Lakeshore Rehabilitation Center Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Waseca, Minnesota.
- Location
- 108 8th Street Northwest, Waseca, Minnesota 56093
- CMS Provider Number
- 245388
- Inspections on file
- 16
- Latest survey
- March 27, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Lakeshore Rehabilitation Center Llc during CMS and state inspections, most recent first.
Surveyors found that the facility failed to maintain proper storage of frozen and refrigerated foods, with significant ice buildup in the walk-in freezer and multiple opened food items in coolers and storage areas lacking required labels and dates. Staff and administration confirmed these deficiencies, and some food items were found to be expired or spoiled, contrary to facility policy.
A resident with multiple chronic conditions and requiring significant assistance with daily living was allowed to self-administer nebulizer treatments without a documented assessment or physician order. Staff set up the nebulizer and left the resident to complete the treatment alone, despite facility policy requiring an interdisciplinary assessment for self-administration. Staff interviews confirmed the absence of the required assessment and order in the resident's record.
A resident requiring substantial assistance with ADLs, including personal hygiene, was observed over several days with significant facial hair growth and expressed a desire to be shaved. Despite staff awareness of the need to assist with shaving and the facility's policy on person-centered care, no staff provided the necessary assistance, and the resident's care plan lacked documentation of shaving preferences.
The facility's QAPI committee did not identify or address ongoing freezer maintenance issues, including persistent ice buildup, despite repeated citations in past surveys for similar food storage and sanitation concerns. Interviews revealed that the dietary manager was aware of the problem, but the administrator was not, and QAPI meeting minutes showed no evidence of monitoring or corrective action for the freezer deficiency.
The facility failed to properly store frozen food in a walk-in freezer due to significant ice buildup, risking cross-contamination and foodborne illness. The director of culinary services confirmed ongoing issues with ice buildup, and the facility's policy lacked guidance on addressing this problem.
The facility failed to assess residents for suitability to be assisted by paid feeding assistants (PFAs) and did not ensure supervision by a nurse during meals. Six residents with cognitive impairments and swallowing difficulties were not formally assessed for PFA assistance, and staff were unaware of which residents could be assisted. The facility's policy required interdisciplinary assessments, but this was not followed, leading to unsupervised feeding assistance.
The facility failed to offer and provide recommended pneumococcal vaccinations to four residents, as per CDC guidelines. Despite having a policy to offer vaccinations, the facility did not ensure shared clinical decision-making or document the provision of newer PCV15/20 vaccines. Interviews with the DON and RNC confirmed the oversight, affecting residents with various medical conditions.
A resident experienced a breach of privacy when a nursing assistant entered her room without knocking, despite her preference for privacy. Another resident faced a prolonged wait for her meal, highlighting issues with the facility's dining service. The facility's policies on resident dignity and dining audits were not effectively implemented, leading to ongoing resident concerns.
A resident on hospice care complained of constipation, but the facility failed to comprehensively assess and develop a proactive bowel management program. Initial assessments were incomplete, and the care plan lacked interventions beyond toileting assistance. Despite the resident's preference for dietary interventions, the facility relied on laxatives, which the resident disliked. Staff interviews revealed lapses in communication and documentation, and the facility lacked a policy on bowel management programs.
Improper Food Storage and Labeling in Kitchen and Freezer
Penalty
Summary
Surveyors observed that the facility failed to properly store frozen food items in the walk-in freezer, resulting in significant ice buildup on the ceiling, walls, floor, and shelving. Cardboard food boxes were found to be soft, mushy, and covered in ice, with one box partially melted into a mound of ice on the floor. The cooling fan in the freezer was not functioning properly, and maintenance had only recently attempted repairs. The culinary services director acknowledged that the ice buildup had been an ongoing issue and could lead to food contamination, freezer burn, or food spoilage. The administrator was unaware of the current ice buildup, despite it being a concern during the last annual survey. Additionally, the facility did not ensure that food items stored in refrigerators and dry storage were properly labeled, dated, or discarded as required. Multiple opened food items, including salsa, hot dogs, cottage cheese, egg salad, lettuce, sliced cheeses, and sour cream, were found without labels or dates, and some were expired or spoiled. Staff interviews confirmed that the expectation was to label and date all opened food items, but this was not consistently followed. Facility policies required proper labeling, dating, and storage of food, but these procedures were not adhered to during the survey.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident was comprehensively assessed for self-administration of medications, as required by policy. The resident, who had intact cognition but required substantial to maximal assistance with all activities of daily living, including personal hygiene, was observed self-administering nebulizer treatments without a documented assessment or physician order permitting self-administration. Staff interviews confirmed that the resident's electronic health record did not contain an order for self-administration, and the director of nursing acknowledged that no assessment had been completed for this purpose. Observations showed the resident independently using the nebulizer in her room, with staff setting up the medication and equipment but leaving the resident alone to complete the treatment. Staff reported that they would return after 10-15 minutes to check on the resident and turn off the machine. Additionally, nursing assistants noted that the resident sometimes required assistance to properly position the nebulizer mask. The facility's policy required an interdisciplinary team assessment to determine if self-administration was clinically appropriate and safe, but this process was not followed for the resident in question.
Failure to Provide Assistance with Facial Hair Removal
Penalty
Summary
A resident with intact cognition and diagnoses including diabetes mellitus and arthritis was identified as requiring substantial to maximal assistance with activities of daily living (ADLs), specifically personal hygiene. The resident's care plan did not document shaving preferences. Over several days of observation, the resident was noted to have approximately one inch of white facial hair on the chin, and the resident expressed a desire to be shaved, stating that staff had assisted with shaving in the past. Multiple staff interviews revealed that nursing assistants and an LPN were aware of the need to assist residents with shaving when facial hair was noticed, but none had provided this care to the resident in question. The DON confirmed that staff are expected to shave residents' facial hair, especially for women, and that razors are available for use. The facility's ADL policy emphasized person-centered care and honoring resident preferences, but this was not reflected in the care provided to the resident, resulting in a failure to assist with facial hair removal.
Failure of QAPI Committee to Address Ongoing Freezer Maintenance Deficiencies
Penalty
Summary
The facility failed to ensure its Quality Assurance and Performance Improvement (QAPI) committee identified, investigated, analyzed, and responded to ongoing freezer maintenance issues, specifically the prevention of ice buildup. Despite the facility's QAPI plan outlining a proactive approach to quality improvement and a process for addressing high-risk or problem-prone areas, the committee did not address or monitor recurring concerns related to freezer maintenance. The deficiency was noted during interviews and document reviews, which revealed that the QAPI committee had not discussed or tracked the freezer issue, even though similar deficiencies had been cited in the last three recertification surveys. These previous citations included failures to properly label and store food, sanitize equipment, and prevent cross-contamination in the kitchen and freezer areas. During interviews, the dietary manager acknowledged that the freezer fan had been blocked and that ice buildup had persisted for several weeks, potentially affecting food quality. The administrator was unaware of the current ice buildup and confirmed that the issue had been identified in the past, with previous corrective actions not sustained. Review of QAPI meeting minutes showed no documentation of the freezer issue, and there was no evidence of ongoing monitoring or follow-up on the previously identified deficiency.
Improper Storage of Frozen Food Due to Ice Buildup
Penalty
Summary
The facility failed to ensure proper storage of frozen food items in their main production kitchen's walk-in freezer, which posed a risk of cross-contamination and potential foodborne illness. During an inspection, it was observed that the freezer had significant ice buildup on the cooling fan, ceiling, back wall, floor, and metallic shelving. Food items, including an opened box of salmon and an unopened box of cod, were stored in this environment. The salmon box was open, with fillets exposed and covered in ice, while the cod box was sealed but had wet spots and loose tape. The temperature inside the freezer was recorded at -8 degrees Fahrenheit. The director of culinary services confirmed the ongoing issue with ice buildup, stating that maintenance had chiseled the ice out multiple times over the past seven months. Despite these efforts, the ice buildup persisted, and the salmon was discarded due to contamination concerns. The facility's policy on refrigerator and freezer maintenance lacked specific guidance on addressing repeated ice buildup, contributing to the deficiency.
Failure to Assess and Supervise Feeding Assistance
Penalty
Summary
The facility failed to ensure that residents were properly assessed for their suitability to be assisted by paid feeding assistants (PFAs) during meals. This deficiency was observed in six residents, all of whom had varying degrees of cognitive impairment and required assistance with activities of daily living, including eating. The facility did not conduct assessments to determine if these residents, some of whom had conditions like dysphagia, were appropriate candidates for assistance by PFAs. The care plans and clinical nutrition evaluations for these residents lacked documentation of such assessments, and there was no mention of the residents' ability to be assisted by PFAs. Additionally, the facility did not ensure that PFAs were supervised by a nurse while assisting residents with meals. Observations revealed that activity department staff, who had completed the PFA training, were assisting residents without the presence of a nurse. Interviews with staff confirmed that there was no formal list of residents who could be assisted by PFAs, and the staff were under the impression that they could assist any resident needing help with eating. The director of nursing acknowledged the lack of formal assessments and supervision, stating that they relied on informal knowledge of residents' needs. The facility's policy on paid feeding assistants required an interdisciplinary team assessment to determine residents' eligibility for feeding assistance, but this was not adhered to. The director of nursing and other staff members confirmed that there was no formal assessment process in place, and the facility did not maintain a list of residents who could be assisted by PFAs. This lack of formal assessment and supervision posed a risk to residents, particularly those with swallowing difficulties or other complex feeding needs.
Failure to Provide Recommended Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that recommended pneumococcal vaccinations, as outlined by the CDC, were offered and/or provided in a timely manner to four out of five residents reviewed for immunizations. The CDC's guidelines for pneumococcal vaccine timing for adults, dated March 2023, recommend shared clinical decision-making between the resident and healthcare provider to determine if the PCV20 vaccine is appropriate. However, the facility did not adhere to these guidelines, as evidenced by the lack of documentation and shared decision-making for residents R3, R2, R8, and R24. Resident R3, with moderate cognitive impairment and medical conditions such as heart failure and diabetes mellitus, had received the PPSV23 vaccine in 1997 but had no record of receiving the newer PCV15/20 vaccines. Similarly, resident R2, with intact cognition and conditions including diabetes mellitus and heart failure, received the PPSV23 vaccine in 2005 but lacked evidence of subsequent pneumococcal vaccinations. Both residents did not recall being offered the newer vaccines, and their medical records lacked evidence of shared clinical decision-making regarding these vaccinations. Resident R8, with moderate cognitive impairment and conditions like anemia and chronic kidney disease, had received the PPSV23 in 2009 and PCV13 in 2017 but not the newer PCV15/20 vaccines. Resident R24, with intact cognition, had received the PPSV23 in 2000 and PCV13 in 2017, also without evidence of being offered the newer vaccines. Interviews with the DON and RNC confirmed that the facility had not provided the newer pneumococcal vaccinations to these residents, despite being aware of CDC recommendations. The facility's pneumococcal policy, dated February 2024, stated that vaccinations would be offered to all residents, but this was not followed in practice for the identified residents.
Deficiencies in Resident Privacy and Dining Experience
Penalty
Summary
The facility failed to maintain a dignified and personal space for a resident, identified as R8, when a nursing assistant entered the resident's room without knocking or waiting for a response. R8, who had moderate cognitive impairment, expressed a preference for privacy and for staff to knock before entering. Despite this, the nursing assistant entered the room abruptly during an interview with a surveyor, claiming to have knocked, although R8 and other residents had previously commented on staff not always knocking. The Director of Nursing was unaware of such issues but emphasized the importance of knocking to respect residents' dignity and privacy. In another incident, the facility failed to provide a dignified dining experience for a resident, identified as R29, who waited an extended period for her meal while her tablemates were served and finished eating. R29, who was cognitively intact and independent with eating, had ordered a grilled cheese sandwich from the always available menu, which was delayed due to a cooking issue. The dietary aide and certified dietary manager acknowledged the delay, with the latter stating that meals should be served within 30-40 minutes. Despite efforts to improve meal service times, residents continued to express concerns about long wait times during resident council meetings. The facility's policy on dining room audits required regular checks to ensure residents' needs were met and that dining was a pleasant experience. However, the policy did not seem to be effectively implemented, as evidenced by the ongoing complaints about meal wait times. The administrator acknowledged the issue and mentioned plans to have items from the always available menu prepared in advance, but residents continued to experience delays, impacting their dining experience and sense of dignity.
Failure to Implement Proactive Bowel Management Program
Penalty
Summary
The facility failed to comprehensively assess and develop interventions for a proactive bowel management program for a resident (R31) who complained of constipation. Upon admission, R31 was identified as having intact cognition and was continent of bowel, but the initial assessments lacked a thorough evaluation of bowel patterns and preferences. The bowel evaluation conducted was incomplete, with sections left blank and no individualized treatment plan documented. Despite R31's complaints of constipation and her preference for dietary interventions like prunes and graham crackers, the facility did not engage with her to develop a proactive management plan, instead opting for laxatives which she disliked. R31's care plan, which included hospice enrollment for heart failure and a lung mass, did not adequately address her bowel management needs. The care plan only listed a single intervention of assistance with toileting, lacking any comprehensive strategies to manage her bowel movements. Progress notes from hospice visits indicated potential constipation concerns due to narcotic use, but there was no follow-up or re-evaluation of R31's bowel management needs by the facility after a certain date. The facility's documentation did not reflect any proactive measures or reassessment of R31's bowel management program, despite hospice's observations and R31's own input. Interviews with staff revealed a lack of communication and documentation regarding R31's bowel management. Nursing staff acknowledged lapses in creating daily listings for bowel interventions and noted that comprehensive bowel evaluations were considered the responsibility of hospice. The Director of Nursing admitted that the facility's assessments were more focused on incontinence rather than proactive bowel management. The facility did not have a policy on bowel management programs, and there was no evidence of a comprehensive assessment or management plan to address R31's constipation and promote her comfort.
Latest citations in Minnesota
A resident with dry eye syndrome and degenerative eye disease had orders for cyclosporine ophthalmic emulsion and Refresh Tears, both scheduled at the same time. Medication records and direct observation showed a TMA instilled cyclosporine drops in both eyes and immediately followed with Refresh Tears in both eyes without waiting between medications. This practice conflicted with referenced professional guidance recommending several minutes between multiple eye drops and with the medical provider’s recommendation to wait fifteen minutes between the two ophthalmic medications. No facility policy on ophthalmic medication administration was provided when requested.
A resident with severe cognitive impairment, impaired mobility, and high fall risk was care planned to have wheelchair footrests in place at all times, with staff ensuring proper positioning and monitoring for leaning during transport. A NA transported the resident in a manual wheelchair from the shower without the footrests, and while going through the doorway the wheelchair struck the door frame, causing the resident, who was leaning forward, to fall out. The resident sustained a T12 fracture, head injury with concussion, abrasions and contusions, and multiple right-hand lacerations requiring sutures, and the DON confirmed the care plan had not been followed.
A high‑risk, immobile resident with MS and prior heel DTI developed an avoidable unstageable coccygeal pressure ulcer after staff failed to consistently assess and document skin status, did not transfer or timely provide ordered pressure‑relieving mattresses, and did not reliably perform q2h repositioning. The resident was repeatedly left on a bedpan for prolonged periods despite early reports of this issue, and the toileting care plan was not revised to a bedside commode until after the coccygeal wound had significantly worsened. Wound assessments lacked complete measurements and staging, changes in wound size and color were not promptly recognized as deterioration or reported to providers, and recommended interventions from a wound NP (including an air mattress and offloading) were not promptly implemented. As a result, the coccygeal ulcer rapidly progressed to a large, necrotic, malodorous wound requiring hospital transfer and surgical debridement.
A resident with spastic hemiplegia, muscle weakness, and moderate cognitive impairment was observed using bilateral bed grab bars for bed mobility and transfers, but the care plan did not address grab bar or side rail use. Review of the EMR showed no completed bed mobility device or side rail assessment to determine the necessity or safety of the grab bars, and no documentation that risks and benefits were discussed or that informed consent was obtained. An LPN and the ADON stated that a bed mobility device assessment is required before grab bars are installed and confirmed that no such assessment existed for this resident.
A resident with bilateral heel pressure ulcers and multiple comorbidities received wound care during which an RN removed dressings from both heels, cleansed both wounds, and wiped each heel without changing gloves or performing hand hygiene between wounds or after disposing of soiled dressings. This practice conflicted with the facility’s written wound care procedure, which requires glove removal and hand hygiene after dressing removal and after wound cleansing. In interviews, the RN, NP, and DON/IP acknowledged that hand hygiene and glove changes are expected between dirty and clean tasks and between separate wounds to prevent infection.
A resident with MS, neurogenic bladder, mobility limitations, and existing pressure injuries was identified as dependent for toileting hygiene and at risk for pressure ulcers, yet the care plan lacked an individualized toileting/incontinence plan and a defined repositioning schedule. Despite a new coccyx pressure ulcer and documentation that interventions such as increased repositioning and incontinent care were needed, the care plan was not revised for a period of time to reflect these changes. During this time, the resident sometimes fell asleep on a bedpan and remained on it until staff removed it, and staff were not initially informed that the bedpan should no longer be used. The DON later acknowledged that the care plan revisions for turning, repositioning, and toileting were delayed until after the resident’s coccyx ulcer had significantly worsened.
A resident with diabetes, Crohn’s disease, bowel incontinence, and a history of MASD on the right gluteus developed an open, painful lesion on the right gluteal area that was documented over time without complete wound characteristics, clear etiology, or timely provider notification. Wound care orders were written for a stage 3 pressure ulcer on the left buttocks, while staff reported the wound was only on the right side and applied the left‑sided orders to the right gluteal wound in the absence of specific right‑side treatment orders. The DON acknowledged discomfort with staging the wound, lack of early physician notification, and confusion over wound classification, despite a facility policy requiring comprehensive wound assessment, consistent measurement, and provider notification when treatment orders are absent.
A resident with diabetes, chronic leg ulcer, kidney transplant, and a documented gluteal wound was care-planned for Enhanced Barrier Precautions (EBP), with posted instructions requiring gown and gloves for high-contact care such as transfers and wound care. During a telehealth wound assessment, the DON donned a gown and initially performed hand hygiene but then applied gloves without hand hygiene, removed a soiled dressing from the resident’s gluteal area, discarded it, removed gloves, and applied new gloves again without performing hand hygiene between glove changes. On another occasion, during use of a sit-to-stand lift, an NA wore gown and gloves, but the DON handled the lift harness, the resident’s clothing, and assisted with the transfer and repositioning while wearing a gown but no gloves, despite EBP requirements for transfers. The DON stated EBP was only needed for catheter or wound care and not for transfers, contradicting the posted EBP instructions and facility policy.
A resident with severe dementia, psychiatric disorders, and high dependence for ADLs was verbally abused during evening care when a NA, frustrated with the resident’s crying and resistance, loudly ridiculed her as acting like a two-year-old, threatened to hit her back if struck, told her she would be sent to a locked unit, and questioned who would want to care for her when she cried like a baby. Multiple staff witnessed the loud, stern, and intimidating tone and reported it to an LPN, who recognized it as verbal abuse but did not immediately remove the NA from duty or promptly report the allegation per policy, allowing the NA to continue working on the unit. Following this incident, the resident demonstrated increased crying, combativeness, resistance to care, wandering, self-isolation, and refusal of food, fluids, and medications above baseline, with documentation of significant emotional distress and subsequent ED evaluation for aggressive behaviors and poor intake.
A resident with dementia, bilateral above‑knee amputations, vascular disease, and severe protein‑calorie malnutrition developed a wound on an amputation stump that had a dressing dated several days before any documentation or treatment orders appeared in the record. Although bath audits and nursing notes initially reported no skin issues, a later assessment described a full‑thickness stage 4 ulcer/diabetic ulcer on the stump with exposed bone, erythema/edema, slough, and moderate serosanguineous drainage. Nursing staff interviews showed no one could identify who first discovered the wound or applied the initial dressing, and there was no evidence that the wound was assessed, the provider notified, or standing orders implemented when it was first present, despite facility expectations that new wounds be promptly evaluated and reported.
Failure to Follow Professional Standards for Ophthalmic Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice for administering ophthalmic medications to a resident with dry eye syndrome and degenerative eye disease. The resident was cognitively intact, required assistance with ADLs, and had physician orders for cyclosporine ophthalmic emulsion 0.05% one drop in both eyes twice daily and Refresh Tears ophthalmic solution one drop in both eyes four times daily for dry eyes. The administration summary showed that both eye medications were scheduled for the same time and were documented as being given at the same time on multiple dates. During a medication pass observation, a trained medication aide administered the ordered oral medications, then applied gloves and instilled one drop of cyclosporine in each eye, immediately followed by one drop of Refresh Tears in each eye, without any waiting period between the two medications. The surveyors referenced guidance from the American Academy of Allergy, Asthma, and Immunology stating that when more than one eye drop is ordered, three to four minutes should be allowed between drops in the same eye, and five to fifteen minutes should be allowed between different eye medications to prevent dilution. Interviews with the DON, pharmacy consultant, and medical provider confirmed that best practice and the provider’s recommendation were to wait between administration of cyclosporine and Refresh Tears, with the medical provider specifying a fifteen-minute interval. The facility did not provide a policy on ophthalmic medications when requested. The observed practice and documented administration times demonstrated that staff did not follow these professional standards or the medical provider’s recommended interval between the two eye medications.
Failure to Follow Wheelchair Transport Care Plan Leads to Fall With Injuries
Penalty
Summary
The deficiency involves the facility’s failure to implement care-planned fall prevention interventions for a resident at high risk for falls, resulting in a fall with injury. The resident had diagnoses including aphasia, dysphagia, muscle weakness, traumatic brain injury, and impaired mobility, with severe cognitive impairment documented on the MDS and dependence on staff for transfers and wheelchair transport. A care plan addressing wheelchair transport safety and positioning directed staff to ensure the resident was fully positioned and supported in the wheelchair prior to transport, verify footrests were in place prior to transport, and monitor for leaning, sliding, or unsafe positioning. An additional care-planned approach required wheelchair pedals to be on at all times. On the date of the incident, a nursing assistant transported the resident in a manual wheelchair from the shower room to the resident’s room without the foot pedals in place, contrary to the care plan. While being wheeled through the doorway, the wheelchair struck the door frame, causing the chair to stop and the resident, who had begun leaning forward, to fall out of the wheelchair onto the floor. Progress notes and ED documentation identified that the resident sustained a T12 vertebral fracture, a head injury with concussion, an abrasion and contusion to the head, a bruise to the left knee, and multiple lacerations to the right hand requiring sutures. The nursing assistant later acknowledged awareness that the foot pedals should have been on but did not apply them because the transport was only from the shower to the room. The DON confirmed that the resident’s care plan had not been followed when the fall occurred.
Failure to Implement and Update Pressure Ulcer Prevention and Treatment Led to Avoidable Unstageable Coccygeal Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, monitor, and implement individualized pressure ulcer prevention and treatment interventions for multiple high‑risk residents, resulting in an avoidable, unstageable coccygeal pressure ulcer for one resident that required surgical debridement and hospitalization. The resident had primary progressive multiple sclerosis, hereditary spastic paraplegia, obesity, and pre‑existing pressure‑related deep tissue injury to the left heel, and was identified as high risk for pressure ulcers on the Braden Scale due to constant moisture, chairfast status, very limited mobility, inadequate nutrition, and friction/shear risk. Hospital records on readmission documented irritant contact dermatitis of the bilateral gluteal cleft with specific cleansing and barrier cream orders, and facility documentation showed the resident could not reposition in bed or chair and required assist of two and a full‑body mechanical lift for transfers. Despite this, the admission/readmission skin assessment and weekly skin checks lacked measurements and detailed wound characteristics for the heel ulcer and gluteal dermatitis, and the care plan did not include comprehensive, individualized interventions beyond generic repositioning and wound care orders. After a new coccyx pressure ulcer was identified and documented as a stage 2 lesion, the facility failed to promptly and accurately update the care plan and implement recommended pressure‑relieving interventions. The wound nurse practitioner on 3/5 ordered coccyx wound care, an air mattress, pressure offloading, and a dietician consult, but the care plan was not revised and there was no evidence that an air mattress was placed on the bed for nearly two weeks. The environmental services director later confirmed that when the resident was moved to a new room, the gel mattress was not transferred, and the air mattress requested on 3/17 was not actually placed until the following day, despite being marked as completed. During this period, TAR documentation showed gaps in the every‑2‑hour repositioning order, and staff interviews revealed that CNAs were unaware of which residents were on repositioning programs, were not consistently repositioning residents, and had not received recent education on pressure ulcer prevention. The DON and RN case manager acknowledged that the coccyx wound increased in size and changed color between assessments, that the bed lacked the ordered gel mattress, and that the physician was not notified of the wound’s deterioration at that time. The facility also failed to timely modify toileting and incontinence care practices despite knowledge that the resident was being left on a bedpan for extended periods. The DON reported hearing before an IDT meeting that the resident had fallen asleep on a bedpan for an undetermined amount of time, but the care plan was not revised to discontinue bedpan use and implement a bedside commode until after the coccyx wound had significantly worsened. CNAs confirmed that the resident sometimes fell asleep on the bedpan and that they were not informed she should no longer use it until after the sore had worsened. Subsequent wound assessments documented rapid progression of the coccyx wound from a small stage 2 ulcer to a large, malodorous, necrotic wound with eschar, slough, erythema, and purulent drainage, ultimately classified as an unstageable pressure ulcer. The DON, NP, PA, and medical director all indicated that the lack of a pressure‑relieving mattress, failure to adjust pressure‑reducing interventions, and prolonged time on a bedpan likely contributed to the development and deterioration of the resident’s pressure ulcer, which was determined to be avoidable and resulted in hospitalization and surgical debridement. Additional documentation and interviews showed systemic assessment and communication failures related to pressure ulcer management. Weekly skin checks and wound assessments often omitted complete measurements, staging, and wound characteristics, and changes in wound size and appearance were not consistently recognized as deterioration or communicated to providers. The DON acknowledged that a 3/12 assessment showing increased wound size and purple discoloration should have been identified as a deep tissue injury and reported to the physician, but this did not occur. When nursing later documented foul odor, increased pain, and expanding necrotic tissue, telemedicine and PA responses deferred in‑person evaluation and ED transfer despite earlier recommendations that the resident be sent to the ED if an in‑person provider could not assess the wound. The NP ultimately found a large, malodorous, purulent wound with expanding eschar and ordered transfer to the hospital, where imaging and surgical findings confirmed a large necrotic sacral wound requiring extensive debridement. Throughout this sequence, the facility did not consistently follow its own pressure ulcer protocols, did not ensure ordered pressure‑relieving equipment was in place, and did not promptly revise care plans or interventions in response to known risk factors and documented wound changes. The report also notes that other residents reviewed for pressure ulcers were affected by similar failures in monitoring and individualized intervention, though detailed narratives focus primarily on this resident. Staff interviews revealed that CNAs relied on paper care guides that did not clearly identify residents on repositioning programs or at risk for skin breakdown, and that they were unaware of some residents’ special mattress orders or toileting restrictions. The DON and medical director stated that residents at risk for pressure ulcers should have immediate pressure‑relieving interventions and that existing ulcers require ongoing evaluation to prevent deterioration, but the documented practices for this resident did not align with those expectations. These combined actions and inactions—insufficient assessment detail, delayed or missing care plan revisions, failure to implement ordered support surfaces and repositioning, and delayed response to wound deterioration—constituted the deficiency in providing appropriate pressure ulcer care and preventing new ulcers from developing.
Failure to Assess, Care Plan, and Obtain Consent for Bed Grab Bar Use
Penalty
Summary
The deficiency involves the facility’s failure to follow required procedures before installing and using bed grab bars for a resident. The resident had diagnoses including spastic hemiplegia affecting the left side and muscle weakness, and an admission MDS indicating moderate cognitive impairment. During observation, the resident was seen in a power chair with bilateral grab bars on the bed and reported using them to roll in bed and for transfers. The resident’s care plan, dated 1/23/26, documented a need for assistance with bed mobility and independence with transfers but did not mention or address the use of grab bars or side rails. Review of the electronic medical record showed no completed grab bar/side rail or bed mobility device assessment to determine the necessity of the grab bars or whether the resident could safely use them. There was also no evidence that the resident or the resident’s representative had been educated on the risks of having a grab bar on the bed or that informed consent had been obtained. In interviews, an LPN and the ADON both stated that a bed mobility device assessment was required to determine need and safety prior to installing grab bars, and both confirmed that no such assessment was present in the resident’s record.
Failure to Perform Hand Hygiene and Change Gloves During Wound Care
Penalty
Summary
Surveyors observed that a registered nurse (RN) and a nurse practitioner (NP) did not follow the facility’s established infection control practices during wound care for one resident. During a wound treatment, the RN wore gloves while removing the dressing from the resident’s left heel, then removed the dressing from the right heel, sprayed both wounds with wound cleanser, wiped the left heel with gauze, and then used a clean gauze pad to wipe the right heel. The RN did not remove her gloves or perform hand hygiene after disposing of the soiled dressings or between cleaning the left and right heel wounds, contrary to the facility’s written wound care procedure, which requires glove removal and hand hygiene after removing the previous dressing and again after cleaning the wound. The resident’s admission MDS documented diagnoses including multiple rib fractures, heart failure, dementia, anxiety, and the presence of a pressure ulcer, and indicated the resident was cognitively intact and required staff assistance with care and transfers. The resident’s care plan identified pressure ulcers on both heels requiring wound care. In interviews, the RN, NP, and the DON/infection prevention nurse each stated that gloves should be changed when moving from dirty to clean areas and that hand hygiene is expected after glove removal and between wounds to prevent infection, confirming that the observed practice did not align with facility policy or expected infection control standards.
Failure to Timely Revise Care Plan for Toileting and Skin Integrity
Penalty
Summary
The deficiency involves the facility’s failure to timely revise and individualize a resident’s care plan to address toileting and incontinence needs in relation to impaired skin integrity. The resident had diagnoses including primary progressive multiple sclerosis, hereditary spastic paraplegia, obesity, and a pressure-induced deep tissue injury to the left heel. A Significant Change MDS identified the resident as dependent for toileting hygiene, with lower extremity range-of-motion limitations, wheelchair use, dependence for transfers, occasional urinary incontinence, intact cognition, and at risk for pressure ulcers with existing unhealed pressure injuries and MASD. The resident’s skin-focused care plan, revised on various dates, included skin inspections, wound care orders, weekly skin checks, pressure ulcer care to the left heel, nutritional supplements, and a gel mattress, but did not include an individualized toileting or incontinence plan. On a weekly skin check dated 3/3/26, nursing staff identified a new Stage 2 pressure ulcer on the coccyx and contact dermatitis on both gluteal folds. An IDT Final Post Review Follow Up dated 3/10/26 (signed 3/23/26) documented that a new skin issue had occurred and that interventions after the incident included wound care treatment orders, increased repositioning, and increased incontinent care. However, the resident’s care plan from 3/3/26 through 3/16/26 did not show revisions reflecting increased incontinence care or a repositioning schedule, and the care plan was not updated to include these elements until 3/17/26. During this period, the care plan still lacked an individualized toileting plan despite the resident’s identified incontinence and new coccyx pressure ulcer. Progress notes on 3/17/26 documented that the resident’s coccyx wound had declined, with an evaluation describing a deteriorating wound characterized as a Kennedy terminal ulcer/End of Life, staged as a Stage 4 pressure ulcer, in-house acquired, with increased size, exudate, odor, pain, and surrounding erythema. On that same date, the skin focus care plan was revised to include prompt incontinence care and keeping the skin clean and dry, and the elimination focus care plan was revised to address incontinence due to neurogenic bladder with use of a bedside commode offered every 2–3 hours. A nursing assistant reported that when working with the resident, the resident would sometimes fall asleep on the bedpan and forget to ask staff to remove it, and that she was not aware the resident was not supposed to use the bedpan until after the sore had worsened. The DON stated that the resident’s care plan had not been revised earlier to include a turning and repositioning schedule or toileting changes, and that it should have been revised as soon as staff learned the resident was falling asleep on the bedpan, rather than waiting until after the pressure ulcer worsened.
Failure to Assess and Notify Provider for Right Gluteal Wound
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess and appropriately manage a non‑pressure skin issue on a resident’s right gluteal area, and to notify the physician in a timely manner. The resident had diagnoses including diabetes, Crohn’s disease, and a kidney transplant, and the MDS indicated occasional bowel incontinence, no pressure ulcers, and no moisture‑associated skin damage at that time. Earlier documentation identified a resolved MASD to the right gluteus, and a progress note later described a sacral wound with creams applied, noting that sores were still open and painful during application, but without any measurements, wound characteristics, or evidence of physician notification. Subsequent wound assessments documented an open lesion on the right gluteus with specific measurements on multiple dates, but did not identify the wound type or other characteristics, and the record did not show physician notification or treatment orders for the right gluteal lesion. Provider orders in place initially addressed cleansing the buttocks and applying barrier cream, and later included a detailed wound care order for a stage 3 pressure ulcer documented on the left buttocks. However, the resident’s record did not contain a specific treatment order for the right gluteal wound, despite the ongoing documentation of an open lesion in that area. Interviews revealed confusion and inconsistency in wound identification and classification. The DON stated that the right gluteal wound was documented as an open lesion because she did not feel comfortable determining the wound type, and acknowledged that the physician should have been notified when the wound was first identified. The DON was unaware that the NP had documented the wound as being on the left buttocks and as a stage 3 pressure ulcer, while the RN reported that the wound had never been on the left buttocks and that she had been applying the left‑sided wound orders to the right gluteal area because there was no open area on the left. The resident reported a recurring painful area on the right buttocks and chronic stool leakage since prior anal fistula surgery. The facility’s own wound treatment policy required comprehensive assessment of wound etiology and characteristics, consistent measurement and documentation, and provider notification in the absence of treatment orders, which were not followed for this resident’s right gluteal wound. The deficiency centers on the lack of a comprehensive wound assessment for the right gluteal lesion, incomplete documentation of wound characteristics, failure to clearly determine and document the wound etiology, and failure to notify the physician and obtain appropriate treatment orders when the wound was identified and remained open. These actions and inactions resulted in a discrepancy between the documented wound location and type and the actual clinical presentation, as well as a period during which the right gluteal wound had no specific, clearly ordered treatment despite being open and painful.
Failure to Perform Hand Hygiene and Implement Enhanced Barrier Precautions During Wound Care and Transfers
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper hand hygiene during wound care and to consistently implement Enhanced Barrier Precautions (EBP) for a resident requiring such measures. The resident had diagnoses including diabetes, a non-pressure chronic ulcer of the right lower leg, and a kidney transplant, and a wound assessment documented an open lesion on the right gluteal area. The resident’s care plan and a sign posted outside the room specified that EBP, including gown and gloves, were required for high-contact care activities such as dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, catheter care, and wound care. During one observation, the DON performed hand hygiene and donned a gown before entering the resident’s room for a telehealth wound assessment. Inside the room, the DON went into the bathroom, applied gloves without performing hand hygiene, removed the resident’s brief, and removed a foam dressing from the right gluteal area that had stool on one corner. After discarding the soiled dressing, the DON removed gloves and then applied new gloves without performing hand hygiene between glove changes. When questioned, the DON stated that hand hygiene should be done when hands or gloves are visibly soiled and before and after removing or applying gloves, and acknowledged that hand hygiene had not been performed each time gloves were removed and reapplied. In a separate observation, the resident was transferred using a sit-to-stand mechanical lift while EBP requirements were not fully followed. An NA entered the room wearing a gown and gloves with the lift, and the DON applied the lift harness under the resident’s arms and cinched the waist strap, encountering the resident’s clothing, while not wearing gloves. After the transfer to bed, the DON pulled down the resident’s pants and removed the harness while touching the resident’s clothes. Following wound care by a CNP-WOC, the DON again assisted the resident by sitting the resident on the edge of the bed, applying the lift harness, and adjusting the resident’s pants and shirt while wearing a gown but no gloves. The DON stated that EBP was only needed for catheter or wound care and not for transfers, and only upon reading the posted EBP sign acknowledged that EBP was required for all high-contact resident care activities, including transfers.
Failure to Protect Resident From Verbal Abuse and Delay in Removing Alleged Perpetrator
Penalty
Summary
The deficiency involves the facility’s failure to protect a vulnerable resident from mental abuse and to respond appropriately to an allegation of abuse. The resident had severe cognitive impairment, Alzheimer’s disease, dementia, anxiety, depression, psychotic disorder, and significant functional dependence, including frequent incontinence and the need for extensive assistance with ADLs and transfers. Her care plan identified behavioral and mood issues such as wandering, yelling, combative behavior, and calling staff names, with interventions including calm approaches, emotional support, redirection, and monitoring for emotional distress and mood/behavior changes. She was identified as a vulnerable adult, with instructions to monitor for signs of emotional distress and to follow the facility’s abuse reporting policy. On the evening in question, while the resident was crying on the phone with her son and expressing a desire to leave, NA-A and NA-B entered to provide evening care using an EZ stand lift. After the resident ended the phone call, multiple staff reported that NA-A spoke to the resident in a loud, stern, and frustrated tone, telling her to stop crying and that she was acting like a two-year-old. When the resident swatted at NA-A, NA-A stated, “If you hit me, I’m going to hit you back,” and later told the resident she was “in trouble now.” Staff reported that NA-A told the resident she would be sent to a locked unit so she could not get out, and questioned who would want to care for her when she cried like a baby, and that nobody would want to keep working with her. NA-C described NA-A yelling commands such as “HOLD ON!” and “Stop crying! Where would you be if you were not here? Probably lying on the floor,” and felt NA-A was obviously upset and overwhelmed. These statements were made in the presence of the resident while she was already distressed and crying. Following this interaction, the resident exhibited crying, yelling, combativeness, resistance to care, wandering into other residents’ rooms, self-isolation, and refusal of food, fluids, and medications above her prior baseline, as documented in behavior charts, target behavior monitoring, and nursing progress notes. Staff documented that she cried most of the morning, was very restless, difficult to redirect, hit and pinched staff, called staff names, and refused care and meals. She required repeated redirection, 1:1 attention, and non-pharmacological interventions, and was ultimately sent to the ED for evaluation of combativeness and emotional distress, where she was treated for dementia with aggressive behavior and hypoglycemia related to poor intake. The report identifies that the resident’s actual response and the reasonable person concept showed serious psychosocial harm, including increased crying and combative behavior above baseline, fear/anxiety manifested as combativeness, resistance to care and social interaction, and self-isolation. The facility also failed to immediately remove the alleged perpetrator from resident care and to promptly report and investigate the allegation in accordance with its abuse policy. After NA-B and NA-C reported to LPN-A that NA-A had yelled at and threatened the resident, LPN-A acknowledged it as verbal abuse but did not initiate immediate protective measures or timely reporting. LPN-A stated she believed she had 24 hours to report because there was no injury, despite facility policy requiring reporting within two hours. NA-A remained on the unit and continued working until the end of her shift, including after staff had clearly communicated their concerns to LPN-A. TMA and NA staff described uncertainty about their authority to remove NA-A and reliance on the nurse to act, while the DON later informed LPN-A that NA-A should have been removed from the floor to prevent further danger to residents. The Immediate Jeopardy was determined to have begun when NA-A’s derogatory, intimidating, and threatening statements were made and continued while she remained on duty with access to the resident and other vulnerable residents.
Failure to Timely Assess and Treat Newly Discovered Stump Wound
Penalty
Summary
The deficiency involves the facility’s failure to provide timely treatment and care for a newly discovered wound on a resident’s above‑knee amputation stump. The resident was admitted with diagnoses including unspecified dementia with behavioral disturbances, vascular dementia, bilateral above‑knee amputations, vascular disease, reduced mobility, and severe protein‑calorie malnutrition, and had no documented ulcers or skin problems on admission or on the most recent MDS. A weekly bath audit on 3/17/26 documented only non‑tender lymph nodes on the right upper hip and did not identify any open areas. However, when the wound was later assessed, the dressing on the stump was dated 3/16/26, indicating that a wound and dressing existed at that time, even though no corresponding assessment, provider notification, or treatment orders were documented. On 3/23/26, nursing staff documented a new skin issue above the resident’s knee at the amputation site, describing a stage 4 pressure ulcer/injury with full‑thickness skin and tissue loss, exposed bone, erythema/edema, and moderate serosanguineous exudate. The wound measured 1.56 cm by 1.64 cm, with 20–29% granulation tissue and 80% slough. A progress note and skin issues assessment on that date confirmed the wound characteristics and staging, and the NP, after reviewing a picture, determined the wound to be a diabetic ulcer with peripheral vascular disease and severe protein‑calorie malnutrition as contributing factors. On that same date, the NP was notified, antibiotic therapy (doxycycline) was ordered for possible cellulitis, and specific wound care orders were initiated, with documentation on the MAR that these treatments were carried out beginning 3/23/26. Multiple interviews with nursing staff revealed that no one could identify who discovered the wound or who applied the initial dressing dated 3/16/26, and there was no documentation of a wound assessment, provider notification, or interim treatment between 3/16/26 and 3/22/26. Several RNs and LPNs who worked shifts from 3/16/26 through 3/20/26 stated they did not notice a wound on the stump and that, per their usual practice, they would have contacted the provider and initiated treatment if they had found one. One LPN recalled seeing a band‑aid with a date on the stump but could not recall the date, and another LPN stated she did not see the wound because she was not looking for one. The facility’s standing orders required staff to assess all wounds daily, change dressings every three days and as needed, treat with normal saline or non‑cytotoxic cleanser and appropriate dressings, and notify the provider the next business day when a new wound or injury was found. Despite these expectations, the wound identified by the dated dressing on 3/16/26 was not assessed, reported, or treated according to orders and facility policy until 3/23/26.
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