Park River Healthcare And Rehabilitation Center Ll
Inspection history, citations, penalties and survey trends for this long-term care facility in Coon Rapids, Minnesota.
- Location
- 9899 Avocet Street Northwest, Coon Rapids, Minnesota 55433
- CMS Provider Number
- 245448
- Inspections on file
- 21
- Latest survey
- June 12, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Park River Healthcare And Rehabilitation Center Ll during CMS and state inspections, most recent first.
Three residents with significant medical conditions and care needs were left unsupervised during mealtimes, despite requiring assistance or monitoring with eating. Staff interviews confirmed that a NA was expected to be present in the dining room at all times during meals, but this did not occur, and no policy was provided when requested.
A medication cart was repeatedly left unlocked and unattended, allowing a resident with severe cognitive impairment to access and remove items from the cart. Staff interviews confirmed the expectation that medication carts should be locked when not in use, but the cart was left out of sight and unsecured for several minutes, with no policy provided upon request.
A resident with diabetes and multiple comorbidities was not given the option to continue using a Continuous Glucose Monitoring (CGM) device, despite hospital discharge orders including both CGM and Accu-Chek methods. The facility implemented only Accu-Chek monitoring without consulting the resident or family, and staff confirmed that CGMs were allowed and used by others. No documentation or policy was provided to show that resident choice was considered.
A resident with multiple medical conditions and a fall risk was placed in an electric recliner that they could not operate independently, as staff placed the remote out of reach. Staff confirmed the resident could not get out of the chair alone or use the remote due to cognitive impairment. The care plan and health record lacked documentation or assessment for the recliner's use, contrary to facility policy requiring such evaluation.
Two residents received PRN psychotropic medications without required 14-day stop dates or provider justification for extended use. One resident was given ongoing Prochlorperazine for nausea and vomiting, and another received frequent PRN lorazepam for anxiety, with both orders lacking appropriate time limitations. Staff interviews and policy review revealed a lack of awareness and missing procedures regarding the 14-day rule for PRN psychotropic medications.
A resident with a Foley catheter and a diagnosis of benign prostatic hyperplasia was admitted and required assistance with all ADLs. The care plan did not address catheter use or monitoring for side effects, despite staff acknowledging the need for such documentation to ensure proper monitoring for infection and other catheter-related care. Facility policy required comprehensive and current care plans, but this was not followed.
A resident with multiple chronic conditions and moderate cognitive impairment developed a non-pressure wound on the right foot, but the care plan was not updated to reflect this new skin concern. The care plan only addressed general risks for skin alterations and did not include specific interventions for the identified wound, despite facility policy and expectations for timely updates.
Two residents dependent on staff for ADL support did not receive appropriate assistance with personal hygiene and grooming. One resident, with multiple health conditions, was not asked about or assisted with shaving despite expressing a preference to be clean-shaven. Another resident received improper peri-care when a nursing assistant used the same washcloth for both the buttocks and groin, contrary to infection control procedures. Care plans lacked specific directions for these needs.
The facility failed to provide routine assistance with proper positioning for a resident dining in bed, did not consistently assess and monitor a non-pressure wound for another resident, and did not monitor blood pressure and pulse prior to administering Metoprolol as ordered. Staff did not consistently offer or provide positioning help, wound documentation was incomplete with gaps in progress notes, and vital sign monitoring was not performed or documented before medication administration.
A resident with multiple chronic conditions and a stage four pressure ulcer did not receive weekly wound assessments as required by facility policy. Although care plans and provider orders specified regular monitoring and treatment, documentation showed that wound audits were missed between two assessment dates. Both the ADON and DON confirmed the lapse in weekly assessments, which is contrary to the facility's protocol for pressure ulcer management.
A resident with an indwelling Foley catheter did not receive proper catheter care when a nursing assistant cleaned the catheter tubing in the wrong direction, used the same rag for both bowel movement residue and catheter care, and failed to sanitize the catheter and collection bag connections before switching bags. These actions did not follow facility policy or infection control standards, as confirmed by interviews with the NA, infection preventionist, and DON.
A resident with end-stage renal disease who received hemodialysis outside the facility did not have required monitoring of their dialysis shunt for bruit and thrill, as directed by their care plan and facility policy. Nursing staff did not perform or document these assessments, and both an LPN and the DON confirmed that such monitoring was not conducted.
Pharmacist consultant recommendations regarding medication orders were not acted upon, and irregularities in monthly drug regimen reviews were not identified or addressed for multiple residents. For example, a resident's PRN antipsychotic order lacked a required stop date despite repeated pharmacist recommendations, and other residents' records lacked evidence of necessary lab monitoring or proper documentation for PRN psychotropic use. Facility policies did not address these requirements, contributing to the deficiencies.
A resident with multiple diagnoses and prescribed antipsychotic, antidepressant, and statin medications did not receive appropriate laboratory monitoring for potential side effects or treatment effectiveness. The facility lacked documentation of pharmacy consultant recommendations for lab monitoring, and staff interviews revealed no standing orders or policies for medication-related lab testing. The facility's policy required monitoring for side effects but did not address lab monitoring for antipsychotic medications.
Staff failed to consistently perform hand hygiene after glove removal and did not properly use PPE, such as gowns, during high-contact care for two residents with significant care needs, including incontinence and indwelling devices. Despite facility policies and posted precautions, staff often neglected required infection control practices, as confirmed by staff interviews and direct observation.
A resident with significant cognitive impairment and right-sided hemiplegia was repeatedly found without access to a call light within reach, as staff placed the device on the resident's affected side despite his inability to use it. The care plan did not direct staff to place the call light on the resident's functional side, and no facility policy for call light use was available. Staff and resident interviews confirmed the deficiency.
The facility did not make available the required survey and complaint investigation results, including 2567 reports and facility responses, for residents, families, visitors, and staff to review. Only recertification survey results were posted, while documentation from complaint investigations was missing, and the administrator was unaware of the full posting requirements.
A resident with Alzheimer's disease and osteoarthritis, who was non-ambulatory and required two staff and a mechanical lift for transfers, was instead transferred by one nursing assistant using a gait belt. This deviation from the care plan led to the resident falling into her wheelchair and sustaining a comminuted distal humeral shaft fracture. Staff interviews and documentation confirmed that the care plan was not followed, resulting in actual harm.
The facility failed to clarify and document a resident's advance directive upon admission, despite conflicting documentation and the resident's alert and oriented status. Multiple staff members confirmed the absence of the advance directive in the resident's chart, contrary to facility policy.
The facility failed to ensure that the consulting pharmacist identified irregularities in the monthly drug regimen reviews for four residents taking psychotropic medications. The pharmacist did not recommend necessary monitoring for hypotension or conducting AIMS assessments, and the medical records lacked evidence of these measures. The DON confirmed the oversight, emphasizing the importance of monitoring for adverse effects and preventing falls.
The facility failed to monitor for potential cardiovascular and neurological adverse consequences and obtain informed consent for psychotropic medication use in four residents. Medical records lacked evidence of pharmacy consultant recommendations, monitoring for hypotension, AIMS assessments, and informed consent documentation.
The facility failed to ensure that four residents were offered and/or provided the pneumococcal vaccine series as recommended by the CDC. The immunization records lacked documentation of being offered or receiving the PCV20 vaccine, and there was no evidence of shared clinical decision-making with their physicians.
The facility failed to ensure the proper assessment and use of a reclining wheelchair for a resident with severe cognitive impairment and multiple diagnoses, leading to several falls. Despite therapy recommendations and staff education, the wheelchair was often fully reclined, contrary to guidelines. The director of nursing confirmed that necessary assessments, provider orders, and consents were not obtained as required by facility policy.
Failure to Provide Required Supervision During Mealtimes
Penalty
Summary
The facility failed to provide required supervision during mealtimes for three residents who needed assistance or monitoring while eating. Observations showed that these residents, who had diagnoses such as cerebral palsy, dementia, malnutrition, progressive neurological conditions, Alzheimer's disease, Parkinson's disease, cancer, and heart failure, were left unsupervised in the dining room during breakfast. Staff were not present in the dining room for several minutes while residents were eating, despite the residents' care plans indicating a need for supervision or assistance with eating. One resident was observed coughing while eating, but no staff were present at that time to provide immediate assistance. Interviews with dietary and nursing staff confirmed that facility policy and expectations required a nursing assistant to be present in the dining room whenever residents were eating, to ensure safety and provide assistance if needed. Staff acknowledged that there were periods when no staff were present in the dining room during meals, and that this was not consistent with facility expectations. The facility was unable to provide a policy regarding dining supervision when requested.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure the safe storage of medications as required, specifically by leaving a medication cart unlocked and unattended on the west unit. Multiple observations showed a resident with severe cognitive impairment and a history of fidgeting with items accessing the medication cart and its contents while staff were not present. The resident was seen sitting at, touching, and retrieving items from the medication cart, including supplement drinks, and was able to remove and conceal items in his wheelchair. At times, the medication cart was left in the hallway, unlocked, and out of the direct line of sight of nursing staff. Interviews with staff, including the LPN, ADON, DON, and consultant pharmacist, confirmed that the expectation was for medication carts to be locked whenever not in use or when the nurse was not in direct control of the cart. Staff acknowledged the resident's tendency to wander and pick up items, and confirmed that the cart was left unlocked for several minutes while unattended. The facility was unable to provide a policy regarding medication cart security when requested.
Failure to Honor Resident Choice in Blood Glucose Monitoring Method
Penalty
Summary
The facility failed to honor a resident's right to make choices regarding the method of blood glucose monitoring. A resident with a history of diabetes mellitus, neuropathy, aphasia, hemiplegia, cancer, hypertension, hyperlipidemia, arthritis, depression, and cataracts, and who had experienced cognitive decline since admission, was not given the option to continue using a Continuous Glucose Monitoring (CGM) device as previously used. The resident's hospital discharge summary included orders for both traditional Accu-Chek monitoring and CGM supplies, but the facility only implemented Accu-Chek monitoring without consulting the resident or their family about their preference. During interviews, the resident's family expressed concern that the facility did not allow the use of CGM devices and that no choice was offered regarding the monitoring method. Facility staff, including an LPN and the DON, confirmed that CGMs were permitted and used by other residents, and that the expectation was to discuss monitoring preferences with the resident or their representative. However, there was no documentation of such a discussion or a process for CGM use in the facility's policies. Additionally, the facility was unable to provide policies regarding the admission process, order implementation, or resident choice when requested.
Failure to Assess and Prevent Use of Electric Recliner as Physical Restraint
Penalty
Summary
A deficiency occurred when a resident with intact cognition and multiple medical diagnoses, including cancer, heart failure, and malnutrition, was placed in an electric recliner that functioned as a physical restraint. The resident required assistance with all activities of daily living and was identified as a fall risk. Observations revealed that staff placed the resident in the recliner, elevated the footrest, and then positioned the remote control out of the resident's reach, preventing independent operation of the chair. The care plan did not address the use of the electric recliner, and the electronic health record lacked documentation of an assessment for its use. Interviews with staff confirmed that the resident was unable to get out of the recliner independently and did not know how to use the remote due to cognitive impairment. The facility's policy required a physical device assessment to ensure safe operation of such devices, but no assessment was completed for this resident. The director of nursing acknowledged that without the ability to operate the chair, its use constituted a restraint, and confirmed that the required assessment had not been performed.
Failure to Limit PRN Psychotropic Medication Orders to 14 Days or Provide Justification
Penalty
Summary
The facility failed to ensure that as-needed (PRN) psychotropic medications were limited to 14 days or extended with a specific date and supporting rationale from the medical provider for two residents. For one resident with diagnoses including cancer, diabetes, arthritis, and malnutrition, the medication administration record showed an ongoing order for Prochlorperazine Maleate, an antipsychotic often used for nausea and vomiting, without a stop date or documented rationale for continued use beyond 14 days. This omission was consistent across several months of medication records. Interviews with nursing staff revealed a lack of awareness regarding the requirement for a stop date on such orders, and the facility's policy did not address the 14-day limitation or the need for provider evaluation for continued PRN psychotropic use. Another resident, with a history of Alzheimer's, dementia, anxiety, and other chronic conditions, had an active order for PRN lorazepam for anxiety that also lacked a 14-day stop date. Medication records indicated frequent administration of lorazepam over several weeks. Observations documented the resident repeatedly calling out for help, with staff responding to needs but the behavior persisting. Interviews with staff confirmed regular administration of PRN lorazepam and acknowledged the absence of a required stop date or provider justification for extended use. The facility's policy on psychotherapeutic medications required documentation of diagnosis, consent, and assessment prior to administration but did not specify requirements for PRN psychotropic medication duration, provider evaluation, or clear parameters for use. Both the director of nursing and consultant pharmacist confirmed that the orders should have included a stop date or provider justification, but these were not present in the reviewed cases.
Failure to Include Urinary Catheter Management in Care Plan
Penalty
Summary
The facility failed to ensure that the care plan for a resident with a urinary catheter included management and monitoring of the catheter. The resident, who had intact cognition and required assistance with all activities of daily living, was admitted with a diagnosis of benign prostatic hyperplasia and had a Foley catheter in place as ordered in the electronic health record. However, review of the care plan revealed that it did not address the use of the Foley catheter or include monitoring for side effects related to the catheter. Interviews with facility staff confirmed that the catheter was not included in the care plan upon admission, and that it should have been documented to ensure appropriate monitoring for signs and symptoms of infection, urine output, and other catheter-related care. The facility's policy required that care plans be comprehensive, current, and updated as the resident's care needs changed, but this was not followed in the case of the resident with the urinary catheter.
Care Plan Not Updated for Non-Pressure Wound
Penalty
Summary
The facility failed to revise the care plan to include a non-pressure wound for a resident who had moderate cognitive impairment and required extensive assistance with activities of daily living. The resident had multiple diagnoses, including chronic respiratory failure, congestive heart failure, heart disease, osteoarthritis, anemia, hypertension, and Alzheimer's disease. Although the care plan addressed the potential for skin alterations due to immobility and incontinence, it did not identify or include interventions for a non-pressure wound on the resident's right foot second toe, which was identified by staff. The director of nursing confirmed that care plans were expected to be updated with any change in resident status or new skin concerns, and facility policy required care plans to be current at all times.
Failure to Provide Adequate ADL Assistance and Proper Hygiene Practices
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for two residents who were dependent on staff support. One resident, with intact cognition and multiple diagnoses including cancer, heart failure, and malnutrition, required help with all ADLs. The resident's care plan did not include preferences or instructions for shaving and personal hygiene. Observations over several days showed the resident had significant facial hair, and interviews revealed that staff had not inquired about or assisted with shaving. The resident expressed a preference to be clean-shaven and stated that staff had not asked about or provided shaving assistance. The director of nursing confirmed that staff were expected to ask about shaving preferences and provide assistance, especially since the resident might not be able to request it due to confusion. Another resident, with moderate cognitive impairment and multiple chronic conditions, also required staff assistance with all ADLs. The care plan indicated a need for help with grooming but lacked specific directions for personal hygiene. During peri-care after incontinence, a nursing assistant used the same washcloth to clean both the buttocks and groin, which was acknowledged as an infection control concern by both the assistant and the infection preventionist. The facility's procedure required separate cleaning methods to prevent cross-contamination, but this was not followed. The activities of daily living policy was requested but not provided.
Failure to Provide Proper Positioning, Wound Monitoring, and Medication Administration Monitoring
Penalty
Summary
The facility failed to provide routine assistance with proper positioning for a resident who was dining in bed, despite the resident's care plan indicating the need for support due to hemiplegia, GERD, dysphagia, and COPD. Observations showed the resident repeatedly leaning to one side while eating, with staff either not noticing or not providing hands-on assistance unless prompted. The care plan did not include instructions for eating in bed, and facility policy lacked guidance on proper body alignment or support for dining in bed. Staff interviews confirmed that assistance was not consistently offered or provided, and the resident acknowledged improved comfort and ability to eat when repositioned. The facility also failed to consistently assess and monitor a non-pressure wound for another resident. Although the wound was identified and measured at times, there were multiple gaps in documentation and progress notes regarding the wound's status, measurements, and assessments over several months. The care plan did not reflect the presence of the wound, and weekly wound audits were not always accompanied by corresponding progress notes. Staff interviews revealed that daily assessments were not documented in the electronic medical record, and the assistant director of nursing was responsible for weekly measurements, but gaps occurred when the wound was scabbed over without clear documentation of changes. Additionally, the facility did not monitor blood pressure and pulse prior to administering Metoprolol to a resident with physician-ordered parameters. Review of the medication administration record showed no documentation of vital sign monitoring before medication administration over a period of more than two months. Staff interviews confirmed that nurses were unaware of the need to check blood pressure and pulse before giving the medication, despite the order being present in the record. The director of nursing and consultant pharmacist both confirmed that the order required monitoring, but it was not performed or documented.
Failure to Complete Weekly Pressure Ulcer Assessments
Penalty
Summary
A deficiency occurred when the facility failed to comprehensively assess and monitor a pressure ulcer for a resident with multiple complex medical conditions, including moderate cognitive impairment, multiple sclerosis, peripheral vascular disease, neurogenic bladder, arthritis, Alzheimer's disease, non-Alzheimer's dementia, malnutrition, and localized edema. The resident was identified as being at risk for pressure sores and had an existing stage four pressure ulcer on the left heel. Provider orders and the care plan included specific interventions such as the use of pressure redistribution boots, nutritional supplementation, wound cleansing, and weekly skin audits by licensed staff. Despite these interventions, documentation and interviews revealed that wound assessments were not completed weekly as required by facility protocol and policy. The electronic medical record showed that wound audits were performed on two specific dates, with no assessment documented in the intervening period. Both the assistant director of nursing (ADON) and the director of nursing (DON) confirmed that weekly wound assessments were not conducted as expected, acknowledging that this lapse could hinder the ability to monitor healing and detect complications in a timely manner. The facility's policy on the treatment and prevention of pressure ulcers mandates weekly wound assessments and documentation, including detailed wound descriptions and progress notes. The failure to adhere to this protocol resulted in a lack of consistent monitoring for the resident's stage four pressure ulcer, which could compromise the effectiveness of the treatment plan and the resident's overall skin integrity management.
Improper Catheter Care and Infection Control Lapse
Penalty
Summary
A deficiency occurred when a nursing assistant (NA) failed to provide proper catheter care to a resident with an indwelling Foley catheter. The resident, who had moderate cognitive impairment and multiple diagnoses including neurogenic bladder, multiple sclerosis, and dementia, required assistance with all activities of daily living. During evening care, the NA cleaned the catheter tubing in the wrong direction, wiping from the tubing up toward the urethral opening, and used the same rag to clean both bowel movement residue and the catheter. Additionally, the NA did not sanitize the ends of the catheter tubing or the overnight collection bag before connecting them. Interviews with the NA, infection preventionist, and DON confirmed that the catheter care provided did not follow facility policy or standard infection control practices. The facility's policy required cleaning from the urethral opening down the tubing, using separate rags for cleaning BM and catheter care, and sanitizing connections with alcohol before attaching a new collection bag. The observed actions were identified as improper and posed a potential risk for urinary tract infection.
Failure to Monitor Dialysis Shunt for Bruit and Thrill
Penalty
Summary
The facility failed to ensure appropriate post-dialysis assessment and monitoring for a resident with end-stage renal disease who received hemodialysis outside the facility. The resident's care plan required daily assessment of the dialysis shunt, including checking for a palpable thrill and auscultating for a bruit, with instructions to report the absence of these signs to the dialysis unit and physician. However, the medical record lacked documentation of any monitoring for bruit and thrill, and the Medication Administration Record (MAR) and Treatment Administration Record (TAR) did not include directions or evidence of such monitoring. Interviews with the resident and staff confirmed that nursing staff did not perform or document these assessments. Further, an LPN was unaware of the requirements to check for bruit and thrill and stated that nothing needed to be done with the access site, while the DON confirmed that staff did not check for bruit and thrill on dialysis patients. The facility's own Hemodialysis Access Care policy required staff to check the patency of the site at regular intervals by palpating for thrill or auscultating for bruit, but this was not followed for the resident in question.
Failure to Act on Pharmacist Recommendations and Identify Medication Irregularities
Penalty
Summary
The facility failed to ensure that pharmacist consultant recommendations were acted upon and that irregularities in monthly drug regimen reviews were properly identified and addressed for several residents. For one resident with multiple diagnoses including cancer, diabetes, and chronic pain, the consultant pharmacist made recommendations regarding a PRN order for Prochlorperazine, noting the need for a 14-day stop date or a switch to an alternative medication. These recommendations were documented in the consultant pharmacist's reports for two consecutive months, but there was no evidence in the medical record that the recommendations were implemented or that the provider was contacted for clarification. The medication remained on the resident's record without use, and the facility lacked a tracking system to ensure follow-up on pharmacist recommendations. For another resident with diagnoses including bipolar disorder and major depression, the medical record showed active orders for several medications, including statins and antipsychotics, but lacked evidence of pharmacy consultant recommendations for necessary laboratory monitoring. Interviews with nursing staff and the DON revealed that there was no facility policy or standing order for lab monitoring of these medications, and the consultant pharmacist did not identify or recommend lab monitoring during monthly reviews, relying instead on the provider to order labs. A third resident with Alzheimer's disease and anxiety had an active PRN order for lorazepam without a required 14-day stop date. The consultant pharmacist did not identify or recommend an end date for this medication during the monthly review, and the order remained in place without proper documentation or justification for continued use. The facility's policies and procedures were also found to be lacking, as they did not address requirements for lab monitoring, PRN psychotherapeutic medication use, or the necessary 14-day stop date and face-to-face provider evaluation for PRN psychotropic medications.
Failure to Monitor Antipsychotic and High-Risk Medications with Required Lab Testing
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs by not appropriately monitoring antipsychotic and other high-risk medications in accordance with standard-of-care laboratory testing. The resident, who was cognitively intact but totally dependent on staff for activities of daily living, had multiple diagnoses including bipolar disorder, major depression, and hyperlipidemia, and was prescribed several medications such as rosuvastatin, aripiprazole, venlafaxine, and olanzapine. Despite these prescriptions, the resident's medical record lacked evidence of laboratory monitoring for potential side effects and treatment effectiveness of the statin, antidepressant, or antipsychotic medications since admission. Additionally, there was no documentation of pharmacy consultant recommendations for laboratory monitoring related to these medications. Interviews with facility staff, including an LPN, the DON, and the consultant pharmacist, revealed that there were no standing orders or facility policies regarding lab monitoring for medication safety, and that the consultant pharmacist did not routinely check for annual lab monitoring, relying instead on the provider to order necessary labs. The facility's policy on psychotherapeutic medications required ongoing monitoring for side effects but did not address laboratory monitoring for antipsychotic medications.
Failure to Consistently Implement Hand Hygiene and Enhanced Barrier Precautions
Penalty
Summary
Facility staff failed to consistently implement proper hand hygiene and use of personal protective equipment (PPE) during resident care activities. In one instance, a nursing assistant did not perform hand hygiene after removing gloves and before exiting a resident's room, subsequently touching a door handle and attempting to enter another room. The nursing assistant acknowledged not performing hand hygiene and recognized the importance of this practice to prevent the spread of germs. Facility policies required handwashing before and after resident care, but these were not followed in this case. Another deficiency was observed regarding the use of Enhanced Barrier Precautions (EBP) for a resident with an indwelling catheter and a stage four pressure ulcer. Although signage and supplies for EBP were present, a nursing assistant provided peri-care and catheter care while wearing gloves but not a gown, despite coming into contact with the resident and their environment. Multiple staff interviews confirmed that gowns and gloves should be used for residents on EBP, but it was reported that gowns were rarely used, and staff often did not follow posted precaution guidance. The infection preventionist and other staff members acknowledged that compliance with EBP protocols was lacking, with staff frequently neglecting to wear gowns as required. The facility's EBP policy specified that gowns and gloves should be worn during high-contact care activities for residents at increased risk for multidrug-resistant organisms (MDROs), such as those with wounds or indwelling devices. Despite repeated education, staff did not consistently adhere to these protocols, resulting in the observed deficiencies.
Failure to Ensure Call Light Accessibility for Resident with Hemiplegia
Penalty
Summary
A deficiency occurred when staff failed to consistently ensure that a resident with significant cognitive impairment and right-sided weakness had access to a working call light within reach. The resident's care plan identified cognitive deficits, vascular dementia, cerebral infarction, and hemiplegia affecting the right side, but did not provide specific instructions for staff to place the call light on the resident's unaffected left side. Multiple observations showed the call light was repeatedly placed on the resident's right side, which he was unable to use due to his physical limitations. Interviews with the resident confirmed he could not reach or use the call light when it was placed on his right side, and staff acknowledged the improper placement during the survey. The care plan lacked direction for staff to accommodate the resident's self-care deficits by ensuring necessary items, including the call light, were accessible on his functional side. Additionally, the facility did not have a policy available for call light use. The failure to provide the call light within reach limited the resident's ability to communicate needs, as observed and confirmed through staff and resident interviews.
Failure to Post Complete Survey and Complaint Investigation Results
Penalty
Summary
The facility failed to ensure that both recertification survey results and documentation from complaint investigations, including the 2567 reports and facility responses, were available for review by residents, families, visitors, and staff. Observations showed that only recertification survey results from the past three years were posted, while documentation related to complaint investigations was missing. Review of the Aspen Central Office system confirmed that several complaint investigations had been completed, some with citations, but these were not posted as required. During an interview, the administrator acknowledged unawareness of the requirement to post all investigation letters and 2567 documentation. No facility policy regarding the posting of survey results was available.
Failure to Follow Transfer Protocol Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident, who had diagnoses of Alzheimer's disease and osteoarthritis and was non-ambulatory, was not transferred according to her care plan. The care plan, nursing assistant care sheet, and physical therapy discharge plan all directed that the resident required the assistance of two staff members and the use of a mechanical lift for transfers. However, on the day of the incident, a nursing assistant transferred the resident from her bed to her wheelchair using only a gait belt and without the assistance of a second staff member. During this transfer, the resident fell backward into her wheelchair, resulting in immediate pain and a comminuted distal humeral shaft fracture, as confirmed by x-ray. Interviews with staff and review of documentation confirmed that the care plan was not followed, despite clear instructions on the care sheets and recent updates to the resident's transfer requirements due to her decline in mobility. The incident report, progress notes, and staff interviews all indicated that the resident was expected to be transferred with two staff and a mechanical lift, but this protocol was not adhered to at the time of the accident. The director of nursing and assistant director of nursing both acknowledged that the root cause of the injury was the failure to follow the established care plan.
Failure to Clarify and Document Advance Directive
Penalty
Summary
The facility failed to clarify the current advance directive for a resident (R328) when there was conflicting documentation in the record. R328 had diagnoses including Parkinson's Disease, adult failure to thrive, and chronic kidney disease, with a BIMS score indicating intact cognition. The hospital discharge summary indicated a DNR status, but there was no evidence of a discussion about changing the code status. Despite being alert and oriented, R328 stated that no one in the facility had talked to her about her wishes in the event of an emergency. Multiple staff members, including an LPN, TMA, ADON, and LSW, were interviewed and confirmed that there was no advance directive document present in the resident's chart, and the resident's code status was not clarified upon admission. The facility's policy required that advance directives be reviewed and documented upon admission, but this was not done for R328. The DON confirmed that the resident did not have any advance directives available in either the electronic medical record or paper copies. The failure to clarify and document the resident's advance directive could lead to staff not knowing how to respond in an emergency. The facility's policy stated that advance directives should be reviewed and updated at least quarterly, but this was not adhered to in this case.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to ensure that the consulting pharmacist identified irregularities in the monthly drug regimen reviews for four residents who were taking psychotropic medications. Specifically, the pharmacist did not recommend monitoring for hypotension or conducting AIMS assessments for residents R4, R25, R35, and R69. These residents had various diagnoses, including Alzheimer's disease, anxiety disorder, depression, Parkinson's disease, and dementia, and were prescribed medications such as Seroquel, Bupropion, Lorazepam, Haloperidol, Pimavanserin, Trazadone, and Citalopram. The medical records for these residents lacked evidence of the necessary monitoring and assessments as recommended by the pharmacist, such as orthostatic blood pressures and AIMS assessments, which are crucial for detecting side effects like hypotension and involuntary movements associated with psychotropic medications. The pharmacist admitted during an interview that he had missed recommending the necessary monitoring and assessments for these residents. He stated that orthostatic blood pressures should be done at least monthly for anyone taking psychotropic medications and that AIMS assessments should be completed as a baseline with the start of an antipsychotic. The pharmacist also acknowledged that he had missed recommending the facility to obtain new orders from the provider for the continued use of prn psychotropic medications like Lorazepam and Haloperidol for R25. The Director of Nursing (DON) confirmed that the facility relied on the pharmacist's recommendations and that the medical records for the residents in question lacked the necessary monitoring and assessments. The DON emphasized the importance of these measures for monitoring adverse effects and preventing falls. The facility's policy on psychotherapeutic medications also required documentation of outcomes, consent, and baseline AIMS assessments, which were not followed in these cases.
Failure to Monitor Psychotropic Medication Use and Obtain Informed Consent
Penalty
Summary
The facility failed to ensure proper monitoring for potential cardiovascular and neurological adverse consequences and obtaining informed consent with the use of psychotropic medications for four residents. These residents had various diagnoses, including Alzheimer's disease, Parkinson's disease, and major depressive disorder, and were prescribed psychotropic medications such as Seroquel, Bupropion, Lorazepam, Haloperidol, Pimavanserin, Trazadone, and Citalopram. The medical records for these residents lacked evidence of pharmacy consultant recommendations for monitoring hypotension and conducting AIMS assessments, as well as documentation of informed consent for the use of antipsychotic medications. For Resident 4, the medical record did not show any monitoring for hypotension or AIMS assessments since the initiation of psychotropic medications. Similarly, Resident 25's record lacked evidence of communication with the provider to obtain new orders for continued use of Lorazepam and Haloperidol. Resident 35's record also did not include monitoring for hypotension or pharmacy consultant recommendations. Resident 69's record was missing evidence of monitoring for hypotension, AIMS assessments, and informed consent for the use of antipsychotic medications. Interviews with the pharmacy consultant and the Director of Nursing (DON) confirmed these deficiencies. The pharmacy consultant admitted to missing recommendations for monitoring and AIMS assessments, while the DON acknowledged the lack of orthostatic blood pressure monitoring and informed consent documentation. The facility's policy on psychotherapeutic medications requires documentation of outcomes, informed consent, and baseline AIMS assessments, which were not followed in these cases.
Failure to Offer and Provide Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that four residents were offered and/or provided the pneumococcal vaccine series as recommended by the CDC. Specifically, residents R29, R33, R35, and R69 did not receive the PCV20 vaccine at least five years after their last pneumococcal dose, nor was there evidence of shared clinical decision-making with their physicians regarding this vaccination. The immunization records for these residents lacked documentation of being offered or receiving the PCV20 vaccine, despite having received previous doses of PPSV23 and PCV13 within the recommended timeframes. During an interview, the infection preventionist confirmed that immunizations are reviewed upon admission and that the CDC's pneumococcal vaccine recommendations were used to determine eligibility. However, the infection preventionist verified that the four residents had not been offered or provided education on the PCV20 vaccine and that there had been no shared clinical decision-making with their providers. The facility's policy indicated that adults of the specified age should receive a single dose of PCV15 followed by PPSV23 or a single dose of PCV20, but this was not adhered to in these cases.
Failure to Assess and Properly Use Reclining Wheelchair
Penalty
Summary
The facility failed to ensure the initial and ongoing assessment of physical device equipment restricting independent movement for a resident using a reclining wheelchair. The resident, who had severely impaired cognition and multiple diagnoses including non-Alzheimer's dementia and Parkinson's disease, experienced several falls from the reclining wheelchair. The care plan indicated the need for a high-backed wheelchair and identified the risk for falls related to poor safety awareness and balance problems. However, the medical record lacked a physical device assessment and care plan identifying the use of the reclining wheelchair as a potential physical restraint. The occupational therapy (OT) evaluation and plan of treatment identified the need for staff education on the proper use of the reclining wheelchair, specifically recommending the use of the tilt feature rather than fully reclining the chair. Despite multiple instances of staff education and labeling of the wheelchair, staff continued to fully recline the chair, which was against the therapy recommendations. Observations confirmed that the resident was often found fully reclined in the chair, and staff interviews revealed a lack of awareness of the therapy recommendations. The director of nursing (DON) confirmed that the fully reclined position and footrests of the wheelchair could hinder the resident from safely rising when attempting self-transfers. The DON also confirmed that a physical device assessment had not been completed, a provider order had not been obtained, and responsible party education on the risks and benefits or consent for use had not been obtained. The facility's policy on physical device assessment required these steps to be taken, but they were not followed in this case.
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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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