New Richland Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in New Richland, Minnesota.
- Location
- 312 Northeast 1st Street, New Richland, Minnesota 56072
- CMS Provider Number
- 245316
- Inspections on file
- 29
- Latest survey
- March 31, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at New Richland Care Center during CMS and state inspections, most recent first.
The facility failed to provide physician-ordered dressing changes, assess wounds during dressing changes, monitor for signs of worsening infection, notify the physician of changes in condition, and ensure timely administration of antibiotics for three residents with complex wounds and infection risks. Staff did not consistently document wound care, communicate supply shortages, or recognize early signs of sepsis, resulting in missed treatments and inadequate monitoring.
The facility failed to develop a comprehensive QAPI plan, as the administrator and DON could not provide a written plan during a survey. Although they mentioned ongoing performance improvement projects, the absence of a formalized plan indicates a lack of structured guidance. The existing QAPI policy was inadequate, lacking details on feedback utilization, data monitoring, and systematic problem analysis.
The facility failed to conduct fit testing for N95 respirators as per CDC guidelines. Staff, including a housekeeping assistant and nursing assistants, were observed using N95 masks without fit testing. The infection preventionist confirmed that fit testing was not routinely conducted, and the director of nursing was unaware of the plan for PAPRs, which were not in use. The facility's policy referenced OSHA and CDC guidelines, but these were not followed.
A resident with a history of falls and moderate fall risk slid out of a power lift recliner due to the facility's failure to assess her ability to use the chair safely. The facility lacked policies on lift chairs, and no assessment was completed before the resident used the chair, despite staff acknowledging the need for such assessments.
The facility did not ensure that the most recent survey results were accessible to residents or visitors. A binder labeled 'Survey Results' near the entrance contained outdated results, and the latest federal recertification survey results were missing. The social services director confirmed the absence of current results, and the administrator was unaware of the issue. No policy on posting survey results was provided.
A resident with chronic right heart failure was not adequately monitored for fluid overload, and physician-prescribed daily weights were not consistently obtained or documented. Despite significant weight gain and observed edema, the facility failed to notify the physician of the resident's refusals to be weighed and did not have a protocol for such notifications. Interviews with staff revealed a lack of communication and documentation regarding the resident's condition.
A facility's failure to implement a comprehensive system for pressure ulcer prevention and management led to a resident developing a stage 4 pressure ulcer, resulting in sepsis, osteomyelitis, and death. The facility did not conduct comprehensive assessments, failed to monitor wounds effectively, and did not involve physicians in a timely manner. The resident's care plan was not updated with necessary interventions, and wound care practices were inadequate, with treatments applied without physician orders and assessments lacking critical information.
The facility's QAPI/QAA program was ineffective in addressing impaired skin integrity and pressure injuries, as revealed by inadequate documentation and lack of comprehensive action plans during QA meetings. Despite ongoing skin issues, including one resulting in a resident's death, no new quality improvement projects were developed. Staff interviews highlighted a lack of awareness and training in wound care and pressure ulcer management.
The facility failed to notify physicians and family members of pressure injuries for four residents. One resident developed severe sepsis due to unreported wounds, while another had a pressure sore from shoes that went unreported for months. Two other residents had multiple pressure ulcers without physician notification. Staff interviews revealed confusion about notification processes and standing orders for wound care.
The facility failed to ensure that nursing staff were trained and competent in pressure ulcer assessment and management, potentially affecting all residents at risk for or with existing pressure ulcers. Interviews revealed that the infection preventionist/wound nurse (IPWN-A) and other LPNs lacked adequate wound care training. Despite the Director of Nursing and Administrator's belief that training had occurred, records showed only one training session from 2021 to 2024. Competencies and education records were not provided upon request.
The facility failed to implement Enhanced Barrier Precautions (EBP) and proper hand hygiene, leading to potential infection risks. Staff did not adhere to EBP protocols for residents with conditions like osteomyelitis and pressure ulcers, and vital sign equipment was not disinfected between uses. Hand hygiene was inadequate, with staff failing to sanitize hands before and after resident contact. Interviews revealed a lack of understanding and training on EBP and hygiene practices.
The facility failed to report allegations of abuse involving two residents to the State Agency as required by their policies. One resident reported being slapped by a nursing assistant, and another reported being yelled at due to incontinence issues. Despite being informed of these allegations, the facility did not report them, as confirmed by interviews with staff.
A resident with multiple diagnoses reported being yelled at by a nursing assistant due to incontinence, which upset him. The facility failed to conduct a thorough investigation as required by its policy, despite confirming the need for such an investigation. The nursing assistant's hours were reduced, and they were reassigned, but no comprehensive investigation was completed.
Failure to Provide Physician-Ordered Wound Care and Monitor for Infection
Penalty
Summary
The facility failed to provide physician-ordered dressing changes, assess wounds during dressing changes, monitor for signs and symptoms of worsening infection, notify the physician of changes in condition, and acquire necessary dressing change supplies for three residents. In one case, a resident with a history of chronic venous hypertension, severe sepsis, and multiple lower extremity ulcers did not receive daily dressing changes as ordered, and wound assessments were not completed with each dressing change. There were missed wound assessments and treatments on several dates, and staff did not notify the physician when the wound increased in size or when there were changes in wound characteristics such as increased drainage, odor, and pain. The resident experienced increased redness and pain, which was not promptly assessed or communicated to the physician, and antibiotics were not administered in a timely manner despite being available in the facility's emergency kit. Another resident with severe cognitive impairment, osteomyelitis, pressure ulcers, and on hospice care did not consistently receive dressing changes as ordered. Documentation was lacking regarding whether dressing changes were completed, and wound dressings were not dated or initialed as required by professional standards. Staff interviews revealed inconsistent communication about supply shortages and a lack of clear processes for ensuring that dressing supplies were available and accessible to all staff, particularly on weekends. Additionally, staff demonstrated a lack of knowledge regarding the identification and monitoring of sepsis, with some nurses unaware of the specific criteria for early recognition. There was also a failure to document baseline assessments after residents returned from wound clinic visits, and staff did not consistently monitor or document changes in residents' conditions, including signs of infection or sepsis. These deficiencies were observed through interviews, record reviews, and direct observation, and affected the care and treatment of all three residents reviewed.
Facility Lacks Comprehensive QAPI Plan
Penalty
Summary
The facility failed to develop a Quality Assurance and Performance Improvement (QAPI) plan, which is essential for maintaining and improving care and services. During the entrance conference, the administrator and director of nursing (DON) were unable to provide a written QAPI plan. Although the administrator had a template from TMF Quality Innovation Network, it had not been utilized to create a comprehensive QAPI plan. The administrator and DON acknowledged their responsibility for the QAPI program and mentioned ongoing performance improvement projects related to falls and pressure wound management. However, the absence of a formalized QAPI plan indicates a lack of structured guidance for these efforts. The facility's QAPI Program policy, updated in October 2024, was found to be inadequate. It did not outline how feedback from residents, representatives, and staff would be used to identify issues or opportunities for improvement. Additionally, the policy lacked details on maintaining effective systems for data collection and monitoring across departments. It also failed to describe methods for identifying, tracking, and analyzing adverse events or problem-prone concerns. Furthermore, the policy did not specify how performance indicators would be developed, monitored, or evaluated, nor did it include systematic approaches for determining underlying causes of problems. The facility assessment did not demonstrate integration with the QAPI program, highlighting a significant gap in the facility's quality assurance processes.
Failure to Conduct N95 Fit Testing for Staff
Penalty
Summary
The facility failed to ensure compliance with CDC guidance for fit testing of N95 respirators prior to use and annually. Observations and interviews revealed that staff, including a housekeeping assistant and nursing assistants, were using N95 masks without having undergone fit testing. The housekeeping assistant was observed placing an N95 mask over a regular surgical mask and was unaware of any fit testing. Similarly, a nursing assistant could not recall if she had completed fit testing. Interviews with other staff, including LPNs and the infection preventionist, confirmed that fit testing was not routinely conducted at the time of hire or annually, and was only performed on request. The facility's infection preventionist acknowledged the importance of fit testing for ensuring a tight seal and staff safety but admitted that it was not part of the regular protocol. The director of nursing expected staff entering COVID isolation rooms to have been fit tested but was unsure about the use of PAPRs, which were available but not observed in use. An untitled facility document allowed staff to decline fit testing without identifying the associated risks. The facility's policy referenced OSHA and CDC guidelines, which require a comprehensive respiratory protection program, including fit testing, but these were not being followed.
Failure to Assess Resident's Use of Power Lift Recliner
Penalty
Summary
The facility failed to assess a resident's ability to safely operate a power lift reclining chair and did not develop or implement policies and procedures related to the use of such chairs. The resident, who had no cognitive impairment but required substantial assistance for various activities, was found on the floor after sliding out of the recliner while trying to reposition herself. The incident occurred despite the resident having a history of falls and being at moderate risk for falls, as indicated in her care plan and fall risk assessment. Interviews with facility staff revealed that the responsibility for assessing the use of electric lift chairs lay with the nursing staff, specifically registered nurses or the Director of Nursing. However, no assessment was completed for the resident before she used the chair, and the facility lacked a policy on lift chairs. The resident confirmed she was not educated on the use of the recliner, and the facility's admission packet indicated that residents using lift chairs should be assessed by nursing or therapy.
Survey Results Not Accessible to Residents and Visitors
Penalty
Summary
The facility failed to ensure that the most recent survey results were readily accessible for residents or visitors to view. During an observation, a black three-ring binder labeled 'Survey Results' was found near the front entrance of the facility, containing survey results dated 9/14/2022. However, the results of the most recent federal recertification survey were not included, and there was no posted information indicating the availability of other results. The social services director confirmed that the most current survey results were not in the binder and were not posted elsewhere in the facility. The administrator was unaware of this issue, and no policy regarding the posting of survey results was provided.
Failure to Monitor and Notify Physician of Fluid Overload in Resident with Heart Failure
Penalty
Summary
The facility failed to comprehensively assess and monitor a resident with congestive heart failure for signs and symptoms of fluid overload and did not evaluate the effectiveness of physician-prescribed treatments. The resident, who was cognitively intact and had diagnoses including chronic right heart failure and atrial fibrillation, had a care plan that lacked individualized interventions or goals for managing fluid overload. Despite physician orders for daily weight monitoring, the facility did not consistently obtain or document the resident's weights, and there was no evidence that the physician was notified of the resident's refusals to be weighed. Between early December and late December, the resident's weight was not consistently documented, and significant weight gain was noted without timely physician notification. The resident's weight increased by 17 pounds over two weeks, and slight edema was observed, but the extent was not documented. The facility's staff, including nursing assistants and licensed practical nurses, acknowledged the resident's frequent refusals to be weighed but did not notify the physician of these refusals or monitor for fluid overload symptoms as required. Interviews with facility staff, including the nurse manager and DON, revealed that there was no protocol for notifying the physician when prescribed weights were refused. The DON expected that refusals and changes in condition would be documented and communicated to the physician, but this did not occur. The physician was unaware of the weight refusals and expected the nursing staff to assess and monitor for fluid overload symptoms, which was not adequately done. The facility did not provide a policy regarding the monitoring and notification process for such cases.
Systemic Failure in Pressure Ulcer Management Leads to Resident's Death
Penalty
Summary
The facility failed to implement a comprehensive system for pressure ulcer prevention and management, which led to significant deficiencies in the care of four residents with ongoing, recurrent, and deteriorating pressure wounds. The facility did not conduct comprehensive assessments, failed to monitor the wounds effectively, and did not involve physicians in a timely manner. This systemic failure resulted in one resident developing a stage 4 pressure ulcer that led to sepsis, osteomyelitis, and ultimately death. The resident in question had a history of pressure injuries and was at risk for developing new ones. Despite this, the facility did not update the resident's care plan to include necessary interventions such as turning and repositioning. The facility also failed to notify the physician of changes in the resident's condition, including increased drainage and pain, which delayed necessary medical intervention. The resident's wound assessments were inconsistent and did not accurately reflect the condition of the wounds, leading to inadequate treatment and monitoring. Additionally, the facility's wound care practices were inadequate, with treatments being applied without physician orders and assessments lacking critical information such as wound measurements and progress toward healing. The facility's staff, including the wound nurse, lacked formal training in wound management, contributing to the deficiencies in care. The lack of a structured turning and repositioning program further exacerbated the risk of pressure injuries for residents, highlighting a systemic issue in the facility's approach to wound care management.
Deficient QAPI/QAA Program Fails to Address Skin Integrity Issues
Penalty
Summary
The facility failed to maintain an effective Quality Assurance Performance Improvement/Quality Assurance Activity (QAPI/QAA) program, which was necessary for identifying, assessing, and implementing appropriate plans of action related to impaired skin integrity and pressure injuries. The deficiency was identified through a review of QAPI/QAA project documents and plans from January to October 2024. The review revealed that QA meetings were held only in January, June, and October, and the documentation was inadequate. In January, there were no meeting agendas or minutes, and no corrective actions or comprehensive evaluations of previous project performance activities were documented. In June, the QA files lacked a comprehensive action plan, and although data on falls and infection control were provided, no comprehensive action plans were evaluated or revised. Additionally, ongoing issues with impaired skin integrity were identified in resident records, but no new quality improvement projects were developed to address these issues. In October, the QA file included a QAPI Meeting Agenda with attendee names but no areas of focus were identified. The Consultant Dietician Report indicated skin issues in three residents, but no nursing department data was provided, and no action plans were developed or implemented despite ongoing impaired skin integrity issues, one of which resulted in a resident's death. Interviews with facility staff revealed a lack of awareness and training regarding wound care and pressure ulcer management. The facility's QAPI program was supposed to be ongoing, facility-wide, and data-driven, focusing on care outcomes and quality of life, but it failed to track and measure performance, establish goals, identify deficiencies, analyze causes, develop corrective actions, and monitor effectiveness as required.
Failure to Notify Physician and Family of Pressure Injuries
Penalty
Summary
The facility failed to notify the physician and family or resident representative of new or existing wounds for four residents reviewed for pressure injuries. Resident 1, who was cognitively intact and dependent on staff for various activities, developed wounds on the buttocks that were not reported to the physician. Despite the presence of moisture-associated skin damage and signs of infection, the physician was not notified until the resident was sent to the emergency room with severe sepsis and sacral osteomyelitis. The family was also unaware of the pressure injury until informed by the emergency department. Resident 2 was at risk for pressure ulcers and developed a pressure sore on the left second toe, which was not reported to the physician for several months. The wound was initially identified as a pressure sore from shoes, and treatment was administered without physician notification. It was only after a significant delay that new orders were obtained from the physician for wound care, indicating a lack of timely communication regarding the resident's condition. Resident 3, who was cognitively intact and dependent for transfers and bed mobility, had multiple pressure ulcers identified over several months. Despite ongoing wound assessments and treatments, there was no evidence that the physician or family was notified of the new skin issues. Similarly, Resident 4 had a new coccyx wound and an ear wound from a hearing aid, but there was no indication that the physician was informed. Interviews with staff revealed a lack of clarity regarding the notification process and standing orders for wound care, contributing to the deficiency.
Inadequate Wound Care Training for Nursing Staff
Penalty
Summary
The facility failed to ensure that licensed nursing staff were adequately trained and competent in pressure ulcer assessment and management, which could potentially affect all residents at risk for or with existing pressure ulcers. The facility's assessment included a section on staff competency in pressure ulcer prevention and treatment, but interviews revealed that the infection preventionist/wound nurse (IPWN-A), a licensed practical nurse (LPN), had not received training on wound care. Another LPN, LPN-D, also confirmed the lack of wound training at the facility. LPN-B mentioned receiving training from IPWN-A, but demonstrated a misunderstanding of pressure injury staging. The Director of Nursing (DON) and Administrator believed that IPWN-A had received wound training the previous year and expected her to monitor wound changes and consult with medical providers. However, a review of the facility's education transcripts showed that IPWN-A had only completed one training on wound identification and assessment from 2021 to 2024, with no further wound care training. The medical doctor (MD-B) expected the facility nurse to have expertise and provide additional training for staff dealing with wound issues. The Administrator stated that education was standard from annual reviews and monitoring by registered nurses, but competencies and education records were not provided upon request.
Failure to Implement Enhanced Barrier Precautions and Hand Hygiene
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for three residents, leading to potential cross-contamination and infection risks. Observations revealed that staff, including a Licensed Practical Nurse (LPN) and Nursing Assistants (NAs), did not adhere to EBP protocols when providing care to residents with conditions such as osteomyelitis, pressure ulcers, and indwelling urinary catheters. Staff entered rooms without performing hand hygiene or donning the required personal protective equipment (PPE), despite signage indicating the need for EBP. This included instances where staff assisted residents with transfers and personal care without using gowns and gloves. Additionally, the facility failed to ensure proper cleaning and disinfection of vital sign equipment between uses for two residents. Equipment used on a resident with a pressure ulcer was not disinfected before being used on another resident, contrary to the facility's policy requiring disinfection between each resident. Staff interviews revealed a lack of understanding and inconsistent practices regarding when EBP and equipment disinfection were necessary, with some staff believing EBP was only required for wound or catheter care. Hand hygiene practices were also inadequate, as observed with five residents. Staff, including dietary aides, did not perform hand hygiene before entering or after leaving residents' rooms, nor did they apply EBP when required. Interviews with staff, including the Infection Preventionist Wound Nurse (IPWN), highlighted a lack of training and documentation on EBP competencies, particularly for dietary staff. The facility's policies on hand hygiene, EBP, and equipment disinfection were not consistently followed, contributing to the deficiencies observed.
Failure to Report Allegations of Abuse to State Agency
Penalty
Summary
The facility failed to report allegations of abuse and neglect to the State Agency as required by their policies and procedures. Two residents, identified as R2 and R5, were involved in separate incidents of alleged abuse by a nursing assistant. R2, who has a history of mild cognitive impairment and traumatic brain injury, reported being slapped on the foot by a nursing assistant, which was later confirmed by a family member. The facility was informed of this allegation by the local police chief but did not report it to the State Agency. R5, who has end-stage renal disease and anxiety disorders, reported being yelled at by the same nursing assistant due to incontinence issues. This allegation was documented by the social services director but was also not reported to the State Agency. Interviews with facility staff, including the social services director, director of nursing, and administrator, confirmed that the allegations were not reported as required. The facility's policy mandates immediate reporting of suspected abuse to the appropriate state agencies, but this was not followed. The social services director and other staff were unsure why the reports were not made, despite acknowledging the requirement to do so. The facility's failure to report these incidents represents a significant deficiency in adhering to established protocols for handling allegations of abuse and neglect.
Failure to Investigate Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation following an allegation of staff-to-resident abuse involving a resident with diagnoses including end-stage renal disease, PTSD, panic disorder, depression, and generalized anxiety disorder. The resident, who had intact cognition, reported that a night shift nursing assistant yelled at him due to incontinence, which upset him. The social services director documented the grievance but did not conduct a thorough investigation as required by the facility's policy. Interviews with the social services director, director of nursing, and administrator confirmed that no comprehensive investigation was conducted, despite the facility's policy mandating prompt and thorough investigations of abuse allegations. The policy also required interviewing relevant parties and suspending the accused employee pending investigation, which was not followed in this case. The nursing assistant's work hours were reduced, and they were reassigned to a different hallway, but these actions did not constitute a complete investigation.
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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