Littlefork Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Littlefork, Minnesota.
- Location
- 912 Main Street, Littlefork, Minnesota 56653
- CMS Provider Number
- 245542
- Inspections on file
- 23
- Latest survey
- December 10, 2025
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Littlefork Care Center during CMS and state inspections, most recent first.
Two residents were involved in an incident where one physically assaulted the other, resulting in injury. Although internal documentation was completed promptly, the required report to the state agency was not made in a timely manner, contrary to facility policy.
A resident with severe cognitive impairment and behavioral disturbances was sent to the ED after physically assaulting another resident. The facility subsequently refused re-admission and discharged the resident without providing the required notice of intent to discharge, as confirmed by the administrator. The facility's discharge policy was not provided upon request.
The facility failed to implement transmission-based precautions for residents with respiratory symptoms, leading to an influenza A outbreak affecting eight residents. The facility did not initiate droplet precautions for a resident who tested positive for influenza A and lacked strategies to mitigate the outbreak, such as active surveillance and isolation of symptomatic residents. Staff were observed not wearing appropriate PPE, and there was a lack of signage to alert staff and visitors of the outbreak.
The facility failed to limit the use of as-needed psychotropic medication to a 14-day period and ensure re-evaluation by a provider for two residents. One resident with severe cognitive impairment received lorazepam multiple times without a documented provider evaluation. Another resident was prescribed multiple psychotropic medications without documented monitoring of specific behaviors or justification for dosage increases. The facility did not adhere to its policy requiring evaluation and documentation for continued medication use.
A resident with severe cognitive impairment and dementia-related behaviors was inadequately managed, leading to multiple altercations with other residents. Despite being on psychotropic medications, the resident's care plan lacked specific interventions for resident-to-resident interactions. Observations and interviews revealed frequent intrusions into other residents' spaces, causing distress and confrontations. The facility's policy required a comprehensive assessment and individualized care plan, which was not adequately implemented, and staff interventions were inconsistent due to staffing limitations.
The facility failed to act on the consulting pharmacist's recommendations for three residents, leading to unaddressed medication irregularities. One resident was prescribed quetiapine without appropriate diagnosis verification, another received multiple PRN antipsychotics without required evaluations, and a third was at risk due to a combination of benzodiazepines and opioids. The lack of physician response and documentation highlights a communication breakdown in medication management.
A resident with severe cognitive impairment and a history of Alzheimer's and MRSA developed a hematoma that was not timely communicated to the physician. The hematoma was first noted after a fall but was not documented until weeks later when the medical director assessed it during routine rounds. The hematoma later opened and drained, but the physician was not notified of this change until days later, contrary to the facility's policy requiring immediate notification of significant changes.
A resident with severe cognitive impairment and multiple falls did not have their care plan updated in a timely manner to include necessary fall prevention interventions. Despite the facility's policy requiring frequent reviews and updates, the care plan was not revised to reflect new interventions such as assisting the resident back to their room after meals and toileting every two hours until days after the incidents.
A resident with hemiplegia and dietary needs was left without necessary assistance during a meal, despite requiring supervision and help to cut food. The resident was observed in the dining room with food not prepared to their needs, and staff failed to offer assistance for an extended period. Interviews revealed a lack of communication and clarity regarding the resident's dietary requirements.
A facility failed to provide adequate wound care and edema management for two residents. One resident with a hematoma did not receive timely monitoring or physician notification, leading to infection and surgical intervention. Another resident with edema did not have prescribed Ace Wraps applied, resulting in unmanaged swelling. The facility did not adhere to its skin integrity policies, leading to these deficiencies.
The facility failed to provide timely repositioning for a resident at risk for pressure ulcers and did not follow treatment orders for another resident with existing pressure ulcers. Despite care plans and policies in place, staff did not assist with repositioning or complete daily dressing changes as required, leading to deficiencies in care.
A resident with severe cognitive impairment and high fall risk experienced multiple falls due to the facility's failure to update the care plan with necessary interventions. Despite being identified as needing regular toileting and assistance, the care plan was not revised promptly, and staff did not consistently offer toileting every two hours. This oversight contributed to repeated falls, highlighting a lack of adherence to care plan protocols.
A facility failed to assess and address trauma-informed care for a resident with PTSD, anxiety, insomnia, and bipolar disorder. The resident's care plan lacked specific interventions for PTSD, despite a history of childhood sexual abuse. The social worker admitted to not completing a Trauma-Informed Care Assessment, leaving staff unaware of potential triggers. The DON confirmed the necessity of such assessments to ensure individualized treatment, as outlined in the facility's policy.
A resident with chronic lung disease and mild cognitive impairment was not offered a pneumococcal vaccination upon admission, despite being identified as not up to date with vaccinations. The facility's policy required offering vaccinations based on CDC guidelines, but the staff failed to do so, and there was no documentation of vaccine education or offering in the resident's electronic health record.
The facility did not update the nurse staffing information daily or include the census on the posting, as required. Observations showed the posting was outdated, and the DON was unaware of who was responsible for updates. The facility's policy required daily updates by the Night Charge Nurse, but this was not consistently done, potentially affecting all 38 residents and visitors.
The facility failed to ensure that state agency survey results were accessible to residents, as two residents who attended council meetings were unaware of their location. The survey binder, labeled for Minnesota Department of Health results, was missing several recent surveys and lacked a notice about the availability of the last three years of results. The DON acknowledged the binder should have contained these results, but the most recent entry was from 2022, and no policy for survey posting was provided.
A resident with Alzheimer's and mobility impairments experienced multiple falls from bed due to inadequate interventions by the facility. Despite being identified as high risk for falls, the facility's measures, such as staff assistance and non-skid strips, failed to prevent repeated incidents. The interdisciplinary team did not effectively address the root causes, such as the resident's tendency to slide out of bed, leading to ongoing fall risks.
A resident with cerebral palsy, PTSD, bipolar disorder, and anxiety filed a grievance alleging verbal abuse by staff, but the facility failed to act on it. The social services designee did not file the grievance as the resident's family member advised against it, despite the resident being her own decision-maker. The grievance was reported to the DON but not submitted to the administrator, contrary to facility policy requiring investigation and written response.
A resident with cerebral palsy, PTSD, bipolar disorder, and anxiety alleged emotional abuse and neglect by staff, but the facility failed to report the allegations to the state agency within the required timeframe. The DON and administrator were aware of the allegations but did not report them, citing the resident's history of false accusations. The facility's policy required immediate reporting of suspected maltreatment, leading to a deficiency in reporting the alleged abuse.
A resident with multiple diagnoses, including cerebral palsy and PTSD, reported feeling emotionally abused and neglected by staff during the p.m. shift. Despite the resident's care plan noting her tendency to make false accusations, the facility failed to investigate her allegations thoroughly. The DON was aware of the complaints but did not provide evidence of an investigation, and the administrator's expectation for a comprehensive investigation was not met.
A resident with moderate cognitive impairment and daily wandering behaviors was at risk for elopement. The facility failed to conduct an elopement risk assessment when removing and reinstating a Wander Guard (WG). The resident was found outside the facility, and the fenced area was inadequately secured with a bungee cord and an unsecured latch.
Failure to Timely Report Resident-to-Resident Abuse to State Agency
Penalty
Summary
The facility failed to ensure timely reporting of an allegation of resident-to-resident abuse to the state agency for two residents. One resident, who had a diagnosis of neurocognitive disorder with dementia, agitation, and psychotic disturbance, was identified as having severe cognitive impairment and a risk for harm to self or others. This resident engaged in aggressive behavior at the nurses' station, where he grabbed another resident's walker, yelled, pushed, and struck the other resident multiple times in the chest and shoulder before staff could intervene. The second resident, who had a history of cerebral infarction and was identified as potentially verbally aggressive, sustained injuries including pain and a lump on her right shoulder and bicep as a result of the incident. Despite facility policy requiring immediate reporting of suspected maltreatment to the state agency, the incident was not reported in a timely manner. The social service designee completed an internal report promptly but did not notify the correct agency. The administrator confirmed that the incident was not reported to the state agency until it was identified by a corporate consultant, which was not within the required timeframe outlined in facility policy.
Failure to Provide Required Discharge Notice After Resident Transfer
Penalty
Summary
The facility failed to provide the required notice of intent to discharge for a resident who was sent to the hospital and subsequently discharged from the facility. The resident, who had diagnoses including neurocognitive disorder with Lewy bodies, dementia with mood disturbance, agitation, and psychotic disturbance, was identified as having severe cognitive impairment and a risk for harm to self or others. The care plan included specific interventions for managing aggressive behavior and directed staff to contact law enforcement and send the resident to the emergency department if necessary. On the day of the incident, the resident physically assaulted another resident, leading staff to intervene and send the resident to the emergency department for further placement. Following the incident, the facility received notification that the hospital intended to return the resident, but the facility administrator instructed staff not to accept the resident back, citing a lack of resources to meet his needs. The resident was officially discharged and placed in a behavioral health unit. During an interview, the administrator confirmed the discharge was due to the resident's aggression and acknowledged that the facility did not provide the required notice of intent to discharge. The facility's discharge policy was requested but not provided.
Failure to Implement Transmission-Based Precautions Leads to Influenza A Outbreak
Penalty
Summary
The facility failed to implement transmission-based precautions (TBP) for residents exhibiting respiratory symptoms until confirmatory test results were obtained. This oversight affected six residents who showed symptoms but were not isolated or placed on TBP, leading to the spread of influenza A among eight residents. The facility also failed to initiate droplet precautions for a resident who tested positive for influenza A, and did not implement strategies to mitigate the risk of an influenza outbreak, such as active surveillance, isolation of symptomatic residents, and posting signage to notify visitors of the outbreak. The deficiency was further compounded by the facility's failure to track and trend all resident infections on the monthly tracking form, which hindered the identification of symptoms and the reduction of infection spread. Specific cases included residents who were not placed on droplet precautions despite testing positive for influenza A, and others who exhibited symptoms but were not isolated or monitored adequately. Staff were observed not wearing appropriate personal protective equipment (PPE) when interacting with symptomatic residents, and there was a lack of signage to alert staff and visitors of the necessary precautions. The facility's infection prevention and control program was inadequate, as evidenced by the lack of active surveillance and the delayed implementation of droplet precautions. The Director of Nursing (DON) and the infection preventionist acknowledged the lapses in protocol, including the failure to isolate symptomatic residents and the absence of a system for ongoing active surveillance. These deficiencies resulted in a system-wide failure to prevent the spread of influenza A within the facility, placing all residents at a high risk of serious illness.
Failure to Re-evaluate Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure the use of as-needed psychotropic medication was limited to a 14-day period and re-evaluated by the provider for two residents. Resident R18, who had severe cognitive impairment and diagnoses including Alzheimer's disease and dementia, was administered lorazepam on multiple occasions without a documented face-to-face provider evaluation to assess the continued need for the medication. The nursing progress notes indicated instances where R18 exhibited anxiety and agitation, leading to the administration of lorazepam, but there was no evidence of a provider evaluation to justify the ongoing use of the medication. Resident R11, who had severe cognitive impairment and was at risk for elopement and wandering, was prescribed quetiapine, gabapentin, and escitalopram for behavior management. However, the medical record lacked documentation of specific behaviors being tracked or monitored to ensure the efficacy of these medications. The care plan did not address R11's anxiety, and there was no assessment to support the increase in gabapentin dosage. Interviews with staff revealed that R11 was generally pleasant and did not exhibit aggressive behaviors, raising questions about the necessity of the prescribed psychotropic medications. The facility's policy on psychotropic medications required that the underlying cause of behavioral symptoms be determined and that non-pharmacological interventions be utilized before resorting to medication. The policy also mandated that PRN psychotropic medications be limited to 14 days, with a documented evaluation by the prescribing practitioner. The facility failed to adhere to these guidelines, as evidenced by the lack of documented evaluations and assessments for the continued use of psychotropic medications for residents R18 and R11.
Inadequate Management of Dementia-Related Behaviors
Penalty
Summary
The facility failed to adequately assess and manage the dementia-related behaviors of a resident, identified as R22, who exhibited severe cognitive impairment and a range of challenging behaviors. R22's behaviors included delusions, physical and verbal aggression towards others, pacing, rummaging, and wandering, which significantly impacted his care and posed risks to other residents. Despite being on antipsychotic, antidepressant, and antianxiety medications, R22's care plan lacked specific interventions to address his interactions with other residents, leading to multiple incidents of resident-to-resident altercations. Observations and interviews revealed that R22 frequently intruded into other residents' personal spaces, leading to confrontations. For instance, R22 was observed pacing hurriedly, pushing staff, and attempting to enter other residents' rooms, which caused distress among the residents. Several residents reported feeling threatened by R22's actions, such as shaking his fist and making verbal threats. Staff interventions were inconsistent, and there was no comprehensive behavior assessment to identify triggers or effective interventions for R22's behaviors. The facility's policy on dementia care required a comprehensive assessment and individualized care plan for residents with dementia-related behaviors. However, R22's medical record lacked such an assessment, and the care plan did not adequately address the resident-to-resident incidents. Interviews with staff indicated that while some attempts were made to manage R22's behaviors through one-to-one supervision and diversional techniques, these measures were insufficient due to staffing limitations. The medical director was not informed of R22's interactions with other residents, indicating a communication gap in managing the resident's care.
Failure to Address Pharmacist Recommendations on Medication Use
Penalty
Summary
The facility failed to ensure that the consulting pharmacist's recommendations were addressed, acted upon, and documented in the medical records for three residents reviewed for unnecessary medication use. For one resident with severe cognitive impairment and Alzheimer's disease, the pharmacist identified an irregularity with the prescription of quetiapine, noting that dementia was not an appropriate diagnosis for its use. Despite the recommendation to verify the indication's accuracy, there was no recorded response from the physician, and the issue was not addressed within the specified timeframe. Another resident with severe cognitive impairment and neurocognitive disorder with Lewy bodies was prescribed multiple PRN antipsychotic and psychotropic medications without appropriate stop dates or face-to-face evaluations as required by CMS guidelines. The pharmacist's recommendations to re-evaluate the clinical appropriateness and add stop dates were not acted upon, and the resident continued to receive these medications frequently without the necessary evaluations or documentation. A third resident with intact cognition and multiple diagnoses, including anxiety and bipolar disorder, was prescribed a combination of benzodiazepines and opioids, which posed a risk for CNS/respiratory depression. The pharmacist recommended reassessing the use of these medications and providing clinical rationale for their continued use, but there was no recorded response from the physician. The facility's failure to address these recommendations highlights a lack of communication and follow-up on medication reviews, leading to potential risks for the residents involved.
Failure to Notify Physician of Resident's Hematoma
Penalty
Summary
The facility failed to timely notify the physician when a hematoma was identified and subsequently opened, requiring a new intervention for a resident with severe cognitive impairment and a history of Alzheimer's disease and MRSA infection. The resident had an undated care plan that directed staff to monitor and provide wound care, but the hematoma was not documented in the medical record until several weeks after it was first noted by staff. On the night of the incident, the resident was found on the floor with a large bruised lump on her right inner shin. Although the resident's son was contacted and the resident was sent to the emergency room, the hematoma was not properly documented or communicated to the physician until the medical director happened to be in the facility for routine rounds. The medical director assessed the hematoma and recommended monitoring, but no further treatment was deemed necessary at that time. The hematoma later opened and began draining, but the physician was not notified of this change in condition until several days later. The facility's policy required immediate notification of significant changes to the resident's condition, but this was not followed. Interviews with staff revealed a lack of awareness and communication regarding the resident's condition, leading to a delay in appropriate medical intervention.
Failure to Update Care Plan Timely for Fall Prevention
Penalty
Summary
The facility failed to update the care plan in a timely manner to prevent falls for a resident with severe cognitive impairment and diagnoses including Alzheimer's disease, dementia, and osteoporosis. The resident experienced multiple falls, including one without injury and another with injury. Despite these incidents, the care plan was not revised to include new interventions such as assisting the resident back to their room after meals, toileting every two hours, and placing a flat sensor under the sheet. These interventions were identified after the falls but were not promptly incorporated into the care plan. The facility's policy required that care plans be reviewed every 90 days or more frequently if necessary, with updates made as needed based on changes in the resident's condition. However, the care plan for this resident was not updated to reflect the necessary fall interventions until several days after the incidents occurred. Interviews with the RN and DON confirmed that the care plan was not revised to include the identified interventions, which were expected to be followed to prevent further falls.
Failure to Assist Resident with Meal Setup
Penalty
Summary
The facility failed to ensure that a resident, identified as R38, received the necessary assistance with meal setup to promote safety and independence in eating. R38, who had intact cognition, required supervision or touching assistance with eating due to hemiplegia following cardiovascular disease and venous insufficiency. Despite being assessed by Occupational Therapy as needing supervision and assistance to cut up food, and having a care plan that required supervision during meals, R38 was left without the necessary assistance during a meal in the dining room. On the day of the incident, R38 was observed sitting in the dining room with a meal that included a sloppy joe bun cut into quarters and whole french fries, which were not cut into small bite-sized pieces as required. R38 did not attempt to eat and remained seated with his hands in his lap, indicating he was hungry but unable to eat the food without assistance. Despite the presence of staff in the dining room, no one approached R38 to offer help for an extended period. It was only after the Director of Nursing intervened that R38 was assisted to his room with his meal. Interviews with staff revealed a lack of clarity and communication regarding R38's dietary needs and assistance requirements. Nursing assistants and a registered nurse acknowledged the oversight in not providing the necessary assistance, and the dietary aide was unaware of any current order for small bite-sized food, despite R38's known difficulties. The facility's policy on Activities of Daily Living was not effectively implemented, as staff failed to supervise and assist R38 adequately, leading to the deficiency in care.
Failure in Wound Care and Edema Management
Penalty
Summary
The facility failed to provide ongoing monitoring and appropriate wound care for a resident with a significant hematoma on the right leg. The resident, who had severe cognitive impairment and a history of Alzheimer's disease and MRSA infection, sustained a fall resulting in a large hematoma. Despite the presence of a care plan directing staff to monitor and provide wound care, the hematoma was not documented until several weeks after the incident. The hematoma eventually broke open, leading to significant drainage and infection, but the physician was not notified of the change in condition until much later, resulting in the resident requiring surgical intervention. Another resident with a history of hemiplegia and venous insufficiency was not provided with the necessary interventions for edema management. The resident's care plan included the use of Ace Wraps to manage leg swelling, but these were not applied as ordered. Nursing staff failed to apply the wraps before the resident got out of bed, leading to visible edema. The lack of communication and responsibility among staff members resulted in the resident not receiving the prescribed treatment, which was crucial for managing the resident's condition. The facility's policies on skin integrity and wound care were not adhered to, as evidenced by the lack of timely documentation, monitoring, and communication with healthcare providers. The deficiencies in care for both residents highlight a failure to follow established protocols, resulting in inadequate treatment and monitoring of their conditions.
Failure in Pressure Ulcer Care and Repositioning
Penalty
Summary
The facility failed to provide timely assistance with repositioning for a resident identified as R4, who was at risk for pressure ulcers. Despite being cognitively intact and having a care plan that included repositioning every two hours, R4 was observed propelling herself in a wheelchair from breakfast to the activity room and then to a common area without any staff offering to assist with repositioning. Interviews with nursing assistants and the registered nurse confirmed that staff were aware of the need to encourage repositioning but failed to do so on the day of observation. Another resident, R31, who had intact cognition and was at risk for pressure ulcer development, was found to have deficiencies in the care of existing pressure ulcers. R31 had a stage two and a stage four pressure ulcer acquired at the facility, and the care plan included specific interventions such as elevating the leg and daily dressing changes. However, observations revealed that the dressing on R31's left calf was not changed daily as ordered, and the right heel was left open to air with drainage on the bed sheet. The Treatment Administration Record showed multiple days where dressing changes were not documented as completed. Interviews with nursing staff indicated that if orders were not initialed on the Treatment Administration Record, it was assumed the care was not provided. The Director of Nursing stated that dressings were expected to be completed daily to promote healing and prevent infection. The facility's policy on skin integrity emphasized the need for daily observation and documentation of pressure ulcers, which was not adhered to in R31's case.
Failure to Update Care Plan for High Fall Risk Resident
Penalty
Summary
The facility failed to comprehensively assess and update the care plan for a resident identified as a high fall risk, leading to multiple falls. The resident, who had severe cognitive impairment and conditions such as Alzheimer's disease, dementia, and osteoporosis, experienced several falls, some resulting in injury. Despite being identified as a high fall risk, the resident's care plan was not timely updated to include necessary interventions such as regular toileting and assistance back to the room after meals. The resident's care plan lacked specific interventions for toileting, which was a significant oversight given the resident's history of falls and incontinence. Incident reports documented several falls where the resident attempted to move independently, often resulting in falls. Staff interviews revealed that the resident was not consistently offered toileting every two hours, despite being identified as needing this intervention. Additionally, the care plan was not revised promptly to reflect new interventions after each fall, such as the use of sensor alarms. The facility's failure to update the care plan and implement timely interventions contributed to the resident's repeated falls. Staff interviews indicated a lack of consistent adherence to the care plan, with some staff unaware of the need for regular toileting. The director of nursing acknowledged that care plans should be revised with identified fall interventions, but this was not consistently done, leading to ongoing risks for the resident.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to comprehensively assess and address trauma-informed care for a resident diagnosed with PTSD, anxiety, insomnia, and bipolar disorder. The resident's care plan did not identify PTSD triggers or specific interventions related to PTSD, despite the resident's history of childhood sexual abuse. The care plan included general interventions for behavior management but lacked specific strategies to prevent re-traumatization. The facility's social worker, who was also the activities director, acknowledged that a Trauma-Informed Care Assessment was not completed for the resident. The social worker had recently learned of her responsibility to conduct such assessments and had done so for another resident. The absence of this assessment meant that staff were not fully informed of the resident's trauma history and potential triggers, such as the presence of male caregivers during personal care tasks. The director of nursing confirmed that a Trauma-Informed Care Assessment should have been completed to ensure individualized treatment for the resident. The facility's policy on trauma-informed care outlined a multi-faceted approach to identifying a resident's trauma history, including the use of a universal screening tool and the incorporation of trauma-related interventions into the care plan. However, these procedures were not followed for the resident in question.
Failure to Offer Pneumococcal Vaccination
Penalty
Summary
The facility failed to offer a pneumococcal vaccination to a resident, identified as R36, according to CDC guidelines. R36 was admitted to the facility with a history of chronic lung disease, tobacco use, and mild cognitive impairment. The admission Minimum Data Set (MDS) indicated that R36 was not up to date with pneumococcal vaccinations, and the vaccine was not offered upon admission. Although R36 had previously received the PPSV23 and PCV13 vaccines, there was no evidence in the electronic health record that R36 or their representative were offered education or a booster vaccine, such as PCV15 or PCV20, in conjunction with their provider. During interviews, RN-A stated that vaccines were discussed and offered upon admission, using the CDC's PneumoRecs VaxAdvisor to determine vaccine needs. However, RN-A acknowledged that the pneumococcal vaccine should have been offered to R36 but was not. The Director of Nursing (DON) confirmed that staff were expected to use the PneumoRecs vaccination website to ensure residents were up-to-date with their vaccines but was unaware of when residents were offered the vaccine. The facility's Resident Immunizations policy, revised in January 2025, required that all residents be offered vaccinations based on CDC recommendations, with documentation in the electronic medical record, which was not followed in this case.
Failure to Update Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the nurse staffing information was updated daily and that the census was included on the nurse staff posting. This deficiency was observed during a survey when the nurse staff posting, located near the front entrance, was found to be outdated. The posting was dated 2/21/25, but during a subsequent observation on 2/25/25, it had not been updated. The Director of Nursing (DON) was unaware of who was responsible for updating the posting. A review of the nurse staff postings from 1/19/25 through 2/25/25 revealed that the postings were not updated with actual working staff hours on 12 days and the facility census was not recorded on 26 days. Interviews with the DON indicated that night shift staff were responsible for completing the nurse staff posting, and each shift's nurse was expected to update the posting to reflect staffing changes. However, this was not consistently done. The facility's policy required the Night Charge Nurse to count the number of nursing staff responsible for resident care daily, include the facility census, and update the information as needed. The policy also required the information to be posted by the main entrance and kept for eighteen months. Despite these requirements, the facility failed to maintain accurate and up-to-date nurse staffing information, potentially affecting all 38 residents and visitors who may wish to view the information.
Failure to Provide Accessible Survey Results
Penalty
Summary
The facility failed to ensure that the state agency (SA) survey results were available and accessible for residents, as evidenced by the experiences of two cognitively intact residents who regularly attended resident council meetings. These residents were aware that the survey results should be available but did not know where to find them. During an observation, it was noted that the binder labeled 'Minnesota Department of Health Survey Results' was missing several recent survey results, including those from 2023 and 2024, as well as a recertification survey from 2025. Additionally, there was no notice indicating that the last three years of survey results were available upon request or information on whom to contact for them. The director of nursing (DON) confirmed that the survey binder should contain the past three years of survey results for review by residents, family, and visitors. However, the most recent survey result in the binder was dated December 5, 2022. The facility did not provide a policy for survey binder posting when requested, indicating a lack of adherence to proper procedures for maintaining and displaying survey results. This deficiency had the potential to affect all 38 residents and their families who might wish to review the survey results.
Inadequate Fall Prevention Measures for Resident with Multiple Falls
Penalty
Summary
The facility failed to perform a comprehensive assessment of falls for a resident, identified as R2, who experienced multiple falls from bed. R2 was admitted to the facility with diagnoses including Alzheimer's disease, hemiplegia, hemiparesis, dementia, and insomnia. Despite being identified as having moderate cognitive impairment and a high risk for falls, the facility's interventions were insufficient in preventing repeated falls. R2's care plan included measures such as staff assistance with mobility, ensuring the call light was within reach, and placing non-skid strips on the floor. However, these interventions did not effectively address the root causes of R2's falls, which included sliding out of bed and impulsive behavior due to cognitive impairments. The facility's interdisciplinary team (IDT) reviewed R2's falls but failed to implement effective interventions to prevent further incidents. R2 experienced several falls, often late at night or early in the morning, and was found on the floor multiple times. The IDT's actions included educating R2 on call light use, ensuring proper footwear, and moving R2 closer to the nurse's station. Despite these efforts, R2 continued to fall, indicating that the interventions were not adequately addressing the underlying issues. Observations and interviews revealed that R2 often slept perpendicular on the bed and had a tendency to slide off, which was not sufficiently mitigated by the existing interventions. The facility's policy on fall prevention and management required a comprehensive analysis of falls when a resident experienced two or more incidents. This analysis was intended to identify trends, evaluate current interventions, and develop new strategies if necessary. However, the facility did not effectively follow this policy, as evidenced by the repeated falls and lack of new, effective interventions for R2. The IDT's failure to conduct a thorough root cause analysis and implement appropriate measures contributed to the ongoing risk of falls for R2.
Failure to Address Resident Grievance of Verbal Abuse
Penalty
Summary
The facility failed to act on a grievance filed by a resident who alleged verbal abuse by staff. The resident, who had diagnoses including cerebral palsy, PTSD, bipolar disorder, and anxiety, filed a grievance report indicating verbal abuse by a staff member on multiple occasions. Despite the resident being her own decision-maker, the social services designee (SSD) did not file the grievance because the resident's family member advised against it. The SSD reported the concerns to the Director of Nursing (DON) but did not submit the grievance to the administrator. The facility's policy required that grievances be investigated within 72 hours and that a written response be provided. However, the grievance was not formally filed or investigated as per the policy. The administrator expected written grievances to be responded to in writing, but this process was not followed. The facility's failure to adhere to its grievance policy resulted in the grievance not being properly addressed, leaving the resident's concerns unresolved.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to immediately report an allegation of abuse to the state agency within the required timeframe for a resident who alleged abuse from staff. The resident, who had diagnoses including cerebral palsy, PTSD, bipolar disorder, and anxiety, was dependent on staff for toileting and transfers. Her care plan noted a history of making false accusations of abuse and directed staff to manage her behaviors by discussing them if reasonable or leaving her alone to calm down. Despite these instructions, the resident wrote a letter to the administrator alleging emotional abuse and neglect by staff, which was not reported to the state agency as required. The Director of Nursing (DON) and the administrator were aware of the allegations but did not report them, citing the resident's history of false accusations as the reason. The facility's policy required reporting any suspected maltreatment to the state agency immediately, but not later than two hours after the allegation if it involved abuse. Interviews with the DON and the administrator revealed that they conducted an internal review and decided the allegations were not reportable due to the resident's history, which led to the deficiency in reporting the alleged abuse.
Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to investigate an allegation of abuse reported by a resident with cerebral palsy, post-traumatic stress disorder, bipolar disorder, and anxiety. The resident, who was dependent on staff for toileting and transfers, had a care plan that noted her tendency to make false accusations of abuse and directed staff on how to manage her behavior. Despite this, the resident reported feeling emotionally abused and neglected by staff, particularly during the p.m. shift, and expressed these concerns in a letter to the administrator. The resident also filed a grievance report alleging verbal abuse by a nursing assistant. Interviews and document reviews revealed that the Director of Nursing (DON) was aware of the resident's allegations but did not conduct a thorough investigation. The DON had conversations with staff and the resident but could not provide evidence of an investigation. The administrator expected a comprehensive investigation, including interviews with other residents, but this was not carried out. The facility's policy required a completed investigation report to be submitted within five working days, which was not adhered to in this case.
Failure to Assess and Secure Resident at Risk of Elopement
Penalty
Summary
The facility failed to comprehensively assess and manage the use of a Wander Guard (WG) for a resident with moderate cognitive impairment and daily wandering behaviors. The resident was identified as being at risk for elopement, and a WG was initially placed. However, the WG was removed at the family's request without a documented elopement risk assessment. Subsequently, the resident was found outside the facility grounds, indicating a lapse in supervision and security measures. The incident revealed that the fenced area where the resident was allowed to sit was not adequately secured, as the gate was only held by a bungee cord and an unsecured latch. Staff interviews confirmed that no changes had been made to the fence since the resident's elopement. Additionally, there was no documented elopement assessment when the WG was removed or when it was reinstated after the incident, contrary to the facility's policy requiring such assessments for residents at risk of elopement.
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 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 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 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 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 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 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 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 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 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 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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