Oakland Park Communities, Inc.
Inspection history, citations, penalties and survey trends for this long-term care facility in Thief River Falls, Minnesota.
- Location
- 123 Baken Street, Thief River Falls, Minnesota 56701
- CMS Provider Number
- 245592
- Inspections on file
- 17
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 20 (1 serious)
Citation history
Health deficiencies cited at Oakland Park Communities, Inc. during CMS and state inspections, most recent first.
A resident with recent stroke, right-sided hemiparesis, severe cognitive impairment, and high fall risk was care planned for Hoyer lift transfers with assist of two. Shortly after admission, family brought in a power lift recliner that staff began using without notifying administration or obtaining the required RN/therapy assessment for safe use. Multiple staff transferred the resident into the lift chair over several days, despite her dependence for all mobility and poor safety awareness, and the remote was left where she could potentially access it. The resident was later found on the floor next to the lift chair, which was in the full stand position, and was diagnosed in the ER with a trimalleolar ankle fracture with talar subluxation, attributed to an unwitnessed fall from the unassessed lift chair.
A resident admitted after a CVA with documented hypokalemia was discharged from the hospital on potassium chloride 10 mEq BID, with an e-prescription confirmed by the pharmacy and potassium tablets delivered to the facility. The potassium order was not entered on the EMAR at admission, and the resident missed multiple potassium doses over several days. Staff observed that the potassium card was untouched and that the medication was not on the EMAR, but the medication was set aside and no provider notification occurred at that time. Interviews with nursing staff, the DON, and the MD confirmed that the physician was not informed of the omissions or the low potassium level, despite facility policy requiring timely physician notification when treatment or medications are altered significantly. This failure to notify the physician of omitted potassium doses constituted the cited deficiency.
A resident with recent CVA, hypokalemia, and multiple comorbidities was discharged from the hospital with an e-prescribed order for potassium chloride 10 mEq BID, which the pharmacy confirmed and delivered to the facility. The potassium order was not included on the paper transfer orders and was not entered into the EMAR on admission. A TMA received the potassium, noted it was not on the EMAR, did not administer it, and left the medication on the medication room counter with a note, without documented communication to nursing leadership. The potassium remained unused through multiple shifts until a night-shift RN later discovered the untouched card, located the hospital order, and entered it into the resident’s record, at which point administration began. Facility documentation identified that at least six doses of potassium were missed during this period and classified this as a medication error, reflecting a failure to ensure the resident was free from significant medication errors.
A deficiency was cited due to the facility not ensuring an area was free from accident hazards and not providing adequate supervision to prevent accidents. The report notes that safety standards were not met and supervision was lacking, but does not specify further details about those involved.
A resident with cognitive impairment and multiple medical conditions sustained a third-degree burn due to improper use of a microwave-heated gel pack. The facility failed to follow the manufacturer's instructions, conduct a comprehensive assessment, and implement timely interventions. There was a significant delay in notifying the physician, and staff lacked training on the proper use of gel packs.
The facility failed to accurately submit licensed nursing staff hours on the PBJ, affecting all 32 residents. The PBJ report indicated low weekend staffing and lack of 24-hour coverage on several days, but payroll records showed otherwise. Discrepancies arose from salaried staff not using the timeclock and manual data entry errors by the administrator, who was unavailable due to a family emergency.
The facility failed to develop, monitor, and evaluate performance measures, affecting all 46 residents. The QAPI process lacked measurable goals and actions, with projects like fall reduction and infection control not showing evidence of effectiveness. Despite scheduled meetings, the facility did not track performance improvements, indicating a deficiency in their QAPI process.
The facility did not ensure that the Quality Assessment and Assurance (QAA) committee meetings included the required members, such as the medical director and director of nursing, on a quarterly basis. Meeting minutes showed their absence, and an RN confirmed this, although they believed the members were available by phone. This oversight potentially affected all 32 residents in the facility.
The facility failed to implement enhanced barrier precautions for two residents with wound care needs and did not ensure proper PPE use during soiled laundry sorting. A resident with a toe wound and another with a hip wound were not provided with appropriate PPE, and the facility's policy lacked guidance on EBP. In the laundry department, a single contaminated apron was used throughout the day, with no disposable gowns available.
A facility failed to notify physicians of incidents involving two residents. One resident, with cognitive impairment and multiple medical conditions, developed a burn from a heat pack, but the physician was not informed until weeks later. Another resident, on anticoagulant therapy, fell and sustained a large bruise, but the physician was not notified. The facility's policy required notifying physicians of such incidents, but this was not adhered to, resulting in delayed medical evaluation and intervention.
A resident with cognitive impairment and diabetes suffered a burn on the right hip due to improper use of a hot pack by an RN. The RN was unaware of the manufacturer's instructions and did not report the incident to the state agency. The burn, initially a blister, developed into a chronic full-thickness burn. Other staff members, including the DON, were unaware of the incident, and the facility's policy on reporting was not followed.
A resident with cognitive impairment and diabetes suffered a burn on the right hip due to improper use of a hot pack. The RN who applied the pack was not educated on its heating instructions and did not read them, leading to the resident lying on the pack and sustaining a full-thickness burn. The incident was not reported promptly, and no investigation was conducted to determine the appropriateness of the pack's use or staff awareness of its instructions.
A facility failed to accurately code the MDS for a resident with Type 2 Diabetes, who received Trulicity, a GLP-1 receptor agonist, weekly. A registered nurse incorrectly identified Trulicity as insulin on the MDS, despite acknowledging it was not insulin. This error occurred while the facility's MDS nurse was on medical leave, leading to a misunderstanding of medication classification.
A resident with severe cognitive impairment developed a pressure ulcer on the right great toe, which was not documented in the care plan. Nursing staff performed dressing changes, but there was a lack of comprehensive assessment and documentation of interventions to promote healing. Interviews revealed that staff were not fully aware of the wound's condition or interventions, and the facility's pressure ulcer protocol was not provided.
A resident with severely impaired cognition was administered oxycodone despite an allergy listed in their medical record, and received acetaminophen exceeding the recommended daily dose. The consultant pharmacist failed to identify the discrepancy, and the DON found that the provider had overridden the allergy alert without facility staff questioning it.
A consulting pharmacist failed to identify and report a discrepancy between a resident's documented allergy to oxycodone and its administration over several months. Despite the allergy being listed, the resident received oxycodone multiple times without documented adverse reactions. The pharmacist did not report this irregularity, and the facility's policy requiring such reporting was not followed.
A LTC facility failed to provide timely pain management for two residents. One resident, with severe cognitive impairment, experienced a delay in receiving as-needed oxycodone due to a medication shortage and insufficient use of emergency resources. Another resident, with chronic pain, faced a delay in receiving a Lidocaine patch, which was crucial for pain relief. These deficiencies highlight issues in medication availability and timely administration, impacting residents' comfort and care.
Failure to Assess and Safely Manage Use of Power Lift Chair Resulting in Fall With Fracture
Penalty
Summary
The deficiency involves the facility’s failure to implement its standards of practice for assessing and safely using a power lift chair for a resident with severe cognitive and physical impairments. The resident was admitted after a recent left PCA stroke with right-sided hemiparesis, expressive and receptive aphasia, severely impaired cognition, disorganized thinking, impaired vision, and dependence on staff for all ADLs and transfers. On admission, therapy evaluations and the care plan identified that the resident could not bear weight on the right lower extremity, had right knee buckling, poor trunk control, leaned to the right, and required a Hoyer lift with assistance of two for transfers. The Morse Fall Scale score placed the resident at high risk for falls, and the care plan directed staff to follow therapy recommendations, including use of a Hoyer lift for transfers. After admission, the resident’s family brought in an electric lift recliner that the resident had never used before and was not familiar with. The family did not explicitly notify administrative staff, but facility staff observed the chair being delivered and began using it for the resident within a day or two of admission. Multiple NAs and RNs reported transferring the resident into the lift chair using a Hoyer lift on several occasions over the following days. Staff interviews revealed that no lift chair assessment was completed by nursing or therapy prior to the resident’s use of the chair, despite an existing facility policy requiring evaluation of a resident’s ability to safely operate an electric recliner by therapy or an RN. Several staff members acknowledged they were aware that a lift chair assessment should have been completed before use, but they either assumed the chair was safe because it was in the room or did not verify whether an assessment existed. Therapy staff, including the PTA and PT, observed the resident seated in the lift chair during therapy sessions and used the remote themselves to adjust the chair, but no formal lift chair assessment was initiated. Interviews with the DON, care coordinator RN, MDS coordinator, therapy staff, and NAs consistently described the resident as confused, forgetful, unable to stand or walk, with right-sided paralysis and poor safety awareness, and indicated that the resident would not have been safe to use the lift chair or its remote independently. On the day of the incident, NAs transferred the resident via Hoyer lift from bed to the lift chair, elevated the feet with the remote, reclined the chair, covered the resident with a blanket, and placed the remote either over the left armrest or in the side pocket, in a manner that still allowed the resident potential access to the cord or remote. Shortly thereafter, the resident was found on the floor on her right side between the bed and the lift chair, with the chair in the fully upright stand position and the right foot in eversion with obvious ankle deformity. The resident was unable to provide a clear account of what happened. ER evaluation and x-rays confirmed a new trimalleolar fracture of the right ankle with lateral subluxation of the talus, which staff and providers attributed to the unwitnessed fall from the lift chair in the context of the resident’s inability to safely use or tolerate the lift mechanism.
Failure to Notify Physician of Omitted Potassium Doses After Admission
Penalty
Summary
The deficiency involves the facility’s failure to notify the resident’s physician of omitted potassium doses following admission, despite existing orders and documented hypokalemia. The resident was admitted from an acute hospital with a recent CVA and multiple comorbidities, including hypokalemia attributed to Lasix use. Hospital records showed a potassium level of 3.1 mEq/L on the morning of discharge and discharge instructions that the resident was to receive potassium chloride 10 mEq by mouth twice daily for approximately one month, with the possibility of discontinuation if levels normalized. An e-prescription for potassium chloride 10 mEq CR twice daily was sent to the pharmacy and receipt was confirmed, and the pharmacy delivered a card of potassium tablets to the facility on the day of admission. On admission, the facility’s care plan directed staff to administer medications as ordered and report abnormal labs or vital signs to the primary care provider. However, the potassium order was not entered onto the facility’s EMAR at the time of admission, and the resident did not receive the ordered potassium doses from the evening of admission through several subsequent medication passes. The facility’s own Medication Error document later identified that the resident potentially missed three doses on the evening of admission and four additional doses over the next two days, with potassium therapy not started until several days after admission. During this period, there is no documentation that the resident’s physician or on-call provider was notified of the missed doses or of the resident’s low potassium level on admission. Staff interviews confirmed that the potassium medication was delivered and recognized as not appearing on the EMAR, but the issue was not escalated to a provider. The TMA who accepted the delivery noted that the potassium was not on the EMAR and placed the medication with a note in the medication room, consistent with what she stated she had done in similar situations in the past, but she did not administer the medication or contact a nurse or provider before going off work. A night-shift RN later discovered the untouched potassium card in the cart, identified this as a red flag, and located the hospital order in the hospital record, but did not notify a provider at that time because it was the middle of the night. The DON and the primary provider both stated in interviews that nursing staff would have been expected to notify the prescribing provider or on-call provider about the missed potassium doses and the low potassium level, and the facility’s policy on Notification of physician and family required timely notification of physicians when treatment or medications are altered significantly, including when existing medications are discontinued or not given as ordered. Despite this, there was no evidence that the physician was notified of the omissions, constituting the cited deficiency. The resident’s subsequent clinical course included an ED visit after an unwitnessed fall with a right ankle fracture, during which her potassium level was within normal limits, and a later ED visit for hyperkalemia, hypernatremia, acute renal failure, and severe dehydration, with a potassium level of 7.2 mEq/L. At both ED encounters, the outpatient medication list still reflected potassium chloride 10 mEq twice daily. The primary provider reported she was not aware of the missed potassium doses prior to her initial visit several days after admission and that she had not initiated provider coverage until that visit. The facility’s Medication Error document related to the missed potassium doses contained no documentation of any notifications to agencies or people, and sections for such notifications were left blank. This sequence of events demonstrates that the facility did not follow its own policy requiring timely physician notification when treatment is altered by missed medication doses, specifically failing to notify the physician of the potassium omissions for this resident with documented hypokalemia.
Failure to Transcribe and Administer Ordered Potassium Resulting in Multiple Missed Doses
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when a prescribed potassium supplement was not properly transcribed and implemented, resulting in multiple missed doses. The resident was admitted from the hospital with a history of CVA, UTI, hypokalemia, hypertension, hyperlipidemia, arteriosclerotic disease, and recent stroke with severely impaired cognition, aphasia, and disorganized thinking. Hospital documentation showed hypokalemia with a potassium level of 3.1 mEq/L on the day of discharge and a plan for approximately one month of potassium supplementation, with an e-prescribed order for potassium chloride 10 mEq twice daily. The hospital pharmacy confirmed receipt of the e-prescription and delivered potassium tablets to the facility on the day of admission, and the facility’s care plan directed staff to administer medications as ordered and report abnormal labs. Despite the hospital’s e-prescribed order and delivery of potassium, the medication was not entered into the facility’s EMAR on admission and was not included on the interagency transfer discharge orders. A TMA received the potassium from the pharmacy, verified it against the packing slip, and noted that potassium was not listed on the EMAR. The TMA did not administer the medication and instead placed the potassium on the counter in the medication room with a sticky note, consistent with an informal practice she described, but there was no documented communication to the charge nurse, RCC, or DON. The potassium remained on the counter through multiple shifts without being investigated or reconciled with the resident’s orders, and the DON later confirmed that the medication stayed in the medication room and that there should have been follow-up when potassium arrived without a corresponding order. The missed potassium order was eventually discovered days later by a night-shift RN who, while checking the medication cart, found the potassium card untouched and recognized this as a red flag. This RN searched the hospital’s electronic record, located the provider’s potassium order, printed and scanned it into the resident’s chart, and entered it into the facility’s orders and EMAR on 1/18. Facility documentation, including a medication error report prepared by the DON, identified that the resident potentially missed at least six doses of potassium between the evening of admission and the start of administration on 1/18. The primary provider stated she was unaware of the missed doses and indicated that nursing staff should have followed facility protocol and notified a provider when potassium doses were missed in the context of a low potassium lab value. The DON acknowledged that multiple process failures occurred, including lack of follow-up when the potassium arrived without an order and failure to ensure the order was placed in the EMAR, and confirmed that missed doses of potassium constituted a medication error. Later clinical events documented in the record showed that the resident was sent to the ER on one occasion for a fall with a trimalleolar ankle fracture, at which time potassium was 3.8 mEq/L, and on another occasion for hyperkalemia, hypernatremia, acute renal failure, and severe dehydration, with a potassium level of 7.2 mEq/L. However, the deficiency cited in the survey focused specifically on the facility’s failure to transcribe and implement the potassium order upon admission and the resulting missed doses from the date of admission until the order was entered into the EMAR. The facility’s own medication error document characterized these missed doses as a medication error and noted that no notifications were documented on the error form and that the form was incomplete.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, and supervision was insufficient to prevent potential accidents. Specific actions or omissions by staff or details about the residents involved are not provided in the report.
Failure to Follow Gel Pack Instructions Leads to Resident Burn
Penalty
Summary
The facility failed to follow the manufacturer's instructions for the use of a microwave-heated gel pack, leading to a resident, identified as R15, sustaining a third-degree burn. R15, who had a moderate cognitive impairment and various medical conditions including type 2 diabetes and chronic kidney disease, was at risk for pain due to several musculoskeletal issues. On the day of the incident, R15 complained of hip pain after a fall, and a registered nurse (RN-A) applied a gel pack heated in the microwave without following the manufacturer's instructions. The gel pack was placed on R15's hip, and R15 was positioned to lie on it, resulting in a burn. The nursing staff failed to conduct a comprehensive assessment of the burn and did not implement timely interventions to promote healing. The initial response to the burn was inadequate, as RN-A did not apply ice or cool water and left the burn open to air. The facility's documentation lacked a detailed assessment of the burn, and there was a significant delay in notifying R15's physician about the injury. The burn was not properly evaluated until several weeks later, and the physician was not informed until there was concern about a potential infection. Interviews with facility staff revealed a lack of awareness and training regarding the proper use of gel packs. The acting director of nursing (DON) and other staff members were not fully informed about the circumstances of the burn, and there was no formal education provided to staff on the use of gel packs. The facility also failed to investigate the incident thoroughly to ensure that the equipment was used correctly and to prevent similar occurrences in the future. The facility did not provide requested policies on first aid, wound monitoring, or the use of gel packs, indicating a lack of preparedness and protocol adherence in handling such incidents.
Inaccurate PBJ Staffing Data Submission
Penalty
Summary
The facility failed to ensure that licensed nursing staff hours were accurately submitted on the payroll-based journal (PBJ), which had the potential to affect all 32 residents residing in the facility. The PBJ Staffing Report for fiscal year Quarter 4 2024 identified that the facility had excessively low weekend staffing and failed to have licensed nursing coverage 24 hours a day on multiple days throughout July, August, and September 2024. However, a review of the facility's payroll and working schedule for the same period showed that there was licensed nursing staff present 24 hours a day on all the days identified in the PBJ report. Interviews conducted during the investigation revealed that the discrepancies were due to salaried employees not using the timeclock system, even though they worked charge nurse shifts. RN-B, a salaried employee, confirmed that she did not use the timeclock during the period in question. Additionally, RN-D, the corporate nurse, stated that the administrator, who was responsible for submitting the PBJ data, was unavailable due to a family emergency and had difficulty submitting the data, leading to manual entry errors. The facility did not provide a policy or procedure regarding PBJ data submission when requested.
Deficiency in QAPI Process Due to Lack of Measurable Goals
Penalty
Summary
The facility failed to develop, monitor, and evaluate their identified performance measures, which had the potential to affect all 46 residents residing in the facility. The facility's Quality Assurance Performance Improvement (QAPI) process was not effectively implemented, as evidenced by the lack of measurable goals and actions taken in their performance improvement projects. Despite holding QAPI meetings on a scheduled quarterly basis and more often if indicated, the facility did not track performance to ensure that improvements were realized and sustained. The facility's QAPI meetings identified several performance improvement projects, including fall reduction and infection control. However, the data from these meetings failed to show that the facility developed and implemented action plans with measurable goals. For instance, the 'Walk to Dine' program and restorative programs were mentioned, but there was no evidence of measurable outcomes or actions taken to evaluate their effectiveness. Similarly, infection control projects focused on audits and training, but again lacked measurable goals and actions. During an interview, the RN-D acknowledged that while the minutes identified actions aimed at performance improvement, they did not include measurements of success or track performance. The facility's QAPI policy outlined the need for a comprehensive, data-driven program focusing on outcomes of care and quality of life, but the facility did not demonstrate evidence of meeting these requirements. The lack of measurable goals and tracking of performance improvements indicates a deficiency in the facility's QAPI process.
Failure to Ensure Required Attendance in QAA Meetings
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) committee held meetings with the required members on at least a quarterly basis. Specifically, the meeting minutes from the Quality and Safety Meeting dated 7/18/24 did not indicate the presence or review participation of the medical director. Similarly, the meeting on 10/16/24 lacked attendance or review participation from the director of nursing, consultant pharmacist, and medical director. This oversight had the potential to affect all 32 residents residing in the facility at the time of the survey. During an interview, the registered nurse (RN-D) acknowledged that the meeting minutes reflected the absence of required members but believed they were available by phone if needed. The facility's policy on Quality Assurance and Performance Improvement (QAPI) outlines the necessity of a comprehensive, data-driven program focusing on care outcomes and quality of life. The policy mandates the presence of the director of nursing and the medical director or their designee in the QAA committee, which was not adhered to, as evidenced by the meeting minutes.
Failure to Implement Enhanced Barrier Precautions and Proper PPE Use
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for two residents with wound care needs. Resident R14, who had severe cognitive impairment and a right great toe wound, was not placed under EBP despite having a chronic wound. Observations revealed that nursing assistants and a registered nurse did not use gowns during high-contact activities and dressing changes, and there was no signage or personal protective equipment (PPE) available in R14's room. Similarly, Resident R15, who had a moderate cognitive impairment and a right hip wound, was not provided with appropriate PPE during transfers, despite the care plan indicating the need for EBP. The facility's infection prevention and control policy did not specify when EBP should be used. In the laundry department, the facility failed to ensure proper PPE was used during the sorting of soiled laundry. A single black fabric apron was used throughout the day by laundry staff, which was visibly contaminated and only washed at the end of the day. Disposable gowns were not available, and the facility did not provide a policy regarding infection prevention and control during soiled laundry sorting. Interviews with staff confirmed the expectation for laundry staff to wear long sleeve, impermeable gowns to prevent contamination, but this was not practiced due to the lack of available PPE.
Failure to Notify Physicians of Resident Incidents
Penalty
Summary
The facility failed to inform the physician of a burn incident involving a resident, R15, who had a moderate cognitive impairment and various medical conditions including type 2 diabetes and chronic kidney disease. On 10/19/24, R15 developed a blister on her right hip after a heat pack was applied, which was not overly warm but may have caused the blister due to R15's fragile skin. Despite the blister leaking fluid and increasing in size over the following days, the physician was not notified until 11/7/24, when there was concern about a potential infection. The delay in notifying the physician resulted in a lack of timely evaluation and treatment, which could have impacted the healing process of the burn. Another incident involved a resident, R29, who experienced a fall on 11/29/24 while trying to hang up a shirt in her closet. R29, who had intact cognition and was on anticoagulant therapy, fell and hit her right side, resulting in a large bruise and swelling on her right hip. Although a physical assessment was completed and the family was notified, the physician was not informed of the fall. R29 later complained of pain and was seen in urgent care, where a hip X-ray was performed and found to be negative. The facility's policy required notifying the physician of all resident falls, but this was not done in R29's case. The facility's failure to notify the physicians promptly in both cases highlights a deficiency in communication and adherence to policy. The delay in informing the physicians of the incidents involving R15 and R29 resulted in a lack of timely medical evaluation and intervention, which could have affected the residents' recovery and well-being. The facility's policy on incidents and accidents required the nurse to contact the resident's provider to inform them of any incidents or accidents, but this protocol was not followed in these instances.
Failure to Report Resident Burn Incident
Penalty
Summary
The facility failed to report a burn incident involving a resident, identified as R15, to the state agency. R15, who had a moderate cognitive impairment and medical conditions including type 2 diabetes and chronic kidney disease, suffered a burn on the right hip due to the inappropriate use of a hot pack. The incident occurred when a registered nurse (RN-A) applied a gel pack heated in the microwave for approximately 30 seconds, wrapped in a hand towel, and placed it under R15's right hip. R15 was positioned to lie on the gel pack, which led to the development of a blister that later evolved into a chronic full-thickness burn. The manufacturer's instructions for the gel pack emphasized the need for caution, especially for individuals with circulatory or diabetes issues, and advised against unattended use by elderly or incapacitated individuals. However, RN-A was not educated on these instructions and did not report the burn to the state agency, as she was unsure if the reddened area would persist. The burn was discovered during a routine skin assessment after R15 had a shower, but the incident was not reported to the state agency as required by the facility's policy. Interviews with other staff members, including RN-B and the Director of Nursing (DON), revealed a lack of awareness and follow-through regarding the incident. RN-B was informed of the burn but did not consider reporting it to the state agency. The DON, who assumed her role after the incident, was unaware of the circumstances surrounding R15's burn. The facility's policy mandates immediate reporting of suspected abuse, neglect, or exploitation to the appropriate authorities, but this protocol was not followed in this case.
Failure to Investigate Burn Incident from Hot Pack Use
Penalty
Summary
The facility failed to investigate a burn incident involving a resident who was reviewed for wound care. The resident, who had a moderate cognitive impairment and diagnoses including type 2 diabetes and chronic kidney disease, suffered a burn on the right hip due to the inappropriate use of a hot pack. The nursing assistant discovered a blister on the resident's hip, which was later identified as a chronic full-thickness burn. The burn was attributed to the resident lying on a hot pack that was not overly warm but may have caused the blister due to the resident's fragile skin. The registered nurse (RN) who applied the hot pack was not educated on the manufacturer's heating instructions and did not read them before use. The RN heated the gel pack in the microwave for approximately 30 seconds, wrapped it in a hand towel, and placed it on the resident's hip, positioning the resident to lie on it. The RN discovered the burn during a routine skin assessment after the resident's shower. The RN disposed of the gel packs, believing them to be defective, but did not verify their correct usage or document any verbal directions given to other staff. The incident was not reported to the acting director of nursing until two days later. The acting director of nursing confirmed that no investigation was conducted to determine if the gel pack was used appropriately or if it should have been used for the resident, given their diabetic condition. The facility's interdisciplinary team meetings and purchasing orders failed to address the causative factors of the burn or ensure staff awareness of the gel pack's heating instructions. The new director of nursing and another RN were unaware of the incident's circumstances, indicating a lack of assessment and follow-through to prevent similar occurrences. The facility's policy on abuse prevention and reporting required an investigation, which was not conducted in this case.
Inaccurate MDS Coding for Diabetes Medication
Penalty
Summary
The facility failed to ensure the medications section of the Minimum Data Set (MDS) was accurately coded for a resident reviewed for MDS accuracy. The resident, identified as having a moderate cognitive impairment and a diagnosis of Type 2 Diabetes, received a weekly injection of Trulicity, a GLP-1 receptor agonist used to control high blood sugar. However, during an interview, a registered nurse (RN-D) assisting with MDS completion stated that Trulicity was incorrectly identified as insulin on the MDS, despite acknowledging that it was not insulin but a GLP-1 medication. The facility's policy on Resident Assessment, revised in January 2025, mandates standardized assessments of each resident's functional capacity, including medication administration. The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual outlines the steps for assessing insulin injections, which include reviewing medication records and determining if insulin injections were received during the look-back period. The RN-D's misunderstanding of the medication classification led to the incorrect coding of the MDS, which is a tool used to assist in the resident's individualized plan of care.
Failure to Document and Address Pressure Ulcer
Penalty
Summary
The facility failed to comprehensively assess and implement interventions for a pressure ulcer on a resident's right great toe. The resident, who had severe cognitive impairment and was at risk for pressure ulcers, developed a pressure ulcer that was not documented in the care plan. The care plan did not include interventions to prevent the ulcer from worsening or to promote healing. Nursing progress notes indicated that the ulcer was first noticed when a nursing assistant removed the resident's socks, causing pain and bleeding. Despite the presence of the ulcer, the care plan and resident care sheet did not reflect this condition or any specific interventions. The nursing staff documented the presence of the ulcer and performed dressing changes, but there was a lack of comprehensive assessment and documentation of interventions to promote healing. Interviews with nursing assistants and a licensed practical nurse revealed that they were not fully aware of the wound's condition or the interventions being implemented. The registered nurse acknowledged that the wound was caused by pressure from the resident's shoe and that interventions were communicated verbally but not documented. The facility's pressure ulcer and wound dressing policies were requested but not provided. The director of nursing stated that staff were expected to follow the facility's pressure ulcer protocol, but the lack of documentation and comprehensive assessment indicates a deficiency in the facility's wound care practices. The report highlights the need for proper documentation and implementation of interventions to address pressure ulcers and prevent further complications.
Failure to Clarify Medication Allergy and Dosage Exceedance
Penalty
Summary
The facility failed to ensure proper pharmaceutical services for a resident, R27, who had severely impaired cognition and was receiving both scheduled and as-needed pain medications. Despite having an allergy to oxycodone listed in the medical record, R27 was administered PRN oxycodone multiple times from September to December 2024. The consultant pharmacist reviewed R27's medical record monthly but failed to identify the discrepancy between the oxycodone order and the listed allergy. There was no documentation that the potential drug interaction was identified or addressed by the facility staff. Additionally, on November 29, 2024, R27 was administered a total of 3,650 mg of acetaminophen, exceeding the recommended daily dose for elderly patients, which is 3,000 mg. The Director of Nursing (DON) acknowledged that the acceptable dose for the elderly would be 3,000 mg of Tylenol in a day. The trained medication assistant (TMA) who administered the PRN Tylenol was unaware that R27 was over the maximum limit and was instructed by a nurse to give the PRN Tylenol due to increased pain and awaiting a provider refill prescription for oxycodone. The consultant pharmacist, CP-H, stated that it was common practice to review a resident's allergy list during monthly medication reviews. However, CP-H was unable to find documentation that the previous pharmacist had identified the discrepancy of the ordered medication with R27's allergy list. The DON found that R27's provider had overridden the allergy alert when first ordering the oxycodone, but there was no evidence that the allergy had been questioned by the facility staff or discussed with the provider when it was ordered.
Consulting Pharmacist Fails to Identify Allergy Discrepancy
Penalty
Summary
The consulting pharmacist failed to identify and report irregularities related to a resident's allergies for a prescribed medication. The resident, who had severely impaired cognition, was administered oxycodone despite having an allergy to it documented in their medical record. Over several months, the resident received oxycodone multiple times, with no documentation of an allergic reaction occurring. The consultant pharmacist reviewed the resident's medical record monthly but did not identify the discrepancy between the oxycodone order and the allergy list. During interviews, it was revealed that the consultant pharmacist had not completed the reviews, as they were done by a recently retired pharmacist. The Director of Nursing (DON) found that the resident's provider had overridden the allergy alert when initially ordering the medication, but there was no evidence that the facility staff questioned the allergy or discussed it with the provider. The facility's policy required the consultant pharmacist to report findings and recommendations to the DON, which was not done in this case.
Pain Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure that as-needed pain medications were available to treat acute breakthrough pain for a resident, R27, who had severe cognitive impairment and impaired range of motion. R27's care plan included administering pain medications as ordered and observing for pain using a non-verbal pain scale. However, the facility ran out of R27's as-needed pain medication, oxycodone, and there was a delay in obtaining a refill. During this time, R27 exhibited non-verbal signs of pain, such as crying and grimacing, and family members expressed concerns about the lack of pain management. The facility's staff attempted to manage R27's pain with non-pharmacological interventions and scheduled Tylenol, but these measures were insufficient. The facility's emergency medication kit contained pain medications with Tylenol, which R27 could not use due to already receiving the maximum allowed dose of Tylenol. The staff did not utilize the on-call doctor or the medical director to address the medication shortage promptly. As a result, R27 experienced increased pain until the medication was finally delivered. Another resident, R29, experienced a delay in receiving a Lidocaine patch for pain management. R29, who had intact cognition and chronic pain conditions, reported that the patch was usually applied in the morning but was delayed on one occasion. The nurse, RN-E, informed R29 that the patch was not due until later, resulting in a delay in pain relief. The facility's policy allowed for morning medications to be administered between 6:00 a.m. and 10:00 a.m., but the patch was applied later than usual, causing discomfort for R29.
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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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