Laurels Peak Care & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Mankato, Minnesota.
- Location
- 700 James Avenue, Mankato, Minnesota 56001
- CMS Provider Number
- 245516
- Inspections on file
- 27
- Latest survey
- January 6, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Laurels Peak Care & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with osteoporosis, atrial fibrillation, and mobility needs care-planned to ambulate with a FWW and staff supervision was allowed by a per diem NA to walk in the hallway without the prescribed walker and without the NA maintaining control of the gait belt. The NA reported she had been told to let the resident do what she wanted and, after the resident declined use of the FWW and resisted hands-on assistance, the NA followed behind as the resident walked independently. While turning near the therapy area, the resident mis-stepped on an uneven area of the floor, fell forward, and sustained facial trauma and a brain bleed, later confirmed as a closed facial bone fracture. Interviews and documentation showed that the fall occurred because staff did not adhere to the resident’s care plan and did not consistently use or control the required assistive devices during ambulation.
A resident with moderate cognitive impairment and dementia, who was dependent on staff for daily care, repeatedly refused care and was verbally abusive towards staff over a seven-day period. Despite daily documentation of these behaviors in nursing progress notes, the MDS did not reflect any incidents of care rejection or abuse, and the facility could not provide a policy on MDS completion when asked.
A resident with cognitive deficits and a history of refusing care did not receive a revised, person-centered behavioral care plan or the required psychiatric follow-up after being started on sertraline for anxiety and agitation. The facility failed to document risk versus benefit assessments, conduct a root cause analysis, or identify triggers for the resident's behaviors, resulting in ongoing refusals of hygiene and incontinence care and the eventual discovery of maggots during wound care.
A resident with a history of cancer, atrial fibrillation, and diabetes continued to receive a blood thinner for 11 days after hospital discharge, despite instructions to hold the medication. Nursing staff did not clarify conflicting orders between the hospital's After Visit Summary and the facility's active medication list, resulting in ongoing administration of the anticoagulant and continued hematuria.
The facility failed to implement enhanced barrier precautions (EBP) for two residents during high-contact care activities. One resident with a brain neoplasm and an unstageable wound received peri care without the use of gowns, and another resident with diabetes and pressure ulcers was repositioned without a gown. The Director of Nursing confirmed that EBP should be used during such activities, as per facility policy.
The facility failed to consistently offer evening snacks to residents, affecting those with conditions like diabetes and COPD. Interviews revealed that residents were not offered snacks after dinner, and staff reported inconsistencies in snack availability. Snack bins were often inadequately stocked, and some residents were unaware of their existence. The dietary manager acknowledged budget constraints for snacks, and no facility policy on snacks was provided.
A resident with end-stage renal disease experienced inadequate monitoring and assessment post-dialysis, inconsistent enforcement of fluid restrictions, and lack of communication regarding dialysis refusals. The facility failed to perform necessary post-dialysis assessments, adhere to fluid restriction orders, and notify the provider of treatment refusals, compromising the resident's care.
The facility failed to label insulin pens with opened and expiration dates for three residents and did not provide clear resident identification on an insulin pen for one resident. Additionally, expired eye drop medication was administered to a resident. An LPN acknowledged the potential for medication errors, and the DON confirmed the labeling requirements. Facility policies were not adhered to, resulting in the administration of expired medication.
A resident with venous ulcers experienced inadequate infection control during wound care, as an LPN used scissors and a measuring tape that were placed on the floor without cleaning them. The resident, with a history of diabetes and peripheral vascular disease, required frequent dressing changes due to drainage. The facility's infection preventionist confirmed that items should not be placed on the floor, highlighting a breach in the facility's infection prevention policy.
The facility failed to maintain the kitchen ceiling tiles, tracks, lights, and vents in a clean and sanitary condition, potentially affecting all 51 residents. Observations revealed thick dark fuzzy material and black/brown debris on these components, with no clear responsibility for cleaning them. The dietary manager and director confirmed the need for cleaning or replacement, and no kitchen cleaning policy was provided.
The facility did not post daily nursing staffing information, affecting all residents and visitors. The document was outdated, and the DON confirmed the lapse, noting the previous receptionist responsible for posting had changed roles. No policy existed for posting nursing hours.
A resident with congestive heart failure was not properly monitored for fluid intake, weight gain, and edema as per physician orders. The facility failed to document significant weight changes and edema assessments, and staff did not consistently assist with compression socks. Interviews revealed a lack of communication and documentation, contributing to the deficiency.
Failure to Ensure Safe Ambulation and Adherence to Care Plan Leads to Resident Fall With Facial Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure that staff were competent in transferring and walking a resident who required transfer assistance, resulting in a fall with injury. The resident had diagnoses including respiratory failure, atrial fibrillation, osteoporosis, variants of Turner’s syndrome, and disorientation. On admission assessment, the resident had no documented cognitive or communication issues, used a front-wheeled walker (FWW), and required only supervision or partial assistance for transfers, ambulation, and toileting. The resident’s care plan directed staff to follow PT/OT for mobility, provide standby assistance for toileting and transfers with a FWW, and to have the resident ambulate to the bathroom with the FWW while staff remained present to provide encouragement. The care plan also noted mild loss of balance with the ability to recover independently and documented that the resident ambulated more safely with the FWW. On the day of the incident, the resident requested to walk as part of a walking program. According to the facility’s incident report and nursing progress notes, the resident was walking without the walker when she fell forward and struck her face, resulting in visible bruising, a hematoma to the right side of the head, and a nosebleed. The resident was transported to the ED, where she was diagnosed with a closed facial bone fracture and a brain bleed, and remained overnight before returning to the facility. The resident later reported that the nursing assistant had applied a gait belt but did not recall using the walker during the walk, and stated that the assistant was not holding the gait belt when they were walking. The resident described turning a corner and suddenly falling forward, characterizing the event as very traumatic. In a subsequent interview, the per diem nursing assistant reported that she had been told by other staff to let the resident do what she wanted and to stand by and watch. She stated that she found the resident in the bathroom without a walker or gait belt, assisted with toileting, and then allowed the resident to walk from the bathroom to the wheelchair without assistive devices. When the resident requested to walk in the hallway, the assistant offered the FWW with a wheelchair to follow, but the resident declined. The assistant stated she applied a gait belt, but when she attempted to hold it, the resident refused, insisting on walking independently. The assistant then followed behind as the resident walked from her room to the therapy entrance, where the resident mis-stepped at a dip in the floor and fell forward. The nurse manager, involved in the fall review, identified the root cause as the resident’s refusal to use the FWW combined with the assistant allowing the resident to ambulate without the prescribed assistive devices, contrary to the care plan and facility policies requiring use and proper handling of gait belts and assistive devices when indicated.
Failure to Accurately Document Resident Behaviors and Care Rejection in MDS
Penalty
Summary
The facility failed to accurately document a resident's verbal and physical abuse towards staff and repeated rejection of care in the Minimum Data Set (MDS) for one of three residents reviewed. During the seven-day evaluation period, nursing progress notes indicated that the resident, who had moderate cognitive impairment and dementia following a stroke, refused multiple aspects of care daily, including medication, hygiene, and housekeeping, and exhibited yelling at staff. However, the MDS for the same period did not reflect any behaviors or refusals of care. The social worker confirmed that such behaviors should be documented in the MDS, and the facility was unable to provide a policy on MDS completion when requested.
Failure to Revise Behavioral Care Plan and Provide Ordered Psychiatric Follow-Up
Penalty
Summary
A deficiency occurred when the facility failed to develop and revise a person-centered behavioral care plan, document risk versus benefit assessments for care refusals, conduct a root cause analysis, identify triggers for anxiety and agitation, and provide ordered psychiatric follow-up care for a resident with significant cognitive deficits. The resident had a history of refusing care, including bathing, changing soiled clothing and linens, and allowing housekeeping to clean her room. Despite repeated documentation of her refusals and the associated health hazards, the care plan interventions remained unchanged over multiple assessments, and no new strategies were developed to address her ongoing behavioral health needs. The resident was started on sertraline for irritability and anxiety following a psychiatric appointment, with instructions for staff to monitor her response and schedule a follow-up appointment in one month. However, the follow-up appointment was not scheduled as ordered, and this omission was not documented in the care plan. Staff delayed the appointment, hoping to find alternative placement for the resident, despite continued refusals of care and worsening hygiene. The facility was unable to provide documentation of risk versus benefit assessments related to the resident's refusals, and there was no evidence of a root cause analysis or identification of specific triggers for her behaviors. The resident's condition deteriorated, culminating in the discovery of maggots in her skin folds during wound care after ongoing refusals of hygiene and incontinence care. Interviews with staff and family confirmed that the facility had not implemented new interventions or scheduled the required psychiatric follow-up, and that the family had not requested a delay in psychiatric care. The care planning policy required individualized, person-centered interventions, but these were not developed or revised in response to the resident's persistent behavioral health issues.
Failure to Clarify Medication Orders After Hospital Discharge
Penalty
Summary
A deficiency occurred when nursing staff failed to clarify medication orders for a resident with a history of prostate cancer, atrial fibrillation, and diabetes, who was recently hospitalized for gross hematuria. Upon the resident's return from the emergency department, the After Visit Summary (AVS) instructed that the blood thinner rivaroxaban should be stopped, but the medication remained active in the facility's records. The nurse on duty relied on a nurse-to-nurse report stating there were no medication changes and did not seek clarification, resulting in the resident continuing to receive rivaroxaban for 11 days after the hospital had instructed it to be held. Documentation showed that the resident continued to experience blood in the urine during this period, and the facility's monitoring records reflected ongoing hematuria. Interviews with facility staff, including the RN, DON, and MD, confirmed that the order should have been clarified with the hospital, as the AVS instructions conflicted with the active medication list. The facility's policy required medications to be administered only upon written order from an authorized prescriber, but this was not followed in this instance.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for two residents, R3 and R5, during high-contact care activities. R3, who had a diagnosis of malignant neoplasm of the brain and an unstageable wound, was observed receiving peri care for urine incontinence by nursing assistants (NAs) without the use of gowns, although gloves were worn. The NAs did not perform hand hygiene before changing gloves and their uniforms came into contact with the resident and the bed. Despite R3 being on EBP for a wound, the NAs did not adhere to the facility's policy requiring gowns for high-contact activities. Similarly, R5, who had diabetes, osteomyelitis, and pressure ulcers, was observed being repositioned by an NA without the use of a gown. The NA acknowledged the oversight after exiting the room. The Director of Nursing confirmed that it was expected for EBP to be used during high-contact activities, such as changing briefs and repositioning, as outlined in the facility's policy. The failure to adhere to these precautions was noted during the survey, indicating a lapse in infection prevention and control practices.
Inadequate Provision of Evening Snacks to Residents
Penalty
Summary
The facility failed to consistently offer and provide a nutrient and/or calorie-substantive snack after the dinner meal and before bedtime to all residents, affecting 19 residents who voiced concerns. These residents included individuals with intact cognition and various diagnoses such as diabetes, chronic obstructive pulmonary disease (COPD), epilepsy, hypertension, and congestive heart failure. Interviews with residents revealed that they were not offered snacks after dinner, and some were unsure if they could receive snacks if requested. Observations and interviews with staff indicated that snack bins were available at nurses' stations, but they were often inadequately stocked, containing only a few items like pudding containers. Nursing assistants reported that they would provide snacks if residents asked, but many residents preferred items from vending machines, which required payment. The dietary manager and director acknowledged inconsistencies in offering snacks, particularly to diabetic residents, who should be offered snacks in the evening. During a resident council meeting, 16 residents confirmed they were not offered snacks after dinner. Some residents were unaware of the snack bins, and others noted that the bins usually contained only Jello cups. Diabetic residents specifically mentioned not receiving snacks after dinner, and one resident reported being told by the dietary manager that there was no budget for resident snacks. The facility did not provide a policy on snacks by the end of the survey.
Failure to Monitor Dialysis Care and Communication Lapses
Penalty
Summary
The facility failed to consistently monitor and assess a resident, identified as R99, for potential complications related to dialysis treatment. R99, who has diagnoses including end-stage renal disease, diabetes type 2, and peripheral vascular disease, was observed returning from dialysis in distress, having stopped treatment early due to shortness of breath and leg discomfort. Despite these symptoms, no staff entered R99's room to perform a post-dialysis assessment, which is a critical step in ensuring the resident's safety and well-being. The facility also failed to adhere to fluid restriction orders and monitor daily weights as prescribed. R99 reported inconsistent enforcement of fluid restrictions by staff, leading to confusion and potential health risks. Documentation revealed that fluid intake was not consistently recorded, and daily weights were not performed as ordered, with significant gaps in the records. This lack of adherence to prescribed care plans and orders indicates a systemic issue in the facility's management of R99's dialysis care. Furthermore, the facility did not notify the provider of R99's refusal to attend dialysis sessions or complete treatments, which is a critical communication lapse. Interviews with staff revealed a lack of awareness regarding R99's current care orders, including fluid restrictions and daily weights. The facility's Hemodialysis policy mandates that such refusals and complications be communicated to the resident's care team, yet this protocol was not followed, compromising R99's health management and continuity of care.
Medication Labeling and Expiration Oversight
Penalty
Summary
The facility failed to properly label insulin pens with opened and expiration dates for three residents, and did not provide clear resident identification on an insulin pen for one resident. During an observation of medication storage, it was noted that insulin pens for three residents were missing labels indicating when they were opened and their expiration dates, despite having labels available for this purpose. Additionally, an insulin pen for one resident was only marked with a room number, lacking clear and concise resident identification. This oversight was acknowledged by an LPN, who recognized the potential for medication errors and compromised resident safety. Furthermore, the facility did not dispose of expired eye drop medication for one resident. The expired medication was observed to have been administered after its expiration date, as confirmed by the medication administration record. The director of nursing confirmed that insulin pens should be labeled with resident information, opened date, and expiration date, and that eye drops should be dated upon opening. The facility's policy requires that medications be checked for expiration before administration and that expired medications be removed and destroyed. However, these procedures were not followed, leading to the administration of expired medication.
Infection Control Deficiency in Wound Care
Penalty
Summary
The facility failed to maintain a clean field and use clean supplies during wound care treatments for a resident with venous ulcers, leading to a deficiency in infection prevention and control. The resident, who had a history of diabetes type 2, peripheral vascular disease, end-stage renal disease, and cellulitis, required frequent dressing changes due to drainage from her lower extremities. During an observation, an LPN was seen using bandage scissors and a measuring tape that were repeatedly placed on the floor during the dressing change process. The LPN did not clean the scissors after they were placed on the floor or after the wound care was completed, which is against the facility's infection prevention and control policy. The resident had recently been hospitalized for an infection in her lower legs, and she reported that her dressings needed to be changed multiple times per day due to weeping. The LPN confirmed that the scissors and tape measure should not have been placed on the floor and acknowledged the failure to use a clean basin or barrier. The facility's infection preventionist also confirmed that items used during dressing changes should not be placed directly on the floor. The facility's policy emphasizes the importance of identifying potential infections and ensuring staff adhere to proper techniques to prevent infection.
Unsanitary Kitchen Ceiling Conditions
Penalty
Summary
The facility failed to maintain the kitchen ceiling tiles, tracks, lights, and vents in a clean and sanitary condition, which had the potential to affect all 51 residents. During an observation and interview with the dietary manager (DM)-A, it was noted that the kitchen ceiling components were covered with thick dark fuzzy material, and the vents were operational. DM-A was unsure who was responsible for cleaning these areas, suggesting it might be maintenance, but acknowledged that the kitchen staff clean according to a cleaning book that does not include the ceiling. The facility currently lacks a maintenance person, as the previous one left some time ago. Further observations revealed black/brown debris on the light above the meal tray preparation area, with similar debris on the ceiling tiles, tracks, and vents over food preparation areas. The dietary director (DD)-B confirmed the presence of debris and the need for cleaning or replacement of the ceiling components. A request for a policy on kitchen cleaning was made, but none was provided, indicating a lack of documented procedures for maintaining kitchen cleanliness.
Failure to Post Daily Nursing Staffing Information
Penalty
Summary
The facility failed to ensure the required nursing staffing information was posted daily, which had the potential to affect all 51 residents and visitors. On three consecutive days, the document titled 'Today's Total Nursing Staffing' was found to be outdated, with the last update dated over two months prior. The Director of Nursing (DON) confirmed that the nurse staff posting was not current and acknowledged that the facility was expected to post this information daily. The DON also revealed that the previous receptionist, who was responsible for posting the nursing staffing information, had changed roles, and the facility did not have a policy regarding the posting of nursing hours.
Failure to Monitor Fluid Restriction and Edema
Penalty
Summary
The facility failed to adhere to physician orders for a resident with congestive heart failure, specifically regarding fluid restriction and monitoring of weight gain and edema. The resident had a fluid restriction order of 2000 mL per day, divided between dietary and nursing, and was to be weighed daily with the physician notified of any significant weight gain. However, the resident's weight log showed instances of weight gain that were not reported to the physician, and there were missing entries for fluid consumption, indicating a lack of monitoring. Observations and interviews revealed that the resident experienced 3+ pitting edema, yet there was no documentation of edema assessments or monitoring in the resident's records. The resident reported that staff were often too busy to assist with compression socks, leading him to manage on his own. Nursing staff admitted to not documenting edema findings or consistently monitoring fluid intake, and there was no system in place to evaluate 24-hour fluid intake totals. The facility's policies required changes in a resident's condition to be reported to the physician, but this was not followed in the case of the resident's weight gain and edema. Interviews with staff, including the DON, indicated a lack of communication and documentation regarding the resident's fluid intake and edema, contributing to the deficiency in care.
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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