Mission Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Plymouth, Minnesota.
- Location
- 3401 East Medicine Lake Boulevard, Plymouth, Minnesota 55441
- CMS Provider Number
- 245546
- Inspections on file
- 30
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Mission Nursing Home during CMS and state inspections, most recent first.
A resident with Parkinson’s disease, dementia, and a history of falls was admitted on hospice, but the facility failed to integrate the hospice plan of care into the resident’s comprehensive care plan. The hospice coordination note identified pain management goals and visit frequencies, yet these were not reflected in the facility’s ADL or nursing care plans, and the hospice plan of care was not available in the record. A NA knew the resident was on hospice but was unaware of hospice-specific interventions such as pain monitoring frequency or comfort-focused ADL assistance. An RN confirmed the absence of hospice-specific goals and interventions in the care plan, and a hospice RN acknowledged she had not provided the comprehensive hospice plan of care to the facility. The DON stated the facility relied on hospice to manage the plan of care and could not confirm that hospice-related interventions for pain, anxiety, dyspnea, and psychosocial support were included, despite a policy requiring comprehensive care plans for all residents.
A resident with severe cognitive impairment, hemiplegia, aphasia, dysphagia, and end-of-life cancer was care planned as a vulnerable adult requiring a calm, consistent approach, monitoring for emotional status, and protection from abuse. Video evidence showed a CNA removing a clean incontinent pad the resident kept under his pillow, throwing it on the floor, pushing the bed toward the wall, striking the resident’s hand with the call light, and repositioning the bed and remote out of his easy reach while he softly protested. The CNA then repeatedly gave the resident the middle finger, mocked him with facial expressions and grunting sounds, threw a bedspread over him, and left him in a lowered bed struggling to reach the remote, during which he cried and appeared visibly upset. Family interviews confirmed the resident became tearful, felt frustrated and defeated, and later more distrustful and withdrawn, while the facility’s written abuse prevention policy expressly prohibited such maltreatment.
The facility failed to complete and document ordered weekly head-to-toe skin assessments for three high-risk residents with existing PUs and multiple risk factors such as immobility, incontinence, diabetes, PVD, malnutrition, and chemotherapy. Provider orders and care plans required weekly skin checks, but electronic records showed missed weeks for each resident, with no documentation that assessments were done or refused. Nursing staff, including an LPN, RNs, and the DON, confirmed that admission body audits and wound rounds did not replace weekly skin assessments and acknowledged that the required weekly assessments were not consistently performed or recorded.
The facility failed to verify that multiple nurse aides and trained medication aides held active status on the state registry before allowing them to perform nursing and nursing-related services. Review of personnel files showed that four nursing assistants had inactive registry status with no evidence of renewal, yet they reported providing resident care such as toileting, transfers, peri care, and medication administration under RN/LPN supervision. Interviews confirmed that these staff had been working in NA/TMA roles without current certification, and the facility could not produce documentation of active NA or TMA credentials, despite written job descriptions requiring completion of approved training and good standing with the state registry.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact circumstances or individuals involved.
A resident experienced a significant medication error due to a failure in the medication administration process. The report does not provide further details about the circumstances or the resident's condition at the time.
The facility did not have an infection prevention and control program in place, as observed by surveyors. This lack of a systematic approach to infection prevention was identified during the survey process.
A resident with chronic pain and a history of stroke did not receive prescribed pain medications prior to a scheduled surgery due to staff failing to reorder hydrocodone-acetaminophen in a timely manner. The resident left for surgery without pain management, arriving at the surgery center in severe pain. Staff did not follow protocols for medication reordering or documentation, leading to actual harm.
A resident with left-sided hemiplegia and substantial care needs was found unable to access the call light, which staff had left wrapped around a bed grab bar out of reach. The resident reported having to use a personal phone to contact family for help or self-propel to the nurses' station, as he could not reach the call light due to his physical limitations. Staff and DON confirmed the expectation that call lights be accessible, but this was not consistently followed.
A resident assessed as needing a smoking apron for safety was not consistently provided this adaptive equipment while smoking, despite facility policy and interdisciplinary team determination. Staff responsible for assisting with adaptive equipment did not always implement the required intervention, resulting in the resident smoking without the prescribed safety measures.
The facility did not develop a QAPI plan with measurable goals or a feedback system from residents and their representatives. The DON could not provide documentation outlining specific goals or evaluation methods. Meeting minutes lacked evidence of target goals and resident feedback, despite the QAPI policy requiring benchmarks and goals for performance improvement.
The facility failed to complete thorough smoking assessments for residents who wished to smoke, affecting five individuals with various medical conditions. These assessments were either incomplete or not conducted in a timely manner, contrary to facility policy. The Director of Nursing confirmed the deficiencies, highlighting the importance of completing and communicating these assessments to ensure resident safety.
A facility failed to complete a Level II PASSAR for a resident with mental illness prior to admission. The resident had a history of major depressive disorder, anxiety, PTSD, ADHD, and opioid dependency. The preadmission screening indicated the need for a Level II assessment, which was not documented in the medical record. The social services designee confirmed the lack of documentation and its importance for mental health services.
The facility did not submit accurate staffing data to CMS for a quarter, resulting in a 1-star staffing rating. Despite having adequate nursing coverage, the data was inaccurately reported. The payroll manager lost access to the CMS site, and the administrator, who took over, failed to submit the required information. No policy on PBJ entries was available.
The facility's infection control program failed to include symptom tracking and analysis of resident infections, with logs for March and April 2024 lacking critical information and analysis. Following the previous DON's departure, neither the current DON nor the infection preventionist LPN-A analyzed data or trends, contrary to the facility's policy.
The facility failed to implement an effective antibiotic stewardship program, lacking documentation and analysis of antibiotic use among its residents. Infection control logs were inconsistently filled, missing critical information, and there was no clear responsibility for monitoring antibiotic trends after the previous DON left. Despite daily team meetings, there was no structured follow-up on antibiotic efficacy, leading to a gap in oversight.
A resident with hemiplegia and cognitive intactness experienced repeated dignity violations due to improper clothing adjustments after transfers. Despite staff acknowledging the importance of maintaining resident dignity, observations showed the resident's clothing was often disheveled, exposing the stomach and adult incontinent product, causing embarrassment. The facility lacked a policy to ensure dignity, contributing to the deficiency.
A resident reported receiving opened mail, violating their right to privacy. Social services staff admitted to searching mail for contraband with resident consent, but the administrator was unaware and expected searches only with probable cause. The facility's policy guarantees privacy in communication, which was not upheld.
A facility failed to accurately document a resident's advanced directives in the EMR, leading to a discrepancy between the resident's wishes for DNR status and the physician orders indicating full code. The error occurred due to a lack of communication and verification during the admission process, as the HUC entered initial hospital orders without updating them to reflect the resident's signed DNR status. Staff interviews highlighted the need for consistent documentation across all records to ensure appropriate emergency interventions.
A resident's room was observed to be unclean for several days, with debris and what resembled brown ground meat on the floor. Despite expectations for daily cleaning, the room had not been cleaned for five days, and no cleaning policy was provided. The resident's family also reported seeing garbage during visits.
A facility failed to notify the Ombudsman of a resident's hospital transfers, as required by policy. The resident, with complex medical conditions, was hospitalized twice, but no evidence of notification was found. Staff interviews revealed uncertainty about whether the notifications were completed, and the Ombudsman confirmed no notifications were received.
A resident with multiple diagnoses, including heart failure, returned from hospitalization with a new order for a 1500 ml fluid restriction. However, the facility continued to implement the previous 2000 ml restriction. The DON confirmed the discharge orders were not followed, which was crucial to prevent further exacerbations.
A resident developed pressure injuries due to improper use of a mechanical lift sling in a LTC facility. The resident, who required assistance for daily activities, was transferred using a wet sling that was not centered correctly, causing uneven weight distribution and discomfort. Despite the resident's complaints of pain, staff did not address the issue, leading to injuries in the groin, thighs, and buttocks. The facility's procedures for sling use were not followed, contributing to the deficiency.
A resident requiring substantial assistance due to hemiplegia experienced discomfort during transfers due to improper use of a mechanical lift and sling. Observations showed staff failed to perform necessary assessments and follow manufacturer's guidelines, leading to uneven weight distribution and discomfort. Interviews revealed inadequate training and inconsistencies in staff knowledge regarding sling size and use.
A resident with multiple health conditions, including paraplegia and pressure ulcers, did not have their weight monitored monthly as required by their care plan. Despite orders for monthly weighing, significant lapses in recorded weights were noted, with the last documented weight on 4/3/24. The RD highlighted the absence of updated weights, but there was no evidence of physician notification. Interviews revealed that weights were expected to be taken monthly, and any refusals should be documented, but this was not consistently done.
A facility failed to conduct proper post-dialysis assessment and monitoring for a resident with ESRD. The resident's care plan and treatment records lacked necessary orders and documentation for monitoring the AV fistula and post-dialysis condition. Interviews revealed the absence of a dialysis care policy, leading to inconsistent care practices.
A facility failed to document a clinical rationale for extending the use of PRN Ativan beyond 14 days for a resident with multiple diagnoses, including anxiety disorder. Despite recommendations from the consultant pharmacist and CMS regulations requiring re-evaluation and documentation, the physician's order lacked the necessary clinical rationale. The director of nursing and pharmacist confirmed the deficiency, which had been previously addressed in pharmacy reviews.
A resident with multiple health conditions did not receive a pneumococcal vaccine despite consent and a physician's order. The facility failed to follow up on a pharmacy's approval form, and the vaccination was not administered. The DON expected vaccinations upon admission, but no policy was provided.
The facility failed to ensure the confidentiality of a resident's personal and medical records by sharing information with the resident's probation officer and electronic health monitor case manager without authorization. Staff admitted to communicating concerns about the resident's alcohol use and behavior without having a release of information on file.
Failure to Integrate Hospice Plan of Care Into Resident’s Comprehensive Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident receiving hospice services had a comprehensive written plan of care that incorporated the hospice plan of care and clearly described the services the facility would provide. The resident was discharged from the hospital with diagnoses including repeated falls, Parkinson’s disease with dyskinesia, and dementia, with hospice care as the discharge disposition. A hospice initial coordination note documented goals related to pain management and visit frequencies for nursing and social work, and indicated hospice would deliver the initial hospice plan of care to the facility. However, these hospice goals and interventions were not integrated into the facility’s care plan, and the hospice plan of care was not provided to the surveyor upon request. The resident’s ADL care plan did not include the most recent hospice plan of care and lacked documentation of how the facility would coordinate or provide services to support hospice interventions. Record review for the month showed there was no comprehensive written plan of care that combined the hospice plan with facility services such as nursing interventions, ADL assistance, and pain monitoring. A NA reported knowing the resident was on hospice but not knowing the specifics of hospice care needs, including required pain monitoring frequency or comfort-focused ADL approaches, stating she had not been informed of hospice-specific interventions. An RN confirmed that the resident’s comprehensive care plan should have reflected individualized hospice goals and interventions but acknowledged she could not locate a comprehensive hospice care plan in the record. A hospice RN stated she did not provide the comprehensive hospice plan of care to the facility, focusing instead on medication management, and stated staff should have access to a hospice plan of care identifying needs and interventions. The DON stated the facility relied on hospice to manage their plan of care, was unaware whether the hospice plan had been integrated into the resident’s comprehensive care plan, and could not confirm whether hospice-related interventions such as pain, anxiety, shortness of breath management, and psychosocial support were present. The facility’s comprehensive care plan policy was requested but not provided, while the resident assessment policy required a comprehensive care plan for all admitted residents.
Failure to Protect a Vulnerable Resident From Physical and Verbal Abuse by a Nursing Assistant
Penalty
Summary
The deficiency involves the facility’s failure to protect a vulnerable resident from staff-to-resident abuse by a nursing assistant (NA-A). The resident had a history of stroke, cancer with a prognosis of less than six months to live, hemiplegia and hemiparesis affecting one side of the body, aphasia, dysphagia, a prior neck of femur fracture, depressed mood, restlessness, and anxiety. The admission MDS documented severe cognitive impairment, no mood or behavioral issues at baseline, and dependence on staff for ADLs, with bladder and bowel incontinence. The care plan identified the resident as a vulnerable adult expected to decline due to end-of-life status, required assistance with incontinent care and transfers, and directed staff to use a calm, consistent approach, monitor for pain and emotional status, avoid overstimulation, and maintain an environment free of abuse, neglect, and exploitation. On the date of the incident, video footage showed the resident lying in bed wearing only an incontinent pad and partially covered by a sheet. NA-A removed a clean incontinent pad from under the resident’s pillow and tossed it on the floor, then used her hip to push the bed toward the wall. The resident, in a soft voice, said “no, no, no” while looking at the pad on the floor. NA-A told the resident he already had one on his body and did not need the extra pad. NA-A then grabbed the resident’s call light, moved to the other side of the bed, and when the resident raised his left hand, she hit his hand with the call light and told him to stop before plugging the call light into the wall and stating she was trying to help him. She then lowered the bed to the floor and placed the bed remote on the bedside dresser handle, out of the resident’s immediate reach. The video further showed that as NA-A picked up items from the floor, the resident pointed and faintly said “here, here, here,” indicating the area where the pad had been thrown. Standing at the foot of the bed, NA-A dropped a clear bag on the floor, raised and lowered her right hand, extended her middle finger toward the resident three times, and stuck her tongue out at him. She walked past him mocking him with facial expressions while picking up dirty linen. The resident pointed his finger and said “no, no, no,” after which NA-A left the room and the resident began crying, placed his left hand over his forehead, and appeared visibly upset. He struggled to reach the bed remote on the nightstand handle to raise his bed. When NA-A re-entered, she made grunting sounds mimicking the resident, threw a bedspread over him, lowered the bed back to the floor, placed the bed remote inside the bedside stand, and left the room with the lights on, without addressing or speaking to him. The resident again struggled to reach the remote and remained lying on his side looking at the floor with the bed in the lowered position. Family interviews corroborated the impact of the incident on the resident. One family member reported that she monitored a camera in the resident’s room, noticed his bedding torn apart, and called the facility for assistance, then observed the abusive interaction on the camera. She explained that the resident liked to keep an incontinent pad under his pillow to try to change himself and that he became very upset when NA-A took it away and threw it on the floor. She stated he briefly cried because of how he was treated and his inability to communicate or speak up, and that he felt angry, frustrated, then defeated, and ultimately very upset and tearful when NA-A flipped him off. Another family member stated the incident made the resident more distrustful of staff and withdrawn, and that in the moment it made him cower and cry, and she believed he felt disrespected, helpless, and in physical danger. The facility’s abuse prevention policy stated that maltreatment of residents, including abuse and neglect, would not be tolerated and that all employees were responsible for ensuring residents were free from maltreatment, but the actions of NA-A toward this resident constituted physical and verbal abuse contrary to that policy. The facility’s written Abuse Prevention and Prohibition policy, reviewed in 2022, specified that the facility would not tolerate maltreatment of residents, including abuse and neglect, and that all employees were responsible for assuring residents were free of maltreatment. It also stated that the facility would not knowingly employ individuals who had been convicted of abusing, neglecting, or mistreating individuals, and that reports of maltreatment would be promptly and thoroughly investigated. Despite these written expectations, the documented and observed conduct of NA-A toward this resident—throwing his clean incontinent pad on the floor, hitting his hand with the call light, mocking him with gestures and facial expressions, extending her middle finger at him multiple times, mimicking his vocalizations, and placing the bed and remote out of his reach while he cried and was visibly upset—constituted the abusive actions and inactions that led to the cited deficiency for failure to protect the resident from abuse.
Failure to Complete and Document Ordered Weekly Skin Assessments for High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to perform and document comprehensive weekly head-to-toe skin assessments as ordered for three residents with existing pressure ulcers and high risk for skin breakdown. For one resident with cancer, deep vein thrombosis, malnutrition, bowel and bladder incontinence, chemotherapy treatment, and mobility limitations requiring a wheelchair, provider orders dated 12/5/25 required weekly head-to-to-toe skin checks on Fridays. This resident had pressure wounds on both ischial tuberosities and later a sacral wound, and the care plan identified multiple risk factors for skin alteration, including a non-healing surgical wound, immobility, nutritional risk, and incontinence. Despite these orders and risk factors, the electronic health record showed only one weekly skin assessment on 12/26/25, with no documented weekly assessments for multiple weeks and no documentation that assessments were completed or refused. A second resident, with intact cognition, peripheral vascular disease, kidney disease, neurogenic bladder, paraplegia, diabetes, and wheelchair dependence, also had provider orders for weekly head-to-toe skin checks on Fridays. This resident had a stage IV sacral pressure ulcer and ongoing pressure wound care orders, indicating high risk for pressure injury. Skin assessments were documented on 1/2/26, 1/9/26, 1/23/26, and 2/6/26, but there was no documentation of weekly skin assessments for the weeks of 1/16/26 and 1/30/26. The progress notes did not show that the missing assessments were completed or that the resident refused them. A third resident, with intact cognition, current pressure ulcers, bowel and bladder incontinence, peripheral vascular disease, diabetes, lung disease, and wheelchair dependence, had provider orders for weekly head-to-toe skin checks on Sundays and ongoing pressure wound care orders for bilateral ischial tuberosity wounds. The care plan identified potential skin alteration and a non-healing open area related to diabetes, PVD, immobility, nutrition risk, incontinence, and impaired cognition. Documented weekly skin assessments occurred on 1/11/26, 1/25/26, 2/1/26, and 2/8/26, but there was no weekly skin assessment documented for the week of 1/18/26, nor any indication in the progress notes that the assessment was completed or refused. Nursing staff, including an LPN, two RNs, and the DON, acknowledged that weekly skin assessments were required by provider orders and facility policy, that admission body audits and wound rounds did not replace weekly head-to-to-toe assessments, and that these residents missed required weekly skin assessments without documented reasons.
Failure to Verify Active NA and TMA Registry Status Before Allowing Nursing Duties
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nurse aides and trained medication aides had active certification and were in good standing on the state registry before performing nursing or nursing-related services. Document review showed that four of seven reviewed nursing assistants (NA-A, NA-B, NA-C, NA-D) had inactive registry status with no evidence of renewal in their personnel files. NA-A’s certificate, originally issued in 2006, showed inactive status effective 8/24/2025, and there was no documentation of renewal or verification of active NA or TMA status, despite NA-A reporting ongoing work as a nursing assistant and trained medication aide and providing nursing-related care to residents that morning. NA-B’s certificate, dated 1995, showed inactive status effective 4/02/2023, with no renewal documentation in the file, even though NA-B reported working as an NA/TMA since 2003 and was unaware of the inactive status. NA-C’s certificate, dated 1995, showed inactive status effective 8/24/2025, with no evidence of renewal in the personnel file, while NA-C reported obtaining an NA certificate in Boston, moving to Minnesota, and providing nursing-related services such as toileting, transfers, and peri care to residents. NA-D’s certificate, dated 2014, showed inactive status since 8/24/2021, with no renewal documentation, and NA-D stated she did not know if her certificate was active, while acknowledging that nursing staff must have active status to perform nursing-related work. During interview, the administrator stated they could not provide TMA documentation for NA-A, NA-B, and NA-C and acknowledged that staff should not perform nursing-related work with inactive registry status. Facility job description policies for nursing assistants and TMAs, dated 12/21, required completion of approved training and being in good standing with the Minnesota Nursing Assistant Registry, which was not met for these staff members.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident received a significant medication error, indicating a failure in the medication administration process. Specific details regarding the actions or inactions that led to the error, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, as the facility did not have an established or operational program to prevent and control infections among residents and staff. The absence of such a program was directly observed and documented by surveyors, indicating a lack of systematic measures to address infection risks within the facility. No specific residents or staff members were mentioned in relation to the deficiency, and no additional details about individual medical histories or conditions were provided in the report.
Failure to Provide Timely Pain Medication Results in Resident Harm
Penalty
Summary
A resident with chronic pain syndrome, hemiplegia, depression, and anxiety, who was cognitively intact, experienced almost constant pain rated at 8/10. The resident had physician orders for scheduled and PRN doses of acetaminophen and hydrocodone-acetaminophen, including specific instructions to administer these medications prior to a pre-scheduled surgery. Despite these orders, the medications were not administered before the resident left for surgery due to a lack of available supply, and there was no documented rationale for the omission in the resident's record. Staff identified that a new prescription for hydrocodone-acetaminophen was needed two days before the surgery, with only 10 tablets remaining at that time. The medication was not reordered in a timely manner, and the last available dose was given the night before surgery. Although staff contacted the pharmacy and requested a new script, the medication was not delivered before the resident's departure for surgery. The resident left the facility without receiving the ordered pain medications and arrived at the surgery center in severe pain, tearful, and expressing distress over not having received pain management. Documentation and interviews revealed that staff did not follow established protocols for timely medication reordering, did not escalate the issue to the provider or DON when the medication was unavailable, and failed to document the resident's refusal of alternative pain medication. The facility's policy required controlled medications to be reordered when a 5-7 day supply remained, but this was not adhered to, resulting in the resident experiencing actual harm due to unmanaged pain prior to surgery.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
A deficiency occurred when staff failed to ensure that a resident's call light was within reach and accessible. The resident, who had a history of hemiplegia and hemiparesis following a stroke affecting the left side, chronic pain syndrome, depression, and anxiety disorder, required substantial assistance with activities of daily living, including transfers and mobility. During observation, the resident was found sitting in a wheelchair with the call light wrapped around the bed's grab bar on the far side of the room, making it inaccessible. The resident reported having to use a personal cell phone to contact family for help or self-propel to the nurses' station to request assistance, as he could not reach the call light due to his physical limitations. Interviews with nursing staff and the DON confirmed that staff were expected to ensure call lights were within reach for all residents, especially those dependent on staff for care. However, staff had not consistently followed this expectation, as evidenced by the call light being left out of reach. Facility policy also required that residents be provided with a means to call staff for assistance from their bed and other locations, but this was not adhered to in the resident's case.
Failure to Provide Required Smoking Safety Equipment
Penalty
Summary
A deficiency occurred when the facility failed to provide required adaptive equipment for a resident assessed as needing a smoking apron for safety while smoking. The resident, who had diagnoses including chronic obstructive pulmonary disease and schizophrenia and was cognitively intact, was identified through assessment and interdisciplinary team review as requiring a smoking apron as part of a modified smoking plan. Facility documentation and policy indicated that staff were responsible for ensuring residents used adaptive equipment as identified in their care plans. However, during observation, the resident was allowed to smoke in the designated smoking room without being provided the required apron. The door monitor, responsible for assisting with adaptive equipment, did not provide the apron and stated he believed it was only necessary for outdoor smoking, despite facility documentation indicating otherwise. Interviews with the resident and multiple staff members confirmed inconsistent implementation of the adaptive equipment requirement, with some staff providing the apron and others not. The assistant director of nursing, a registered nurse, and the director of nursing all confirmed that the process involved assessment, interdisciplinary review, and communication of adaptive equipment needs to staff responsible for implementation. Despite these procedures, the resident was not consistently provided the required safety equipment while smoking, as observed and confirmed by staff and the resident.
Lack of Measurable Goals and Feedback System in QAPI Plan
Penalty
Summary
The facility failed to develop a comprehensive Quality Assurance and Performance Improvement (QAPI) plan that included measurable goals and a system for collecting feedback from residents and their representatives. During the survey, the Director of Nursing (DON) was unable to provide a document outlining specific goals or methods for evaluating the success of quality improvement focuses. Although meeting minutes from the last four quarters were provided, they lacked evidence of target goals for sustainability and did not demonstrate that feedback from residents and their representatives was obtained. The facility's QAPI policy, dated March 2020, stated that it was the committee's duty to establish benchmarks and goals for performance improvement, which was not reflected in the documentation provided.
Incomplete Smoking Assessments for Residents
Penalty
Summary
The facility failed to ensure thorough smoking assessments were completed for residents who wished to smoke, affecting five residents. These residents were identified as current smokers, yet their smoking assessments were either incomplete or not conducted in a timely manner. For instance, one resident's smoking assessment was marked as in progress with entire sections left blank, and another resident had not been reassessed annually as required. The facility's policy mandates that smoking assessments be completed upon admission, annually, and with any significant change in condition, but these protocols were not followed. The residents involved had various medical conditions, including stroke, brain dysfunction, dementia, and hemiplegia, which could potentially impact their ability to smoke safely. Despite these conditions, the facility did not complete the necessary assessments to determine whether these residents could smoke independently or required supervision. The Director of Nursing confirmed that the assessments were incomplete and emphasized the importance of completing, documenting, and communicating the results to ensure resident safety. Interviews with staff revealed that no single person was responsible for completing the smoking assessments, leading to a lack of accountability. The Director of Nursing stated that the initial smoking assessment should be part of the admission process and completed before allowing residents to smoke independently. However, the assessments were not completed as required, and the interdisciplinary team was not adequately informed of the residents' needs, potentially compromising their safety.
Failure to Complete Level II PASSAR for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure a Level II Pre-Admission Screening and Resident Review (PASSAR) was completed prior to the admission of a resident who required it for mental illness. The resident, identified as cognitively intact, had a history of major depressive disorder, anxiety disorder, post-traumatic stress disorder, attention deficit hyperactivity disorder, and opioid dependency. The resident's preadmission screening indicated the need for a Level II assessment due to mental illness, which was not documented in the medical record. The social services designee confirmed the absence of the Level II assessment documentation and acknowledged its importance in providing necessary mental health services. The facility policy regarding this process was requested but not provided.
Failure to Submit Accurate Staffing Data to CMS
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) for the first quarter of the year. The Payroll Based Journal (PBJ) report for this period showed a 1-star staffing rating and a failure to submit the required data. Despite having a registered nurse on duty for at least 8 hours every 24 hours and a licensed nurse available 24/7, the data submitted to CMS was inaccurate. The payroll manager, who was initially responsible for submitting the PBJ report, lost access to the CMS submission site, leading the administrator to take over the task. However, the administrator acknowledged inadvertently failing to submit the staffing information for the quarter. Additionally, there was no policy related to PBJ entries provided by the end of the survey.
Inadequate Infection Control Program and Data Analysis
Penalty
Summary
The facility failed to ensure its infection control program included symptom tracking and ongoing analysis of resident infections to prevent the spread of infections. The infection control logs for March and April 2024 were reviewed and found to lack documentation of analysis or trending of patterns identified. The logs were inconsistently filled out, missing critical information such as the location of infection, type of infection, cultures, and whether isolation was necessary. Additionally, the logs did not document any analysis or tracking of symptoms and infections within the facility. The deficiency was further compounded by a lack of clarity in roles and responsibilities following the departure of the previous Director of Nursing (DON) in late March 2024. The current DON and the infection preventionist LPN-A both confirmed that neither had been analyzing the data and trends with symptom tracking and antibiotic stewardship since the previous DON's exit. The administrator was under the impression that the DON was handling these tasks, but it was confirmed that they were not being completed. The facility's Infection Control-Surveillance Policy, last reviewed in July 2023, indicated that the infection preventionist or designated personnel was responsible for gathering and interpreting surveillance data, which was not being adhered to.
Failure in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement a comprehensive antibiotic stewardship program, which is crucial for monitoring the appropriate use of antibiotics among its 58 residents. The infection control logs for March and April 2024 were reviewed and found to be lacking in critical documentation, such as analysis, trending of patterns, and efficacy of antibiotic use. The logs were inconsistently filled out, missing essential information like symptoms, infection location, type, cultures, diagnostics, and antibiotic start dates. Furthermore, there was no documentation of whether the criteria for infections were met or if isolation was necessary. The Quality Assurance meeting minutes provided minimal details on infection control, and there was no evidence of a systematic approach to analyzing antibiotic usage trends. The deficiency was exacerbated by a lack of clear responsibility and follow-through in the antibiotic stewardship process. After the previous Director of Nursing (DON) left in late March 2024, the responsibility for antibiotic stewardship was not clearly assigned. The current DON and the infection preventionist LPN-A both confirmed that they had not been analyzing data or trends related to antibiotic use. Although daily interdisciplinary team meetings were held to discuss new antibiotic orders, there was no structured follow-up to assess the effectiveness of the antibiotics, leaving it to the floor nurses to document any reactions or efficacy in progress notes. The administrator was under the impression that the DON was managing the antibiotic stewardship program, but this was not the case, leading to a gap in oversight and management of antibiotic use in the facility.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to maintain the dignity of a resident, identified as R19, who was cognitively intact but required substantial assistance with activities of daily living due to hemiplegia and muscle weakness. Observations revealed that R19 was often seen in public areas with clothing disheveled, exposing parts of the stomach and the edges of an adult incontinent product. The resident expressed discomfort and embarrassment about the situation, stating that it made him feel bad and that people made fun of him. Despite the resident's clear distress, staff did not consistently ensure that his clothing was properly adjusted after transfers, as confirmed by interviews with CNAs and the Director of Nursing (DON). The facility's failure to provide a policy on maintaining resident dignity further highlights the deficiency. Interviews with staff, including CNAs and the DON, indicated an expectation that clothing should be adjusted after transfers to maintain resident dignity. However, this was not consistently practiced, as evidenced by multiple observations of R19 inappropriately dressed in public areas. The resident's care plan and occupational therapy assessment indicated a need for extensive assistance, yet the facility did not adequately address these needs, resulting in repeated exposure and embarrassment for the resident.
Violation of Resident's Right to Privacy in Mail Handling
Penalty
Summary
The facility failed to ensure that a resident received unopened mail, violating their right to privacy in communication. The issue was identified during a resident council meeting where a resident mentioned that social services staff sometimes went through their mail for contraband. The social services staff member responsible for sorting and delivering mail admitted to performing searches of the mail for suspected illicit drugs or alcohol, but claimed it was done with the resident's consent. However, the administrator was unaware of these actions and expected staff to only search mail with probable cause. A specific resident, identified as R55, reported receiving two pieces of mail that had been opened before they received them, including a medical bill and paperwork from their case manager. The director of nursing was also unaware of any policy regarding mail searches and expected searches to be conducted only with suspicion of drugs or alcohol and with the resident's consent. The facility's Resident Rights Policy guarantees residents the right to communicate by mail with privacy, which was not upheld in this instance.
Inaccurate Documentation of Advanced Directives
Penalty
Summary
The facility failed to ensure that a resident's advanced directives were accurately documented in the electronic medical record (EMR) under physician orders. The deficiency involved a resident who had been discharged from the hospital with orders for full code status, which was intended only for the duration of their surgical procedures. However, upon admission to the facility, the resident's EMR banner and paper chart indicated a do not resuscitate (DNR) status, which was consistent with the resident's wishes. Despite this, the physician orders in the EMR incorrectly reflected a full code status, leading to a discrepancy in the documentation. Interviews with facility staff revealed that the error occurred because the health unit coordinator (HUC) entered the initial hospital orders for full code into the system, and the subsequent signed code status form indicating DNR was not communicated to her. The assistant director of nursing (ADON) or a floor nurse was supposed to perform a second check of the orders, but the mismatch between the admission orders and the signed forms was not clarified immediately. The director of nursing (DON) acknowledged the importance of ensuring that the resident's code status was consistent across all parts of the EMR and paper charts to implement appropriate interventions in an emergency situation.
Failure to Maintain Clean Environment for Resident
Penalty
Summary
The facility failed to maintain a clean and safe environment for a resident, identified as R36, who was moderately cognitively impaired with diagnoses including heart failure, hypertension, and hemiparesis. On multiple occasions, surveyors observed a large amount of what resembled brown ground meat and various debris on the floor of R36's room, which remained uncleaned for several days. The resident's family member also reported seeing garbage on the floor during visits on consecutive weeks, indicating a lack of regular cleaning. Interviews with housekeeping staff revealed that rooms were cleaned daily only if all housekeepers were present; otherwise, some rooms were skipped. The director of environmental services and the director of nursing both stated that their expectation was for rooms to be cleaned daily and for any messes to be addressed immediately. However, documentation showed that R36's room had not been cleaned for five days. The facility was unable to provide a policy for room cleaning when requested.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to ensure that a written notification of transfer was sent to the Office of the Ombudsman for Long Term Care for a resident who was hospitalized on two separate occasions. The resident, who had multiple complex medical conditions including heart failure, arthritis, and chronic kidney disease, was transferred to the hospital for acute chronic systolic congestive heart failure and later for a fall. Despite the facility's policy requiring the nurse handling the transfer to complete and fax a notification form to the Ombudsman, there was no evidence in the resident's medical record that this was done for either hospital transfer. Interviews with facility staff revealed uncertainty about whether the required notifications were completed. A registered nurse mentioned the usual process of updating the provider, obtaining a transfer order, preparing resident information, and sending a copy of the transfer to the Ombudsman, but was unsure if these steps were followed for the resident in question. The Director of Nursing expected the floor staff to fax the bed hold form to the Ombudsman, but this was not confirmed. An email from the Ombudsman's office confirmed that no notifications were received for the resident's transfers.
Failure to Implement Updated Fluid Restriction Order
Penalty
Summary
The facility failed to accurately implement a physician's order for a resident, identified as R44, who was reviewed for hospitalizations. R44 was admitted with a minimum data set indicating a cognitively intact status and had multiple diagnoses, including heart failure and chronic kidney disease. Upon returning from a hospitalization for acute chronic systolic congestive heart failure, R44 had a new physician's order for a 1500 ml fluid restriction. However, the facility continued to implement the previous order of a 2000 ml fluid restriction, as confirmed by a registered nurse (RN) and the director of nursing (DON). The DON stated that the expectation was for discharge orders to be entered and verified by nursing staff upon a resident's return from hospitalization. However, it was assumed that the order for the 1500 ml fluid restriction was missed and not entered appropriately. The DON confirmed that the hospital discharge orders were not followed, which was important to prevent further exacerbations of the resident's condition. The facility's Admission Criteria policy indicated that necessary information for immediate care, including orders for diet and medication, should be provided by the resident's physician prior to admission.
Improper Use of Mechanical Lift Sling Causes Pressure Injuries
Penalty
Summary
The facility failed to prevent an avoidable pressure injury for a resident, identified as R19, due to improper use of a mechanical lift sling. R19, who was cognitively intact and required substantial assistance for daily activities due to hemiplegia, developed pressure and shearing injuries in the groin, thighs, and buttocks. The care plan for R19 indicated a risk for pressure ulcers and required specific interventions to prevent skin damage, but it lacked details on the appropriate size or color of the sling to be used. During observations, nursing assistants improperly positioned and used a wet sling for transferring R19, which was not centered correctly and caused uneven weight distribution. Despite R19 expressing discomfort and pain during the transfer, the staff did not address these concerns. The improper technique and use of a wet sling led to the development of pressure injuries, as confirmed by the Assistant Director of Nursing (ADON) during a skin inspection. Interviews with staff revealed a lack of knowledge regarding the appropriate sling size for R19, who weighed 298 lbs, and the routine practice of leaving slings under residents. The facility's procedure required staff to be trained and demonstrate competency in using mechanical lifts, including ensuring the correct sling size and checking for resident comfort. However, these procedures were not followed, resulting in harm to R19.
Improper Use of Mechanical Lift and Sling
Penalty
Summary
The facility failed to perform mechanical lift and lift sling assessments for a resident, identified as R19, to ensure the appropriate use and proper size of the equipment. R19, who was cognitively intact with a BIMS score of 15/15, required substantial assistance for activities of daily living due to hemiplegia and muscle weakness. The care plan indicated total dependence on a Hoyer lift for transfers but lacked specific details about the size or color of the sling required. Observations revealed that R19's record did not include a comprehensive safe transfer assessment to determine the appropriate sling for use with the mechanical lift. During multiple observations, staff were seen improperly using the mechanical lift and sling with R19. On one occasion, CNAs assisted R19 with changing an incontinent product and clothing, but the sling was left wet and improperly positioned, causing discomfort to R19 during the transfer. On another occasion, staff struggled to properly position the sling under R19, resulting in an uneven distribution of weight and discomfort during the transfer process. The staff's actions demonstrated a lack of understanding and adherence to the manufacturer's guidelines for the mechanical lift. Interviews with various staff members, including CNAs, RNs, and the DON, revealed inconsistencies in training and knowledge regarding the appropriate use of mechanical lifts and slings. Staff were unclear about who was responsible for determining sling size and often left slings under residents unless instructed otherwise. The DON and ADON acknowledged the need for improved training, as staff were not adequately educated on the facility's mechanical lift procedures. The manufacturer's instructions for the EZ Way Smart Lift were not being followed, contributing to the deficiency in safe transfer practices.
Failure to Monitor Resident's Weight as Ordered
Penalty
Summary
The facility failed to ensure ongoing monitoring of weight for a resident, identified as R45, who was at nutritional risk due to multiple health conditions including paraplegia, hypertension, hyperlipidemia, and pressure ulcers. R45's care plan required monthly weight monitoring, but the electronic medical record showed significant lapses in recorded weights, with the last documented weight being on 4/3/24, despite orders for monthly weighing. The registered dietician (RD) noted the absence of updated weights in several progress notes and recommended obtaining updated weights, but there was no evidence of physician notification regarding the lapse in weight monitoring. Interviews with the RD and the Director of Nursing (DON) revealed that weights were expected to be taken monthly, and any refusal by residents should be documented with physician notification. However, R45's weights were not consistently recorded as ordered, and there was no documentation of refusals or physician updates. The facility's policy emphasized the importance of weight monitoring as an indicator of nutritional status and medical condition, but this was not adhered to in R45's case, leading to a deficiency in care.
Failure in Post-Dialysis Monitoring and Assessment
Penalty
Summary
The facility failed to ensure proper post-dialysis assessment and monitoring for a resident with end-stage renal disease (ESRD) who required dialysis. The resident's physician order report did not include necessary orders to monitor the arteriovenous (AV) fistula for a thrill and bruit daily. Additionally, the treatment administration history lacked documentation for post-dialysis monitoring, such as blood pressure checks, overall condition assessment, and fistula site monitoring. There was also inconsistency in the documentation regarding which arm had the AV fistula, as the care plan indicated the right forearm, while other records suggested the left arm. Interviews revealed that the facility did not have a policy for dialysis care, and the Director of Nursing (DON) confirmed that post-dialysis assessments were not completed, and daily monitoring of the fistula was not conducted. The dialysis center nurse emphasized the importance of monitoring blood pressure and ensuring the resident was not lightheaded or dizzy post-dialysis. The lack of a formal policy contributed to the absence of standardized care for dialysis residents, leading to the deficiency identified by the surveyors.
Failure to Document Clinical Rationale for Extended PRN Ativan Use
Penalty
Summary
The facility failed to ensure a clinical rationale for the extended use of a PRN antianxiety medication, Ativan, beyond 14 days for a resident receiving hospice services. The resident, who had a BIMS score of 11, required substantial to maximum assistance for daily activities and had diagnoses including hypertension, diabetes mellitus, dementia, hemiparesis, and anxiety disorder. The physician's order for Ativan, dated 5/1/24, indicated a start date of 3/13/24 and an end date of 9/13/24, but lacked documentation of clinical rationale for extending the use beyond the 14-day limit as required by CMS regulations. The consultant pharmacist had previously recommended that the PRN Ativan order be re-evaluated within 14 days of initiation and that clinical rationale be provided for any extensions. Despite these recommendations, the physician's response on 3/13/24 did not include the necessary clinical rationale. The director of nursing confirmed the expectation that PRN psychotropic medication orders should last only 14 days unless a clinical indication for extension is documented. The pharmacist also confirmed the facility's failure to provide a clinical rationale for the extended order, noting that this issue had been addressed in previous monthly pharmacy reviews.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to ensure that a resident received a pneumococcal vaccine as offered by the facility. The resident, who was a current smoker and had multiple diagnoses including traumatic subdural hemorrhage, dysphagia, diabetes mellitus, atrial fibrillation, congestive heart failure, and depression, was admitted to the facility with a physician's order indicating they may receive pneumococcal vaccinations if indicated. Despite receiving education and giving consent to receive the vaccine upon admission, the resident's vaccination record lacked evidence of administration. The infection preventionist LPN confirmed the vaccine was not given, and an email from the pharmacy indicated that an approval form for the vaccine was faxed but not responded to by the facility. The Director of Nursing expected staff to administer vaccinations upon admission, but a pneumococcal vaccination policy was not provided when requested.
Breach of Resident Confidentiality
Penalty
Summary
The facility failed to ensure the confidentiality of a resident's personal and medical records. The resident, who was admitted with diagnoses including alcoholic gastritis, alcohol-induced acute pancreatitis, and alcohol dependence, was cognitively intact as indicated by a BIMS score of 15. Despite this, the facility shared the resident's medical information with his probation officer and the electronic health monitor case manager without obtaining the resident's authorization. This included details about the resident's alcohol use, behavior, and compliance with his probation conditions. Interviews with facility staff, including the interim director of nursing and the admissions director, confirmed that they had communicated with the resident's probation officer and case manager regarding concerns about the resident's alcohol use and behavior. Both staff members admitted that they did not have a release of information on file to speak with these external parties. The resident also confirmed that he did not give the facility permission to share his information. This breach of confidentiality was documented in various progress notes and email correspondences reviewed during the survey.
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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