaviors for a resident (R383) who was receiving antipsychotic medication. The resident's orders included Olanzapine, an antipsychotic medication, but lacked a clear indication for its use. The care plan mentioned the use of antipsychotic medication related to several mental health diagnoses but did not specify target behaviors. Interviews with staff confirmed that the medication administration record did not contain an indication for use, and the psychotropic behavior monitoring was not tailored to be resident-specific. Another resident (R164) was receiving as-needed antipsychotic medication without a specific duration of therapy, contrary to recommendations. The resident had severely impaired cognition and was dependent on staff for daily activities. The facility's records showed that the resident was receiving quetiapine for agitation, which is not considered an appropriate indication for antipsychotic use. Despite recommendations from the consulting pharmacist to include a 14-day stop date for as-needed lorazepam and to clarify the diagnosis for quetiapine use, the facility continued the orders without addressing these recommendations. Interviews with staff and the consulting pharmacist revealed ongoing issues with the facility's response to pharmacy recommendations. The consulting pharmacist had difficulty getting the facility to fully respond to her recommendations, and the nurse practitioner confirmed that a stop date had not been added to the as-needed lorazepam. The director of nursing acknowledged a misunderstanding regarding the requirement for a stop date for as-needed psychotropic medication and confirmed that agitation was not an appropriate indication for antipsychotic medication use.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to provide or offer routine dental services to promote oral hygiene and reduce the risk of complications for four residents reviewed for dental services. Resident R39, who was admitted in April 2024, expressed frustration as he had been without dentures for a long time and had not been assisted in arranging a dental examination. Despite conflicting evaluations regarding his oral condition, there was no evidence in his medical record that he had been asked or offered a dental examination since admission. The care plan lacked specific problem statements or interventions for his dental needs, and the Care Conference Summary did not document any dental appointments. Resident R50, admitted in June 2024, was cognitively intact and required assistance with oral care. She had broken dentures and no natural teeth, yet her electronic medical record lacked evidence of a dental visit being offered since her admission. During an interview, R50 confirmed that staff had not offered any dental services to address her broken dentures. Similarly, Resident R134, with severe cognitive impairment and multiple diagnoses, had not had a dental evaluation or visit documented since October 2022. The care plan directed staff to coordinate dental care, but the Care Conference Summary lacked any indication of dental appointments. Resident R179, admitted in June 2024, was cognitively intact and reported tooth pain, yet her electronic medical record lacked evidence of a dental visit being offered. She confirmed to social services her desire for a dental appointment to address her tooth pain. Interviews with staff revealed inconsistencies in the process of offering dental services, with some staff unaware of residents' dental issues. The facility's Dental Services policy outlined the availability of routine and emergency dental services, but the lack of documentation and follow-up indicated a failure to adhere to this policy.
Failure to Complete Self-Administration Assessment for Resident
Penalty
Summary
The facility failed to ensure a self-administration of medications (SAM) assessment was completed for a resident, identified as R184, who was observed self-administering a nebulizer treatment without the necessary assessment or physician's order. R184, who had moderate cognitive impairment and multiple medical conditions including dysphagia, hemiplegia, and chronic respiratory failure, was observed by a registered nurse (RN-G) filling the nebulizer chamber with medication and indicating he would start the machine himself after smoking. Despite this, there was no documented assessment or physician's order authorizing R184 to self-administer medications. Interviews with RN-G and the nurse manager (RN-E) confirmed that a doctor's order and a self-administration assessment were required for a resident to self-administer medications. However, it was verified that R184 did not have such an order or assessment. The facility's policy and procedure for self-administration of medications were requested but not provided, indicating a lack of adherence to protocol and oversight in ensuring the resident's ability to safely self-administer medication.
Lack of Staff Training on Ventilator Use for Resident with Respiratory Disease
Penalty
Summary
The facility failed to ensure that direct-care nursing staff were appropriately trained and competent in the use of an external ventilator machine for a resident with significant respiratory disease. The resident, who had intact cognition and several medical conditions including heart failure, Parkinson's Disease, seizure disorder, respiratory failure, and chronic lung disease, used a Respironics Trilogy 100 machine during overnight hours. The resident reported that staff did not manage the device, and there was no evidence of staff training on the device or guidance on how to handle alarms. Interviews with nursing staff revealed a lack of training and knowledge regarding the ventilator machine. A registered nurse stated that they had not received training on the device, and a licensed practical nurse expressed that they would troubleshoot the machine if it alarmed, despite no formal education on its use. The registered nurse manager acknowledged the absence of training and the importance of staff understanding the machine's operation and alarm management. The facility lacked a user manual for the device at the nurses' station, and no evidence of staff training or alarm reporting was provided during the survey. The director of nursing confirmed that no education on the device had been completed following the resignation of the previous nurse educator. The facility did not provide a policy on staff competency with medical device training, and a user manual for the device was not readily available. The deficiency highlights the facility's failure to ensure staff competency in managing the resident's ventilator machine, which is critical for the resident's respiratory care.
Improper Medication Administration via Gastric Tubes
Penalty
Summary
The facility failed to maintain a medication administration error rate of less than 5%, resulting in a 64.52% error rate for two residents. The errors were primarily due to the improper administration of medications via gastric tubes without appropriate provider orders. For one resident, medications such as baclofen, metoprolol, escitalopram, and sennoside were crushed and mixed together, then administered through a gastric tube without individual administration or water boluses in between, as required by facility policy. The second resident experienced similar issues, with medications like sertraline, cholecalciferol, folic acid, and others being crushed and mixed together before administration. The licensed practical nurse involved was unsure if it was safe to mix all medications together and admitted it was their first experience with tube feeding medication administration. This lack of clarity and adherence to proper procedures contributed to the high medication error rate. Interviews with nursing staff and the director of nursing revealed a lack of understanding and adherence to the facility's policy, which mandates that each medication be administered separately unless a provider order specifies otherwise. The director of nursing emphasized the importance of clarifying medication orders upon admission to prevent potential interactions and ensure safe administration practices.
Failure to Honor Resident Drink Preferences
Penalty
Summary
The facility failed to ensure that a resident, identified as R39, received drinks according to their preferences, which impacted their fluid intake and meal satisfaction. R39, who had moderate cognitive impairment, expressed dissatisfaction with the meal service, specifically noting a preference for milk over the red-colored juice that was consistently served. Despite repeatedly requesting milk, R39's requests were not consistently honored, leading to ongoing dissatisfaction with the meal service. During an observation of the meal service, it was noted that the nursing assistant (NA-H) did not follow the resident's documented preferences. Although the menu slip on R39's meal tray indicated a preference for milk, NA-H did not serve it, instead opting to serve a red-colored drink. NA-H claimed familiarity with the residents' preferences but did not verify the menu slip or ask R39 about their drink choice for that meal. This oversight resulted in R39 not receiving their preferred beverage, milk, despite it being clearly marked on the menu slip. Interviews with staff revealed a lack of clarity and communication regarding the significance of starred items on the menu slips, which were intended to indicate resident preferences. The kitchen supervisor confirmed that the starred items were meant to denote beverage preferences, and staff were expected to ask residents about their drink choices at each meal. However, this practice was not consistently followed, as evidenced by the failure to provide R39 with their preferred drink. The facility did not have a policy on resident drink preferences with meals, contributing to the inconsistency in honoring resident preferences.
Failure to Offer Timely Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that recommended pneumococcal immunizations, as outlined by the CDC, were offered and/or provided in a timely manner to two residents reviewed for immunizations. One resident, identified as R158, had intact cognition and several medical conditions, including chronic lung disease and was a current smoker. Despite being admitted to the care center months prior, R158's medical record showed he had only received two doses of the PPSV23 vaccine, with the last one in 2010, and lacked any evidence of subsequent recommended pneumococcal vaccinations being offered or discussed. R158 confirmed in an interview that he had not been asked about additional vaccinations since his admission. Another resident, R17, also had intact cognition and medical conditions including heart failure and respiratory failure. R17's immunization history showed she had received both the PPSV23 and PCV13 vaccines, with the last administration over five years prior. Her medical record lacked evidence of any subsequent recommended pneumococcal vaccinations being offered or discussed. In an interview, R17 stated she had not been asked about the newer PCV15/20 vaccination, although she would have accepted it due to her poor breathing. The assistant director of nursing and regional nurse consultant confirmed the lack of documentation for offering these vaccinations and acknowledged the oversight in managing the facility's infection control program after the previous infection preventionist resigned.
Failure to Provide Interpretive Services for Non-English Speaking Resident
Penalty
Summary
The facility failed to provide interpretive services for a resident whose primary language was Somali, resulting in the resident not being fully informed about his health status, care, and treatments. The resident, who had moderately impaired cognition and a cognitive communication deficit, was observed to be agitated and unable to communicate effectively with staff due to the language barrier. Despite the resident's need for an interpreter being documented in various medical and social worker notes, the facility did not consistently provide access to interpretive services, relying instead on ad-hoc methods such as using picture cards or family members for interpretation. The resident's medical history included diabetes, metabolic encephalopathy, and dementia with behavioral disturbances, which required careful management and communication about his treatment plan. However, the facility's staff often did not use an interpreter, even when discussing important aspects of his care, such as dietary restrictions and insulin therapy. This lack of communication led to the resident's frustration and refusal of care, as he was unable to understand the reasons behind the staff's actions, such as the removal of snacks from his room. Interviews with staff revealed a lack of consistent access to a language line or in-person interpreters, despite the facility's policy stating that interpreters should be used for medical discussions. The resident's inability to understand English-written materials, such as menus and activity schedules, further compounded his isolation and confusion. The facility's failure to provide adequate interpretive services hindered the resident's ability to participate in his care and make informed decisions about his treatment options.
Failure to Use Interpreter and Misunderstanding of Resident Rights
Penalty
Summary
The facility failed to use an interpreter during the admission process for a resident whose preferred language was Somali, impacting the resident's ability to fully understand their rights and participate in care decisions. The resident, identified as having moderately impaired cognition and a cognitive communication deficit, was not provided with interventions to improve communication, despite these needs being documented in their care plan. The resident's medical history included conditions such as metabolic encephalopathy, diabetes, and dementia with behavioral disturbances, which further complicated their ability to communicate effectively. During interviews, staff acknowledged that the resident did not have an interpreter during the admission process, and the social worker confirmed that the resident's code status should not affect their right to refuse treatment. Additionally, there was a misunderstanding among staff regarding the resident's right to refuse care based on their code status. The Director of Nursing and a medical doctor expressed that the resident's full code status influenced their approach to the resident's care, suggesting that a change to a do not resuscitate (DNR) status might align better with the resident's wishes to refuse certain treatments. The administrator and social worker, however, emphasized that a resident's code status should not impact their right to refuse treatment. An incident was noted where a nurse practitioner attempted to remove sweets from the resident's room, which was seen as an inappropriate interference with the resident's rights. The facility's policy on resident rights clearly stated that residents have the right to refuse treatment regardless of their medical condition or code status.
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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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