Neilson Place
Inspection history, citations, penalties and survey trends for this long-term care facility in Bemidji, Minnesota.
- Location
- 1000 Anne Street Northwest, Bemidji, Minnesota 56601
- CMS Provider Number
- 245039
- Inspections on file
- 31
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Neilson Place during CMS and state inspections, most recent first.
A resident with dementia and a history of falls was left unsupervised in a wheelchair with foot pedals attached, contrary to her care plan. Staff interviews and documentation confirmed that the foot pedals should have been removed when not transporting her, as she was prone to attempting to stand independently. The resident fell and sustained a right femoral fracture requiring surgery.
A deficiency was cited when a resident was not protected from separation from others, their room, or confinement to their room, as required by regulations. The report does not provide further details about the circumstances or the individuals involved.
A nurse used shared glucometers to check blood sugar for multiple residents with diabetes without cleaning the devices between uses, despite facility policy and training requiring disinfection after each use. Disinfectant wipes were not available on the medication cart, and the nurse reported not being instructed to clean the glucometers. The infection preventionist confirmed that each resident should have an assigned glucometer and that cleaning is required after every use.
A resident with multiple health issues, including mild cognitive impairment, experienced a deteriorating skin condition due to the facility's failure to implement care plan interventions for refusal of care. Despite directives to document refusals and re-approach the resident, staff inconsistently followed these guidelines, and the resident's POA was not contacted as instructed. This led to the resident remaining in soiled briefs for extended periods, exacerbating skin issues.
A resident with multiple health issues, including mild cognitive impairment, experienced worsening skin conditions due to inadequate toileting and hygiene care. Despite a care plan requiring substantial assistance, the resident was often left in soiled briefs, leading to significant skin issues. Staff interviews revealed inconsistent care and failure to follow facility policy on refusal of treatment, resulting in the need for physician-ordered treatment.
A resident with impaired mobility and a care plan requiring a gait belt for ambulation fell and sustained bilateral sacral fractures when staff failed to use the gait belt. The incident occurred as the resident reached for a pen, causing the walker to fall forward. Staff interviews confirmed the care plan was not followed, and the facility's policy on gait belt use was not adhered to.
The facility failed to maintain sanitary conditions in the kitchen, affecting all residents receiving food. An industrial mixer was found with food debris, and the ice and water dispenser had a black substance in the spout. Staff were unclear about cleaning procedures, and dietary aides were observed not wearing hairnets while preparing food, violating facility policy and FDA guidelines.
The facility failed to implement an effective infection control plan, as evidenced by inadequate tracking of residents with diarrhea and lack of infection analysis. Staff did not adhere to enhanced barrier precautions for residents with medical devices, and during a COVID-19 outbreak, a dietary aide was observed not wearing a mask properly while serving food. These deficiencies highlight lapses in infection prevention and control measures.
A resident with a history of stroke and hemiplegia, dependent on staff for care, did not receive routine oral care and shaving assistance as required. Observations revealed the resident was unshaven, and staff failed to offer necessary grooming services during morning care. Interviews with staff confirmed that these services should have been provided according to facility policy.
A resident with severe cognitive impairment and multiple diagnoses experienced significant weight loss over several months without comprehensive dietary assessments or interventions. The facility's staff failed to consistently monitor and evaluate the resident's weight, and there was a lack of communication with the medical provider regarding significant weight changes. The facility's policy required dietary assessments on admission and quarterly, but these were not completed, contributing to the deficiency in care.
The facility did not consistently post daily nurse staffing information, affecting transparency for residents, staff, and visitors. An outdated staffing document was observed, and the responsible staff member acknowledged the oversight. The DON and Administrator confirmed the expectation for daily updates, but a policy was not provided.
A facility failed to ensure a consulting pharmacist identified the need for a gradual dose reduction (GDR) or provided medical justification for a resident's continued use of antipsychotic medication. The resident, with severe cognitive impairment and multiple diagnoses, received daily olanzapine without documented GDR attempts or contraindications. Despite monthly pharmacy reviews, no irregularities were noted, and staff interviews revealed an expectation for the pharmacist to recommend a GDR, which was not done.
A facility failed to attempt a gradual dose reduction (GDR) or provide medical justification for a resident receiving daily olanzapine for bipolar disorder. Despite severe cognitive impairment and multiple diagnoses, there was no documentation of GDR attempts or justification. Staff interviews revealed reliance on pharmacist recommendations, which were not made, and a lack of communication regarding GDR. The facility's policy required annual GDR consideration, which was not followed.
Two residents in an LTC facility experienced medication administration errors, resulting in a 6.9% error rate. One resident received an incorrect dose of Voltaren gel due to a lack of dosing instructions, while another resident was initially given only one vitamin D3 tablet instead of two. The facility's policy did not specify how to administer topical medications per manufacturer's instructions.
The facility failed to serve the correct diet texture to a resident with Alzheimer's, risking choking, and did not accommodate another resident's vegetarian diet preferences, leading to inadequate protein intake. Staff did not consistently follow dietary orders, as confirmed by interviews with facility personnel.
A facility failed to offer and educate a resident with severe cognitive impairment on the risks and benefits of immunizations, as per CDC guidance. The resident's medical record lacked evidence of being offered the most recent COVID-19 booster, annual influenza, and pneumococcal vaccinations. The LPN responsible for infection prevention admitted to missing the opportunity to provide these immunizations and the necessary education and consent documentation, contrary to the facility's policy.
A resident with a documented DNR status was subjected to CPR due to a failure in verifying code status. Despite multiple staff members questioning the decision, the DON relied on an outdated paper chart indicating full code, leading to unwanted medical interventions. The incident highlights a deficiency in the facility's handling of advance directives and emergency response protocols.
A resident with dementia and diabetes exhibited food-seeking behaviors, such as taking snacks from the kitchen, which were not addressed in their care plan. Despite staff and family concerns about the impact on the resident's health, the facility failed to implement effective interventions. The care plan lacked specific strategies to manage these behaviors, and attempts to secure the kitchen were insufficient.
The facility failed to administer insulin and perform blood sugar checks timely for three diabetic residents, leading to significant medication errors. Staff interviews revealed a lack of adherence to protocols, with blood sugar checks and insulin doses often administered late. The Director of Nursing confirmed the expectation for timely administration, but staff did not complete medication error reports, contributing to the issue.
Failure to Implement Fall Prevention Interventions Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when the facility failed to implement care planned fall interventions for a resident with a history of falls, cognitive deficits, and diminished safety awareness. The resident, who had diagnoses including Alzheimer's disease, dementia, and a prior sacral fracture, was identified as high risk for falls and required specific interventions such as keeping the bed at transfer height, hourly purposeful rounding, and removal of wheelchair footrests except during transport. Despite these interventions being documented in the care plan, they were not followed on the day of the incident. On the day of the fall, the resident was found seated in her wheelchair with foot pedals attached and a blanket wrapped around her, placed there by overnight staff. Staff interviews confirmed that the foot pedals should have been removed when the resident was not being transported, as she was known to attempt to stand up independently and was not directable due to her cognitive condition. The resident was left unsupervised in a common area, and staff were occupied in other rooms when a yell and crash were heard. The resident was found on the floor against a plastic barrier, exhibiting signs of a right femoral fracture. Documentation and staff interviews indicated that the presence of the foot pedals may have contributed to the resident's fall. The care plan was not followed, as the foot pedals were not removed and adequate supervision was not provided. As a result, the resident sustained a hip fracture that required surgical intervention.
Failure to Protect Residents from Unwarranted Separation or Confinement
Penalty
Summary
A deficiency was identified regarding the protection of residents from being separated from other residents, their rooms, or being confined to their rooms. The report notes that the facility failed to ensure that each resident was protected from such separation or confinement, as required by regulations. Specific actions or inactions by staff or facility policies that led to this deficiency are not detailed in the report. No additional information about the residents involved, their medical history, or their condition at the time of the deficiency is provided in the report.
Failure to Clean Shared Glucometers Between Uses
Penalty
Summary
The facility failed to ensure proper cleaning and disinfection of shared glucometers between patient use for three residents with diabetes mellitus who required regular blood glucose monitoring. Observations showed that a registered nurse used a glucometer to check blood sugar levels for multiple residents without cleaning the device between uses. Disinfectant wipes were not present on the medication cart, and the nurse confirmed during an interview that he had not been instructed to clean the glucometers between uses. The infection preventionist stated that nurses were trained to clean glucometers during orientation and that each resident should have their own assigned glucometer, but this was not being followed in practice. Facility policy required that blood glucose meters be cleaned and disinfected after each use, regardless of whether the meter was shared or assigned to a single resident. Documentation confirmed that the residents involved had orders for frequent blood glucose monitoring and that the glucometers were shared among them without proper cleaning. The failure to follow established infection control protocols was identified through observation, interview, and document review.
Failure to Implement Care Plan for Resident Refusal of Care
Penalty
Summary
The facility failed to develop and implement care planned interventions to address a resident's refusal of care, which contributed to a deteriorating skin condition. The resident, who had diagnoses including congestive heart failure, hypertension, cellulitis, and mild cognitive impairment, was identified as being at risk for skin breakdown. Despite the care plan directing staff to document refusals and re-approach the resident, staff interviews revealed inconsistencies in following these directives. The resident's power of attorney (POA) had instructed staff to call if the resident refused care, but this was not consistently done, leading to the resident sitting in soiled briefs for extended periods. The resident's condition worsened, as noted in a physician's progress note, which documented significant skin issues due to prolonged incontinence. Staff interviews indicated a lack of awareness and implementation of the care plan updates regarding the resident's refusal of care. The interim director of nursing acknowledged that interventions should have been implemented when refusals put the resident at risk. The facility's policy required individualized, comprehensive care plans, but this was not effectively executed for the resident in question.
Failure to Provide Adequate Toileting and Hygiene Care
Penalty
Summary
The facility failed to ensure proper toileting and hygiene care for a resident, resulting in a worsening skin condition that required physician-ordered treatment. The resident, who was admitted with diagnoses including congestive heart failure, hypertension, cellulitis, and mild cognitive impairment, was identified as being at risk for skin breakdown. Despite a care plan that required substantial assistance for grooming and toileting, the resident was frequently found in soiled briefs, leading to significant skin issues. Interviews with the resident's power of attorney and staff revealed that the resident often sat in soiled briefs for extended periods, sometimes up to 48 hours, without receiving necessary care. The resident's care plan directed staff to check for incontinence and reposition the resident at night, but these directives were not consistently followed. Staff interviews indicated a lack of consistent care, with some staff members marking the resident as refusing care without attempting to re-approach or notify a nurse. The resident's physician noted a rash and significant maceration in the groin area, requiring antibiotic treatment. Despite the resident's occasional refusal of care, staff failed to implement interventions or notify the physician as required by facility policy. The facility's policy on refusal of treatment was not adequately followed, as staff did not consistently document refusals or discuss the health consequences with the resident. The interim director of nursing acknowledged that interventions should have been implemented when refusals put the resident at risk.
Failure to Use Gait Belt Results in Resident Fall and Injury
Penalty
Summary
The facility failed to adhere to the care plan intervention for a resident who required the use of a gait belt while ambulating. The resident, who had a history of osteoarthritis, osteoporosis, and impaired mobility, was being assisted by a nursing assistant and a licensed nurse when the incident occurred. The care plan specified that the resident required assistance from one staff member using a gait belt and a walker, with a wheelchair following behind. However, during the incident, the staff did not use a gait belt, which was a critical component of the resident's care plan. The incident occurred when the resident was ambulating with staff assistance and reached for a pen at the nurse's station. The walker fell forward, causing the resident to fall on top of it, resulting in bilateral sacral fractures. Interviews with staff revealed that the nursing assistant did not use a gait belt during the ambulation, and the registered nurse confirmed that the care plan intervention was not followed. The facility's policy required the use of a gait belt for residents needing assistance with ambulation, which was not adhered to in this case. The resident's fall and subsequent injury were attributed to the staff's failure to follow the care plan, specifically the omission of the gait belt. The physical therapist highlighted the importance of the gait belt in providing stability and preventing falls. The nursing assistant involved in the incident acknowledged the oversight and received education on the proper use of gait belts and the importance of following care plans. The facility's policy clearly stated the necessity of using a gait belt for residents requiring assistance, which was not implemented during the incident.
Sanitation and Hygiene Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to maintain clean and sanitary conditions in the kitchen, which had the potential to affect all 69 residents receiving food from the kitchen. During an initial tour, a large industrial mixer was found with tan-colored food debris on the underside of the mixer head and white dust on the mixing bowl arms. This condition persisted over several days, indicating a lack of proper cleaning after each use. The administrator confirmed that staff were expected to clean kitchen equipment after every use to prevent food contamination and foodborne illness. Additionally, the facility did not ensure proper cleaning of the ice and water dispenser, as observed in the kitchenette. A black tar-like substance was found inside the spout, and there was confusion among staff about the cleaning responsibilities and procedures. The facility's policy did not specify the cleaning procedure for the mixer or the ice and water dispenser. Furthermore, dietary aides were observed not wearing hairnets while preparing food, which is against the facility's policy and the FDA Food Code. These deficiencies highlight lapses in maintaining sanitary conditions and adherence to hygiene protocols.
Infection Control and PPE Deficiencies in LTC Facility
Penalty
Summary
The facility failed to develop and implement an effective infection control surveillance plan, as evidenced by the lack of documentation and monitoring of residents with potential infection symptoms. Two residents, identified as having diarrhea, were not properly tracked or reported to the infection control nurse, leading to a lack of awareness and monitoring by the infection preventionist. The facility's monthly infection control logs also failed to provide an analysis of infection patterns or interventions to reduce further incidences, particularly concerning COVID-19, pneumonia, and urinary tract infections. Additionally, the facility did not adhere to enhanced barrier precautions (EBP) for residents with wound care and indwelling medical devices. Observations revealed that staff members entered rooms of residents requiring EBP without donning the necessary personal protective equipment (PPE), such as gowns and gloves, during high-contact care activities. This non-compliance with EBP guidelines was acknowledged by staff members, who admitted to forgetting or misunderstanding the requirements. Furthermore, during a COVID-19 outbreak, the facility failed to ensure that staff utilized masks appropriately. A dietary aide was observed not wearing a mask properly while preparing and serving food to residents, despite the facility being in outbreak status and requiring masks to be worn at all times. This lapse in mask usage was acknowledged by the staff member, who only adjusted the mask upon the approach of a state surveyor. The facility's policy on mask use during an outbreak was requested but not provided.
Failure to Provide Routine Oral Care and Shaving Assistance
Penalty
Summary
The facility failed to provide routine oral care and shaving assistance to a resident who was dependent on staff for all care activities. The resident, who was cognitively intact and had a history of stroke resulting in hemiplegia, was observed to have a self-care deficit due to left-sided hemiparesis. The care plan for the resident, revised on December 3, 2024, directed staff to assist with grooming but did not specify the frequency of shaving or oral care. During observations, the resident was found unshaven with significant beard growth, and staff did not offer shaving or oral care assistance during morning care. Interviews with nursing assistants, a registered nurse, the director of nursing, and the administrator confirmed that shaving and oral care should have been offered during care activities. The facility's policy on Activities of Daily Living, revised on December 4, 2023, stated that residents unable to perform activities of daily living should receive necessary services to maintain grooming and personal hygiene. Despite this policy, the resident did not receive the required assistance, leading to the identified deficiency.
Failure to Address Resident's Weight Loss
Penalty
Summary
The facility failed to comprehensively assess and develop interventions to prevent continued weight loss for a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's and congestive heart failure. The resident's weight was not consistently monitored or evaluated, as evidenced by the lack of completed dietary assessments at admission, quarterly, or when significant weight loss was identified. The resident experienced a notable weight loss over several months, yet there was no evidence of dietary assessments or interventions being implemented to address this issue. Staff interviews revealed that the facility had a dietician who was shared with other facilities, and documentation was often incomplete or missing. The dietician had recently been hired and was in the process of reviewing resident charts. Nursing staff were responsible for entering resident weights into the medication administration record (MAR) but failed to recognize significant weight discrepancies. The facility's policy required licensed nurses to notify the director of food and nutrition and the medical provider of any significant weight changes, but this was not consistently done. The director of nursing and other staff members acknowledged that dietary assessments should have been completed on admission and during quarterly reassessments. The facility's policy outlined the need for comprehensive assessments to ensure residents maintained acceptable nutritional status, but this was not adhered to in the case of the resident in question. The lack of timely dietary assessments and communication with the medical provider contributed to the deficiency in care for the resident experiencing weight loss.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that required nurse staffing information was consistently posted on a daily basis, which had the potential to affect all 72 residents, staff, and visitors who might wish to review this information. On December 3, 2024, it was observed that the staffing information posted near the front doors was outdated, displaying information from November 26, 2024, which was seven days prior. Medical Records staff member, MR-I, who was responsible for the daily staffing posting, acknowledged the oversight and mentioned working on a system to prevent future lapses. The Director of Nursing and the Administrator both confirmed the expectation for daily updates to the staffing information to ensure transparency with staff, family, and state officials. A policy regarding the nurse staff posting was requested but not provided.
Failure to Ensure Gradual Dose Reduction for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that the consulting pharmacist identified the need for a gradual dose reduction (GDR) or provided medical justification for the continued use of antipsychotic medication for one resident. The resident, who had severe cognitive impairment and was receiving daily antipsychotic medication, did not have a documented attempt at GDR, nor was there any indication from the physician that a GDR was contraindicated. The resident's diagnoses included Alzheimer's, bipolar disorder, drug-induced subacute dyskinesia, heart disease, and kidney failure. Despite monthly pharmacy reviews from December 2023 to November 2024, no irregularities were identified, and there was no evidence of a GDR attempt or medical justification for the continued use of olanzapine. Interviews with facility staff revealed that the registered nurse and the director of nursing expected the consulting pharmacist to recommend a GDR for the resident's medication. The consulting pharmacist acknowledged that he should have asked the physician to review the resident's dose of olanzapine to ensure it was the minimal effective dose. The facility's policy on psychotropic medications required a GDR to be addressed annually, but this was not done for the resident in question. The administrator also expressed that he expected the consulting pharmacist to have reviewed and requested a GDR for the resident's medication.
Failure to Attempt Gradual Dose Reduction for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure a gradual dose reduction (GDR) was attempted or medically justified for a resident receiving antipsychotic medication. The resident, who had severe cognitive impairment and was diagnosed with Alzheimer's, bipolar disorder, and other health issues, was receiving olanzapine daily for bipolar disorder. Despite the requirement for GDR, there was no documentation of an attempt to reduce the dose or any medical justification for the continued use of the medication. The resident's care plan included goals for medication effectiveness and reduction in targeted behaviors, but the necessary steps for GDR were not taken. Interviews with facility staff revealed a lack of communication and follow-up regarding the GDR process. The registered nurse responsible for reviewing psychotropic medication use relied on pharmacist recommendations, which were not made in this case. The consultant pharmacist acknowledged the oversight in not recommending a GDR. The director of nursing and the facility administrator both expressed expectations that the provider should have been notified to consider a GDR. The facility's policy required annual consideration of GDR for psychotropic medications, but this was not adhered to for the resident in question.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure medications were administered in accordance with physician orders and manufacturer guidelines, resulting in a medication administration error rate of 6.9%. For one resident, who was cognitively intact and had a history of hemiplegia due to a stroke, a registered nurse applied an incorrect dose of Voltaren gel to the resident's thigh/knee, contrary to the physician's order to apply it to the back. The nurse was unaware of how to measure the correct dose and did not have access to the manufacturer's dosing chart, which had been removed from the packaging. The Director of Nursing stated that staff were expected to measure the gel per the manufacturer's instructions. Another resident, who had severe cognitive impairment and diagnoses including high blood pressure and hypokalemia, was prescribed vitamin D3 tablets. During a medication pass, a registered nurse initially dispensed only one tablet instead of the ordered two tablets. The nurse failed to cross-check the medication label with the resident's Medication Administration Record (MAR), which led to the error. The Director of Nursing and the facility's administrator both stated that they expected nurses to follow the six rights of medication administration and perform three checks to ensure accuracy, but the facility's policy did not specify how to administer topical medications per manufacturer's instructions.
Dietary Deficiencies in Meeting Resident Needs
Penalty
Summary
The facility failed to ensure the correct diet texture was served to a resident with severe cognitive impairment and Alzheimer's disease, who required a mechanically altered diet due to chewing and swallowing difficulties. The resident's dietary order specified a minced and moist texture, but during a meal service observation, the dietary aide served pork that was not minced and moist, and no sauce or gravy was added to the meal. The dietary aide admitted to relying on the kitchen for sauce availability and did not follow the dietary orders correctly, which could potentially increase the risk of choking or aspiration. Another resident, who was an ovo pescetarian with severe cognitive impairment and Type 2 diabetes, did not have their dietary preferences adequately accommodated. The resident's care plan and physician orders specified a regular vegetarian diet with specific food preferences, but during meal service, the dietary aide did not consult the dietary orders and served the resident vegetables without protein. The family member expressed concerns about the resident not receiving adequate protein, and the registered dietitian confirmed that the resident's food choices should be followed to ensure adequate nutrition. Interviews with facility staff, including the registered dietitian, director of nursing, and administrator, revealed expectations for staff to follow dietary orders and menus to prevent risks such as choking and aspiration. However, the dietary staff did not consistently adhere to these expectations, leading to deficiencies in meeting the nutritional needs and preferences of the residents.
Failure to Offer and Educate on Immunizations
Penalty
Summary
The facility failed to offer and provide education on the risks versus benefits of receiving or declining immunizations, as per CDC guidance, for one resident reviewed for immunizations. The resident, who was 38 years old with severe cognitive impairment and a diagnosis of malignant neoplasm of the prostate, had an immunization record indicating previous COVID-19 and pneumococcal vaccinations. However, the medical record lacked evidence that the most recent COVID-19 booster, annual influenza, and pneumococcal vaccinations were offered or that the resident or their representative was educated on the risks and benefits of these vaccinations. During an interview, the LPN responsible for infection prevention acknowledged missing the opportunity to offer these immunizations and provide the necessary education and consent documentation. The facility's policy required that immunizations be reviewed upon admission and regularly, with education and consent documented. The Director of Nursing expected adherence to this policy, but the deficiency occurred due to the failure to follow these procedures, resulting in the resident not being offered the necessary immunizations and education.
Failure to Honor Resident's DNR Status
Penalty
Summary
The facility failed to immediately identify and act on a resident's code status, resulting in the initiation of cardiopulmonary resuscitation (CPR) against the resident's wishes. The incident involved a resident who was found in distress in the common area, exhibiting symptoms such as pale skin, blue lips, and difficulty speaking. Despite the resident's documented Do Not Resuscitate (DNR) status, CPR was initiated, leading to the resident being sent to the hospital and requiring mechanical ventilation. The deficiency arose from a lack of clear communication and verification of the resident's code status. The resident's advance directive indicated a DNR status, which was also reflected in the electronic medical record and discussed during a care conference attended by the Director of Nursing (DON). However, during the emergency, the DON relied on an outdated paper chart that incorrectly indicated a full code status, leading to the initiation of CPR despite multiple staff members questioning the decision and the availability of correct information in the electronic record. Interviews with staff revealed confusion and inconsistency in accessing and verifying code status information. The DON, despite being aware of the resident's DNR status from previous discussions, failed to verify the information in the electronic record and insisted on CPR based on the incorrect paper chart. This miscommunication and failure to follow proper procedures resulted in the resident undergoing unwanted medical interventions, highlighting a significant deficiency in the facility's handling of advance directives and emergency response protocols.
Removal Plan
- Reviewed policy for advance directives
- Educated staff to the policy and procedure for verification of advance directives
- Initiated use of a binder for verification of code status
- Implemented an audit process to ensure accuracy
Failure to Address Food-Seeking Behaviors in Resident with Diabetes
Penalty
Summary
The facility failed to develop a comprehensive care plan with person-centered interventions for a resident with food-seeking behaviors, despite the resident's diagnosis of dementia and type 2 diabetes mellitus with hyperglycemia. The resident exhibited behaviors such as taking food and beverages from the kitchen without permission, which were not addressed in the care plan. The care plan only included monitoring blood glucose levels and signs of hyperglycemia but lacked specific interventions to manage the resident's food-seeking behaviors. The resident's behaviors were documented multiple times, including taking milk, Boost shakes, and other snacks from the kitchen. Staff and family members expressed concerns about the impact of these behaviors on the resident's blood sugar and potassium levels. Despite these concerns being raised at care conferences and with facility management, the care plan was not updated to include interventions to address the resident's behaviors. Interviews with staff revealed that the resident's behaviors had been ongoing since admission, and various attempts to secure the kitchen and restrict access to snacks were made. However, these measures were not effective, and the resident continued to access food and beverages. The facility's policy on behavioral causes and interventions was not effectively implemented, as there was no evidence of staff guidance or communication of appropriate interventions to prevent or decrease the resident's behaviors.
Failure in Timely Insulin Administration for Diabetic Residents
Penalty
Summary
The facility failed to ensure timely blood sugar checks and insulin administration for three residents diagnosed with diabetes. Resident 1, who also had dementia, experienced late blood glucose monitoring and insulin administration multiple times throughout June 2024. Similarly, Resident 2 and Resident 3 had their blood glucose checks and insulin doses administered late on numerous occasions during the same period. These delays were not in accordance with the physician's orders, which specified specific times for these procedures. Interviews with staff revealed a lack of adherence to the expected protocol for blood sugar monitoring and insulin administration. A family member of Resident 1 noticed the discrepancies in insulin administration timing, and staff members, including registered nurses and a nurse practitioner, acknowledged the issue. They expressed concerns about the accuracy of blood sugar readings and the subsequent insulin administration when not performed as ordered. The staff admitted to not completing medication error reports, which would have helped track and address these issues. The Director of Nursing confirmed that staff were expected to perform blood sugar checks and administer insulin before meals or within a short time frame after meals. The facility's policy on medication errors required prompt reporting and documentation of any deviations from prescribed orders. However, the staff's failure to follow these procedures resulted in significant medication errors, as defined by the facility's policy, due to the late administration of insulin and blood sugar checks.
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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