Lyngblomsten Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Paul, Minnesota.
- Location
- 1415 Almond Avenue, Saint Paul, Minnesota 55108
- CMS Provider Number
- 245347
- Inspections on file
- 20
- Latest survey
- June 5, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Lyngblomsten Care Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple diagnoses was left unsupervised to complete a nebulizer treatment without a required assessment or provider order for self-administration. Staff and record reviews confirmed that facility policy was not followed, as there was no documentation or authorization allowing the resident to self-administer medications.
A resident with severe cognitive impairment and mobility deficits was regularly placed in a recliner with the feet elevated and the remote out of reach, restricting independent movement. Staff and therapy confirmed no assessment or order justified the use of the recliner as a restraint, and documentation lacked evidence of evaluation or consent. The use of the recliner limited the resident's freedom of movement without proper assessment or authorization, resulting in a deficiency related to restraint use.
A resident's MDS assessment was inaccurately coded to indicate discharge to a hospital, while documentation and staff interviews confirmed the resident was actually discharged home to an assisted living facility and enrolled in hospice. The MDS coordinator and DON both acknowledged the error and confirmed that the assessment did not reflect the resident's true discharge status.
A resident who is deaf and uses ASL did not consistently receive communication support as outlined in their care plan, with staff often failing to use the iPad interpreter for care interactions and instead relying on written notes, despite the resident's clear preference for interpreter use. Only the social worker regularly used the interpreter, and several staff were unaware of or did not follow the resident's communication preferences.
Two residents with cognitive impairments and specific activity preferences were not consistently offered or included in individualized activities, and their participation was not documented as required. Observations, interviews, and record reviews showed that both residents were often left without engagement in preferred activities, with staff failing to implement or record activity offerings according to care plans and facility policy.
A resident with severe cognitive impairment and limited mobility was repeatedly transferred using a mechanical standing lift despite being unable to bear weight and having only one functional hand. Staff demonstrated inconsistent understanding of transfer criteria, and the resident was observed hanging from the lift during transfers. Facility policies required residents to bear weight and hold the lift handles, but staff failed to identify unsafe transfers or refer for reassessment, resulting in a deficiency.
A resident with multiple chronic conditions was administered a crushed extended-release blood pressure medication by a trained medication aide, who assumed it was safe to do so based on a general order to crush medications. Neither the aide nor the RN verified whether the extended-release formulation could be crushed, and the warning label was overlooked. The error was discovered only after the nurse practitioner was consulted, leading to a change in the medication order.
Survey results, including required CMS 2567 documentation for several complaint investigations and standard surveys, were not made readily accessible to residents, visitors, or families. The binder intended for survey results was missing key documents, and a resident confirmed that survey results were not available for review. No relevant policies were provided when requested.
Two residents with moderately impaired cognition had POLST forms inaccurately reflecting their resuscitation wishes, leading to an immediate jeopardy situation. Despite verbal confirmations of their DNR preferences, the forms indicated full code status due to errors by nursing staff. This discrepancy could have resulted in CPR being performed against the residents' wishes.
A resident with Alzheimer's and osteoarthritis fell from a sit-to-stand lift due to inadequate staff training and lack of proper assessment for lift use. The resident was left suspended while staff changed batteries, resulting in a fracture and tendon tear. The facility lacked a routine maintenance program and proper training on emergency lift functions.
Failure to Complete Assessment and Obtain Order for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a self-administration of medication (SAM) assessment was completed and a provider order was obtained for a resident to self-administer medications. The resident in question had severely impaired cognition, Alzheimer's disease, heart failure, and anxiety, and required significant assistance with personal and oral hygiene. Documentation showed that the resident did not wish to self-administer medications, and there was an active order stating the resident was not capable of safely self-administering medications. Despite this, staff left the resident unsupervised to complete a nebulizer treatment in her room, without a provider order or documented assessment supporting her ability to self-administer the treatment. Observation revealed that a trained medication aide set up the nebulizer treatment and left the resident alone in her room while the treatment was ongoing. The aide later confirmed that there was no provider order or assessment in place allowing the resident to self-administer the nebulizer treatment. Interviews with nursing staff and review of the resident's records confirmed that staff were expected to remain with the resident during such treatments and that the facility's policy required both an assessment and a provider order for self-administration. The facility's policy was not followed, resulting in the resident being left unsupervised during medication administration without the necessary documentation or authorization.
Failure to Ensure Resident Freedom from Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, as required, unless needed for medical treatment. The resident in question had severely impaired cognition, multiple neurological diagnoses including Parkinson's disease and dementia, and was dependent on staff for mobility and transfers. Despite these needs, the resident was regularly placed in a recliner in the common area with the feet elevated and the remote control out of reach, which restricted the resident's ability to get up independently. Staff interviews confirmed that the resident could not activate the chair and could not get up from the recliner without assistance. Documentation and care planning did not include a medical diagnosis or assessment justifying the use of the electric recliner as a restraint, nor was there an order for its use. The care plan addressed fall risk and mobility deficits but did not specify the use of the recliner as a restraint or include an assessment of the resident's ability to rise from it. Occupational therapy and the director of therapy confirmed that no assessment had been completed regarding the safety or appropriateness of the recliner for this resident, and the use of the recliner was not evaluated as a physical restraint. Family members and staff interviews indicated that the recliner was used as a means to prevent falls after bed alarms could no longer be used, and that no consent or waiver was signed for its use. Facility policy defined physical restraints as any device that restricts freedom of movement and cannot be easily removed by the resident, and required evaluation for such devices. The lack of assessment, documentation, and proper authorization led to the use of the recliner in a manner that restricted the resident's freedom of movement, constituting a deficiency in compliance with restraint regulations.
Inaccurate MDS Coding for Resident Discharge Status
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment was accurately coded to reflect the actual discharge status of a resident. Specifically, the MDS for one resident indicated a discharge to a short-term general hospital, while both the resident's progress notes and nursing progress notes documented that the resident was discharged home to an assisted living facility and had signed onto hospice care. This discrepancy was identified during an interview and document review, where the MDS coordinator confirmed the MDS was inaccurately coded and did not match the resident's actual discharge destination. The director of nursing also acknowledged that the MDS was expected to be accurate and that MDS coordinators are required to follow the MDS Resident Assessment Instrument (RAI) manual. The manual specifies that accurate assessments must be based on information from multiple sources, including the resident's medical record and direct care staff, and must reflect the resident's actual status during the observation period. In this case, the failure to accurately code the MDS assessment was confirmed by both the MDS coordinator and the director of nursing.
Failure to Provide Consistent ASL Interpreter Access for Deaf Resident
Penalty
Summary
A deficiency was identified when the facility failed to consistently provide appropriate communication support for a resident who was deaf and used American Sign Language (ASL) as their primary language. The resident's care plan and provider orders specified the need for an ASL interpreter, especially for significant interactions such as care conferences, assessments, and daily care activities. Despite these documented needs and preferences, staff interviews and resident statements revealed that the ASL interpreter, accessible via an iPad, was not regularly used. Instead, staff often relied on written communication, which the resident found confusing and inadequate, particularly when staff were non-English speaking or unfamiliar with ASL structure. The resident repeatedly expressed a preference for the ASL interpreter to be used for all care interactions, but this was not consistently honored. Multiple staff members, including nursing assistants, a trained medical aid, and a registered nurse, confirmed that they did not use the iPad interpreter during their interactions with the resident, often defaulting to written notes or yes/no questions. The social worker was identified as the only staff member who regularly used the iPad interpreter. The Director of Nursing acknowledged that the care plan required use of the ASL interpreter for major interactions and agreed that staff should follow the resident's stated preference. Facility policy also required interpreter use upon resident request and for key care communications, but this was not consistently implemented, resulting in a failure to meet the resident's communication needs as outlined in their care plan.
Failure to Provide and Document Individualized Activities for Residents
Penalty
Summary
The facility failed to ensure that individualized activities were provided and documented for two residents with cognitive impairments and specific activity preferences. For one resident with severe cognitive impairment, a history of loneliness, and interests in activities such as church, music, socialization, and gardening, there was little to no documentation of participation in activities over several months. Observations and interviews revealed that this resident was often found alone, either sleeping, sitting by the nursing station, or watching television, and expressed a desire to be kept busy. Family members reported a lack of available activities and noted that the resident would likely participate if activities were offered. Staff interviews confirmed that activities were not consistently offered or documented for this resident, and the responsible staff member acknowledged the failure to implement the resident's assessed preferences. Another resident with cognitive impairment, Parkinson's disease, and a preference for books, pets, news, religious activities, and outdoor activities also did not have documented participation in activities. The care plan indicated a need for encouragement to attend group programs and support for independent leisure activities, but both paper and electronic records lacked evidence of activity attendance. Family members and a privately paid companion reported that the resident was not invited to activities and that participation only occurred when facilitated by family. Staff interviews confirmed that the resident was not consistently invited to activities, and all recent participation had been with family members rather than facility staff. The facility's policy required comprehensive documentation of residents' interests and involvement in therapeutic recreation programs, including daily attendance records and regular care plan reviews. However, documentation and interviews revealed that these requirements were not met for the two residents reviewed. The lack of consistent offering, encouragement, and documentation of individualized activities led to the deficiency identified during the survey.
Failure to Assess and Safely Transfer Resident Using Mechanical Lift
Penalty
Summary
A deficiency occurred when the facility failed to comprehensively assess a resident's transfer needs and did not develop or implement adequate policies to ensure safe and supervised transfers using a mechanical lift. The resident in question had severely impaired cognition, limited function in the right arm and hand, used a wheelchair, required maximal assistance for mobility, and was on hospice care. The care plan indicated the need for one to two staff for transfers with a mechanical lift, but the electronic medical record did not reflect a reassessment of transfer needs when the mechanical lift was used. Multiple observations showed the resident being transferred with a mechanical standing lift despite being unable to bear weight and having only one functional hand to hold the lift handle. Staff interviews revealed inconsistent understanding of the criteria for using the mechanical lift, with some staff expressing discomfort with the transfer process and others stating the resident met the criteria. During transfers, the resident was observed hanging from the lift, unable to support themselves, and required staff to lift their legs onto the foot plate. The director of therapy confirmed that the resident did not meet the qualifications for the mechanical standing lift and should not have been using it. Facility policies required that residents be able to bear weight and hold onto the lift handles to be suitable for standing transfers. However, the staff failed to identify that the resident's transfers were unsafe and did not refer the resident for a therapy reassessment when their abilities changed. The director of nursing acknowledged that while staff were aware of the transfer process, they did not recognize unsafe transfers, leading to the deficiency.
Crushing of Extended-Release Medication Results in Significant Medication Error
Penalty
Summary
A significant medication error occurred when a resident with diagnoses including reduced mobility, cardiac pacemaker, history of sudden cardiac arrest, Alzheimer's disease, and heart failure was administered metoprolol succinate extended-release in a crushed form. The resident's care plan indicated that medications could be crushed to aid swallowing, and the medication aide prepared and intended to administer several medications, including the extended-release metoprolol, in crushed form. The aide stated she had been crushing this medication for some time, assuming it was permissible due to the general order to crush medications, and did not notice the warning label on the medication card indicating it should not be crushed or chewed. Further interviews revealed that nursing staff were unaware that the extended-release formulation should not be crushed and had not verified this with the provider. The nurse practitioner, when contacted, confirmed that the medication should not be crushed and changed the order to a different formulation. The director of nursing acknowledged that extended-release medications should not be crushed unless specifically ordered and that it was the facility's responsibility to notify the provider if a medication needed to be changed to a crushable form. The facility's policy on crushing medications was requested but not provided.
Failure to Provide Accessible Survey Results to Residents and Families
Penalty
Summary
The facility failed to ensure that complaint investigation survey results were readily accessible and available for review within the campus. During a recertification survey, it was observed that the binder labeled as containing survey results, located near the front desk, did not include required CMS 2567 documentation for several abbreviated complaint surveys and a standard survey conducted on specific dates. Interviews with the administrator and DON confirmed that these survey results were missing from the binder, and a resident stated that survey results were not available for residents to review. Additionally, when policies related to survey results were requested, none were provided.
Inaccurate POLST Forms Lead to Immediate Jeopardy
Penalty
Summary
The facility failed to ensure that the Physician Order for Life Sustaining Treatment (POLST) accurately reflected the current resuscitation wishes for two residents, resulting in an immediate jeopardy situation. One resident, with moderately impaired cognition due to a stroke, had a POLST indicating full code status, contrary to their expressed wish for Do Not Resuscitate (DNR) status with comfort care. Despite the resident's verbal confirmation of their DNR preference, the POLST form was incorrectly filled out by a registered nurse, leading to a potential situation where cardiopulmonary resuscitation (CPR) would be performed against the resident's wishes. Similarly, another resident with moderately impaired cognition due to a femur fracture had a POLST indicating full code status, despite a provider order directing a change to DNR status. The resident also verbally confirmed their wish to be DNR, but the POLST form in their medical record was not updated to reflect this change. Staff members, including registered and licensed practical nurses, confirmed that they would rely on the paper POLST form to determine code status, which in these cases, would have led to actions contrary to the residents' wishes.
Failure to Ensure Safe Transfer with Mechanical Lift
Penalty
Summary
The facility failed to complete a safe transfer assessment for a resident using a sit-to-stand mechanical lift, resulting in a fall and subsequent injuries. The resident, who had Alzheimer's, dementia, and osteoarthritis, was on hospice care and required substantial assistance with daily activities. The care plan did not include specific interventions for the resident's behaviors during transfers, and there was no comprehensive assessment for the appropriate size and type of sling to be used with the mechanical lift. During the incident, the resident was left suspended in the lift while staff changed batteries, unaware of the emergency lowering features. The resident, unable to hold on due to weakness and osteoarthritis, let go and sustained a fracture and tendon tear. Interviews with staff revealed a lack of training on the emergency features of the lift and an absence of a system to ensure the correct sling size was used for each resident. Additionally, the facility did not have a routine maintenance program for the lifts, and staff were not adequately trained on the equipment's emergency functions. The incident highlighted several deficiencies, including inadequate staff training, lack of proper assessments for mechanical lift use, and failure to follow manufacturer instructions for lift maintenance. The resident's family had previously reported concerns about the lift, but these were not addressed. The facility's policies did not adequately cover the assessment and reassessment of residents' transfer needs, contributing to the incident.
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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