Little Sisters Of The Poor
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Paul, Minnesota.
- Location
- 330 Exchange Street South, Saint Paul, Minnesota 55102
- CMS Provider Number
- 245524
- Inspections on file
- 19
- Latest survey
- January 28, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Little Sisters Of The Poor during CMS and state inspections, most recent first.
The facility failed to ensure proper food storage and labeling, impacting all 32 residents. Observations revealed unlabeled and undated lunchmeat, expired milk, and uncovered ice cream in the main kitchen. Additionally, expired thicken-it juice was found in the 3rd floor kitchenette. Staff acknowledged the need for improvements, as the facility policy was not followed.
A facility failed to administer oxygen according to physician's orders for a resident with pulmonary fibrosis, leading to a deficiency in respiratory care. The resident's oxygen saturation levels were not consistently documented, and staff did not always administer oxygen when needed. Observations and interviews revealed inconsistencies in oxygen use and documentation, despite the resident's expressed need for oxygen.
A resident with vascular dementia and severe communication difficulties was not provided with individualized dementia care at the facility. Despite being dependent on staff for daily activities and exhibiting agitation, the facility failed to document and address the resident's behaviors, which were crucial for evaluating the necessity of psychotropic medications. Staff deviated from the care plan by using an EZ stand lift instead of a Hoyer lift, and the lack of consistent documentation hindered the identification of behavior patterns and triggers.
The facility failed to act on pharmacist recommendations for two residents regarding unnecessary medications. One resident continued using a topical antifungal without re-evaluation, and another did not receive a recommended dose reduction for an antidepressant. The DON acknowledged delays in addressing these recommendations.
A facility failed to ensure a resident's drug regimen was free from unnecessary drugs, specifically a topical antibiotic. The resident, with a history of diabetes and hidradenitis suppurativa, was prescribed clindamycin lotion without an end date, and it was unclear if she was still using it. Staff interviews revealed a lack of awareness and tracking of the resident's antibiotic use, with the facility's policy on antibiotic stewardship not being followed.
A resident with diabetes experienced multiple low blood glucose (BG) levels, but the facility failed to notify the physician as required by standing orders. Despite interventions, the resident's BG remained below 70 mg/dl, and symptoms of hypoglycemia were noted. Interviews confirmed the oversight, and the facility's standing orders were not followed, leading to the deficiency.
The facility failed to assess and implement interventions for two residents with wandering and exit-seeking behaviors, leading to one resident eloping and being found on a city street. Despite documented behaviors, care plans were not updated timely, and staff lacked awareness of elopement risks. Interviews revealed a lack of formal assessment processes and communication among staff.
The facility's governing body failed to establish and implement essential policies for management and operation, and did not ensure the administrator's accountability. Key policies were missing or created post-survey, and the administrator's dual role as president of the governing body led to conflicts of interest. Interviews revealed informal oversight and a lack of formal accountability mechanisms.
The facility's assessment was incomplete, lacking evaluations of resident needs based on acuity, specific staffing levels for shifts, and competencies for personnel. It also failed to include job descriptions for contracted staff and volunteers, a recruitment and retention plan, and specific contracted services. Key personnel were either unaware or uninvolved in the assessment's creation, and the assessment was not up to date.
The facility failed to submit accurate staffing data to CMS for Q3, with discrepancies in reported hours for contracted staff. Interviews revealed a lack of process to distinguish direct care from spiritual care hours, and the facility lacked job descriptions for contracted staff. This affected the accuracy of staffing information for all 36 residents.
The facility failed to maintain an effective training program for staff, contracted staff, and volunteers, affecting 36 residents. Annual performance evaluations were incomplete for four nursing assistants, and two did not complete required in-service training. The DON and HR manager acknowledged the absence of a staff development role and a standardized training plan, leading to systemic issues in confirming staff education and training completion.
The facility failed to ensure two nursing assistants completed the required 12 hours of annual in-service training, including abuse and dementia training. NA-F and NA-G lacked documentation of completed training, confirmed by the DON and HR manager. The facility's assessment required staff to be trained with necessary skills, but the job description did not specify abuse or dementia training, potentially affecting all 36 residents.
The facility failed to conduct annual performance evaluations for four nursing assistants, with significant gaps in evaluations noted in their records. Interviews revealed a lack of awareness among staff about the timing of their last evaluations. The absence of a staff development person contributed to this deficiency, and the facility did not provide policies on performance reviews.
The facility did not have a written transfer agreement with a Medicare or Medicaid-certified hospital, which is essential for ensuring timely hospital transfers for residents in emergencies. The DON confirmed the absence of such an agreement and noted no efforts had been made to establish one. The facility's hospital transfer policy did not address this requirement.
Deficiency in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to ensure proper food storage and labeling practices, which had the potential to impact all 32 residents. During an observation of the main kitchen, it was found that an open package of Hillshire Farm sliced turkey lunchmeat was wrapped in saran wrap without a label or date. Additionally, four half gallons of milk were found in the walk-in dairy refrigerator with expired best-by dates. The Dietary Aide and Dietary Director both verified the expired milk and acknowledged the oversight. Furthermore, a tray of vanilla ice cream in the upright freezer was not covered or dated and appeared to be freezer burnt. Cook-A confirmed the lack of labeling on the lunchmeat and the ice cream, stating that they should have been covered and dated. On a separate observation, the 3rd floor kitchenette contained an unopened container of Hormel thicken-it juice with an expired use-by date. Dietary Aide-B verified the expired juice and removed it, noting that dietary staff reviewed items weekly to ensure none were expired, but the juice had been missed. The Dietary Director acknowledged the need for improvements in food storage and stated that with a lower census, items were not being used as frequently. The Administrator also expected expired items to be discarded and all opened items to be covered and labeled. The facility policy directed staff to properly cover, label, and date food items, but this was not adhered to in these instances.
Failure to Administer Oxygen Per Physician's Orders
Penalty
Summary
The facility failed to ensure that oxygen was administered according to physician's orders for a resident with pulmonary fibrosis, leading to a deficiency in respiratory care. The resident, who had moderate cognitive impairment and used oxygen, had physician's orders for oxygen administration to maintain oxygen saturation levels above 91%. However, the medication administration record (MAR) and treatment administration record (TAR) lacked documentation of the resident's oxygen saturation levels and did not consistently record the use of oxygen. Observations and interviews revealed that the resident's oxygen was not always turned on when needed, and staff did not consistently document or administer oxygen as per the physician's orders. The resident's oxygen saturation levels varied, with some instances showing levels below the required threshold without oxygen being administered. Despite the resident expressing a need for oxygen, staff did not always respond appropriately, and there was a lack of documentation in the care plan and care guide regarding the resident's oxygen use. Interviews with staff, including a nursing assistant and a licensed practical nurse, indicated inconsistencies in oxygen administration and documentation. The director of nursing expected staff to monitor oxygen saturations as needed, but the facility's policy on respiratory care was not followed, resulting in the deficiency.
Failure to Implement Individualized Dementia Care
Penalty
Summary
The facility failed to comprehensively assess and implement individualized person-centered dementia care for a resident diagnosed with vascular dementia and other complex medical conditions. The resident, who had severe difficulty communicating due to expressive aphasia and progressive dementia, was dependent on staff for various activities of daily living and exhibited behaviors such as agitation and vocalizations. Despite these challenges, the facility did not adequately document or address the resident's behaviors, which were crucial for evaluating the necessity of psychotropic medications like Seroquel. The resident's care plan and physician orders indicated the use of a Hoyer lift for transfers, but staff frequently used an EZ stand lift due to the resident's combative behavior during care. This deviation from the care plan was not properly documented or communicated, leading to inconsistencies in care delivery. Staff interviews revealed that the resident was often combative during personal care activities, such as toileting and bathing, and that these behaviors were not consistently documented, which hindered the ability to identify patterns or triggers for the resident's agitation. The facility's failure to document and address the resident's behaviors was further compounded by a lack of communication between nursing assistants and nurses. The Director of Nursing acknowledged the issue with behavior documentation, emphasizing the importance of identifying patterns and root causes to develop effective interventions. The facility's behavior management policy required vigilant observation and documentation of behaviors, but this was not adhered to, resulting in a deficiency in providing appropriate dementia care for the resident.
Failure to Act on Pharmacist Recommendations for Medications
Penalty
Summary
The facility failed to ensure timely action on consultant pharmacist recommendations for two residents regarding unnecessary medications. For one resident, who had a history of non-traumatic brain dysfunction, hypertension, diabetes mellitus, aphasia, and non-Alzheimer's dementia, the pharmacist recommended re-evaluating the prolonged use of a topical antifungal, nystatin powder, due to the risk of adverse consequences. Despite this recommendation, there was no documented physician response or signature to indicate that the medication was addressed, and the Director of Nursing (DON) acknowledged that previous recommendations were not followed up on. Another resident, diagnosed with major depressive disorder and receiving duloxetine, had a pharmacy consultation report recommending a gradual dose reduction (GDR) due to federal regulations. However, there was no documented physician response or signature to indicate that the medication was addressed. The pharmacist consultant noted a delay in following up on recommendations, and the DON admitted that pharmacy recommendations were not being followed up on prior to November, without knowing the reason for the oversight.
Failure to Monitor and Track Topical Antibiotic Use
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, specifically a topical antibiotic. The resident, who was cognitively intact and had a history of diabetes and hidradenitis suppurativa, was prescribed clindamycin lotion for a year. However, the order for the clindamycin lotion had no end date, and it was unclear if the resident was still using the medication as she was able to self-administer and store medications unsupervised. The resident's care plan did not indicate that she was prescribed an antibiotic, and there was no documentation of monitoring or evaluation of the effectiveness of the antibiotic. Interviews with staff revealed a lack of awareness and tracking of the resident's use of the topical antibiotic. The registered nurse was not aware of the resident's use of clindamycin and noted that there was no end date on the order. The infection preventionist confirmed that the antibiotic was not included in the facility's tracking, which only covered oral antibiotics. The Director of Nursing acknowledged the oversight and stated that all antibiotics should be tracked. The facility's policy required a duration for antibiotic orders and monitoring of their effectiveness, which was not followed in this case.
Failure to Notify Physician of Abnormal Blood Glucose Levels
Penalty
Summary
The facility failed to ensure timely physician notification of an abnormal lab result for a resident with diabetes. The resident, who had intact cognition and was receiving insulin injections, experienced multiple instances of low blood glucose (BG) levels on a specific day. Despite standing orders requiring physician notification if BG levels were less than 70 after two treatment attempts, the physician was not notified when the resident's BG levels fell below this threshold multiple times. The resident's blood glucose levels were recorded as low as 52 mg/dl, and despite interventions such as administering orange juice and glucose tablets, the levels remained below 70 mg/dl on several occasions. The nursing progress notes indicated that the resident experienced symptoms of hypoglycemia, such as shakiness and dizziness, and admitted to not eating a snack the previous evening. However, there was no documentation indicating that the physician was notified of these low BG levels, as required by the facility's standing orders. Interviews with the LPN and the Director of Nursing (DON) confirmed that the physician should have been notified according to the standing orders. The LPN acknowledged the oversight, and the DON emphasized the importance of notifying the physician to address potential changes in the resident's condition. The facility's medical director later clarified the blood glucose orders, but at the time of the incident, the standing orders were not followed, leading to the deficiency.
Failure to Address Wandering and Elopement Risks
Penalty
Summary
The facility failed to adequately assess and implement individualized interventions for residents with wandering and exit-seeking behaviors, leading to a serious incident involving two residents. Resident 1, who had severe cognitive impairment and a history of wandering, was not comprehensively assessed for elopement risk. Despite multiple documented instances of wandering and exit-seeking behaviors, the facility did not update Resident 1's care plan in a timely manner to address these behaviors. This lack of assessment and intervention resulted in Resident 1 eloping from the facility and being found on a city street by a passerby. Resident 2, also with severe cognitive impairment and a history of dementia, exhibited exit-seeking behaviors but was not comprehensively assessed for elopement risk. The facility failed to implement immediate interventions following Resident 2's exit-seeking incident, and the care plan was not updated until several days later. The facility's inaction in assessing and addressing Resident 2's wandering behaviors contributed to the deficiency. Interviews with facility staff, including the DON and various nursing assistants, revealed a lack of awareness and understanding of the residents' elopement risks and the necessary interventions. Staff members were not consistently informed about residents' behaviors, and there was no formal process for assessing elopement risk. The facility's failure to conduct comprehensive assessments and implement appropriate interventions for residents with wandering and exit-seeking behaviors led to the deficiency identified by surveyors.
Removal Plan
- Comprehensively assessed all residents for elopement risk
- Assessed level of supervision needed
- Implemented appropriate interventions
- Evaluated efficacy of current interventions
- Updated care plans accordingly
- Reviewed and revised elopement policies and procedures
- Identified residents at high risk
Lack of Governing Body Policies and Administrator Accountability
Penalty
Summary
The facility's governing body failed to establish and implement necessary policies for the management and operation of the facility, as well as ensuring the administrator's accountability to the governing body. During the survey, the facility was unable to provide several requested policies, including those related to physician visits, emergency care, and staff licensure verification. Policies that were eventually provided were dated after the survey began, indicating they were not in place prior to the survey. The facility's assessment claimed that policies were reviewed annually, but the lack of documentation contradicted this claim. Interviews with facility staff, including the stand-in for the chief executive officer (SCEO), the director of nursing (DON), and the administrator, revealed a lack of awareness and documentation of essential policies. The SCEO admitted that while physician visits were conducted according to regulations, there was no formal policy in place. The administrator acknowledged that the governing body had not discussed or followed recommendations for policy establishment and implementation. The facility's organizational structure further complicated accountability, as the administrator also served as the president of the governing body, creating a conflict of interest. The governing body consisted of the administrator, an assistant to the administrator, and a contracted registered nurse, with the administrator also holding the role of Mother Superior. This dual role led to confusion about accountability and reporting structures, as the administrator was expected to report to herself in her capacity as Mother Superior. Interviews with other governing body members confirmed the lack of formal oversight and accountability mechanisms, as meetings were informal and updates were provided verbally. The facility was in the process of hiring a non-clergy administrator to separate these functions, but at the time of the survey, the deficiency remained unaddressed.
Incomplete Facility Assessment and Staffing Plan
Penalty
Summary
The facility failed to ensure that the Facility Assessment (FA) was comprehensive and included necessary evaluations and plans. The assessment did not evaluate the resident population's needs based on acuity using evidence-based data-driven methods, and it lacked specific staffing levels required for different shifts. Additionally, the FA did not include competencies and skill sets for all personnel necessary to provide appropriate care, nor did it identify job descriptions for contracted registered nurses, unit supervisors, or volunteers. The assessment also lacked a plan for maximizing recruitment and retention of direct care staff and did not identify specific contracted services required to meet resident needs. Interviews revealed that key personnel, including the Director of Nursing (DON) and the new acting Administrator, were either unaware of the FA or uninvolved in its creation. The regional consultant was unaware of a facility policy for volunteers, and the stand-in chief executive officer (SCEO) and contracted registered nurse (CRN-A) acknowledged that the FA was not up to date. The SCEO indicated that updates were made to include project and quality meeting dates, but other parts of the assessment were not updated due to a lack of responsibility. The DON emphasized the importance of having knowledgeable staff and appropriate policies for education, training, and competency, which were not reflected in the current FA.
Inaccurate Staffing Data Submission to CMS
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) for the third quarter. The Payroll Based Journal (PBJ) report for this period showed discrepancies in the reported hours for contracted staff, specifically for a contracted nursing assistant (CNA-A) and two certified registered nurses (CRN-A and CRN-B). The reported hours in the PBJ did not match the hours documented on the facility's contracted service time sheets, leading to inconsistencies in the data submitted to CMS. Interviews with the facility's payroll administrator and contracted staff revealed a lack of clarity and process in distinguishing between direct care hours and spiritual care hours. The payroll administrator was unaware of any process to separate these hours, and the contracted staff, including CNA-A and CRN-A, reported working on an as-needed basis without a clear method to track their direct care hours. This lack of documentation and tracking contributed to the discrepancies in the reported hours. Additionally, the facility did not have job descriptions or contract information for the contracted staff, which further complicated the accurate reporting of staffing hours. The human resource manager confirmed the absence of job descriptions for the unit supervisors, and the facility's policy on PBJ reporting was not updated to reflect the primary roles and job titles of the staff involved. This oversight in documentation and reporting processes had the potential to affect all 36 residents residing in the facility.
Deficiency in Staff Training Program
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for all new and existing staff, contracted staff, and volunteers, which had the potential to affect all 36 residents receiving care. The deficiency was identified through interviews and document reviews, revealing that the facility did not complete annual performance evaluations for four out of five nursing assistants who had been employed for over a year. Additionally, two out of five nursing assistants did not complete the required 12 hours of annual in-service training, and one nursing assistant lacked abuse or dementia training. The facility's assessment did not specify training or competencies based on the resident population, and the requested training program and orientation plan were not provided. Interviews with the Director of Nursing (DON) and the administrator highlighted concerns about staff education and the absence of a staff development person to track required education. The DON admitted to not having an ongoing training plan for nurses beyond orientation and competency checklists, and there was no standardized training plan in place. The human resources manager confirmed the lack of a process for ensuring staff completed necessary training. The facility's assessment referenced a Training and Orientation Plan, but neither the DON nor the human resources manager was familiar with its contents, indicating a systemic issue in confirming staff education and training completion.
Deficiency in Nursing Assistant Training
Penalty
Summary
The facility failed to ensure that two of the five nursing assistants reviewed for annual training completed the required 12 hours of in-service training. Specifically, NA-F was unaware of the number of training hours completed and did not have documentation of 12 hours of training in their employee file. NA-G reported completing online training through Relias and signing off on letters composed by the DON, but also did not have documentation of 12 hours of training or the required abuse and dementia training in their file. The DON and HR manager confirmed the lack of documentation for both NA-F and NA-G. The facility's assessment indicated that staff were expected to be trained with the necessary skills to care for residents, and that education and credentials were to be verified before hiring and checked annually. However, the job description for certified nursing assistants did not specify the requirement for abuse or dementia training. This oversight had the potential to affect all 36 residents in the facility, as one of the nursing assistants had not received any abuse or dementia training.
Failure to Conduct Annual Performance Evaluations for Nursing Assistants
Penalty
Summary
The facility failed to complete annual performance evaluations for four out of five nursing assistants who had been employed for over a year. Specifically, the personnel records for NA-D, NA-E, NA-F, and NA-G showed significant gaps in performance evaluations. NA-D, hired in 2007, had their last evaluation in 2020, with another one in 2016. NA-E, hired in 2005, had their last evaluation in 2021. NA-F, hired in 2020, had no performance review on record. NA-G, hired in 2015, had their last evaluation in 2020. Interviews with the nursing assistants revealed a lack of awareness about the timing of their last evaluations, with some believing they had been completed more recently than the records indicated. The human resources manager and the director of nursing confirmed the absence of annual performance reviews in the employee files. The director of nursing noted that the facility lacked a staff development person responsible for managing these tasks, which should have been completed yearly and submitted to human resources. Despite requests, the facility did not provide policies regarding performance reviews, indicating a systemic issue in maintaining up-to-date evaluations for nursing assistants.
Lack of Written Hospital Transfer Agreement
Penalty
Summary
The facility failed to maintain a written transfer agreement with a hospital certified by Medicare or Medicaid, which is necessary to ensure the timely transfer and admission of residents requiring emergency hospitalization. This deficiency was identified during a review of the facility's policies and procedures, where no such agreement was found. During an interview, the Director of Nursing (DON) confirmed the absence of a written transfer agreement and acknowledged that no good faith effort had been made to establish one with a hospital. The facility's policy on hospital transfers, dated November 10, did not address the requirement for a transfer agreement with a hospital.
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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