Little Falls Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Little Falls, Minnesota.
- Location
- 1200 First Avenue Northeast, Little Falls, Minnesota 56345
- CMS Provider Number
- 245399
- Inspections on file
- 38
- Latest survey
- December 31, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Little Falls Care Center during CMS and state inspections, most recent first.
A resident with significant mobility and cognitive impairments was transferred for a weight check without required footwear or a gait belt, and was left unsupported by staff. The resident lost balance while stepping off the scale, fell, and sustained a head injury resulting in a brain bleed. Staff and family interviews confirmed that the care plan was not followed during the transfer, leading to the incident.
A resident with severe cognitive impairment sustained a skin tear that was treated by nursing staff, but the physician was not notified until two days later and the resident's representative was not promptly informed. Staff interviews and documentation confirmed that required notifications were delayed, contrary to facility expectations for immediate reporting of new injuries.
A deficiency was cited when a resident's care plan did not include all necessary needs, lacked measurable timetables, and failed to specify actions, resulting in incomplete planning and documentation for the resident's care.
A resident did not receive the necessary behavioral health care and services required, as observed and documented by surveyors.
A resident reported feeling uncomfortable and fearful during personal care by a nursing assistant, who allegedly continued despite her request to stop. The incident, involving the assistant's inappropriate behavior, was not reported to the State Agency until nearly two days later, violating the facility's guidelines for immediate reporting of abuse allegations.
A resident with type 2 diabetes and hypertension fell out of bed while trying to reach the fridge. Despite safety measures, the incident was not reported to the provider or resident representative due to a chaotic night shift. The facility's policy requires immediate notification, which was not followed, resulting in a deficiency.
A facility failed to follow physician orders for pressure ulcer care and infection control practices during a dressing change for a resident with multiple pressure ulcers. The RN did not perform hand hygiene between glove changes and omitted applying Santyl ointment as ordered. The resident had significant tissue damage, and the nurse practitioner highlighted the importance of following orders and maintaining hand hygiene for wound healing.
The facility failed to submit accurate direct care staffing information to CMS for Quarter 1. The PBJ report indicated excessively low weekend staffing, which was not supported by staffing schedules. The administrator stated that a data entry error at the corporate office affected all 15 facilities and was corrected before the next quarter's submission. No PBJ entry policy was available.
The facility failed to notify the families of two residents timely regarding significant changes in condition and their deaths. One resident's family was informed two hours after the resident passed away, and another resident's family was not notified about a fall, facial injuries, or hospitalization until much later. Staff interviews confirmed the lack of timely family notification, contrary to the facility's policy.
The facility failed to ensure three residents were comprehensively assessed for self-administration of medications. Despite assessments indicating they could not self-administer and did not wish to, residents were observed self-administering nebulizer treatments and an inhaler without proper oversight or documentation.
The facility failed to provide a written bed hold policy to a resident or their representative during a hospital transfer. The resident, who required assistance with ADLs, was hospitalized and returned without documented evidence of bed hold communication, contrary to the facility's policy.
The facility failed to follow provider orders for monitoring vital signs for a resident with serious diagnoses and did not obtain a necessary physician order for a lap positioning belt for another resident. Documentation and interviews confirmed these deficiencies.
The facility failed to assess past trauma and implement a trauma-informed care plan for a resident with PTSD, anxiety, and depression. Staff were unaware of the resident's trauma history, and the care plan lacked necessary interventions and trigger identification.
The facility failed to ensure the consulting pharmacist identified irregularities in monthly drug regimen reviews for three residents. The medical records lacked evidence of required orthostatic blood pressure monitoring and AIMS assessments, and the facility's psychotropic medication policy did not address these needs.
The facility failed to monitor orthostatic blood pressures and conduct AIMS assessments for residents on psychotropic medications, leading to a deficiency in ensuring the safety and well-being of these residents. Interviews revealed gaps in the monitoring process and inadequacies in the facility's psychotropic medication policy.
The facility failed to ensure that three residents were offered and/or provided the Influenza and pneumococcal vaccines as recommended by the CDC. Documentation of declination forms, education, and shared clinical decision-making with physicians was missing.
The facility failed to notify the LTC Ombudsman of hospitalizations for five residents, despite their medical records indicating various serious conditions requiring hospitalization. The Ombudsman had not received any notices of transfers or discharges for over a year, and the facility could not provide records or policies to show compliance with notification requirements.
The facility failed to review and revise its infection control policies annually, potentially affecting all residents, staff, and visitors. Key policies had not been updated for several years, and interviews revealed that the facility relied on corporate policies without conducting individual annual reviews.
The facility failed to ensure timely call light responses, leading to prolonged waiting times and incontinence for two residents. One resident waited up to 62 minutes for toileting assistance, while another waited up to 45 minutes, causing feelings of neglect and embarrassment. Staff interviews confirmed that the expected response time was 15 minutes, but this was not met, violating the facility's policies on call light response and resident dignity.
The facility failed to respond to call lights in a timely manner for two residents, leading to significant delays in providing necessary assistance. One resident experienced multiple instances of waiting over 20 minutes, and in one case over an hour, for help with toileting, resulting in urine accidents and discomfort. Another resident also faced delays, leading to incontinence episodes and feelings of shame and embarrassment. Staff interviews confirmed that the expected response times were not being met due to insufficient personnel.
A resident who recently had hip surgery and required assistance with toileting was not checked or changed for almost seven hours due to staffing issues. The resident was found with a large amount of stool and urine in his brief, indicating that the scheduled toileting plan was not followed.
The facility failed to follow physician orders for a resident with moisture-associated skin damage (MASD), leading to the deterioration of the wound. Staff used inappropriate materials and techniques, such as peri wipes and packing the wound with fingers, instead of following the prescribed wound care procedures. The resident's wound showed signs of worsening, including increased tunneling and a strong foul odor.
The facility failed to implement recommended influenza A infection control procedures, specifically the use of masks, during direct care with two residents who tested positive. Staff members were observed entering and exiting the rooms without the necessary PPE, despite the residents' frequent coughing. Interviews revealed a lack of clarity and adherence to infection control policies.
The facility failed to notify a resident's representative and physician of multiple falls, both with and without injuries. The resident, diagnosed with dementia and anxiety disorder, experienced several falls over a period, with no documented notifications to the representative or physician. Interviews with staff confirmed that the expected notifications were not made, contrary to the facility's policy.
A resident with dementia and benign prostatic hyperplasia showed signs of a UTI, including hematuria and increased confusion. Despite these symptoms, the facility failed to implement the UTI protocol or notify the physician promptly. The resident's condition worsened, leading to hospitalization and death. Staff interviews confirmed awareness of symptoms but non-compliance with the facility's UTI protocol.
A facility failed to re-assess and revise the care plan for a cognitively impaired resident with multiple falls. Despite several falls and discussions by the interdisciplinary team (IDT), interventions were not consistently documented or implemented. Incident reports, root cause analyses, and care plan revisions were also lacking for several falls, and staff were not fully aware of all fall interventions.
The facility failed to identify target behaviors, revise care plans to include non-pharmacological interventions, and monitor effectiveness for three residents prescribed psychotropic medications. The Director of Nursing confirmed the lack of evidence in the medical records for target behaviors and monitoring, contrary to the facility's policy.
Failure to Follow Care Plan During Transfer Results in Resident Fall and Head Injury
Penalty
Summary
A deficiency occurred when staff failed to follow a resident's care plan during a transfer, resulting in a fall and significant injury. The resident, who had diagnoses including hypertension, atrial fibrillation, generalized weakness, and mobility impairments, required substantial or maximal assistance for transfers and mobility, as well as the use of a gait belt and appropriate footwear. On the day of the incident, a nursing assistant transferred the resident from bed to the bathroom for a weight check without providing footwear or using a gait belt, and left the resident standing unsupported on the scale. While stepping off the scale, the resident lost balance and fell, hitting her head against the wall. The fall was witnessed, and it was documented that the staff did not assist the resident during the transfer as required by the care plan. The resident was on blood thinners, which increased the risk of complications from head injuries. Following the fall, the resident exhibited increased confusion and drowsiness, and was later found to have a brain bleed confirmed by CT and MRI scans. Interviews with staff and family confirmed that the care plan was not followed during the transfer, and that the resident was left unsupported and without necessary safety measures. The incident was reported to the provider and family, and neuro checks were initiated. The failure to adhere to the care plan and established safety protocols directly led to the resident's fall and subsequent injury.
Failure to Timely Notify Physician and Representative of Resident Injury
Penalty
Summary
The facility failed to notify a resident's physician and resident representative in a timely manner following the discovery of a new skin tear injury. The resident, who had a history of traumatic subdural hemorrhage, cerebral infarction, anxiety disorder, and severely impaired cognition, was found to have a skin tear on the left lower shin while being assisted by staff. The injury was assessed and treated by a registered nurse, but the physician was not notified until two days later, and there was no evidence that the resident's representative was notified at the time of the incident. Documentation showed that the resident's representative only learned of the injury later in the day after inquiring about a bruise, and the physician's office confirmed delayed notification. Interviews with staff and review of facility procedures revealed that staff were expected to notify the physician and resident representative immediately or within the same shift when new injuries occurred. However, the nurse who discovered the injury did not complete the required notifications, citing a busy shift and incomplete charting. The incident report was not completed until later, and the facility was unable to provide a copy of its notification policy when requested. This failure to promptly notify the appropriate parties constituted a deficiency in the facility's response to resident injuries.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the facility's failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This deficiency was observed through review of the resident's records and care plans, which did not contain all necessary elements to ensure comprehensive care as required.
Failure to Provide Necessary Behavioral Health Services
Penalty
Summary
The facility failed to ensure that each resident received necessary behavioral health care and services. This deficiency was identified based on observations and findings that the required behavioral health interventions and supports were not provided to residents as needed. The lack of appropriate behavioral health care and services was directly observed and documented by surveyors during the review.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse immediately to the State Agency as required. A resident, who was cognitively intact and had diagnoses of heart failure and bipolar disorder, reported feeling uncomfortable during personal care provided by a nursing assistant. The resident stated that the nursing assistant continued washing her despite her request to stop and that she felt the assistant's erection, which made her feel anxious and fearful. This incident was reported to the director of nursing nearly two days later, which was not in compliance with the facility's guidelines that require immediate reporting within two hours. The director of nursing was informed of the alleged abuse on the evening of the incident but did not become aware of the details until two days later when reviewing written statements from the staff. The facility's Maltreatment Reporting Guidelines clearly state that any allegations of abuse must be reported to the appropriate authorities immediately, but not later than two hours after the allegation is made if it involves abuse. The delay in reporting this incident to the State Agency constitutes a deficiency in the facility's adherence to these guidelines.
Failure to Notify Provider and Representative of Resident Fall
Penalty
Summary
The facility failed to notify the provider and resident representative of a fall experienced by a resident. The resident, who had diagnoses including type 2 diabetes and hypertension, rolled out of bed while attempting to reach the fridge and fell to the floor. Despite the implementation of safety measures such as a low bed and fall mat, the incident was not reported to the necessary parties as required by the facility's policy. The incident occurred during a chaotic night shift, and the floor nurse forgot to complete an incident report and notify the provider and resident representative. The facility's policy mandates immediate notification of a family member or responsible party when a resident suffers an injury due to an accident or incident. However, in this case, the notification was not carried out, leading to a deficiency in the facility's adherence to its own policies.
Failure to Follow Pressure Ulcer Care Orders and Infection Control Practices
Penalty
Summary
The facility failed to adhere to physician orders for pressure ulcer care and did not follow proper infection control practices during a dressing change for a resident with multiple pressure ulcers. The resident, who had diagnoses of peripheral vascular disease, quadriplegia, and spinal stenosis, was cognitively intact and fully dependent on staff for activities of daily living. The resident had a Stage 4 sacral pressure ulcer, an unstageable left buttock pressure ulcer, and a Stage 3 right buttock pressure ulcer, all of which were documented to have significant tissue damage and drainage. During an observation of wound care, a registered nurse (RN) did not perform hand hygiene between glove changes, which is a critical step in preventing infection. The RN also failed to apply Santyl ointment to the wound beds as ordered by the nurse practitioner, which is essential for removing dead tissue and promoting healing. The RN admitted to forgetting to perform hand hygiene and not following the physician's orders due to nervousness. The nurse practitioner emphasized the importance of following physician orders and maintaining hand hygiene to protect the wound from bacteria and ensure proper healing. The facility's administrator acknowledged that staff should adhere to care plans, orders, and the hand hygiene policy. However, the facility did not provide a policy on pressure ulcers when requested.
Inaccurate Staffing Data Submission to CMS
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information, including data for agency and contract staff, to CMS for Quarter 1. During the review, it was found that the Payroll Based Journal (PBJ) report identified excessively low weekend staffing, which was not supported by the staffing schedules and daily postings for the weekends in question. Interviews revealed that the scheduler was unaware of who submitted the information, and the administrator indicated that the corporate office was responsible for the submission. A data entry error at the corporate office affected all 15 facilities, including this one, and was corrected before the next quarter's submission. No policy related to PBJ entries was available by the end of the survey.
Failure to Notify Family of Significant Changes and Death
Penalty
Summary
The facility failed to ensure timely notification of residents' family members or representatives regarding significant changes in condition, including the death of two residents. For Resident R203, the electronic health record (EHR) indicated that the resident was found unresponsive and without vital signs at 9:45 p.m., and the hospice agency was contacted at 9:51 p.m. However, there was no documentation that the family or resident representative was informed of the resident's passing. A family member reported that the facility did not contact them during the resident's decline and only informed them two hours after the resident had passed away. The Assistant Director of Nursing (ADON) confirmed that typically hospice would update the family, but no documentation of family notification was found in this case. For Resident R205, the facility also failed to notify the family timely regarding significant changes in condition and the resident's death. The EHR showed that the resident experienced weakness, shortness of breath, and was unable to bear weight, but there was no record of family notification. The resident was later found face down on the floor with facial injuries and received CPR before passing away. The family was informed about the fall and the resident's death but not about the facial injuries until the funeral home contacted them. Additionally, the family was not notified when the resident was sent to the hospital earlier. Interviews with staff confirmed the lack of timely family notification during these critical events, and the facility's policy required immediate notification of significant changes, including accidents, health deterioration, transfers, or death.
Failure to Assess and Document Self-Administration of Medications
Penalty
Summary
The facility failed to ensure residents were comprehensively assessed for self-administration of medications for three residents. Resident 24, who was cognitively intact but required assistance with activities of daily living (ADLs), was observed with a nebulizer machine on her nightstand containing a solution from the morning, indicating she forgot to perform her nebulizer treatment. The medication self-administration assessment for Resident 24 indicated she could not correctly administer nebulizer medications and did not wish to self-administer medications, yet she was still left to self-administer her nebulizer treatment without proper oversight or documentation by the nursing staff as per medical doctor orders. Resident 34, also cognitively intact and requiring assistance with ADLs, was observed self-administering a nebulizer treatment without staff present. The medication self-administration assessment for Resident 34 indicated he was not able to self-administer medications and did not wish to do so. Despite this, nursing staff left the nebulizer solution for Resident 34 to self-administer at a later time, and staff only checked afterward to ensure the treatment was completed. This practice was inconsistent with the assessment and medical doctor orders. Resident 46, who had intact cognition and required assistance with all ADLs, was observed with an albuterol inhaler on his over-the-bed table and was seen using it independently. The medication self-administration assessment for Resident 46 indicated he could not correctly administer inhalant medications and did not wish to self-administer medications. Despite this, the inhaler was left within his reach, and he was observed using it without proper assessment or an order for self-administration. The facility's policy required a comprehensive assessment and an order for self-administration, which was not followed for these residents.
Failure to Provide Bed Hold Policy During Hospital Transfer
Penalty
Summary
The facility failed to provide a written bed hold policy to a resident or their representative at the time of hospital transfer. The resident, who was cognitively intact and required assistance with activities of daily living, was hospitalized and returned to the facility without any documented evidence that a bed hold policy was communicated. The assistant director of nursing confirmed that there was no communication regarding the bed hold for the resident's hospitalization, which is a requirement according to the facility's policy. The facility's Bed Hold Election & Hospital Transfer policy mandates that residents or their representatives be informed of the bed hold option during hospitalization or therapeutic leave. In the case of an emergency transfer, the policy requires that a copy of the notice be sent with the transfer papers and a phone call be made to the responsible party. Additionally, the policy states that documentation of this communication should be made in the resident's progress notes, and a copy of the bed hold policy should be mailed within 24 hours. This procedure was not followed for the resident in question, leading to the deficiency noted in the report.
Failure to Follow Provider Orders and Obtain Necessary Orders for Devices
Penalty
Summary
The facility failed to ensure provider orders were followed for monitoring vital signs for a resident with multiple serious diagnoses, including arteriosclerotic heart disease, hypertension, congestive heart disease, and a nontraumatic subarachnoid hemorrhage. The nurse practitioner had ordered vital signs to be taken three times daily due to the increased risk of brain bleed, but the electronic health record and the resident's closed hard chart did not show that these vital signs were recorded for three days. Interviews with the nurse consultant and the assistant director of nursing confirmed the absence of these vital signs in the electronic health record, indicating missed documentation as shown by pink boxes in the electronic medication administration record. Additionally, the facility failed to obtain a provider order for a lap positioning belt for a resident with cerebral palsy and neuromuscular scoliosis, who preferred to wear a seat belt when in his electric wheelchair. The resident's care plan and restrictive device assessment indicated the use of a lap positioning belt, but the physician orders lacked evidence of an order for this device. The assistant director of nursing confirmed that a physician's order was needed for the lap positioning seatbelt and that the facility could not locate such an order. A provider order policy was requested but not received in both cases.
Failure to Implement Trauma-Informed Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to comprehensively assess past trauma and implement care plan interventions utilizing a trauma-informed approach for a resident diagnosed with PTSD, anxiety disorder, and depression. The resident's significant change Minimum Data Set (MDS) indicated cognitive intactness and required assistance with activities of daily living (ADLs). Despite a trauma assessment completed earlier, which indicated the resident had trauma affecting her daily life, the care plan lacked individualized trauma-informed approaches, identification of triggers, and interventions to avoid potential re-traumatization. Interviews with various staff members, including a nurse practitioner, trained medication assistants, and a licensed practical nurse, revealed that they were unaware of the resident's past trauma and PTSD diagnosis. The assistant director of nursing confirmed that the care plan should have included behavior monitoring, PTSD triggers, and interventions to avoid those triggers, but it did not. The facility's policy on trauma-informed care indicated that care practices should account for residents' experiences and preferences to mitigate triggers, but this was not followed in the resident's case.
Failure to Identify Irregularities in Drug Regimen Reviews
Penalty
Summary
The facility failed to ensure that the consulting pharmacist identified irregularities in the monthly drug regimen reviews for three residents. Resident 11, who had multiple medical conditions including hypertension and depression, had an order for monthly orthostatic blood pressure monitoring while on trazodone. However, the medical record lacked evidence of this monitoring from August 30, 2023, to April 18, 2024, and there was no recommendation from the pharmacy consultant regarding this monitoring. Resident 21, who had severe cognitive impairment and was dependent on staff, had orders for psychotropic medications lorazepam and paliperidone. The medical record lacked evidence of orthostatic blood pressure monitoring, and there was no recommendation from the pharmacy consultant for this monitoring. Similarly, Resident 34, who was cognitively intact but required assistance with activities of daily living, had orders for psychotropic medications olanzapine and hydroxyzine. The medical record lacked evidence of orthostatic blood pressure monitoring and an initial assessment for abnormal involuntary movements (AIMS). Interviews with facility staff, including the nurse consultant, pharmacist, licensed practical nurse, and assistant director of nursing, confirmed the lack of monitoring and recommendations. The pharmacist admitted to missing the recommendation for orthostatic blood pressure monitoring and AIMS assessment. The facility's psychotropic medication policy did not address the need for orthostatic blood pressure monitoring, contributing to the oversight.
Failure to Monitor Adverse Effects of Psychotropic Medications
Penalty
Summary
The facility failed to ensure proper monitoring for potential cardiovascular and neurological adverse effects in residents using psychotropic medications. Specifically, three residents were identified as not having their orthostatic blood pressures monitored as required. Resident 11, who had a complex medical history including hypertension and schizotypal disorder, had an order for monthly orthostatic blood pressure monitoring while on trazodone, but only one reading was recorded over several months. Similarly, Resident 21, with severe cognitive impairment and multiple diagnoses including cardiovascular disease and depression, also lacked evidence of orthostatic blood pressure monitoring despite being on multiple psychotropic medications. Resident 34, who was cognitively intact but required assistance with activities of daily living, also did not have orthostatic blood pressures monitored or AIMS assessments completed as required for their psychotropic medication use. Interviews with facility staff, including the pharmacy consultant, nurse consultant, and assistant director of nursing, revealed gaps in the monitoring process. The pharmacy consultant admitted to missing recommendations for orthostatic blood pressure monitoring and AIMS assessments for residents on psychotropic medications. The nurse consultant and assistant director of nursing confirmed that the facility relied on the pharmacy consultant's recommendations for monitoring and assessments, and acknowledged the absence of these critical evaluations in the residents' medical records. The facility's psychotropic medication policy did not address the need for orthostatic blood pressure monitoring, which contributed to the oversight. The policy was intended to ensure appropriate use, evaluation, and monitoring of medications to minimize risks, but it failed to include specific guidelines for monitoring orthostatic blood pressures. This lack of comprehensive policy and oversight led to the deficiency in monitoring residents for potential adverse effects from psychotropic medications.
Failure to Offer and Document Vaccinations
Penalty
Summary
The facility failed to ensure that three residents were offered and/or provided the Influenza vaccine and/or the pneumococcal vaccine series as recommended by the CDC. Specifically, one resident declined the PCV20 and Influenza vaccines, but there was no documentation of the declination form, education, or progress note in the electronic health record (EHR). Another resident received the PCV13 but lacked evidence of shared clinical decision-making with the physician for the PCV20. The third resident received the PPSV23 but also lacked evidence of shared clinical decision-making with the physician for the PCV20. Both of these residents were not offered or provided education on the PCV20 vaccine. During an interview, the infection preventionist (IP) confirmed that immunizations are reviewed upon admission and that the CDC pneumococcal vaccine recommendations were used for eligibility. The IP verified that the two residents had not been offered or provided education on the PCV20 and that there had been no shared clinical decision-making with the provider regarding pneumococcal immunizations. The facility's policy indicated that all residents would be offered vaccinations based on CDC recommendations and physician orders, but this was not followed in these cases.
Failure to Notify LTC Ombudsman of Resident Hospitalizations
Penalty
Summary
The facility failed to ensure the LTC Ombudsman was notified of hospitalizations, which are considered facility-initiated discharges, for five residents. These residents were identified as having various medical conditions and required hospitalization for issues such as elevated temperature, pain, dehydration, urinary tract infection (UTI), shortness of breath, low oxygen saturations, hypotension, and other complications. Despite these hospitalizations, the medical records for these residents lacked evidence that the LTC Ombudsman had been notified as required by regulations. Interviews and document reviews revealed that the LTC Ombudsman had not received any notices of transfers or discharges from the facility for over a year. The Ombudsman had previously discussed this issue with the facility's administrator and activity director. Additionally, the facility's nurse consultant confirmed that they could not locate records indicating that the LTC Ombudsman had been notified of the transfers and/or discharges. The facility's policy on Transfer and Discharge from Facility was requested but not provided, further highlighting the deficiency in compliance with notification requirements.
Failure to Annually Review Infection Control Policies
Penalty
Summary
The facility failed to review and/or revise its infection control program's policies and procedures at least annually, potentially affecting all 51 residents, staff, and visitors. During a review of the facility's infection control policies, it was found that several policies had not been reviewed or amended for several years. For instance, the 'Infection Surveillance' policy had not been reviewed since 2017, and the 'Resident Tuberculosis Prevention and Control' policy had not been reviewed since 2019. Other policies, such as the 'COVID-19 Vaccination' and 'Antibiotic Stewardship Program,' also had outdated review dates, indicating a lack of regular updates and reviews as required by regulations. Interviews with the infection preventionist (IP), assistant director of nursing (ADON), and nurse consultant (NC) revealed that the facility relied on corporate policies and did not conduct individual annual reviews of these policies. The IP and ADON were unaware of the requirement to review the policies annually, while the NC confirmed that the quality team reviewed and amended policies as needed but did not include infection control policies in their recent review. This oversight in policy review and revision could lead to outdated practices and potential risks for infection control within the facility.
Delayed Call Light Response Compromises Resident Dignity
Penalty
Summary
The facility failed to ensure call lights were answered in a timely manner, which compromised the dignity of two residents. One resident, identified as R8, had moderately impaired cognition and required substantial assistance with toileting. On multiple occasions, R8's call light was not answered promptly, leading to prolonged waiting times of up to 62 minutes. During this period, R8 experienced discomfort and had urine accidents due to the delay in assistance. Observations revealed that staff members either ignored the call light or were too busy to provide immediate help, resulting in R8 feeling neglected and afraid of falling when attempting to get up by herself. Another resident, identified as R9, also experienced delays in call light response. R9, who had intact cognition but required assistance with toileting due to limited mobility, reported waiting up to 45 minutes for help. This delay led to instances of incontinence, causing R9 to feel ashamed and embarrassed. Observations confirmed that R9 had to wait for assistance while her roommate, R8, was using the shared bathroom, further highlighting the inadequacy of the facility's response to call lights. Interviews with staff members, including nursing assistants and the assistant director of nursing, revealed that the expected response time for call lights was 15 minutes. However, the actual response times observed were significantly longer, failing to meet the facility's policy. The facility's policies on call light response and maintaining resident dignity were not adhered to, resulting in adverse events and a lack of timely assistance for the residents' toileting needs.
Failure to Respond to Call Lights Timely
Penalty
Summary
The facility failed to respond to call lights in a timely manner for two residents, leading to significant delays in providing necessary assistance. Resident R8, who had moderately impaired cognition and required substantial assistance with toileting, experienced multiple instances where her call light was not answered promptly. On several occasions, R8 had to wait over 20 minutes, and in one instance, over an hour, for assistance to use the bathroom. This delay caused R8 to have urine accidents, leading to discomfort and fear of falling when attempting to get up by herself. Observations confirmed that staff walked past R8's room without responding to her call light, and even when staff did respond, they were unable to assist her immediately due to the unavailability of necessary equipment like the lift. Resident R9, who had intact cognition but required assistance with toileting due to limited mobility and a history of urinary tract infections, also experienced delays in call light responses. R9's call light activity report showed multiple instances where the call light was not answered for over 20 minutes, and in some cases, up to 45 minutes. R9 reported feeling ashamed and embarrassed due to incontinence episodes caused by the delays in receiving assistance. Observations and interviews with staff confirmed that the expected response time for call lights was not being met, with staff citing a lack of sufficient personnel to address all call lights promptly. Interviews with nursing assistants and other staff members revealed that the facility's policy required call lights to be answered within 15 minutes to ensure resident safety and dignity. However, the actual response times frequently exceeded this limit, leading to residents' needs not being met in a timely manner. The assistant director of nursing and the floor manager both acknowledged the importance of prompt call light responses and the negative impact of delays on residents' well-being. The facility's failure to adhere to its call light policy resulted in residents experiencing unnecessary discomfort, incontinence, and a lack of timely assistance with toileting needs.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident (R3) who was dependent on staff for assistance due to a recent hip fracture. R3's care plan required toileting every two to three hours, but during an observation, it was found that R3 had not been checked or changed for almost seven hours. R3 was found with a large amount of stool and urine in his brief, indicating that the scheduled toileting plan was not followed. The nursing assistants (NA-A and NA-C) confirmed that they were short-staffed, which led to the delay in providing the necessary care. Interviews with the nursing assistants and a registered nurse revealed that R3 had recently undergone hip surgery and was no longer independent, requiring more assistance with activities of daily living. The staff acknowledged that R3 should have been checked and changed multiple times during the day but were unable to do so due to staffing issues. The facility's failure to adhere to the scheduled toileting plan resulted in R3 remaining in soiled briefs for an extended period, which was confirmed by the observations and staff interviews.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to follow physician orders and provide appropriate wound care for a resident with moisture-associated skin damage (MASD). The resident, who had multiple medical conditions including peripheral vascular disease, cerebral vascular accident, and chronic obstructive pulmonary disease, was at high risk for skin breakdown as indicated by a Braden assessment score of 11. The resident had a physician order to cleanse the buttocks daily and apply Med-honey with an adhesive foam dressing, but this order was not consistently followed. Observations revealed that the wound dressing was often saturated, and inappropriate materials such as peri wipes were used to clean the wound, which is not designed for wound care and could spread germs instead of cleaning the wound effectively. The resident's wound showed signs of deterioration, including increased tunneling and a strong foul odor, indicating possible infection. Staff were observed using improper techniques, such as packing the wound with their fingers instead of using a small cotton swab, and failing to use the prescribed wound cleaner. The wound continued to worsen, with moderate serosanguinous drainage and a significant amount of slough present. Despite the resident's refusal to reposition, which likely affected the healing process, the staff did not adhere to the physician's orders or the facility's protocols for wound care. Interviews with the nursing staff and the assistant director of nursing revealed a lack of awareness and adherence to the proper wound care procedures. The staff did not follow the physician's orders and failed to verify or seek clarification when the appropriate supplies were not available. The facility's policy required the use of wound cleaner and proper packing techniques, but these were not followed, leading to the worsening of the resident's wound condition.
Failure to Implement Influenza A Infection Control Procedures
Penalty
Summary
The facility failed to implement recommended influenza A infection control procedures for the use of personal protective equipment (PPE), specifically masks, during direct care with residents. This deficiency was observed in two residents who tested positive for influenza A. Despite the presence of contact precaution signs, there was no mention of droplet precautions or the requirement for masks, which are essential to prevent the spread of influenza A. Staff members were observed entering and exiting the rooms of these residents without wearing the necessary PPE, such as masks and gowns, even though the residents were frequently coughing and unable to cover their mouths, increasing the risk of infection spread. One resident tested positive for influenza A and was observed multiple times lying in bed with a frequent loose cough. The contact precaution sign outside the resident's room did not mention the need for masks, and staff members were seen entering the room with inadequate PPE. For instance, an LPN entered the room wearing only gloves and no mask or gown while performing wound care, despite the resident's continuous coughing. Another resident also tested positive for influenza A and was observed sitting in a recliner with the door open and a contact precaution sign that did not mention masks. Staff members were seen entering the room without the required PPE, even though the resident had a frequent loose cough. Interviews with staff members, including nursing assistants and registered nurses, revealed a lack of clarity and adherence to the facility's infection control policies. Staff members acknowledged that droplet precautions, including the use of masks, should have been implemented immediately upon confirmation of influenza A. However, the appropriate signs and PPE usage were not enforced, leading to potential exposure and spread of the infection. The facility's policy on standard and droplet precautions clearly outlined the need for masks when dealing with infections like influenza A, but these guidelines were not followed in practice.
Failure to Notify Resident Representative and Physician of Falls
Penalty
Summary
The facility failed to ensure that the resident representative and physician were notified of falls with and without injuries for one resident reviewed for accidents. The resident, who had diagnoses including dementia and anxiety disorder, experienced multiple falls on various dates. The facility's documentation lacked evidence of notification to the resident's representative or physician for these incidents. Specific falls occurred on 8/8/23, 8/10/23, 8/14/23, 8/20/23, 8/24/23, 9/10/23, 9/19/23, 9/28/23, 10/6/23, and 10/13/23, with no documented notifications to the resident's representative or physician. Additionally, progress notes for falls on 9/19/23, 9/28/23, 10/6/23, and 10/13/23 also lacked evidence of such notifications. Interviews with the registered nurse (RN) and the director of nursing (DON) confirmed that the nursing staff who completed the incident reports were expected to notify the resident's representative and physician following each fall, regardless of injury. The facility's policy required immediate notification of the family or responsible party in case of injury and within a reasonable time frame if there was no injury. The policy also mandated immediate physician notification for injuries or medical treatment and within a reasonable time frame for other events. The RN and DON confirmed that these notifications were not documented for the specified falls, indicating a failure to adhere to the facility's policy.
Failure to Monitor and Treat UTI Symptoms
Penalty
Summary
The facility failed to comprehensively assess and implement continuous monitoring for signs and symptoms of a urinary tract infection (UTI) and notify the physician timely with a change in condition and/or worsening symptoms for one resident. The resident had diagnoses including dementia, anxiety disorder, and benign prostatic hyperplasia (BPH), and required intermittent catheterization. The care plan lacked evidence of being at risk for UTIs or staff direction on monitoring for UTI signs and symptoms. Despite the resident showing signs of a UTI, such as hematuria, increased confusion, and tiredness, the facility did not implement the UTI protocol or notify the physician promptly. On multiple occasions, staff noted the resident's symptoms, including hematuria, increased confusion, foul-smelling urine, and back pain. However, there was no evidence of additional monitoring or timely notification to the physician. The resident's temperature was not recorded until two days after the initial symptoms were noted. The facility's policy required obtaining vital signs every shift and reassessing for UTI symptoms once identified, but this was not followed. The resident's condition worsened, and they were eventually taken to the emergency department, where they passed away. Interviews with staff revealed that they were aware of the resident's symptoms but did not follow the facility's UTI protocol. The Director of Nursing (DON) confirmed that the UTI protocol was not implemented and that the physician was not notified of the resident's condition until it had significantly worsened. The facility's policy required a thorough assessment and monitoring for UTI symptoms, but this was not done, leading to a delay in treatment and the resident's subsequent hospitalization and death.
Failure to Re-assess and Revise Care Plan for Cognitively Impaired Resident with Multiple Falls
Penalty
Summary
The facility failed to comprehensively re-assess and revise a resident's care plan, who was cognitively impaired and had multiple falls resulting in minor injuries. The resident had diagnoses including dementia and anxiety disorder, and was noted to have severely impaired cognition. Despite multiple falls, the care plan lacked evidence of implemented interventions to prevent further falls. The resident's care plan included interventions such as a low bed with fall mats and staff assistance with proper footwear, but these were not consistently implemented or updated following each fall. The resident experienced several unwitnessed falls, and the interdisciplinary team (IDT) discussed the incidents but failed to ensure that the interventions were documented and implemented in the care plan. For instance, after a fall on 8/10/23, the IDT determined that the resident should sleep in his bed at night with the bed low and floor mats down, but this intervention was not reflected in the care plan. Similarly, after a fall on 8/20/23, the IDT decided that the resident should be laid in bed after supper unless restless, but this intervention was also not documented in the care plan. Additionally, the facility's staff failed to complete incident reports, root cause analyses, and IDT reviews for several falls. Progress notes for falls on 9/19/23, 9/28/23, 10/6/23, and 10/13/23 lacked evidence of incident reports, root cause analyses, or care plan revisions. Interviews with staff revealed that they were not aware of all the fall interventions or the need for safety or hourly checks. The facility's policies on accident/incident reporting and fall prevention were not followed, leading to a lack of comprehensive re-assessment and revision of the resident's care plan to prevent further falls.
Failure to Monitor and Document Psychotropic Medication Use
Penalty
Summary
The facility failed to identify target behaviors, revise care plans to include non-pharmacological interventions, and monitor effectiveness for three residents who were prescribed scheduled psychotropic medications. Resident 1 had a diagnosis of depression and was prescribed sertraline, but there was no evidence of behavior monitoring, target behaviors, or non-pharmacological interventions in the care plan. Similarly, Resident 2, who had a diagnosis of depression and exhibited verbal behavioral symptoms, was prescribed Cymbalta without evidence of behavior monitoring or target behaviors in the care plan. Resident 3, diagnosed with Parkinson's Disease and depression, was prescribed Venlafaxine, but the care plan lacked evidence of target behaviors and non-pharmacological interventions. The Director of Nursing confirmed that the medical records for all three residents lacked evidence of target behaviors identified in the care plan and monitoring of behaviors to determine unnecessary psychotropic medication use. The facility's policy on psychotropic medications required the primary care physician to identify target behavior symptoms and for nursing staff to monitor psychotropic drug use daily, noting any adverse effects and the presence of target behaviors. Social Services was expected to develop a behavioral care plan, but this was not done for the three residents reviewed.
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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