Mount Olivet Careview Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Minneapolis, Minnesota.
- Location
- 5517 Lyndale Avenue South, Minneapolis, Minnesota 55419
- CMS Provider Number
- 245071
- Inspections on file
- 25
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Mount Olivet Careview Home during CMS and state inspections, most recent first.
The facility failed to adhere to proper infection control practices, particularly in the use of PPE for residents under COVID-19 precautions and the implementation of Enhanced Barrier Precautions (EBP). Staff were observed entering rooms of COVID-19 positive residents without wearing N95 masks, and inconsistencies were noted in EBP signage and PPE usage for residents with indwelling medical devices. The infection preventionist and director of nursing acknowledged the need for improved staff education and compliance with infection control protocols.
A resident with severe cognitive impairment and multiple diagnoses was not consistently shaved as per their care plan, impacting their dignity. Despite the resident's preference and family assistance, staff interviews revealed confusion about responsibility for shaving, leading to visible facial hair on the resident. The facility's policy on ADL completion was not consistently followed.
A facility failed to properly assess a resident's ability to self-administer medication safely. The resident, with intact cognition and multiple diagnoses, was left with medications without confirmation of ingestion. The TMA relied on verbal confirmation from an RN instead of documented orders. SAM assessments were incomplete, lacking necessary documentation on the resident's understanding of medications and safety. The facility's policy requiring comprehensive assessment by the interdisciplinary team was not followed.
A resident with specific dietary preferences documented in their care plan did not receive the correct food items or portions during meals. Despite having intact cognition and specific dietary needs due to conditions like diabetes and Parkinson's disease, the resident's requests for certain food items and double portions were not consistently honored. Staff confirmed these omissions, which violated the resident's right to self-determination.
A facility failed to implement a comprehensive care plan for a resident with chronic UTIs, omitting documentation of the resident's history and treatment preferences. Despite recommendations to avoid Macrobid due to ineffectiveness, the resident was administered this antibiotic, contrary to their preference and previous medical advice. The Director of Nursing confirmed the care plan's lack of necessary documentation, which was expected per facility policy.
Two residents at a facility experienced deficiencies in pressure ulcer prevention and care. One resident, with a history of pressure injuries, was not consistently repositioned or offloaded as per their care plan, leading to prolonged periods in a wheelchair. Another resident developed a deep tissue injury on their heel, which was not previously identified by staff. The facility's failure to adhere to care plans and document interventions contributed to these issues.
A resident with severe cognitive impairment and a history of falls did not receive care-planned fall interventions, as their wheelchair was incorrectly positioned away from the bed, contrary to the care plan. Staff interviews revealed a lack of adherence to the care plan, increasing the resident's fall risk.
A resident with complicated feeding problems was assisted by an unqualified environmental services staff member during a meal. The resident required supervision and had a care plan outlining specific feeding strategies due to her impaired cognition and risk for altered nutrition. The facility did not employ paid feeding assistants, and the incident highlighted a gap in ensuring only qualified staff provided feeding assistance.
A facility failed to report and investigate sexual abuse incidents involving two residents, leading to repeated abuse. A resident with cognitive impairments and a history of inappropriate behavior touched another resident inappropriately on two occasions. Despite staff witnessing the first incident, it was not reported or investigated, and the resident's care plan lacked interventions for sexually inappropriate behaviors. The facility's abuse prohibition policy was not followed, contributing to the subsequent incident.
A facility failed to report an abuse allegation within the required timeframe. A resident, who was mildly cognitively impaired and legally blind, reported inappropriate touching by another resident. The incident was witnessed by an LPN and a culinary server, but it was not reported immediately. The ADON was informed days later, but no investigation or report to the state agency was made. The facility's policy required immediate reporting and investigation, which was not followed, leading to a deficiency.
A resident with cognitive impairments reported inappropriate touching by another resident, but the LTC facility failed to investigate the allegation. Despite the incident being witnessed and reported to the ADON, no investigation was conducted, violating the facility's abuse prohibition policy.
The facility failed to follow care plans for residents requiring assistance with ADLs, resulting in missed meals and inadequate support. One resident was left in bed during a staffing shortage, missing breakfast, while another was not assisted with eating despite needing help. Staff interviews confirmed care plans were not updated or followed, highlighting challenges in providing necessary care.
Infection Control Lapses in PPE Usage and EBP Implementation
Penalty
Summary
The facility failed to adhere to proper infection control practices, specifically in the use of personal protective equipment (PPE) for residents under COVID-19 precautions. Observations revealed that staff members entered the rooms of residents with active COVID-19 infections without wearing the required N95 masks, despite signage indicating the necessity of such precautions. For instance, nursing assistants were seen wearing regular masks instead of N95 masks while delivering meal trays and providing care to residents who were on transmission-based precautions due to COVID-19. Interviews with staff confirmed a lack of compliance with the expected PPE protocols, as they admitted to either forgetting to wear the correct mask or misunderstanding the requirements. Additionally, the facility demonstrated inconsistencies in implementing Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices. A nursing assistant was observed changing a resident's brief and repositioning them without wearing a gown, contrary to the facility's policy that requires both a gown and gloves for such activities. The infection preventionist and registered nurse manager acknowledged the inconsistency in signage and the challenges faced by staff in understanding and adhering to EBP requirements. The use of an orange magnet to indicate EBP was intended for resident dignity but led to confusion among staff and family members. The facility's policies on infection control and EBP were not effectively communicated or enforced, resulting in lapses in infection prevention measures. The infection preventionist and director of nursing recognized the need for ongoing education and training to ensure staff compliance with PPE protocols. The report highlights the facility's struggle with maintaining consistent infection control practices, particularly in the context of COVID-19 and EBP, which are critical for preventing the spread of infections among residents.
Failure to Maintain Resident Dignity Through Personal Hygiene
Penalty
Summary
The facility failed to ensure the removal of unwanted facial hair for a resident with severe cognitive impairment and multiple diagnoses, including dementia and anxiety disorder. The resident required substantial assistance for personal hygiene, including shaving, as indicated in their care plan. Observations revealed that the resident had visible facial hair on multiple occasions, despite their preference to be shaved. Interviews with family members and staff confirmed that the resident felt better when shaved, and the family often assisted with shaving during visits. Staff interviews indicated a lack of consistent adherence to the resident's care plan regarding shaving. Nursing assistants and registered nurses acknowledged that the care plan directed whether residents wanted to be shaved, but there was confusion about which shift was responsible for this task. The director of nursing expected staff to offer shaving if it was care planned and hair was visible, emphasizing that not being shaved could impact the resident's dignity. The facility's policy on activities of daily living directed staff to follow the care plan and treat residents with respect and dignity, which was not consistently followed in this case.
Failure to Properly Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to comprehensively assess a resident's ability to self-administer medication (SAM) safely. The resident, who had intact cognition and diagnoses including heart failure, high blood pressure, multiple sclerosis, and muscle weakness, was observed during a medication pass where the trained medication assistant (TMA) left medications with the resident without ensuring they were taken. The TMA was unsure of the location of the SAM assessment and relied on verbal confirmation from a registered nurse (RN) that the resident was allowed to self-administer medications, despite the lack of proper documentation in the medication administration record (MAR) and care plan. The resident's SAM assessments were incomplete, lacking documentation on whether the resident could identify medications, dosages, and potential side effects, and whether the interdisciplinary team deemed her safe to self-administer. The nurse manager acknowledged an error in the SAM assessment and confirmed the assessments lacked necessary documentation. The facility's policy required a comprehensive assessment by the interdisciplinary team to determine a resident's safety to self-administer medications, which was not followed in this case.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor a resident's food preferences, which is a violation of the resident's right to self-determination. The resident, who had intact cognition and was diagnosed with high blood pressure, diabetes, high cholesterol, and Parkinson's disease, had specific dietary preferences documented in his care plan. These preferences included a diabetic diet with the option to request regular foods, specific breakfast items, and an evening snack of vegetables. However, the care plan lacked documentation on his preferences for larger or double portions at meals. Despite these documented preferences, the resident repeatedly did not receive the food items or portions he requested, as observed during multiple dining observations. During these observations, the resident was not served the correct portions or items as indicated on his meal ticket. For instance, he did not receive mashed potatoes, an apple fritter, or mandarin oranges as ordered. Staff confirmed these omissions and acknowledged that the resident should have received the items. The resident expressed dissatisfaction with the portions, stating they were insufficient and left him feeling hungry. The facility's policy on person-centered care planning required that each resident's care plan be individualized and reviewed regularly, but the facility failed to adhere to this policy, resulting in the deficiency.
Failure to Implement Resident-Specific Care Plan for Chronic UTIs
Penalty
Summary
The facility failed to develop and implement a comprehensive and resident-specific care plan for a resident with a history of chronic urinary tract infections (UTIs). The resident, who had intact cognition and was occasionally incontinent of urine, used an external catheter and had multiple diagnoses including high blood pressure, benign prostatic hyperplasia, diabetes, Parkinson's disease, and a history of UTIs. Despite these conditions, the care plan revised on October 4, 2023, lacked documentation regarding the resident's chronic UTIs and did not include interventions that reflected the resident's treatment preferences, such as avoiding the antibiotic Macrobid, which the resident reported as ineffective. The deficiency was further highlighted by a provider progress note from July 29, 2024, which recommended discontinuing Macrobid due to a possible chronic prostatitis component and suggested using Cipro instead. However, the resident's medication administration record from January 2025 showed that Macrobid was administered, contrary to the resident's preference and previous recommendations. Interviews with the resident and a family member confirmed ongoing discussions with the facility about the ineffectiveness of Macrobid and the preference for alternative treatments like Keflex. The Director of Nursing acknowledged the omission in the care plan, which was expected to include documentation of the resident's history of UTIs and treatment preferences, as per the facility's policy on person-centered care planning.
Failure in Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for two residents, leading to deficiencies in their care. One resident, identified as R28, had a history of pressure injuries and was at high risk for skin breakdown due to multiple health conditions, including severe cognitive impairment, diabetes, and peripheral vascular disease. Despite having a care plan that included interventions such as repositioning every two hours and offloading after meals, there were multiple instances where these interventions were not documented or carried out. Observations showed that R28 remained in a wheelchair for extended periods without being repositioned, and there was a lack of documentation regarding refusals to reposition or offload, which were supposed to be reported to the charge nurse. Another resident, R45, was also at risk for pressure ulcers due to conditions like morbid obesity and limited mobility. R45's care plan included interventions such as daily skin observation and the use of pressure-reducing devices. However, during an observation, a purplish-red discoloration was found on R45's right heel, indicating a deep tissue injury. This area had not been previously identified or documented by the staff, and it was discovered during routine care. The staff involved were not aware of the discoloration, and there was a lack of communication regarding R45's refusal to wear socks, which could have contributed to the pressure injury. The facility's failure to adhere to care plans and properly document and communicate skin assessments and interventions contributed to the development and risk of pressure injuries in these residents. The director of nursing acknowledged that not following interventions could lead to skin breakdown or worsening conditions, highlighting the importance of timely identification and implementation of preventive measures. The facility's policy required regular skin assessments and communication of care plans to staff, which were not consistently followed in these cases.
Failure to Implement Fall Interventions for Resident
Penalty
Summary
The facility failed to implement care-planned fall interventions for a resident (R34) with a history of repeated falls and severe cognitive impairment. R34's care plan, which was revised recently, included specific interventions to prevent falls, such as ensuring the wheelchair was next to the bed to reduce fall risk if the resident attempted to self-transfer. However, during observations, the wheelchair was found facing away from the resident and out of reach, contrary to the care plan directives. Nursing assistants interviewed were either unaware of the specific fall interventions for R34 or did not follow them, as evidenced by the incorrect wheelchair placement. Interviews with nursing staff, including registered nurses and the director of nursing, revealed that staff were expected to follow the care plan and use the Kardex for guidance on fall interventions. Despite this expectation, the staff did not adhere to the care plan, as the wheelchair was not positioned correctly, increasing the risk of falls for R34. The facility's policy on falls and injuries indicated that care plans should reflect interventions to minimize falls, but this was not effectively implemented for R34, leading to the deficiency.
Unqualified Staff Assisting Resident with Feeding
Penalty
Summary
The facility failed to ensure that a resident with complicated feeding problems received assistance from qualified staff. During a dining observation, an environmental services staff member, ES-A, was seen assisting a resident, R112, with her meal. This resident had moderately impaired cognition and required supervision or touching assistance during eating, as indicated in her care plan. The care plan also highlighted her risk for altered nutrition status and outlined specific strategies for safe feeding, including the use of adaptive equipment and monitoring for signs of swallowing difficulties. Despite these requirements, ES-A, who was not a qualified feeding assistant, was observed feeding the resident. Interviews revealed that ES-A had received some prior training, but it was unclear if this training was at the current facility. The Director of Nursing confirmed that the facility did not employ paid feeding assistants and relied on nursing staff for dining assistance. The facility's policy stated that feeding assistants should only assist residents without complicated eating problems, which was not adhered to in this case. The Registered Nurse, RN-A, who witnessed the incident, acknowledged the need for further discussions with staff about handling such situations, as this was the first occurrence they had observed.
Failure to Report and Investigate Sexual Abuse Incidents
Penalty
Summary
The facility failed to report, investigate, and initiate interventions for sexual abuse, resulting in subsequent incidents involving two residents. On 7/6/24, a registered nurse (RN-A) failed to report an allegation that a resident (R2) had touched another resident (R1) inappropriately. Despite being informed by a licensed practical nurse (LPN-A) and a culinary server (CS) about the incident, RN-A did not notify a supervisor or the director of nursing (DON) because she did not believe the touching was intentional. This lack of action led to a second incident on 7/10/24, where R2 was again observed inappropriately touching R1. R1, who was mildly cognitively impaired with diagnoses including seizures, depression, schizophrenia, and legal blindness, was at risk for abuse due to vision loss. R2, who was severely cognitively impaired with diagnoses including traumatic brain bleed, paralysis, and vision and hearing loss, had a history of grabbing at people and objects. Despite these known behaviors, R2's care plan did not include interventions for sexually inappropriate behaviors until after the second incident. The facility's failure to report and investigate the initial incident on 7/6/24, as well as the lack of appropriate interventions in R2's care plan, contributed to the subsequent incident on 7/10/24. The facility's abuse prohibition policy required immediate reporting and investigation of such incidents, which was not followed. The director of nursing confirmed that the incident should have been reported and investigated, and a report should have been filed with the state agency.
Removal Plan
- Placed R2 on 1:1 supervision
- Initiated care plan changes and interventions for R2
- Initiated education to all staff members regarding vulnerable adult abuse reporting
Failure to Report Abuse Allegation Timely
Penalty
Summary
The facility failed to report an allegation of abuse within the required timeframe to the State Agency. A resident, who was mildly cognitively impaired and legally blind, reported that a male resident had inappropriately touched her. This incident was witnessed by a Licensed Practical Nurse (LPN) and a culinary server, but neither reported it immediately to the appropriate authorities. The LPN informed the Assistant Director of Nursing (ADON) several days later, but no investigation was initiated, and no report was filed with the state agency. The Director of Nursing (DON) acknowledged awareness of the incident but did not have detailed information. The facility's policy required immediate reporting and investigation of such incidents, which was not followed. The policy specified that allegations of abuse should be reported to the state agency within two hours if they involved abuse, serious bodily injury, or suspicion of a crime. The failure to adhere to these procedures resulted in a deficiency in the facility's handling of the abuse allegation.
Failure to Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to investigate allegations of abuse involving a resident, R1, who was mildly cognitively impaired and had diagnoses including seizures, depression, schizophrenia, and legal blindness. R1's care plan indicated a risk for abuse due to vision loss, with instructions for staff to follow vulnerable adult policies. On a specific date, R1 reported that a male resident, R2, who was severely cognitively impaired with traumatic brain bleed, paralysis, and vision and hearing loss, had inappropriately touched her. Despite this report, there was no investigation into the incident. The incident was witnessed by an LPN who reported it to the ADON, but no further action was taken to investigate the matter. The DON was aware of the incident but did not have details, and confirmed that the incident should have been investigated. The facility's abuse prohibition policy required an initial investigation to determine if the incident met criteria for reporting to the state agency, including interviewing involved parties and notifying the police if necessary. However, these steps were not followed, leading to a deficiency in handling the abuse allegation.
Failure to Provide Adequate Assistance with ADLs
Penalty
Summary
The facility failed to provide services in accordance with the residents' written care plans for several residents who were dependent on staff for activities of daily living (ADLs). One resident, who had severe cognitive impairment and required assistance with eating and hygiene, was left in bed during a staffing shortage and missed breakfast. The resident's family member reported that the resident was not checked or changed during the night and was not assisted out of bed until late morning. Video evidence confirmed the lack of care provided during this period. Another resident with severe cognitive impairment and a risk for unintentional weight loss was observed sitting in the dining room with a full plate of food but was not assisted or cued to eat by staff. Despite the resident's care plan indicating the need for assistance with eating, staff failed to provide the necessary support, and the resident's care plan was not updated to reflect the current needs. Staff interviews revealed that the unit was challenging to work in due to the high level of care required by residents. A third resident, also with severe cognitive impairment, was observed not receiving the necessary assistance with eating, despite the care plan indicating the need for meal set-up and supervision. The resident was left alone with a meal tray and did not receive the required cues or assistance to eat. Staff interviews confirmed that the resident's care plan was not followed, and there was an expectation for staff to provide eating assistance to residents who required it.
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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