Olivia Restorative Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Olivia, Minnesota.
- Location
- 1003 West Maple Avenue, Olivia, Minnesota 56277
- CMS Provider Number
- 245290
- Inspections on file
- 31
- Latest survey
- December 3, 2025
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Olivia Restorative Care Center during CMS and state inspections, most recent first.
A resident with a history of traumatic sexual abuse and intact cognition reported inappropriate sexual contact by a nursing assistant during personal care. Despite multiple staff and leadership being made aware of the allegation, the DON and administrator did not report the incident to law enforcement or the State Agency as required by facility policy, citing the resident's history of making false accusations. The facility's policy mandates immediate reporting of all abuse allegations, but this was not followed.
The facility did not maintain verifiable 24-hour licensed nursing coverage, as required, when only an RN's presence could be confirmed for a shift and the hours worked by a contract LPN could not be substantiated through timesheets or other auditable records. This deficiency had the potential to affect all residents in the facility.
The facility did not ensure RN coverage for at least 8 consecutive hours per day, 7 days per week, on six occasions over a three-month period, potentially affecting all residents. Staffing schedules and timesheets showed gaps in RN presence, despite daily review and discussion of staffing needs by the DON and administrator.
Surveyors identified that dietary staff failed to consistently wear required hair and beard nets while preparing and serving food, and that a refrigerator in the dining area was dirty with undated food items and spills. Additionally, expired chlorine test strips were used to monitor the dishwasher's chemical levels, contrary to facility policy. Staff interviews confirmed awareness of these requirements and lapses in compliance.
The facility did not ensure adequate RN coverage on multiple days and failed to verify the presence of required nursing staff through available documentation, resulting in unaddressed gaps in staffing and incomplete facility-wide assessment of resource needs.
The facility did not electronically submit complete and accurate direct care staffing information to CMS, as required, using payroll and other verifiable and auditable data.
A nurse failed to disinfect a glucometer after use on a resident and did not follow proper contact time with disinfectant wipes, leading to potential cross-contamination. Additionally, the facility did not accurately document staff illness absences, return-to-work dates, or clearance procedures for two staff members, as required by policy.
A resident's request to change code status from full code (CPR) to DNR was not updated in the electronic medical record, leaving the dashboard in the PCC system incorrectly showing full code. Both an LPN and the DON confirmed reliance on the dashboard for code status during emergencies, and the discrepancy was acknowledged after review of the signed POLST and system records.
Two residents identified as high risk for elopement were able to leave the facility without proper supervision, one undetected for an hour despite a wander guard, due to missed safety checks, lack of staff communication, and inadequate training for both regular and agency staff. Non-nursing staff, such as dietary personnel, were not informed of residents' elopement risks and allowed a resident to exit unsupervised, with alarms ignored and care plan requirements unmet.
A resident who was cognitively intact, independent in a wheelchair, and assessed as low risk for elopement was unable to freely enter and exit the facility due to a locked entrance requiring staff assistance. The resident expressed frustration about feeling confined, and the facility's policy applied the same restrictions to all residents regardless of elopement risk.
Contracted care staff began working without completing required training or having access to EMR and resident care plans. A nursing assistant started her shift without prior training or access to care plans, and the DON confirmed the lapse. Facility policy did not address EMR access or training on key procedures, potentially impacting all residents.
A resident with moderate dementia and a history of unsafe wandering was able to leave the facility unnoticed on multiple occasions, including one incident where the individual removed a Wanderguard device and was found by a community member several blocks away. Staff failed to document or investigate these elopements, did not update the care plan or interventions, and did not notify family members. Facility policy requiring assessment, individualized care planning, and post-elopement procedures was not followed.
A resident with moderate cognitive impairment and a history of elopement was able to leave the facility undetected on multiple occasions by removing a wanderguard, with staff failing to document, investigate, or report these incidents as required by facility policy. Interviews confirmed staff awareness of the resident's elopement risk, but no formal investigation or state agency notification occurred.
A resident with a known history of wandering and elopement risk was able to remove his WanderGuard and leave the facility without staff knowledge, remaining missing for about an hour before being returned by police. The incident was not documented in the medical record or incident reports, nor was it reported to the State Agency, despite facility policy requiring such reporting for unauthorized departures. Staff interviews confirmed awareness of the resident's risk, but the event was not recognized as an elopement by facility leadership.
During an RSV outbreak, the facility did not consistently implement transmission-based precautions or conduct active respiratory symptom screening for residents. Several residents with respiratory symptoms and positive RSV tests were not isolated or monitored according to infection control protocols, and staff did not always use PPE or enforce mask use. Facility leadership and staff interviews revealed gaps in awareness, surveillance, and adherence to infection control policies, contributing to the spread of RSV among residents.
Two residents with significant fall risks experienced multiple falls, including one resulting in a subdural hematoma and hospitalization, due to the facility's failure to conduct comprehensive fall risk assessments, root cause analyses, and timely care plan updates. Interventions were inconsistently implemented and not individualized, and staff were unclear about supervision requirements and documentation, leading to inadequate fall prevention.
A resident with multiple sclerosis, sepsis, and acute ischemia of the intestine experienced a decline in condition, including nausea, vomiting, and diarrhea. The RN failed to perform an assessment or take vital signs, and did not contact a provider. The resident became unresponsive and CPR was initiated but stopped before EMS arrived. The facility did not notify the provider of the resident's deterioration, leading to the resident's death.
The facility did not employ a full-time DON, affecting all 36 residents. The DON was present only two to three times weekly and did not track her attendance. She acknowledged management challenges, and the administrator was aware of the full-time requirement but did not comply.
The facility failed to provide orientation and training to agency nurses, as required by its policy. Three RNs reported not receiving orientation to the facility or its policies, despite often being the only nurse on duty. The DON and administrator acknowledged the lack of a structured orientation process, and no evidence of orientation was provided, affecting the care of 36 residents.
The facility failed to maintain a safe and sanitary environment due to issues with flooring transitions, including broken tile and frayed carpet at a resident's room entrance, and missing transition pieces between carpeted and wood floors in hallways. These deficiencies posed potential risks for injury and infection control concerns. The maintenance director and administrator were aware of the issues, but no effective solutions were implemented, and no work order requests were submitted for the deficiencies.
The facility failed to ensure dignified meal assistance for residents dependent on staff for eating. Nursing assistants were observed standing and conversing while feeding residents with conditions like multiple sclerosis and cognitive impairment. The facility's policy lacked guidance on maintaining dignity during meal assistance, and staff were unclear about the protocol, contributing to the deficiency.
A resident's MDS was inaccurately coded, indicating discharge to a hospital instead of an assisted living facility. The RN responsible admitted the mistake and planned to correct it. The administrator expected accurate MDS records, but no policy on MDS accuracy was provided.
A resident with severe cognitive impairment and hearing loss experienced negligence when a staff member failed to remove her hearing aid during a shower, resulting in damage. The facility lacked proper documentation and procedures for managing hearing aids, leading to the resident's inability to hear well and uncertainty about the location of the damaged device. Staff interviews revealed a lack of awareness and communication regarding the resident's needs.
A resident with chronic pain syndrome did not receive prescribed lidocaine patches for nine days due to a failure in communication and follow-up by facility staff. The medication aide could not locate the patches, and the LPN was unaware of the issue. The DON confirmed that proper procedures were not followed, including contacting the pharmacy and notifying the physician. No policy was provided by the facility.
A facility failed to implement pharmacy recommendations to adjust medication administration times for a resident with multiple diagnoses, including schizoaffective disorder and thyroid disorder. Despite a pharmacist's advice to separate the administration of calcium carbonate and levothyroxine by four hours to avoid interactions, the resident's MAR showed consistent administration at the same time over several months. Interviews revealed that staff did not clarify or act on these recommendations, leading to a deficiency in medication management.
The facility failed to offer pneumococcal PCV-15 or PCV-20 vaccinations to two residents, as per CDC recommendations. One resident's records showed previous vaccinations but lacked documentation of being offered the newer vaccines. Another resident had consented to vaccination, but there was no evidence of administration. The facility's policy required offering the vaccine within 30 days of admission and providing information on benefits and side effects.
A facility failed to assess and identify appropriate mechanical lifts and slings for residents, leading to an incident where a resident fell during a transfer. The resident, with a history of Alzheimer's and a leg amputation, was not properly assessed for sling size, and staff used available slings without ensuring they were suitable. Interviews revealed inconsistencies in sling usage and a lack of proper measurement, contributing to the deficiency.
The facility failed to verify the professional licensure of a staff member hired as an RN, who did not hold an RN license and had a suspended LPN license. The staff member falsely claimed to have an RN license and worked as a trainee under supervision. The DON discovered the issue and contacted the police department.
The facility failed to follow physician-ordered wound treatments and did not ensure appropriate infection control practices during wound care for two residents. The RN did not perform hand hygiene between glove changes, did not use a barrier for wound supplies, and did not follow the physician's orders for wound care. Interviews with staff confirmed these deficiencies.
Failure to Timely Report Alleged Sexual Abuse to Authorities
Penalty
Summary
The facility failed to timely report an allegation of staff-to-resident sexual abuse to law enforcement and the State Agency as required by policy. A resident with a history of traumatic sexual abuse and intact cognition reported that a nursing assistant had inappropriately touched him during a bath, causing embarrassment. The incident was reported to the DON and ADON, who became aware of the allegation but did not report it to the appropriate authorities within the required timeframe. The DON conducted an internal investigation but withheld reporting due to the resident's history of making false accusations and questioning his own perception of the event. Multiple staff, including an LPN and the social service designee, were aware of the allegation and discussed it during a morning meeting. Despite the facility's policy requiring immediate reporting of all alleged violations, the administrator and DON chose not to report the incident to the State Agency or law enforcement, citing the resident's history of manipulation and falsehoods. The facility's policy specifically mandates reporting all allegations of abuse within two hours if the event involves abuse or results in serious bodily injury, but this protocol was not followed in this case.
Failure to Maintain 24-Hour Licensed Nursing Coverage
Penalty
Summary
The facility failed to provide licensed nursing coverage for 24 hours a day as required, based on review of payroll and other verifiable data for one quarter. On a specific day, documentation showed that only one registered nurse was verifiably present for the shift, while the presence of a contract LPN could not be confirmed through timesheet punches or other auditable records. The assignment sheet and PBJ data indicated that both an RN and an LPN were scheduled and reported as working, but only the RN's hours could be substantiated. Interviews with the DON and administrator confirmed that staffing hours were reviewed daily and that the facility aimed to overstaff to meet resident needs. However, the facility was unable to provide contract staff timesheets to verify the LPN's presence for the shift in question. The facility's staffing plan required at least one RN or LPN per shift, but the lack of verifiable documentation for the LPN resulted in a failure to demonstrate compliance with 24-hour licensed nursing coverage, potentially affecting all 39 residents.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for a minimum of 8 consecutive hours per day, 7 days per week, as required. Review of facility schedules and timesheets for January, February, and March 2025 revealed that there was no RN coverage on six specific days across the three months. This deficiency had the potential to affect all 39 residents living in the facility. Interviews with the director of nursing (DON) and the administrator confirmed that staffing hours were reviewed daily and discussed in interdisciplinary team meetings, but gaps in RN coverage still occurred. The facility's policy required RN coverage as specified, and the DON could serve as a charge nurse when daily occupancy was 60 or fewer residents. The facility was also responsible for submitting accurate staffing data through the CMS payroll-based journal system.
Infection Control and Food Safety Deficiencies in Dietary Services
Penalty
Summary
Surveyors observed multiple failures in infection control and food safety practices within the facility's dietary services. Dietary staff were found not wearing required hair nets and beard nets while preparing and serving food in the kitchen and dining areas. Specifically, a dietary aide was seen preparing drinks without a hair net, and a cook with a mustache and beard was repeatedly observed serving food without a beard net. Both staff members acknowledged the requirement for these protective coverings, with one stating unawareness of the need for a beard net and uncertainty about their availability. The dietary manager assistant confirmed that all dietary staff should be wearing hair and beard nets as needed during food service. Additionally, the central dining room refrigerator was found to be unclean, with pink juice spilled inside and a sticky, dark substance on the floor in front of it. The refrigerator contained undated individually wrapped sandwiches, and staff interviews confirmed that food should be dated and refrigerators regularly cleaned. There was also a failure to monitor the expiration of chlorine test strips used for checking the dishwasher's chemical levels, as expired strips were in use until discovered and replaced. Facility policies reviewed by surveyors required proper use of hair and beard restraints, routine cleaning and disinfection, and daily monitoring of dishwasher sanitizer levels.
Failure to Ensure Adequate RN Coverage and Accurate Staffing Documentation
Penalty
Summary
The facility failed to implement and document a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. Review of staffing documentation for a specific date revealed discrepancies between the assignment sheet, PBJ data, and timesheet punches, with only one RN verifiably working and no way to confirm the presence of an LPN as documented. Additionally, contract staff timesheets were requested but not provided, further limiting verification of staffing levels. A review of facility schedules and timesheets over a three-month period identified multiple days with no RN coverage. Specifically, there were two days in January, three days in February, and one day in March without RN coverage. Interviews with the DON and administrator confirmed that staffing hours were reviewed daily and that the facility had implemented tracking of RN coverage and staff shortages. However, the facility assessment staffing plan only required one RN or LPN per shift, and there were documented gaps in RN coverage that were not addressed or verified through available records.
Failure to Submit Accurate Direct Care Staffing Data
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS. The information was required to be based on payroll and other verifiable and auditable data. This deficiency was identified through review of the facility's records and submission practices, which did not meet the required standards for accuracy and completeness as mandated by CMS.
Failure to Disinfect Glucometer and Incomplete Staff Illness Surveillance
Penalty
Summary
A registered nurse failed to properly disinfect a glucometer after use on a resident during a blood glucose check. After using the device, the nurse placed the used lancet in the sharps container and returned the glucometer to the treatment cart drawer without disinfecting it, despite the presence of another resident's glucometer in the same drawer. When questioned, the nurse admitted to forgetting to disinfect the device and subsequently used disinfecting wipes on both glucometers but did not allow the required wet contact time as per manufacturer instructions. The facility's policy required cleaning and disinfecting glucometers after each use, but this was not followed, and there was confusion among staff regarding the correct disinfection procedure and contact time. Additionally, the facility failed to maintain accurate staff illness surveillance records. For two staff members who called in sick, the illness logs and call-in reports did not document return-to-work dates, clearance procedures, or the number of days absent. The infection preventionist confirmed that the staff illness log and call-in forms were used for surveillance, but these forms lacked critical information. The director of nursing acknowledged the deficiencies in documentation and was unable to provide evidence of additional training or policy updates regarding staff illness surveillance.
Failure to Update Resident Code Status in EMR After Change to DNR
Penalty
Summary
The facility failed to update the code status in the electronic medical record (EMR) for one resident who had requested a change from full code (CPR) to Do Not Resuscitate (DNR). The resident's Provider Orders for Life-Sustaining Treatment (POLST), signed by both the resident and physician, reflected the change to DNR. However, the code status displayed on the resident's dashboard in the Point Click Care (PCC) system continued to indicate full code. Staff, including an LPN and the director of nursing, confirmed that they rely on the PCC dashboard to determine code status in emergencies, and both acknowledged the discrepancy between the POLST and the dashboard information. The director of nursing stated that the new order for DNR should have been entered into the system but was missed following the resident's request during a recent appointment. Audits of code status are conducted only a few times a year, and the last audit occurred prior to the resident's change in code status. The facility's policy outlines the process for determining and documenting code status upon admission and during care planning but does not specify how staff should confirm code status in the event of a need for CPR.
Failure to Provide Adequate Supervision and Accident Hazard Prevention for Residents at Risk of Elopement
Penalty
Summary
The facility failed to provide adequate supervision and accident hazard prevention for two residents identified as being at risk for elopement. One resident, who had moderately impaired cognition and required a walker for mobility, was able to leave the facility undetected for approximately one hour despite wearing a wander guard. The resident exited through the locked front entrance, which was opened by an unknown responsible party with access to the door code. Staff were unaware of the resident's absence until notified by community members, and documentation revealed that required 15-minute safety checks were not completed as directed in the care plan. Interviews with staff indicated a lack of communication and training regarding elopement risks and required supervision. The nurse assigned to the resident was not aware of the need for 15-minute checks, and agency staff did not receive adequate orientation or access to care plans prior to their shifts. The resident was able to leave the facility by following a transportation driver out the door, and staff did not notice the resident's absence until contacted by external parties. The facility's internal investigation confirmed that staff were the only individuals with knowledge of the door code, and no staff admitted to allowing the resident to exit. A second resident, also identified as an elopement risk, was observed being allowed to exit the facility by a dietary staff member who was unaware of the resident's supervision requirements. The dietary staff member used the door code to let the resident outside, and the door alarm sounded, but the staff member did not respond appropriately. The DON confirmed that non-nursing staff did not have access to care plans and relied on verbal communication from supervisors to identify residents at risk for elopement. Facility policy required vigilant supervision and a systemic approach to monitoring residents at risk for elopement, but these procedures were not effectively implemented.
Failure to Allow Cognitively Intact Resident Free Entry and Exit
Penalty
Summary
The facility failed to ensure that a cognitively intact resident, who was not at risk for elopement, could freely enter and exit the facility. The resident, who had diagnoses including osteonecrosis and alcohol dependence, was assessed as a low elopement risk and was independent with locomotion in his wheelchair. Despite this, the facility kept the entrance door locked at all times, requiring staff assistance to unlock it or waiting for an automatic release after 15 seconds, as observed during multiple site visits. The resident was seen waiting at the entrance for staff to unlock the door and expressed frustration about feeling confined and having to sign in and out like a prisoner. The facility's policy on a restraint-free environment states that residents have the right to be treated with respect and dignity and to be free from physical or chemical restraints used for staff convenience. The director of nursing confirmed that the door locking policy was implemented due to the admission of more residents who wander, but this policy also applied to residents who were not at risk for elopement. The lack of a system to allow cognitively intact, low-risk residents to move freely in and out of the facility resulted in a failure to honor the resident's rights to self-determination and dignity.
Failure to Train and Provide EMR Access to Contracted Care Staff
Penalty
Summary
The facility failed to ensure that contracted resident care staff, specifically a nursing assistant, were competently trained on facility procedures and provided access to electronic medical records (EMR) prior to starting their shifts. One nursing assistant reported that on her first shift, she received no training and did not have access to any resident care plans until management arrived later in the morning. The director of nursing confirmed that the required training was not completed before the nursing assistant began working. Additionally, the facility's policy for contracted employees addressed emergency preparedness but did not include provisions for EMR access or education on other critical facility policies, such as those related to elopement. These failures had the potential to affect all 46 residents in the facility.
Failure to Assess and Supervise Elopement Risk Resulting in Resident Leaving Facility Unnoticed
Penalty
Summary
The facility failed to comprehensively assess and address the supervision needs and individualized interventions for a resident identified as an elopement risk. The resident, who had moderate dementia with behavioral disturbances, a history of delusional thinking, and was not safe to live independently, was admitted to the facility with clear documentation of cognitive impairment and safety concerns. Despite being identified as an elopement risk and having a Wanderguard device placed, there was no documented assessment or rationale for the use or changes of the Wanderguard, nor were there updates to the care plan or interventions following previous elopement attempts. On multiple occasions, the resident was able to leave the facility without staff knowledge. In one instance, the resident used a fingernail file to remove the Wanderguard and exited the building, later being found by a community member 12 blocks away, having crossed a major highway and railroad tracks. Staff interviews revealed inconsistent understanding of the resident's risk, lack of clear documentation of elopement incidents, and no comprehensive cognitive or safety assessments to determine the resident's ability to be unsupervised in the community. The facility did not complete incident reports, investigations, or care plan updates after these events, and family members were not notified of the elopements. Facility policy required a systemic approach to monitoring and managing residents at risk for elopement, including assessment, individualized care planning, and post-elopement procedures such as physical assessment, documentation, and family notification. However, these procedures were not followed, as evidenced by the lack of documentation, assessment, and communication after the resident's elopements. Staff interviews further indicated a lack of clarity regarding the resident's supervision needs and the purpose of the Wanderguard, contributing to the failure to prevent the resident from leaving the facility unsupervised.
Failure to Implement Elopement and Abuse/Neglect Policies
Penalty
Summary
The facility failed to implement its Abuse, Neglect, and Exploitation and Elopements and Wandering Resident policy for a resident with a history of elopement. The resident, who had moderate cognitive impairment and was independent with activities of daily living, was observed wearing a wanderguard but reported having previously cut off the device and left the facility on multiple occasions. The resident described using a fingernail file to remove the wanderguard, leaving the facility undetected, and being found by police after walking a significant distance. The resident also stated intentions to elope again and described previous successful attempts, including one where he was gone for about 20 minutes before staff noticed his absence. Review of the resident's medical record revealed a lack of documentation regarding the reported elopement attempts. Facility incident reports did not include any risk management, incident reports, or investigations related to these events. Additionally, the state agency's reporting center had no record of facility-reported incidents for the resident's elopement attempts. Interviews with staff confirmed awareness of the resident's elopement risk and recounted the events of the most recent elopement, including the resident being found by police far from the facility. Staff also noted the resident's pattern of waiting for opportunities to leave undetected. Despite the facility's policy requiring immediate investigation and reporting of suspected neglect or elopement, the incidents were not investigated or reported to the state agency. The DON and administrator both indicated that they did not consider the events to be elopements and therefore did not initiate investigations or reporting, even though the resident had left the facility without staff knowledge. The facility's policy outlines specific procedures for investigation, documentation, and reporting, none of which were followed in these instances.
Failure to Recognize and Report Resident Elopement
Penalty
Summary
The facility failed to recognize and report an elopement incident involving a resident identified as being at risk for elopement. The resident, who had a history of wandering and elopement attempts, was able to remove his WanderGuard bracelet using a fingernail file and left the facility without staff knowledge. He was gone for approximately an hour before being located by police and returned to the facility. The resident reported that he had previously eloped from the facility a couple of months prior, also by removing his WanderGuard, and was gone for about 20 minutes before staff noticed his absence. Review of the resident's medical record and facility incident reports revealed a lack of documentation regarding these elopement attempts. There were no risk management or incident reports related to the events, and the Minnesota Adult Abuse Reporting Center did not have any facility-reported incidents for the resident's elopement attempts. The resident's elopement risk assessment indicated multiple risk factors, including a history of wandering, family concerns, and medications that could cause confusion, but interventions in place were limited to recreational activities, a check-in/out log, staff awareness, room personalization, and a WanderGuard. Interviews with staff, including nursing assistants, an RN, the DON, and the administrator, confirmed that the resident was considered an elopement risk and that staff were aware of his tendencies. Despite this, the incident was not reported to the State Agency, as the facility's leadership did not initially consider the event to be an elopement. The facility's own policy defined elopement as a resident leaving the premises without authorization or necessary supervision, and required immediate reporting of such incidents, but this protocol was not followed.
Failure to Implement Infection Control Measures During RSV Outbreak
Penalty
Summary
The facility failed to implement effective infection prevention and control strategies for respiratory protection, specifically in response to an outbreak of Respiratory Syncytial Virus (RSV). Despite the onset of symptoms and positive RSV test results among multiple residents, the facility did not consistently initiate transmission-based precautions (TBP), such as isolation or droplet/contact precautions, at the onset of symptoms. For example, one resident with significant comorbidities including morbid obesity, COPD, and heart failure, developed respiratory symptoms and tested positive for RSV, but was not placed on appropriate precautions or monitored for ongoing symptoms. The care plan and physician orders did not reflect the need for TBP, and isolation was discontinued prematurely without a respiratory assessment to confirm symptom resolution. Several other residents developed respiratory symptoms and tested positive for RSV, yet their records did not show evidence of respiratory symptom screening, timely implementation of TBP, or consistent monitoring. In some cases, symptomatic residents were not isolated, and staff did not use personal protective equipment (PPE) when providing care. Residents with confirmed or suspected RSV were observed participating in communal dining and activities without masks, and staff failed to enforce isolation or mask use. The facility also lacked active screening protocols for early identification of new cases, and there was no comprehensive respiratory assessment or surveillance log tracking the spread of illness among residents. Interviews with facility leadership and staff revealed a lack of awareness and adherence to infection control policies and CDC guidelines. The Director of Nursing (DON) and Infection Preventionist were not fully informed about the outbreak status, did not conduct contact tracing, and were unaware of the number of cases that constituted an outbreak. Staff were not consistently educated or directed to monitor for respiratory symptoms, and there was no systematic process for implementing or removing TBP. The medical director was not notified of the outbreak in a timely manner, and the facility's infection control policies were not followed, resulting in a system-wide failure to prevent the spread of RSV.
Failure to Assess and Implement Comprehensive Fall Prevention Measures
Penalty
Summary
The facility failed to comprehensively assess and address fall risks for two residents with a history of falls and significant medical vulnerabilities. One resident, who had a history of traumatic brain injuries and severe cognitive impairment, was admitted with multiple facial fractures and a traumatic brain injury. Despite being identified as high risk for falls on admission, there was no fall prevention care plan developed for this resident until after multiple unwitnessed falls occurred, including one that resulted in a subdural hematoma and hospitalization. The care plan did not include specific interventions or clearly defined supervision levels, and staff were unclear about the frequency and documentation of required checks. For this resident, incident reports and progress notes documented repeated falls, wandering, and self-transferring behaviors, but failed to include comprehensive fall analyses or root cause assessments. Interventions such as gripper socks, soft touch call lights, and frequent checks were inconsistently implemented and not reflected in the care plan. Staff interviews revealed confusion about the meaning and frequency of 'frequent checks,' and documentation of interventions was lacking. The care plan was not updated in a timely manner, and interventions were not individualized based on comprehensive assessments of the resident's needs, including toileting and supervision requirements. A second resident, also identified as high risk for falls due to multiple fractures, cognitive impairment, and inability to follow directions, experienced several falls. Incident reports and post-fall analyses were incomplete, lacking documentation of mental status, predisposing factors, and root cause conclusions. Interventions such as frequent checks, fall mats, and medication reviews were inconsistently documented and not incorporated into the care plan. The care plan did not reflect new interventions or comprehensive assessments to address the resident's individualized needs, including toileting and supervision. Staff and the DON confirmed that comprehensive analyses and root cause assessments were not consistently completed for each fall, resulting in inadequate fall prevention measures.
Failure to Assess and Notify Provider Leads to Resident's Death
Penalty
Summary
The facility failed to complete an assessment, including vital signs and general condition, when a change in condition was reported for a resident with multiple sclerosis, sepsis, and acute ischemia of the intestine. The resident required substantial assistance with all activities of daily living and was cognitively intact. Despite the resident's deteriorating condition, which included nausea, vomiting, and diarrhea, the registered nurse (RN) did not perform a physical assessment or take vital signs throughout the day. The RN was aware of the resident's condition from the morning but did not contact the provider, citing it was a Saturday. The situation escalated when the resident experienced a nosebleed and became unresponsive in the afternoon. The RN initiated CPR and called 911, but CPR was stopped before emergency medical services (EMS) arrived. The EMS staff found the resident in asystole, and CPR had been discontinued by the facility staff. The facility's documentation lacked evidence of notifying the provider about the resident's deterioration prior to her death. Interviews with staff revealed that the RN did not follow the facility's protocol for notifying changes in a resident's condition or the American Heart Association guidelines for CPR. The director of nursing and medical director both indicated that an assessment and communication with the provider should have occurred when the resident first showed signs of illness. The nurse practitioner confirmed that there was always a provider on-call to address residents' needs, contradicting the RN's decision not to contact a provider.
Failure to Employ Full-Time Director of Nursing
Penalty
Summary
The facility failed to employ a full-time Director of Nursing (DON), which had the potential to affect all 36 residents. Observations on two consecutive days revealed the absence of the DON in the facility. During interviews, the DON admitted to being present at the facility only two to three times per week and acknowledged not tracking her attendance. She stated her responsibilities included managing staff and ensuring compliance, but also mentioned challenges with management and leadership. The administrator confirmed awareness of the requirement for a full-time DON, yet the facility did not comply with this regulation.
Lack of Orientation for Agency Nurses
Penalty
Summary
The facility failed to provide adequate orientation and training to agency nurses, which is a requirement for individuals providing services under a contractual agreement. Three registered nurses (RN-A, RN-B, and RN-C) who worked at the facility through an agency reported that they did not receive any orientation to the facility or its policies and procedures. These nurses also mentioned that they were often the only nurse on duty during their shifts, which could potentially impact the quality of care provided to the 36 residents of the facility. The Director of Nursing (DON) and the facility administrator acknowledged the lack of a structured orientation process for agency staff. The DON was unsure if there was a specific process in place, while the administrator admitted that agency staff should receive orientation, a review of policies, and a tour on their first shift. However, the administrator was unable to provide evidence of such orientation for the agency nurses. The facility's orientation policy, dated 2023, mandates that all staff, including those under contractual agreements, must complete general orientation before having formal contact with residents, and documentation of this process should be maintained in personnel files. Despite requests, no evidence of orientation for agency staff was provided.
Deficiency in Maintaining Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe, sanitary, and homelike environment due to issues with flooring transitions in several areas. Observations revealed broken tile and frayed carpet at the entrance of a resident's room, which posed a potential risk for injury. The resident reported no incidents of getting caught on the frayed carpet with his wheelchair, but there was no plan in place to address the issue. Additionally, the transition areas between carpeted and wood floors in the hallways were missing plastic transition pieces, leaving uneven surfaces and exposed cement, which could pose a tripping hazard. Interviews with the maintenance director and administrator indicated awareness of the flooring issues, but there was no effective solution implemented to secure the transition pieces. The maintenance director acknowledged the difficulty residents and staff faced maneuvering over the transitions, which contributed to the pieces being ripped off. The administrator confirmed the potential risks associated with the uneven surfaces and missing tiles, recognizing the infection control concern. Despite the facility's policy requiring written work order requests, no such requests were submitted for the observed deficiencies, and there was no policy provided related to maintaining a safe and sanitary environment.
Failure to Ensure Dignified Meal Assistance for Residents
Penalty
Summary
The facility failed to ensure that residents were assisted with their meals in a dignified manner. Observations revealed that nursing assistants stood while feeding residents who were dependent on staff for meal intake, including three residents with various medical conditions such as multiple sclerosis, cognitive impairment, and malnutrition risk. The nursing assistants were seen standing and conversing with each other while feeding the residents, rather than sitting to provide a more dignified experience. The facility's policy did not explicitly mention the need for staff to provide dignity while assisting residents with meals. Interviews with staff and the Director of Nursing (DON) indicated a lack of awareness and clarity regarding the protocol for feeding residents. The DON acknowledged that typically staff should not stand while feeding residents, except in specific cases like supporting a resident's head. The facility was in the process of rearranging seating, which may have contributed to the confusion. The Meal Supervision and Assistance policy emphasized adequate supervision and a relaxing environment but did not address the importance of maintaining resident dignity during meal assistance.
Inaccurate MDS Coding for Resident Discharge
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was accurately coded for a resident's discharge record. Specifically, the MDS for one resident was incorrectly coded to indicate a discharge to a short-term general hospital, while the resident was actually discharged to an assisted living facility. This discrepancy was identified during a review of the resident's care plan, which indicated the resident's intention to move back home and possibly transfer to another skilled nursing facility closer to home. The error was acknowledged by the registered nurse responsible for completing the MDS, who admitted to mistakenly coding the discharge status. The nurse recognized the need to correct the MDS and resubmit it with the accurate discharge information. The facility administrator expressed an expectation for the MDS to accurately reflect the resident's status. However, no policy related to the accuracy of the MDS was provided by the end of the survey.
Failure to Manage Resident's Hearing Aids
Penalty
Summary
The facility failed to ensure that a resident, identified as R29, had her hearing aids appropriately managed, leading to damage and loss. R29, who was hearing impaired and used bilateral hearing aids, experienced an incident where a staff member failed to remove her right hearing aid during a shower, resulting in water damage. This negligence left R29 unable to hear well out of her right ear, and she was unsure of the location of the damaged hearing aid. Despite R29's severe cognitive impairment and her reliance on hospice services, the facility did not have a personal inventory sheet for her upon admission, and there was no documentation of her hearing impairment in the Minimum Data Set (MDS). Interviews with facility staff revealed a lack of awareness and communication regarding R29's hearing aids. The social services designee was informed of the missing hearing aid but was unsure if the administration had addressed the concern. The Director of Nursing (DON) acknowledged the absence of a procedure for handling damaged hearing devices and admitted that no personal inventory sheet was completed for R29. The facility's Personal Property policy required prompt investigation of complaints regarding resident property, but there was no specific policy related to hearing aids. The administrator expected staff to file a grievance for missing items, but this was not done in R29's case.
Failure to Administer Prescribed Pain Medication
Penalty
Summary
The facility failed to provide the necessary pharmaceutical services for a resident diagnosed with Wernicke's encephalopathy, chronic pain syndrome, and dementia. The resident was prescribed lidocaine patches for chronic pain, which were not administered for nine consecutive days. During an observation and interview, a medication aide was unable to locate the lidocaine patches and confirmed they had not been delivered. The resident's medication administration record indicated that the patches were unavailable on multiple dates, yet there was no documentation of increased pain during this period. Interviews with facility staff, including an LPN and the Director of Nursing (DON), revealed a lack of communication and follow-up regarding the missing medication. The LPN was unaware of the missing patches and stated that the medication aide should have notified the nurse if the medication was unavailable. The DON confirmed that the nurse should have contacted the pharmacy and notified the physician if the medication could not be delivered, as well as completed an incident report. However, there was no evidence of any such actions being taken, and the facility failed to provide a policy regarding the procedure for handling such situations.
Failure to Implement Pharmacy Recommendations for Medication Timing
Penalty
Summary
The facility failed to act upon pharmacy recommendations to modify the administration times of medications for a resident diagnosed with schizoaffective disorder, anxiety, chronic kidney disease, and thyroid disorder, who also had moderate cognitive impairment. The pharmacist had identified a potential interaction between Fibercon, calcium carbonate, and levothyroxine, recommending that these medications be separated by four hours to avoid interactions. Despite this recommendation, the resident's Medication Administration Record (MAR) showed that calcium carbonate was consistently administered at 8:00 a.m. alongside levothyroxine over several months. Interviews with the clinical pharmacist and the director of nursing revealed that the staff did not clarify or implement the pharmacy's recommendations, which could lead to potential interactions if continued long-term. The facility's policy on Gradual Dose Reduction of Psychotropic Drugs indicated that medication reviews should occur monthly and that modifications should be made to prevent adverse consequences related to medication interactions. However, the necessary changes were not made, resulting in a deficiency in the facility's medication management practices.
Failure to Offer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that two residents, R24 and R33, were offered the pneumococcal PCV-15 or PCV-20 vaccination or provided with a declination form, as recommended by the CDC. For R24, the Significant Change Minimum Data Assessment (MDS) indicated that pneumococcal vaccinations were up to date, with records showing PCV-13 received on 12/21/15 and PPSV-23 on 12/20/18. However, there was no documentation to confirm that R24 had been offered or declined the newer PCV-15 or PCV-20 vaccines. For R33, the MDS indicated that pneumococcal vaccinations were not up to date, and despite consent being obtained in May 2024, there was no evidence that R33 had received the PCV vaccines. An interview with the director of nursing on 9/26/24 revealed that the facility planned to offer the vaccine to residents. The facility's policy, reviewed on 4/08/24, stated that they would determine residents' PCV status and offer the vaccine within 30 days of admission unless medically contraindicated or previously vaccinated, and provide information on the benefits and potential side effects. The policy also indicated that vaccines would be administered or re-vaccinated according to CDC recommendations.
Inadequate Assessment and Use of Mechanical Lifts
Penalty
Summary
The facility failed to assess and identify the appropriate mechanical lift and corresponding slings for residents based on their height and weight, affecting 10 residents who required total mechanical lifts for transfers. This deficiency was highlighted by an incident involving a resident who was being transferred from her bed to a wheelchair using a total mechanical lift. During the transfer, the resident moved in the sling, causing her to slide out and hit her head. Although the staff reportedly used the correct-sized sling, the facility did not verify the sling size or ensure the correct sling for the lift was used. The resident involved in the incident had a history of Alzheimer's disease, malnutrition, anxiety, depression, and a right leg below-knee amputation. She was dependent on staff for self-care needs and required a two-person transfer with a total body lift. However, her care plan lacked documentation of appropriate sling sheet sizes and measurements. The facility's records did not show any assessment to identify the correct sling size based on the resident's height and weight, nor did they ensure the sling was suitable for the lift used. Interviews with staff revealed inconsistencies in sling sizes used for residents and a lack of proper measurement for sling sheets. Staff were expected to use any available sling sheets for transfers, regardless of the resident's specific needs or the lift manufacturer's instructions. The facility had not ordered additional sling sheets from the manufacturer, and there was no process in place to assess residents for the correct size sling or to ensure that information from a safety assessment was included in the care plan. This lack of a systematic approach to sling usage and lift transfers contributed to the deficiency.
Failure to Verify Professional Licensure of Hired Staff
Penalty
Summary
The facility failed to ensure that a staff member hired as a registered nurse (RN) was not employed with a disciplinary action in effect against his professional license by the Minnesota Board of Nursing. The staff member, who was hired as an RN, did not hold an RN license and had a suspended licensed practical nurse (LPN) license. This deficiency had the potential to affect all residents in the facility. The director of nursing (DON) did not verify the professional licensure of the staff member before allowing him to begin employment. During the initial employment interview, the staff member claimed to hold an RN license, and upon hire, he signed the RN job description. However, the DON or designee failed to confirm the active RN licensure status before the staff member started working. It was later discovered that the staff member had never held an RN license and his LPN license was suspended. The DON discussed the findings with the acting administrator and contacted the police department. The staff member worked as a trainee from February 23 through February 26, shadowing licensed staff at all times and was never left unsupervised. On February 27, the staff member was scheduled to work a day shift but was directed to the DON's office upon clocking in. When asked about his RN license, the staff member falsely claimed to have one. The DON then informed him that a search of the nursing board website revealed that he did not have an RN license and that his LPN license was suspended. The facility did not provide a copy of the license verification policy when requested.
Failure to Follow Wound Care Protocols and Infection Control Practices
Penalty
Summary
The facility failed to follow physician-ordered wound treatments and did not ensure appropriate infection control practices during wound care for two residents. For the first resident, the registered nurse (RN) did not perform hand hygiene between glove changes, did not use a barrier for wound supplies, and did not follow the physician's orders for wound care. The RN also left the wound open to air without covering it as per the physician's instructions and did not address other wounds that required attention. The RN placed the wound kit back into a cupboard without disinfecting it, further risking cross-contamination. The second resident also experienced improper wound care. The RN did not use a barrier for wound supplies, placed wound cleanser on the floor without a barrier, and did not follow the correct procedure for cleaning the wound. The RN also failed to perform hand hygiene between glove changes and did not follow the physician's orders for wound care. The wound kit was again placed back into storage without proper disinfection. Interviews with staff and review of facility policies confirmed that the RN did not follow the expected procedures for wound care and infection control. The facility's Director of Nursing and Wound Ostomy Consultant Nurse Practitioner both stated that the RN did not adhere to the physician's orders and proper infection control practices, which could potentially slow down the healing process and increase the risk of infection.
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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