Martin Luther Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Bloomington, Minnesota.
- Location
- 1401 East 100th Street, Bloomington, Minnesota 55425
- CMS Provider Number
- 245272
- Inspections on file
- 28
- Latest survey
- June 12, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Martin Luther Care Center during CMS and state inspections, most recent first.
Two residents with signed POLST forms indicating DNR status were listed as Full Code in the EMR and MAR, leading staff to state they would have initiated CPR against the residents' wishes. The facility lacked timely transcription, verification processes, and clear procedures for staff to confirm code status, resulting in a critical mismatch between residents' documented directives and the information available to care staff.
Surveyors identified multiple deficiencies, including unclean and cluttered shower rooms with improperly stored medical supplies and personal items, resident rooms with peeling paint, scrapes, and unfinished wall repairs, and a hallway handrail that was insecurely attached and unsafe for use. Staff interviews confirmed that cleaning and maintenance expectations were not consistently met, and residents expressed dissatisfaction with the condition of their living environment.
The facility failed to provide care and treatment according to physician orders and resident preferences in several cases, including not implementing a bowel management program as ordered for a resident with quadriplegia, not timely providing a diabetic monitoring device, failing to assess and treat a new skin condition, not referring a diet modification request for evaluation, inconsistently applying medical devices for edema, and not addressing a resident's hearing concerns, resulting in delays and unmet needs.
Surveyors found medication carts left unattended and unlocked in hallways on two units, with one cart left open for over an hour near a resident and others passing by. RNs responsible for the carts admitted to forgetting to lock them or being distracted, and the DON confirmed that carts are expected to be locked when unattended, as per facility policy.
Multiple residents reported receiving cold or incorrect meals due to delays and errors in the meal ordering and delivery process. Staff interviews and resident council minutes confirmed ongoing complaints about food temperature, late service, and order inaccuracies. Direct observation showed that food was served below the required temperature, and the facility's policy on food service was not provided when requested.
A resident with multiple medical conditions and intact cognition reported that staff repeatedly double briefed her and failed to provide timely assistance, despite her objections and communication of these concerns to various staff members. The facility did not document, investigate, or resolve these grievances as required by its policy, and the grievance log did not reflect the resident's care-related complaints.
A resident with multiple chronic conditions experienced significant weight gain exceeding care plan parameters, but staff did not notify the provider or document the required communication, despite daily monitoring and interdisciplinary awareness.
Two residents dependent on staff for ADLs did not receive adequate personal hygiene and grooming, including nail cleaning, hair care, and beard trimming. One resident was repeatedly observed with soiled fingernails, while another had tangled hair and an untrimmed beard, despite facility policies requiring such care. Staff interviews and documentation confirmed that these hygiene tasks were not consistently performed or offered.
A resident with moderate cognitive impairment and cataracts did not receive timely referral or follow-up for cataract surgery, despite recommendations from in-house optometry services. The resident's care plan and MDS lacked documentation of vision issues, and both the previous and current guardians were not informed about the need for surgery. Facility staff failed to communicate and document necessary actions, contrary to facility policy.
A resident with limited lower extremity ROM and multiple chronic conditions did not consistently receive the prescribed ROM program, as documentation showed frequent missed or refused sessions over several months. Staff interviews confirmed that ROM was often not performed as ordered, and there was no timely reassessment or provider notification regarding the resident's refusals, despite facility policy requiring individualized restorative care and regular assessment.
A resident with a history of bilateral venous wounds and a recent fall received multiple doses of PRN tramadol without documentation of pain symptoms or attempts at non-pharmacological interventions prior to administration. Staff interviews confirmed inconsistent offering and documentation of non-pharmacological pain management, and review of records showed that required pain assessments and interventions were not consistently recorded before giving PRN narcotics.
A resident with significant medical and functional needs was identified as having cavities and broken teeth and expressed a desire for dental care. Although dental assessment was completed and off-site treatment was recommended, the facility did not arrange transportation or alternative options after the resident's family was unable to assist, leaving the dental needs unaddressed.
A resident with cognitive impairment and limited mobility, who required adaptive eating utensils as per their care plan, was observed eating with standard utensils and without needed assistance, resulting in food spillage and lack of personal hygiene. Staff confirmed the adaptive equipment was not provided as required, and documentation did not explain the omission, despite facility policy and care plan directives.
The facility did not post survey results or a notice of their availability in a prominent and accessible area. The survey results binder was placed in an alcove away from the main entrance, and there was no signage at the receptionist desk to inform individuals of its location. Several residents were unaware of any posting, and staff confirmed that people would have to ask to find the binder. Facility policy requires such postings to be clearly visible, which was not done.
Staff failed to keep resident care sheets containing personal and medical information secured on medication carts, leaving them visible and unattended in hallway corridors. Multiple staff and a resident passed by the exposed information, and staff acknowledged that this was a breach of HIPAA and facility policy.
A facility failed to follow proper PPE protocols for a resident on droplet precautions. A nursing assistant entered the resident's room without appropriate PPE, and staff interviews revealed inconsistencies in understanding PPE requirements. The resident had gastrointestinal symptoms and was on droplet and contact precautions, yet the facility was experiencing a norovirus outbreak.
A resident with a DNR order was found unresponsive, and an RN initiated CPR without verifying the resident's POLST, which specified do not resuscitate. Despite being informed of the DNR status, CPR continued until EMS arrived and the order was verified. The resident was pronounced dead after CPR was stopped.
A resident with a surgical incision on her back did not receive appropriate wound care due to the facility's failure to monitor and obtain dressing change orders. The resident's wound was not assessed weekly as required, leading to the wound opening and developing purulent drainage. The resident was sent to the hospital for evaluation and treatment, highlighting the facility's non-compliance with its wound care policies.
A facility failed to conduct comprehensive assessments for grab bars on the beds of three residents, leading to potential safety risks. One resident was found with his head caught between the mattress and the grab bar, although it was later determined that the grab bar did not contribute to his demise. Another resident had incomplete assessment forms, lacking information on alternatives and consent. The third resident, with dementia, had grab bars installed without proper assessment, and observations showed they did not use the bars during care activities. Staff interviews revealed that grab bars were standard on all beds, regardless of individual needs.
A resident was given incorrect medications, leading to hospitalization for bradycardia and anxiety. The facility failed to report the incident to the State Agency within 24 hours, as required. The resident and their family expressed significant distress and distrust towards the facility. The administrator did not report the incident, citing no serious bodily harm, despite the facility's policy requiring such reporting.
A resident was found with over-the-counter Rolaids on his tray table, which he had been taking for two weeks without facility monitoring. This medication interacted with his prescription Rosuvastatin, which requires no antacids within two hours of administration. Despite the facility's policy against self-administration without authorization, the resident's care plan did not permit self-administration, and the medication was not secured. Staff interviews revealed a lack of awareness and communication regarding the medication's presence and potential interaction.
The facility failed to dispose of expired and visibly molding produce in the walk-in cooler, which included broccoli, brussels sprouts, cucumbers, asparagus, zucchini, and precut potatoes. The dietary director confirmed the presence of expired produce and stated that it should be disposed of seven days after delivery or when it appears old. Enough produce was discarded to feed all residents for at least one meal, raising concerns about the potential risk to residents.
The facility failed to implement appropriate infection control measures for a resident on enhanced barrier precautions and did not protect clean personal and facility laundry during transport and storage. Observations revealed improper use of PPE and uncovered linen carts, confirmed by staff interviews and facility policy reviews.
The facility failed to ensure that two medication carts were kept locked or under direct observation of authorized staff in areas accessible to residents, staff, and guests. Unattended and unlocked medication carts were observed in both the west and east sections of the Transitional Care Unit (TCU), with responsible staff acknowledging the oversight. The Director of Nursing (DON) confirmed that medication carts should always be locked when not in use to secure medications and prevent unrestricted access.
A resident with intact cognition and limited mobility due to an injury experienced delays in receiving assistance with a bed pan, leading to frustration and discomfort. Staff miscommunication and a late-arriving staff member contributed to the delay, highlighting a deficiency in promoting dignity and timely care.
The facility failed to ensure resident medical records were kept private, as observed with two unattended medication carts with open laptops displaying resident information. Staff admitted to not following the policy of locking carts and blanking screens when unattended.
The facility failed to provide routine personal hygiene care, specifically nail care, for a resident dependent on staff for ADLs. Despite the resident's moderate cognitive impairment and various medical conditions, observations revealed long, dirty fingernails, indicating a lack of proper care. Staff acknowledged the infection risks and the need for cleanliness and dignity, but failed to adhere to the facility's nail care policy.
The facility failed to ensure wound prevention treatment for a resident with a history of bilateral heel pressure areas and risk for skin breakdown. Despite an order for a Prevalon boot, the resident had not used the boot for at least four months, and the treatment administration record inaccurately documented its use. The resident's multiple diagnoses increased the risk for skin issues, and the nursing staff's failure to implement the boot order and incorrect documentation put the resident at risk for injury.
The facility failed to reassess a resident after repeated refusals of an ambulation program and did not develop interventions to reduce the risk of mobility loss. The resident, with multiple medical conditions, had not participated in the walking program for several months, and no revisions were made. Staff were aware of the resident's non-participation, but the physical therapist was not informed, leading to a lack of proper follow-up and reassessment.
The facility failed to reassess the safety of bilateral, bed-mounted grab bars for a resident who developed seizures after admission. Despite multiple seizures, there was no re-evaluation of the grab bars or consideration of safety interventions to reduce injury risk. Staff interviews confirmed the lack of specific re-evaluation procedures post-seizure.
The facility failed to follow standard practices for gastrostomy tube care for a resident dependent on a feeding tube. Undated and unlabeled equipment was repeatedly observed, and staff confirmed non-compliance with the policy to replace and date syringes every 24 hours, posing an infection control concern.
The facility failed to ensure that complaint investigations and plans of correction from the past three years were posted in prominent and accessible areas. The Annual State Survey Results binder in the main lobby did not include any complaint investigation results for 2023, and there was no signage indicating the availability of such reports. This oversight was confirmed by the administrator, who admitted the necessary documents were missing and there was no signage to guide individuals on where to find these reports.
The facility failed to ensure the kitchen floors and mats were routinely and properly cleaned, leading to a noticeably unsanitary kitchen environment. The dietary director confirmed the absence of a cleaning schedule and expressed concern about potential foodborne illness. The facility's policy on food safety was not being followed, resulting in the observed deficiencies.
Failure to Accurately Transcribe and Reflect POLST Orders in EMR
Penalty
Summary
The facility failed to ensure that written Physician's Orders for Life Sustaining Treatment (POLST) were accurately entered, transcribed, and reflected in the electronic medical record (EMR) in a timely manner, resulting in discrepancies between residents' documented wishes and the code status available to staff during emergencies. For two residents reviewed for advanced directives, the POLST forms indicated Do Not Resuscitate (DNR) status, but the EMR and Medication Administration Record (MAR) listed them as Full Code. Staff interviews revealed that nurses relied on the MAR or EMR banner for code status information and would have initiated CPR based on the incorrect Full Code status, contrary to the residents' documented wishes for DNR. One resident, who had multiple complex medical conditions including heart failure, renal insufficiency, and diabetes, had a POLST form signed by both the resident and the provider indicating DNR status. However, the EMR and MAR continued to display Full Code, and staff were unaware of the discrepancy. Multiple nurses confirmed they would have performed CPR based on the MAR instructions. The process for updating code status in the EMR relied on the health unit coordinator (HUC), but there was no consistent double-check or audit process in place to ensure accuracy. The facility's policy did not specify where staff should verify the most current code status in an emergency, contributing to the confusion. A second resident also had a signed POLST indicating DNR, but the EMR banner still listed Full Code. Staff interviews confirmed that in an emergency, they would have followed the EMR banner and initiated CPR. There was also a delay in obtaining provider signatures on POLST forms, during which time the residents' wishes were not reflected in the active orders. The lack of timely transcription and verification of POLST information into the EMR and MAR, as well as unclear procedures for staff to verify code status, led to the deficiency.
Failure to Maintain Cleanliness, Wall Repair, and Handrail Safety
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment in several areas, as evidenced by observations in two of four shower rooms and three resident rooms. In the shower rooms, surveyors found multiple issues including opened and used medical supplies left on counters, crumpled paper towels and other debris on the floor, a used finger lancet not properly disposed of, and cabinet doors that were either hanging by a single hinge or missing handles. Personal items such as a blue knit hat and eyeglasses were left in the shower area, and open bottles of body wash and lotion were not properly closed or stored. Staff interviews confirmed that the expectation was for nursing assistants to clean and prepare the shower rooms after each use, but this was not consistently done. In three resident rooms, walls were observed to be in poor condition, with peeling and chipped paint, large scrapes, and unfinished patchwork. One resident reported that the scrapes on the wall had been present for at least a year and that staff were aware but had not addressed the issue. Another resident's room had extensive black markings and torn drywall, as well as peeling paint and staining along the wall. Staff interviews indicated that maintenance work orders were expected to be submitted for such repairs, but there was no evidence that this process was consistently followed. Residents expressed dissatisfaction with the appearance of their rooms, describing the conditions as unsightly and not reflective of a homelike environment. Additionally, a hallway handrail was found to be insecurely attached to the wall, with only one bolt holding it in place, allowing it to spin and rotate freely. Staff and maintenance personnel acknowledged that the handrail was not safe for use and required immediate repair. The facility's policy on environmental cleaning required regular checks of hinges, door facings, and handles, but there was no evidence that policies regarding wall repair and handrail security were provided or followed. These deficiencies were identified through direct observation, resident and staff interviews, and review of facility policies.
Multiple Failures in Resident Care, Assessment, and Implementation of Physician Orders
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and resident preferences in several instances. One resident with quadriplegia and a history of neurogenic bowel was not comprehensively assessed or provided with a bowel management program that met her expressed needs. Despite clear documentation of her prior successful use of digital stimulation for bowel movements and multiple provider orders supporting this intervention, staff repeatedly told her it was against facility policy and did not implement the ordered regimen. The care plan and medical record lacked any rationale for denying digital stimulation, and staff were unaware of the actual facility policy, which did not prohibit the procedure. As a result, the resident experienced ongoing constipation and frustration, with minimal recorded bowel movements over an extended period and no effective interventions provided despite available PRN medications and standing orders. Another deficiency involved the failure to act upon a physician order for a diabetic monitoring device. A resident with diabetes had an order for a FreeStyle Libre device to reduce the need for frequent finger sticks. The device was not provided or applied in a timely manner, and documentation showed it was marked as "not available" without evidence of follow-up or action to obtain it. Staff interviews revealed a lack of awareness and communication regarding the order, and the device was only pursued after surveyor inquiry, resulting in unnecessary distress for the resident due to continued finger sticks. Additional deficiencies included the failure to assess and treat a new skin condition for a resident, as weekly skin checks and documentation were not completed as required, and staff were unaware of the resident's needs for facial skin care. Another resident's request for a diet modification was not timely referred for evaluation, as staff did not communicate the request to the appropriate clinical team, resulting in a delay in addressing the resident's dietary preferences. The facility also failed to ensure that medical devices for edema management were consistently applied according to orders, with staff demonstrating a lack of knowledge about the correct procedure and documentation not matching observed care. Lastly, a resident's hearing concerns were not recognized or comprehensively assessed, leading to a delay in identifying and treating cerumen impaction.
Unattended and Unlocked Medication Carts Observed on Two Units
Penalty
Summary
Surveyors observed multiple instances where medication carts were left unattended and unlocked in hallways outside resident rooms on two separate units. On one occasion, a medication cart was left unlocked for over an hour, with a resident sitting nearby and various staff, residents, and a family member passing by. The responsible RN returned and was unable to confirm whether the cart had been locked, admitting to possibly forgetting due to a long day. The RN acknowledged the importance of keeping the cart locked, especially since it contained medications and narcotics. On another unit, a medication cart was also found unattended and unlocked on two separate occasions. The responsible RN admitted to leaving the cart unlocked when distracted by assisting an aide and again when entering a resident room. Both RNs confirmed that the carts should have been locked when unattended. The DON verified that the facility's expectation is for medication carts to be locked when not attended, as per facility policy, and acknowledged that leaving them unlocked is a safety concern.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that food was served in a timely manner and at appropriate temperatures, resulting in multiple residents receiving cold or incorrect meals. Observations and interviews revealed that residents frequently experienced delays in meal service, with food often arriving cold or not matching their orders. Staff interviews confirmed that complaints about food temperature and accuracy were common, and that the process for collecting and fulfilling meal orders was inconsistent. The use of an electronic meal ticket system, which required nursing assistants to collect meal preferences the day before, was identified as a source of confusion and errors, with some residents not being asked for their preferences and others receiving meals they did not order. Resident council meeting minutes over several months documented ongoing concerns about cold food, late meal service, and errors in meal orders. Residents reported that staff did not always offer to reheat food, and that requests for assistance were sometimes ignored due to staff being busy. Specific residents described receiving cold, unappetizing, or incorrect meals, with one resident noting that ice cream was completely melted upon delivery and another stating that food was overcooked and inedible. Staff interviews corroborated these issues, with both nursing and dietary staff acknowledging the persistence of complaints and the disconnect between order collection and meal delivery. Direct observation during meal service confirmed that food temperatures did not meet facility expectations, with test trays showing temperatures below the required 135 degrees Fahrenheit. The facility's policy on food temperatures and serving times was requested but not provided. The deficiency affected all residents who consumed food from the facility kitchenettes, as the issues with timeliness, temperature, and order accuracy were systemic and ongoing.
Failure to Address and Investigate Resident Grievances Regarding Nursing Care
Penalty
Summary
The facility failed to act upon, investigate, or resolve a resident's complaints regarding nursing care. The resident, who had intact cognition and multiple medical diagnoses including heart failure, Parkinson's Disease, and chronic kidney disease, was dependent on staff for most activities of daily living. The resident reported that staff frequently turned off her call light without providing assistance, and that she was repeatedly double briefed with two incontinent products at night despite expressing her objection. She also reported discomfort with a particular staff member assisting with her care. These concerns were communicated to various staff members, including floor staff, a nurse manager, and therapy staff. Despite these complaints, there was no documentation in the resident's progress notes indicating that her concerns were acted upon, investigated, or resolved. The facility's grievance log only contained a grievance related to spiritual care, not the care concerns raised by the resident. Interviews with staff revealed a lack of awareness or follow-up regarding the resident's specific complaints about double briefing and staff assignments. The facility's grievance policy required that all grievances be thoroughly investigated, tracked, and resolved, but this process was not followed in the resident's case.
Failure to Notify Provider of Significant Weight Gain per Care Plan
Penalty
Summary
The facility failed to follow care planned interventions for a resident with multiple complex medical conditions, including heart failure, chronic kidney disease, diabetes, and malnutrition, who was dependent on staff for most activities of daily living. The resident's care plan required daily weights and mandated staff to notify the provider if the resident gained more than three pounds in a day or five pounds in a week. Despite documented weight gains exceeding these parameters over several days, there was no evidence in the medical record that the provider was notified as required by the care plan. Interviews with staff confirmed awareness of the care plan's requirements and the resident's fluctuating lower leg swelling, but also revealed that no progress notes or provider notifications were documented regarding the significant weight gain. The interdisciplinary team, including nursing and dietary staff, discussed weight concerns in meetings, but the lack of timely provider notification and documentation represented a failure to implement the care plan as written.
Failure to Provide Routine Personal Hygiene and Grooming for Dependent Residents
Penalty
Summary
The facility failed to provide routine personal hygiene and grooming, including nail care, hair care, and beard trimming, for two residents who were dependent on staff for activities of daily living (ADLs). One resident with moderate cognitive impairment and limited mobility was observed multiple times over several days with visibly soiled fingernails containing dark debris. Despite care plans and facility policies requiring assistance with personal hygiene and nail care, there was no documentation that nail cleaning was offered or performed, and staff interviews confirmed that nail care was only routinely done on bath days, with cleaning as needed if noticed. The resident was unable to recall when his nails were last cleaned or clipped, and staff acknowledged the importance of clean nails for hygiene and infection prevention. Another resident, who was cognitively intact but had significant physical limitations due to hemiplegia, muscle weakness, and other medical conditions, was observed with long, dull, and tangled hair, as well as an untrimmed mustache and beard. The resident reported that staff only used shampoo caps and did not assist with detangling hair or trimming facial hair, despite expressing a desire for these grooming tasks to be performed. Staff interviews revealed that haircuts and beard trims were not routinely offered or scheduled, and there was confusion among staff regarding responsibility for arranging these services. The resident expressed dissatisfaction with his appearance and the lack of assistance provided. Facility policies required that all residents receive assistance with morning cares, including ensuring nails are clean and trimmed to the resident's desired length, and that nail care be completed on bath day and as needed. The policies also specified that hair should be brushed daily and washed on shower days, with alternatives available for residents preferring sponge baths. Despite these policies, both residents did not receive the necessary personal hygiene and grooming assistance, as evidenced by direct observations, resident interviews, and lack of documentation in the medical record.
Failure to Facilitate Timely Cataract Surgery Referral and Follow-Up
Penalty
Summary
The facility failed to ensure timely referral and follow-up for cataract surgery for a resident diagnosed with cataracts who expressed difficulty with vision. The resident, who had moderate cognitive impairment and multiple medical conditions including high blood pressure and diabetes, was observed without glasses and reported poor vision. The Minimum Data Set (MDS) section for vision status was left blank, and the resident's care plan did not address vision problems beyond noting the presence of a guardian and long-term care status. Documentation showed that the resident was seen by in-house optometry services, which identified cataracts in both eyes and recommended a referral for cataract surgery. The optometrist attempted to contact the resident's guardian but was unsuccessful, and no further referral was made. The medical record lacked evidence that the recommendation for cataract surgery was discussed with the resident's guardian or that any follow-up attempts were made after the initial failed contact. Both the previous and current guardians confirmed they were not informed about the need for cataract surgery. Interviews with facility staff, including the social worker, nurse manager, and DON, revealed a lack of communication and documentation regarding the need for cataract surgery and the process for follow-up. Staff acknowledged that attempts to contact guardians for medical care input should be documented, but this was not done. The facility's policy required staff to coordinate and document necessary appointments and follow-ups, but this was not followed in the resident's case.
Failure to Provide Consistent Range of Motion Program
Penalty
Summary
A deficiency was identified when a resident with limited lower extremity range of motion (ROM) did not consistently receive the prescribed ROM program as outlined in her care plan and treatment administration record (TAR). The resident, who was cognitively intact and had diagnoses including chronic respiratory failure, chronic pain, multiple sclerosis, and recurrent bilateral hip subluxations, was supposed to receive assisted lower extremity ROM exercises twice daily. However, documentation over a seven-month period showed that the resident either refused or did not receive ROM for the majority of scheduled opportunities, with some months showing no ROM provided at all. The care plan specified that staff should assist with daily supine ROM and strengthening exercises, and instructions were available both on the resident's bulletin board and in her possession. Interviews with nursing staff revealed that ROM was often not performed, with some staff stating they only moved the resident's legs during other care activities, such as wound care or repositioning. Staff also indicated that the resident frequently refused ROM, but there was no evidence of timely reassessment or communication with the provider regarding these refusals. The director of nursing confirmed the lack of reassessment and acknowledged that the care plan and provider updates were overdue. Facility policy required that restorative nursing programs be individualized and documented in the care plan, with regular assessment by an RN, but these steps were not consistently followed for this resident.
Failure to Document Pain Symptoms and Non-Pharmacological Interventions Prior to PRN Narcotic Administration
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs by not documenting acute symptoms of distress or pain and not recording or attempting non-pharmacological interventions prior to administering as-needed (PRN) narcotic medications. The resident in question had a history of bilateral venous wounds and had recently sustained a fall, which she believed injured her hip. Her care plan included both pharmacological and non-pharmacological interventions for pain management, such as redirection, offering food, music, and ice/heat, and required monitoring and documentation of pain characteristics every shift and as needed. Despite these care plan directives, review of the resident’s Medication Administration Record (MAR) and progress notes revealed that PRN tramadol was administered multiple times without documentation of the resident’s pain symptoms or any non-pharmacological interventions attempted prior to giving the narcotic. Of the nine PRN doses administered, only one note provided a rationale for the medication, and none of the notes documented the use of non-pharmacological interventions before administering the narcotic. Interviews with staff confirmed that while non-pharmacological options were sometimes discussed, they were not consistently offered or documented, and pain assessments or interventions were not always recorded as required. The facility’s own medication administration policy required documentation of the resident’s specific complaint or symptoms for which PRN medication was given, but did not address the need to document non-pharmacological interventions. The director of nursing confirmed that both pain symptoms and attempted non-pharmacological interventions should be documented prior to administering PRN narcotics, but this was not consistently done in practice for the resident reviewed.
Failure to Coordinate Off-Site Dental Care for Resident with Urgent Needs
Penalty
Summary
The facility failed to coordinate necessary dental care for a resident who was identified as having obvious or likely cavities and broken natural teeth upon admission. The resident, who was cognitively intact but required significant assistance with activities of daily living due to multiple medical conditions including acute respiratory failure, atrial fibrillation, type II diabetes, and hemiplegia following a stroke, had not seen a dentist in two years and expressed a desire to do so. Although the resident signed a consent form for dental services and was assessed by a dental provider, the provider determined that treatment could not be completed on-site and recommended an off-site clinic visit. Despite this recommendation, the facility did not arrange for the resident to be transported to the off-site dental clinic. The health unit coordinator contacted the resident's son, who indicated that accompanying the resident was not convenient, but no further efforts were made to explore alternative transportation options. The facility's policy required staff to ensure all necessary appointments and follow-ups were completed, but this was not done, resulting in the resident's dental needs remaining unaddressed.
Failure to Provide Care-Planned Adaptive Eating Equipment
Penalty
Summary
A resident with moderate cognitive impairment and limited mobility, as identified in their quarterly MDS and care plan, required adaptive eating equipment—specifically, red foam handles for utensils—to promote independence and maintain personal hygiene during meals. During an observation, the resident was found eating in bed with regular metallic utensils, resulting in food spilled onto their chest. The meal tray and menu slip did not indicate the need for adaptive equipment, although a sign in the resident's room directed staff to use the red foam utensils. The adaptive equipment was found unused in the resident's bedside drawer, and the resident was eating without assistance. Interviews with staff, including a nursing assistant and the DON, confirmed that the red foam handles were care-planned and should have been used at all meals. The occupational therapist also verified the resident's need for the adaptive equipment and had communicated this to nursing. The medical record lacked documentation explaining why the adaptive utensils were not provided during the observed meal. Facility policy required that adaptive devices be noted on meal identification cards and care plans, and be provided as needed, but this was not followed in the resident's case.
Failure to Prominently Post Survey Results and Notice of Availability
Penalty
Summary
The facility failed to post survey results or a notice of their availability in prominent and accessible areas, as required. During the survey entrance, the survey results binder was found in an alcove around the corner from the main entrance, not immediately visible to residents, families, or visitors. There was no signage or notice at the receptionist desk or main entrance to inform individuals of the location of the survey results. The lead receptionist confirmed that there was no information posted at the desk and that people would have to ask to find the binder. Multiple residents reported being unaware of any posting at the entrance regarding the survey results. Observations confirmed that a sign directing individuals to the survey results was only posted after the survey began, and residents noted that it was not present prior to that time. The assistant administrator was unaware of when the notice was posted and believed the binder's location was sufficient. Facility policy requires that a notice of the availability of survey results be posted in prominent and accessible areas, which was not followed.
Resident Care Information Left Unsecured on Medication Carts
Penalty
Summary
Staff failed to secure residents' personal and medical information on two of four facility units, resulting in care sheets with sensitive data being left visible and unattended on mobile medication carts in hallway corridors. On the transitional care unit, a medication cart was left unattended with a census sheet displaying resident names, room numbers, diagnoses, bath days, diet orders, nursing care notes, skin impairment, and lab information for nine residents. Multiple staff members and a resident in a wheelchair passed by the exposed information, and a housekeeper acknowledged that the information should not have been visible. A licensed practical nurse later confirmed the care sheet should not have been left out, citing HIPAA concerns. On the long-term care unit, a registered nurse left a medication cart unattended with a care sheet containing personal information for three residents. The nurse walked away to administer medication in another room, during which time additional staff passed by the exposed information. Upon return, the nurse stated the information should have been covered and recognized the privacy breach. Interviews with other staff confirmed the expectation that care sheets be covered and carts locked to maintain confidentiality, in accordance with the facility's policy on HIPAA compliance.
Failure to Follow PPE Protocols for Resident on Droplet Precautions
Penalty
Summary
The facility failed to adhere to proper personal protective equipment (PPE) protocols for a resident on droplet precautions. During an observation, a nursing assistant (NA-A) entered the room of a resident with contact, droplet, and eye protection precautions wearing only a surgical mask and a reusable gown, without eye protection or gloves. Upon exiting, NA-A did not change the mask or perform hand hygiene. Interviews with other staff members revealed inconsistencies in understanding and implementing PPE requirements, with some staff unaware of the need for N95 masks or the specific precautions required for residents on droplet precautions. The resident in question was admitted with a primary diagnosis of moderate protein-calorie malnutrition and additional diagnoses including cold autoimmune hemolytic anemia. The resident had experienced vomiting and gastrointestinal symptoms, leading to the implementation of droplet and contact precautions. Despite the presence of precaution signs on the resident's door, staff members, including the infection preventionist and director of nursing, acknowledged the need for adherence to these signs, yet the facility was experiencing a widespread norovirus outbreak, indicating a potential lapse in infection control practices.
Failure to Honor DNR Order in Resident's POLST
Penalty
Summary
The facility failed to adhere to a resident's Physician Orders for Life-Sustaining Treatment (POLST) which specified do not resuscitate (DNR) and do not intubate (DNI), allowing for natural death. The incident involved a resident who was found unconscious in his bed by a registered nurse (RN-A), who then initiated CPR despite the resident's POLST indicating a DNR status. The resident was severely cognitively impaired and had diagnoses including metabolic encephalitis, coronary artery disease, and diabetes. The RN-A began chest compressions and continued until the POLST was verified, at which point CPR was stopped, and the resident was pronounced dead. The deficiency occurred when RN-A, upon finding the resident unresponsive, initiated a code blue and began CPR without first verifying the resident's code status. The RN continued CPR even after being informed of the DNR status by another staff member, RN-B, who had retrieved the POLST form. The CPR was only halted after the arrival of emergency medical services and further verification of the DNR order. This failure to follow the resident's POLST had the potential to infringe upon the resident's right to a natural death and subjected them to unnecessary life-saving measures.
Removal Plan
- All staff were educated on checking the code status before initiating CPR.
- The Cardiopulmonary Resuscitation policy was reviewed by management and reviewed with all licensed staff.
- All the facility residents were audited to ensure their code status was correctly input in the software system and was current.
Failure to Monitor and Obtain Orders for Surgical Wound Care
Penalty
Summary
The facility failed to monitor and obtain orders for surgical wound dressing changes for a resident with a surgical incision on her back. Upon admission, the resident had a surgical incision measuring 9.4 cm by 0.8 cm, which was noted in the admission assessment. However, the facility did not complete the required weekly skin assessments, and the August and September Wound Treatment Records lacked orders for dressing changes. The resident's surgical wound was not monitored, and no dressing changes were performed, leading to the wound opening and developing purulent drainage. The resident was subsequently sent to the hospital for evaluation and treatment. The Director of Nursing confirmed that the surgical incision was assessed and measured upon the resident's return from the hospital, but no dressing change orders were obtained. The facility's standing orders and policy required daily wound assessments and weekly monitoring, which were not followed. The resident expressed dissatisfaction with the care received, stating that the dressing was not changed, leading to discomfort and the need for further surgery. The deficiency was attributed to the facility's failure to adhere to its policies and procedures for wound care management.
Inadequate Assessment of Grab Bars Leads to Safety Risks
Penalty
Summary
The facility failed to conduct comprehensive assessments for the use of grab bars on the beds of three residents, leading to potential safety risks. One resident, identified as R1, was found with his head caught between the mattress and the grab bar, although the medical examiner later determined that the grab bar did not contribute to his demise. R1 had a history of multiple health issues, including Parkinson's, arthritis, and repeated falls, and required substantial assistance for mobility. Despite these needs, the facility did not adequately assess the risks associated with the use of grab bars, particularly in conjunction with an alternating pressure mattress, which was not mentioned in the device assessment. Another resident, R2, also had grab bars installed without a complete assessment. R2 had a history of falls and required substantial assistance for mobility, yet the device/consent assessment forms were incomplete, lacking information on potential alternatives and whether the device was considered a restraint. The family member of R2 reported that the staff had not discussed the use of grab bars with them, indicating a lack of communication and informed consent. The third resident, R3, who had dementia and required 1:1 supervision due to confusion and self-harm behaviors, also had grab bars installed without a proper assessment. Observations showed that R3 did not use the grab bars during care activities, and the assessment form was filled out without direct observation of the resident's interaction with the grab bars. Interviews with staff revealed that grab bars were standard on all beds, regardless of individual resident needs, and assessments were not consistently completed or understood by the staff.
Failure to Report Medication Error and Resulting Neglect
Penalty
Summary
The facility failed to report an allegation of neglect to the State Agency within the required 24-hour timeframe. A resident was mistakenly administered medications intended for another patient, which included Keppra, metoprolol, and clopidogrel. This error led to the resident experiencing bradycardia, pain, and anxiety, necessitating hospitalization for further evaluation. The incident was not reported to the State Agency over the weekend, and the unit manager only became aware of the situation on the following Monday. The resident, who was cognitively intact, expressed significant distress and fear following the medication error, which also affected his trust in the facility's staff. The family member of the resident also reported ongoing anxiety and distrust towards the facility due to the incident. Despite the resident's low heart rate and change in sedation, the facility's administrator chose not to report the incident, citing the absence of serious bodily harm. The facility's policy mandates reporting such incidents within 24 hours if they do not involve abuse or result in serious bodily injury, which was not adhered to in this case.
Failure to Monitor Resident's Self-Administration of Medication
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for a resident, identified as R4, who was not approved for self-administration of medications. R4 had an over-the-counter medication, Rolaids, on his tray table, which he had been taking for approximately two weeks without the facility's monitoring. This medication interacted with R4's prescription medication, Rosuvastatin, which requires that no aluminum, magnesium, or antacids be taken within two hours of administration. Despite the presence of Rolaids in R4's room, the registered nurse (RN-C) did not inquire about the frequency of R4's intake of the antacid or remove it from the room, assuming it was safe since the facility was aware of it. R4's self-administration assessment indicated he required assistance with various aspects of medication management, including storage, timing, and identification of side effects. The facility's policy stated that residents are not allowed to self-administer medications unless authorized by a physician, and medications must be secured. However, R4's care plan did not authorize self-administration, and the facility failed to secure the medication. Interviews with staff and family revealed a lack of awareness and communication regarding the presence and potential interaction of the Rolaids with R4's prescribed medication, highlighting a deficiency in the facility's pharmaceutical services.
Expired and Molding Produce Found in Walk-In Cooler
Penalty
Summary
The facility failed to ensure expired and visibly molding produce was disposed of to prevent serving expired food. During an initial kitchen tour with the dietary director (DD), the walk-in cooler was observed to contain expired foods, including an unopened bag of broccoli, four unopened five-pound bags of brussels sprouts, a cardboard box with approximately 25 cucumbers with noticeable mold, a box of wrinkled asparagus, three unopened bags of pre-chopped zucchini, and two undated bags of precut potatoes with white mold spots. The DD confirmed the presence of expired produce and stated that fresh produce is delivered on Tuesdays and Fridays, and it is expected to be disposed of seven days after delivery or when it appears old. The DD also mentioned that most produce is delivered with a use-by date and should be dated when opened. The DD stated that enough produce was thrown away to feed all residents for at least one meal and expressed concern about the potential risk of serving expired produce to residents. A review of the facility's Week 3 menu indicated that chicken zucchini and broccoli were scheduled to be served on specific days. The facility's policy on Food Safety, revised recently, indicated that the director of food and nutrition services is responsible for providing safe foods to all residents and ensuring all refrigerated foods are stored and handled properly.
Infection Control and Laundry Handling Deficiencies
Penalty
Summary
The facility failed to ensure appropriate infection control measures were implemented for a resident (R230) who was placed on enhanced barrier precautions (EBP). During observations, a registered nurse (RN-A) exited R230's room wearing gloves, accessed a supply cabinet in the hallway without changing gloves, sanitizing hands, or donning a PPE gown, and then provided oral care to R230. This was repeated multiple times, and RN-A admitted to not following proper PPE protocols. Interviews with other staff members and the director of nursing (DON) confirmed that staff should wear gowns and gloves and sanitize hands when providing direct care to residents on EBP, which was not adhered to in this case. The facility also failed to ensure clean personal and facility laundry was protected during transport and storage. Observations revealed multiple instances where clean linen carts were left uncovered in hallways, including outside rooms with contact precautions signage. Staff interviews confirmed that clean linen carts should be covered to prevent contamination, but this practice was not consistently followed. Additionally, personal laundry items were transported in uncovered metal carts, with items touching walls and handrails, which was acknowledged by laundry aides and the director of environmental services (ESD) as a long-standing practice that did not align with infection control standards. Facility policies on standard precautions for infection control, enhanced barrier precautions, and hand hygiene were not followed, as evidenced by the improper use of PPE and failure to sanitize hands. The policy on linen handling lacked specific guidelines for transporting clean laundry, contributing to the observed deficiencies. Interviews with the infection preventionist (IP) and DON highlighted a lack of awareness and adherence to proper infection control practices, leading to potential risks for all residents utilizing facility-provided laundry services.
Failure to Secure Medication Carts
Penalty
Summary
The facility failed to ensure that two medication carts were kept locked or under direct observation of authorized staff in areas accessible to residents, staff, and guests. On the Transitional Care Unit (TCU), an unattended and unlocked medication cart was observed in the west section, with no staff visible. Registered Nurse (RN)-A admitted responsibility for the cart and acknowledged that it should have been locked and the resident information on the laptop hidden. Similarly, in the east section of the TCU, another unattended and unlocked medication cart was found near a resident lounge and nursing station, with two residents and a housekeeper nearby. Licensed Practical Nurse (LPN)-A, who was responsible for the cart, confirmed that it should have been locked to prevent unauthorized access to medications. Both RN-A and LPN-A were responsible for ten residents each on the TCU, as indicated by the Team Nurses Census Sheets provided to the surveyor. During interviews, RN-C and RN-F reiterated the importance of locking the medication carts and securing patient information on the computer screens when unattended. The Director of Nursing (DON) also confirmed that medication carts should always be locked when not in use to secure medications and prevent unrestricted access. The facility's policy titled 'Medication Administration-General Guidelines,' reviewed on 3/10/23, directs that medication carts must be kept closed and locked when out of sight of the medication nurse or trained medication aide.
Failure to Provide Timely Assistance with Elimination Care
Penalty
Summary
The facility failed to provide timely assistance with elimination care for a resident, leading to a deficiency in promoting dignity and reducing the risk of complications. The resident, who had intact cognition and was mostly bed-ridden due to a sustained injury, reported that staff often responded to her calls for assistance but did not return in a timely manner. This issue was observed when the resident requested help with a bed pan, and staff did not return to assist her for over 20 minutes, causing her frustration and discomfort. During the observation, a registered nurse and a nursing assistant were present but did not provide the necessary assistance. The nursing assistant initially asked for help to turn the resident but then left the room without returning. The registered nurse also left the room to chart medications and did not return to assist the resident. The resident expressed her frustration with the delay, stating that such situations happened often and made her feel neglected. Interviews with staff revealed that the delay was partly due to a staff member arriving late, causing a miscommunication and staff being pulled to other units. The facility's dignity policy emphasized the importance of maintaining residents' dignity and respect, but timely response to requests was not explicitly listed. The incident highlighted a failure in communication and staff coordination, leading to the resident's needs not being met promptly.
Failure to Maintain Resident Privacy
Penalty
Summary
The facility failed to ensure resident medical records containing private, medical, and personal information were kept private and not accessible to unauthorized personnel. This deficiency was observed for two residents. On one occasion, an unattended medication cart with a laptop open to a resident's medication list was found in the hallway of the Transitional Care Unit. The responsible RN admitted that the resident information should have been hidden and the cart locked when unattended. On another occasion, a similar situation was observed in the long-term care unit, where another RN left a medication cart with a laptop open to a resident's electronic medical record. The RN acknowledged the mistake, citing being busy as the reason for the oversight. Interviews with various staff members, including the charge nurse and the director of nursing, confirmed that the facility's policy requires medication carts to be locked and computer screens to be blanked when not in use to maintain patient privacy. The facility's policy on medication administration also emphasizes the importance of maintaining privacy for all resident information. Despite these policies, the observations and staff admissions indicate a failure to adhere to these guidelines, resulting in a breach of patient privacy.
Failure to Provide Routine Personal Hygiene Care
Penalty
Summary
The facility failed to ensure routine personal hygiene care, specifically nail care, for a resident (R64) who was dependent on staff for their activities of daily living (ADLs). R64 had moderate cognitive impairment and required substantial assistance with personal hygiene, dressing, eating, oral hygiene, and was dependent on toileting and showering. Despite these needs, observations revealed that R64's fingernails were about 0.4 centimeters long with black debris underneath, indicating a lack of proper nail care. Interviews with nursing assistants and registered nurses confirmed that nail care was typically performed on shower days, and there was no documentation indicating that R64 refused personal care. The staff acknowledged the potential infection risks associated with long, dirty nails, especially for a resident with R64's medical conditions, which included vascular dementia, type II diabetes mellitus with diabetic neuropathy, major depressive disorder, peripheral vascular disease, and bilateral below-knee amputations. During interviews, nursing assistants and registered nurses admitted to not noticing the state of R64's nails until it was pointed out. The Director of Nursing (DON) and other staff members recognized the infection control issues and the need for cleanliness and dignity for the resident. The facility's policy on nail care, dated September 2022, emphasized the importance of cleanliness, infection prevention, comfort, and skin problem prevention. However, the lack of adherence to this policy led to the deficiency observed in R64's care, highlighting a gap in the routine personal hygiene care provided to the resident.
Failure to Implement Wound Prevention Treatment
Penalty
Summary
The facility failed to ensure wound prevention treatment was implemented for a resident (R36) who had a history of bilateral heel pressure areas and was at risk for skin breakdown. Despite having an order for a Prevalon boot to be worn on the left foot when in a recliner or bed, the resident's care plan lacked documentation of this order, and there was no record of the resident refusing to use the boot. Observations and interviews revealed that the resident had not been using the boot for at least four months, and the boot was found in the back of an armoire drawer. The resident's treatment administration record inaccurately documented that the boot was being used, and a licensed practical nurse admitted to not putting the boot on the resident and falsely signing the treatment administration record. The resident had multiple diagnoses, including type II diabetes mellitus, chronic kidney disease, vascular dementia, chronic obstructive pulmonary disease, morbid obesity, and peripheral vascular disease, which increased the risk for skin issues. The resident's nurse practitioner's visit report indicated a history of peripheral artery disease with a left toe amputation and recurrent ulcers to bilateral heels, emphasizing the high risk for recurrent skin issues. The director of nursing acknowledged that the nursing staff failed to implement the Prevalon boot order and incorrectly documented their actions, putting the resident at risk for injury due to her history of pressure areas.
Failure to Reassess and Develop Interventions for Resident's Mobility Needs
Penalty
Summary
The facility failed to comprehensively reassess a resident after repeated refusals of an ambulation program and did not develop interventions to reduce the risk of mobility loss. The resident, who had moderate cognitive impairment and multiple medical conditions including type II diabetes mellitus, vascular dementia, and chronic obstructive pulmonary disease, was supposed to participate in a walking program. However, the resident had not been offered assistance to walk for a long time and had not participated in the ambulation program for several months, as documented by the staff. Despite this, no revisions were made to the walking program since June 2023, and the program was not linked to the nursing assistants' Kardex, leading to a lack of proper follow-up and reassessment of the resident's needs. Interviews with various staff members, including nursing assistants, registered nurses, and the director of nursing, revealed that the resident's refusal to participate in the walking program was known but not adequately addressed. The physical therapist, who was responsible for the resident's physical therapy services, was not informed about the resident's non-participation in the restorative nursing program. The physical therapist noted a decline in the resident's walking distance and strength, which was expected due to the resident's condition but was not communicated to the therapist for re-evaluation and development of a new restorative nursing program. The facility's policy on the Restorative Nursing Program indicated that residents' abilities in activities of daily living should not deteriorate and that residents should maintain their highest practicable well-being. However, the facility did not follow this policy, as evidenced by the lack of reassessment and intervention for the resident's mobility needs. The director of nursing acknowledged that the resident's walking program was reviewed in February 2024 and deemed appropriate, but no further action was taken despite the resident's non-participation in the program for several months.
Failure to Reassess Safety of Grab Bars for Resident with Seizures
Penalty
Summary
The facility failed to ensure the use of bilateral, bed-mounted grab bars was comprehensively reassessed and, if needed, develop interventions to ensure safety while in bed for a resident who developed seizures after admission. The resident's admission Minimum Data Set (MDS) did not identify a seizure disorder, and the Device Assessment and Consent form lacked evidence of any alternatives attempted prior to the use of grab bars. Despite the resident experiencing multiple seizures after admission, there was no re-evaluation of the grab bars for safety, nor were any potential safety interventions considered or documented to reduce the risk of injury during seizures in bed. The resident's progress notes indicated that she was admitted to the care center after a right shoulder dislocation and was initially not on seizure precautions. However, after experiencing multiple seizures, including one during a therapy session and another in the dining room, the care plan was updated to include seizure precautions. Despite this, there was no specific information on interventions to promote safety while in bed with the use of bilateral grab bars. The resident reported that the left grab bar had been loosened due to her seizures, and it had not been inspected or discussed with her since the seizures began. Interviews with staff revealed that the grab bars were evaluated upon admission and then periodically, but not specifically after the resident developed seizures. The environmental services director confirmed that padding for the grab bars was available but would only be applied if initiated by nursing. The registered nurse unit manager acknowledged that the medical record lacked evidence of re-evaluation of the grab bars for safety after the resident's seizures. The facility's policies on seizure precautions and the assessment and use of grab bars/side rails did not include specific procedures for re-evaluating physical devices post-seizure.
Failure to Follow Standard Practices for Gastrostomy Tube Care
Penalty
Summary
The facility failed to ensure staff provided care according to standard practices for gastrostomy tube care for a resident (R230) who was dependent on a feeding tube for all nutrition and medication administration. The resident's care plan required water flushes via PEG tube every four hours and additional flushes before and after feeds. However, during multiple observations, undated and unlabeled graduated cylinders and piston syringes were found in the resident's room, indicating non-compliance with the facility's policy to replace and date syringes every 24 hours. Interviews with staff confirmed that the equipment was not dated or labeled, and there was no documentation in the electronic medical record (EMR) to verify when the equipment was last replaced. The registered nurse (RN) and infection control personnel acknowledged the importance of dating and labeling the equipment to prevent infection, especially for an immunosuppressed resident. The director of nursing (DON) also confirmed that the lack of dating and labeling posed an infection control concern and that the facility did not have a process to ensure compliance with this practice. The facility's policy on enteral feeding tube care, revised in October 2021, directed staff to replace and date syringes every 24 hours, but this was not followed, leading to the deficiency.
Failure to Post Complaint Investigation Results
Penalty
Summary
The facility failed to ensure that complaint investigations and any plans of correction from the past three years were posted in prominent and accessible areas for residents, families, and visitors. During an observation, it was noted that the Annual State Survey Results binder in the main lobby did not include any complaint investigation results for the year 2023. Additionally, there was no signage indicating the availability of such reports anywhere in the facility. This oversight was confirmed during an interview with the administrator, who acknowledged the responsibility for updating the binder but admitted that the necessary documents were missing and that there was no signage to guide individuals on where to find these reports. The facility's policy, revised on 6/1/23, mandates that survey results, including complaint investigations and plans of correction from the past three years, must be available for review upon request and that a notice of their availability should be posted in prominent and accessible areas. Despite this policy, the facility did not comply, as evidenced by the missing documents and lack of signage. This failure had the potential to affect all 132 residents, their families, and visitors who might have wished to review the information.
Failure to Maintain Sanitary Kitchen Environment
Penalty
Summary
The facility failed to ensure the kitchen floors and mats were routinely and properly cleaned, leading to a noticeably unsanitary kitchen environment. During an initial kitchen tour, surveyors observed that the kitchen floors, including the food preparation area, walk-in cooler, dry storage room, and clean dishware storage room, were significantly soiled. The floors were covered with a white/brown coating, old dried food particles, used food wrappers, broken dishware pieces, and darkened mop heads. These observations were confirmed by the dietary director (DD), who admitted that the kitchen floors and mats were dirty and acknowledged the absence of a cleaning schedule. The DD stated that the night custodian had deep cleaned the floors the previous night but confirmed that there was no established cleaning schedule. The DD expressed concern about the potential for foodborne illness due to the dirty floors and mentioned that they were working on creating a formal cleaning schedule. The facility's policy on food safety, revised in March 2019, indicated that the director of food and nutrition services was responsible for ensuring sanitary conditions in storage, preparation, and food serving areas, and that cleaning schedules should be posted and followed. However, this policy was not being adhered to, leading to the observed deficiencies.
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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