Parkview Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Wells, Minnesota.
- Location
- 55 Tenth Street Southeast, Wells, Minnesota 56097
- CMS Provider Number
- 245436
- Inspections on file
- 23
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Parkview Care Center during CMS and state inspections, most recent first.
A resident admitted after major colorectal surgery with a perineal incision did not have hospital aftercare instructions for offloading, limited sitting, and skin protection transcribed into facility orders or incorporated into the baseline care plan. For nearly two weeks, there were no comprehensive skin assessments or monitoring of the surgical site, and staff were unaware of the need to keep the resident off the surgical area, while the resident routinely sat for extended periods. When the wound began to dehisce, the facility delayed developing a comprehensive care plan, failed to obtain and follow complete wound treatment orders, used non-ordered Vashe cleanser, inconsistently packed the wound, and did not thoroughly document or analyze increasing drainage, odor, and changes in wound size, nor consistently notify the surgical team. These failures, along with poor documentation of refusals and lack of timely reassessment, contributed to progression from partial to complete wound dehiscence with increased depth, tunneling, and pain.
Two residents at high risk for pressure injuries did not receive adequate pressure ulcer prevention and treatment. One resident with multiple comorbidities and limited mobility was identified as at risk but was not initially placed on a turning/repositioning program, had no heel treatments, and lacked a comprehensive tissue-tolerance assessment. When a right heel ulcer and a sacral wound developed, wound assessments were repeatedly inaccurate, ordered heel boots and sacral dressings were not consistently used, pressure-redistributing cushions were improperly positioned, and several ordered treatments were missed; the RD was not informed of the ulcers and made no nutrition recommendations. Another resident with hemiplegia and very poor Braden scores was readmitted with red heels and ordered heel-floating, but developed right heel blisters and subsequent stage 2 ulcers; documentation lacked detailed wound characteristics, treatment orders were delayed, and observations showed the heel resting on the mattress despite heel protectors. The DON and hospice RN later confirmed that assessments were inaccurate and that improper repositioning and failure to float the heel contributed to ulcer development and worsening.
Two residents experienced changes in transfer status recommended by therapy that were not timely incorporated into their care plans. One resident with cancer and recent GI surgery had a care plan indicating assist of one with a walker, while a Rehab Communication form documented that the resident was independent in the room with a walker. Another resident with chronic kidney failure, heart failure, atrial fibrillation, a hip fracture, and a heel pressure ulcer had a care plan requiring a sit-to-stand mechanical lift for toilet transfers, but a Rehab Communication form changed the transfer method to assist of one with a gait belt and wheeled walker. CNAs reported relying on Rehab Communication forms rather than the care plan/Kardex, and the DON acknowledged that the care plans had not been updated to reflect the therapy recommendations, contrary to facility policy requiring care plan review and revision upon status change.
A resident with venous stasis ulcers and multiple comorbidities received wound care during which the ADON removed soiled dressings, handled wound cleanser, and cleaned the wounds while wearing the same pair of gloves, then changed to a new pair of gloves without performing hand hygiene between tasks. The ADON stated that hand hygiene was only needed after completing the entire dressing change and cited the lack of hand sanitizer in the room, despite the RN infection preventionist and the facility’s hand hygiene policy specifying that hand hygiene must be performed before donning gloves, between glove changes, and after contact with soiled items, and that glove use does not replace hand hygiene.
Staff failed to ensure dishes were fully air dried before storage, with wet plates, trays, and covers observed being stacked without proper drainage. Additionally, outdated food items remained in the refrigerator past the required seven-day limit, with unclear staff responsibility for timely disposal. These actions were not in accordance with facility policy and had the potential to affect all residents.
A resident with anxiety and depression, who was cognitively intact, reported $100 in cash missing from her billfold. The social services director was informed but did not report the potential theft to the State Agency or law enforcement, contrary to facility policy. Staff interviews and document review confirmed the incident was not documented or reported as required.
A resident with anxiety and depression, who was cognitively intact and dependent on staff, reported missing cash from her billfold. The social services director conducted a limited investigation, interviewing only a few nursing staff and the resident's family member, and failed to document interviews with other relevant staff or the resident. The investigation and documentation did not meet facility policy requirements for thoroughness and completeness.
A resident with schizophrenia and diabetes mellitus was documented in both the care plan and MAR as receiving olanzapine for schizophrenia, but the MDS assessment incorrectly indicated no antipsychotic use. The DON confirmed the error, acknowledging that the MDS should have reflected the resident's antipsychotic medication use.
A dietary aide used a dusty fan to blow directly on clean, wet dishes during air drying, despite facility policy prohibiting such devices in the dish drying area. Multiple staff, including the dietary director and infection preventionist, were unaware of the fan's condition or cleaning schedule, and the fan had visible dust and debris on its blades and cage.
A resident with a history of edema developed a stage 2 pressure ulcer on the right toe, which progressed to stage 3 due to the facility's failure to consistently assess, monitor, and follow wound care orders. Staff did not document wound healing, missed regular assessments, and failed to communicate changes to the medical provider, resulting in deterioration of the ulcer.
A resident with multiple comorbidities was not properly monitored for fluid intake or changes in condition following a CT scan with contrast dye, despite physician orders intended to protect kidney function. Staff failed to document or communicate critical changes, and the resident was ultimately hospitalized with acute kidney injury and died. Additionally, another resident with a complex wound did not receive consistent or comprehensive wound assessments, with missing measurements and delayed physician notification, contrary to facility policy.
A resident with multiple health issues did not receive timely administration of provider-ordered medications, Rocephin and Z-Pak, despite their availability in the facility's E-Kit. The RN on duty failed to process or administer the medications, and the DON also did not administer them, leading to a deficiency in care.
The facility did not follow proper food safety protocols for thawing frozen meat, as observed when turkey breast and pork were thawed in a water bath without continuous running cold water. This practice contradicts FDA guidelines, which require thawing under refrigeration or running water to prevent foodborne illness. Staff training confirmed the use of a cold-water bath, but the necessary conditions were not met.
A long-term care facility failed to adhere to infection control practices, including hand hygiene and PPE use. Staff were observed not performing hand hygiene when entering and exiting resident rooms, and not wearing required PPE when assisting a resident with an indwelling urinary catheter. Mechanical lifts were not sanitized after use, and an agency staff member used an N95 mask without proper fit-testing. These deficiencies were acknowledged by facility leadership.
The facility failed to clean rooms of residents on transmission-based precautions (TBP) and maintain the environment in good repair. Housekeeping did not clean TBP rooms, and nursing staff were not trained for this task. Observations showed soiled bathrooms and tables, and the infection preventionist was unsure of cleaning responsibilities. Additionally, the tub room flooring was in disrepair, with chipped paint and missing tiles, and there was no policy for facility maintenance.
Two residents in an LTC facility did not receive adequate personal hygiene care, including bathing and oral care, due to staff inaction and lack of adherence to facility policies. One resident, under COVID-19 precautions, was not offered a bed bath as an alternative to a tub bath, and another resident in quarantine did not receive a bath for 10 days. Staff interviews revealed a lack of awareness of policies for bathing residents with COVID-19.
A resident with severe cognitive impairment and multiple health conditions went five days without a bowel movement due to the facility's failure to implement the BM protocol. Despite having standing orders for constipation management, the resident did not receive the prescribed milk of magnesia until the fifth day. Interviews revealed a lack of awareness among staff regarding the alert system in the EMR, and the facility did not provide a bowel management policy when requested.
Failure to Transcribe Aftercare Orders and Manage Surgical Wound Led to Dehiscence
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess, monitor, care plan, and follow physician and hospital aftercare orders for a resident with a recent abdominoperineal resection and perineal surgical wound. The resident was admitted after major colorectal surgery with hospital after-visit instructions that included strict offloading of the surgical area, limits on sitting time, use of a pillow, frequent position changes, and avoidance of hard surfaces and shearing. These aftercare instructions were not transcribed into the facility’s physician orders from admission through at least 1/13, and the baseline care plan dated shortly after admission did not identify any skin integrity issues or the rectal/perineal incision. The admission MDS documented a recent GI surgery and a surgical wound, but the corresponding CAA did not trigger skin issues, and there was no baseline or comprehensive care plan addressing the surgical wound or GI surgery-related nursing care until 1/14, 12 days after admission. During the period from admission through 1/13, the record lacked comprehensive skin assessments and monitoring of the rectal surgical incision, despite the resident having a recent major surgery requiring active skilled nursing. Staff later reported that on admission the incision was closed with sutures and without dehiscence, but there was no ongoing documented assessment. On 1/14, concern for purulent drainage from the surgical site was documented, and a skin integrity care plan and physician orders were initiated to limit sitting and promote offloading; however, prior to that date there was no documentation that offloading had been offered or attempted, and no documentation of refusals. The facility’s own appointment communication form later acknowledged that the resident had not been offloaded as ordered and had been sitting more than 10 minutes per hour without appropriate pillow or cushion use. Nursing staff also reported they were unaware of the surgical incision and offloading requirements until after the wound began to open, and there was no documentation of resident refusals or re-approach efforts. Once the wound began to dehisce, the facility did not consistently obtain or follow complete wound treatment orders, nor did it document thorough wound assessments or timely care plan revisions in response to changes. A skin assessment on 1/15 identified a partially dehisced surgical wound with drainage and a dressing in place, but there were no corresponding wound treatment orders specifying the dressing type or duration at that time. After the surgeon ordered daily packing with iodoform or gauze and later increased packing frequency and volume, facility documentation showed use of Vashe cleanser without a physician order, incomplete descriptions of the amount of packing used, and failure to document or analyze increased drainage, odor, and wound deterioration. Progress notes described heavy, odorous drainage and changes in wound size and depth, including development of undermining and tunneling, but there was no documented comprehensive assessment of these changes, no timely notification of the surgical team when directed, and no evidence that the care plan was revised in response. Observations on 1/30 showed the wound not fully packed to the brim, saturated dressings, and mechanical debridement performed without rinsing, while the resident reported significant pain and prolonged sitting earlier in the stay. The colorectal surgeon stated that aftercare instructions were not followed, the wound was not packed correctly, there was no communication from the facility, and questioned whether facility nurses were properly trained in wound packing, while the DON acknowledged missing the hospital aftercare orders at admission and failing to ensure admission and weekly wound assessments were completed as required. The facility’s documentation between the initial partial dehiscence and later complete dehiscence did not clearly identify when the wound fully opened or when significant changes in size occurred. Although the TAR showed dressing changes as completed per order, narrative notes revealed use of non-ordered cleansing solutions and incomplete packing. The resident reported not being instructed to limit sitting time until after the first surgical follow-up and described routinely sitting for extended periods early in the stay. Staff interviews confirmed lack of awareness of the surgical wound and offloading needs, lack of re-approach or education when repositioning was reportedly refused, and absence of refusal documentation. The DON further stated there was no documentation of monitoring that fully addressed changes to the wound between assessments since admission, despite a facility policy requiring wound treatments to follow physician orders, obtain orders when absent, and monitor effectiveness through ongoing assessment and modification when wounds fail to progress or characteristics change. These combined failures—omission of hospital aftercare orders from admission, lack of early and ongoing comprehensive wound assessment and monitoring, delayed and incomplete care planning for the surgical wound, failure to consistently follow and clarify physician and surgical wound care orders, use of non-ordered wound cleansers, inadequate documentation of wound changes and resident refusals, and lack of timely communication with the surgical team—resulted in documented deterioration of the resident’s surgical wound from partial to complete dehiscence, with increased depth, tunneling, heavy drainage, strong odor, and increased pain requiring ongoing treatment.
Failure to Accurately Assess and Implement Pressure Ulcer Prevention and Treatment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, monitor, and implement individualized pressure ulcer prevention and treatment for two residents at risk for pressure injuries, resulting in actual harm to one resident. One resident with chronic kidney failure, heart failure, atrial fibrillation, obesity, decreased mobility, incontinence, and oxygen use was identified on admission as at risk for pressure ulcers, with dry skin on both heels and a foam dressing on the coccyx. The Braden assessment showed risk but did not include clinical suggestions to reduce pressure ulcer development, and the baseline care plan did not include pressure reduction interventions. The admission MDS identified the resident as dependent for bed mobility and transfers and at risk for pressure ulcers, but the resident was not placed on a turning and repositioning program, had no nutrition or hydration interventions, and had no dressing or treatments to the feet. There was no comprehensive assessment of tissue tolerance to pressure over time to support the chosen repositioning schedule. Several days after admission, staff documented a pressure area on the right heel with redness and a blue area, applied skin prep, a foam dressing, and puffy boots, and notified the provider, but the note lacked detailed wound characteristics. An incident report identified an unstageable pressure ulcer on the right heel, and a skin integrity care plan was initiated two days later, listing multiple interventions such as heel protection boots, pressure-relieving mattress and cushions, and turning and repositioning every two hours. However, the record between admission and this care plan did not show a comprehensive assessment to determine appropriate repositioning frequency. Subsequent wound assessments of the right heel and sacral/coccyx area were repeatedly inaccurate: a dark purple heel wound was documented as a stage 1 pressure injury instead of a deep tissue injury, and an open sacral wound was documented as an open lesion or stage 2 coccyx ulcer instead of an unstageable or stage 3 sacral pressure ulcer as later confirmed by the DON and a wound clinic. The wound clinic documented a stage 3 sacral pressure ulcer requiring debridement and recommended frequent turning and repositioning, but there was no indication that the facility reassessed the repositioning schedule after this visit. Observations showed that ordered interventions were not consistently implemented. The resident was seen in a wheelchair with the right heel resting directly on the metal foot pedal without Prevalon boots, despite care plan directions for heel protection when foot pedals were in use, and the resident reported heel soreness. The sacral area was observed without the ordered dressing on more than one occasion. The pressure-redistributing wheelchair cushion was found slipping forward so that most of the resident’s buttocks were on the bare wheelchair seat, and the NA acknowledged the cushion needed an antiskid pad. Treatment records showed missed applications of ordered skin protectant to the heel and wound dressings to the coccyx/sacrum on multiple days. The consulting RD reported not being informed of the resident’s pressure ulcers and therefore made no nutrition recommendations. A second resident, with hemiplegia, heart failure, atrial fibrillation, and high Braden risk (constantly moist, chairfast, completely immobile, very poor nutrition), was readmitted from the hospital with heels noted as a little red and with instructions that heels had been floated. The facility revised the care plan to include turning, repositioning, and heel protectors, but again there was no comprehensive assessment of tissue tolerance to justify the every-two-hour schedule. For this second resident, a new right heel open area was documented, but the skin assessment lacked detailed wound characteristics and there was no corresponding physician order at that time. A subsequent skin issue assessment described a blister that had reabsorbed fluid, but again lacked detailed descriptors. Hospice documentation identified a right heel blister with peeled skin and a non-adherent dressing, with instructions to ensure heels were floated and to use a foam dressing, but the facility’s physician orders for heel treatment were delayed and changed over several days. Later wound assessments described a blister with light drainage and foam dressing, while corresponding images showed an open blister extending from the lateral to the back of the heel with shiny, macerated skin and irregular edges. The DON acknowledged that the wound appeared worsened and that the assessment was inaccurate. During observation, the resident was in bed with heel protectors, but the right heel was resting directly on the air mattress rather than being fully floated. A hospice RN removed the dressing and identified two stage 2 pressure ulcers on the right heel (lateral and back), and stated these were caused by incorrect repositioning and failure to keep the heel floated. The facility’s own pressure injury prevention and management policy required a systematic approach with prompt assessment, intervention, monitoring, and modification of interventions, which was not followed in these cases.
Failure to Timely Revise Care Plans After Therapy Changes in Transfer Status
Penalty
Summary
The deficiency involves the facility’s failure to revise residents’ comprehensive care plans in a timely manner after changes in transfer status were identified by therapy. For one resident with malignant neoplasm of the anal canal and recent gastrointestinal surgery, the admission MDS documented that the resident was cognitively intact, had no rejection of care behaviors, was independent with bed mobility, and required set up or clean-up assistance for transfers. The ADL care plan dated 1/11/26 documented a self-care performance deficit related to gastrointestinal surgery, with interventions stating the resident was able to transfer with one staff and a front-wheeled walker, requiring partial assistance for bed-to-chair and chair-to-bed transfers and sit-to-stand. However, a Rehab Communication form dated 1/13/26 indicated that the resident’s transfer status had changed to independent in the room with a four-wheeled walker. On the day of surveyor observation, the nursing assistant caring for this resident stated she believed the resident could be independent in the room but had not verified the care plan or Kardex at the beginning of her shift. Upon review, she confirmed that the care plan still showed the resident required assist of one for transfers, while a separate Rehab Communication form showed the resident had been changed to independent on 1/13/26. The DON confirmed that the resident’s care plan for transfers still indicated assist of one and acknowledged that the care plan had not been revised in a timely manner to reflect the physical therapy recommendation for independent transfers with a walker, stating she had not had time to update the care plan. A second resident with chronic kidney failure, heart failure, atrial fibrillation, and a right heel pressure ulcer had an admission MDS indicating dependence for rolling and transfers, risk for pressure ulcers/injuries, and the presence of a surgical wound. The ADL care plan dated 1/6/26 documented a self-care deficit related to a hip fracture, with a goal to improve transfer function and an intervention specifying substantial one-staff assist with a sit-to-stand mechanical lift for toilet transfers. A Rehab Communication form dated 1/26/26 changed this resident’s transfer status to assist of one with a gait belt and wheeled walker, discontinuing the sit-to-stand lift. During observation, a nursing assistant prepared to transfer the resident to the commode using a walker and gait belt and stated she relied on the Rehab Communication form rather than the care plan/Kardex to determine transfer status. She verified that the care plan still required use of the sit-to-stand lift. The DON confirmed that the resident’s transfer status had been changed by therapy on 1/26/26 but that the care plan still reflected the sit-to-stand lift because it had not yet been updated, despite facility policy requiring review and revision of the care plan upon status change.
Failure to Perform Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to ensure proper hand hygiene during wound care for one resident. The resident had multiple diagnoses including chronic venous hypertension with ulcer, CHF, diabetes mellitus with foot ulcer, and atrial fibrillation, and had venous stasis ulcers to both lower extremities. Physician orders and hospital after-visit instructions directed that the bilateral lower extremity wounds be cleansed with normal saline or wound cleanser, followed by application of nonadherent dressings, ABD pads, and Kerlix. During an observed wound care procedure, the ADON wore a gown and gloves, removed the dressing from the resident’s left leg, discarded it, and then handled the wound cleanser bottle without removing gloves or performing hand hygiene. The ADON then sprayed the ulcer, grabbed gauze, and patted the wound with the same gloved hand. After this, the ADON removed her gloves and donned a new pair without performing hand hygiene in between. She then removed the dressing from the right leg and discarded it, again without performing hand hygiene as required. When questioned, the ADON stated that she did not need to perform hand hygiene until the entire dressing change was completed and questioned how she was supposed to perform hand hygiene between steps when there was no hand sanitizer in the room. In contrast, the RN infection preventionist stated that hand hygiene should be performed prior to entering a resident room, before applying gloves, between glove changes, and after contact with soiled items such as wound cleaning, and before touching clean wound supplies. The facility’s Hand Hygiene Policy required all staff to perform proper hand hygiene procedures to prevent the spread of infection, and additional facility guidance specified that glove use does not replace hand hygiene and that hand hygiene must be done before donning and immediately after removing gloves and after handling potentially contaminated items.
Failure to Properly Dry Dishes and Timely Discard Refrigerated Food
Penalty
Summary
The facility failed to ensure that dishes, including plates, trays, and plate covers, were completely dry before being stored. During an observation, a dietary aide was seen stacking dishes that still had visible water droplets on them, without allowing adequate air drying or spacing for drainage. The dietary aide stated she routinely put dishes away before leaving her shift and believed they were dry at the time. The dietary director later confirmed that dishes should be fully air dried or stacked in a way that allows for proper drainage and airflow, and the infection preventionist noted that not allowing dishes to air dry could lead to bacterial growth. The assistant administrator and administrator both stated that dishes should not be put away wet and that staff should follow the dietary director's instructions. Additionally, the facility did not dispose of refrigerated food items in a timely manner. During an inspection of the kitchen refrigerator, food items such as hot fudge and cheese sauce were found to be stored beyond the seven-day limit indicated by a sign on the refrigerator. The dietary aide was unaware of who was responsible for discarding outdated food, and the dietary director admitted she had not checked the refrigerator since the weekend. Facility policies required that refrigerated, ready-to-eat foods be discarded within seven days, and that the head cook or designee check the refrigerator daily for expiring items.
Failure to Report Alleged Theft of Resident Property
Penalty
Summary
The facility failed to report a potential theft of money belonging to a resident to the State Agency as required. The resident, who had diagnoses of anxiety and depression and was cognitively intact, reported that approximately $100 in cash was taken from her billfold while she was out of her room. The resident stated she had received the money from a family member and kept it in her recliner. She informed the social services director (SSD) about the missing money. Despite this, a review of progress notes, grievances, and state agency reports revealed no documentation or reporting of the alleged theft. Interviews with staff indicated that the registered nurse and nursing assistant were unaware of the missing money, while the SSD acknowledged being informed by the family member but did not report the incident. The SSD stated she did not think reporting was necessary because the family member did not want law enforcement involved or any action taken. However, facility policy required reporting all allegations of missing money to the state agency and law enforcement when applicable. The facility's assessment and policies indicated staff were trained in procedures for reporting abuse, neglect, exploitation, and misappropriation of property, but these procedures were not followed in this instance.
Failure to Thoroughly Investigate Alleged Theft of Resident Property
Penalty
Summary
The facility failed to thoroughly investigate an allegation of potential theft of money belonging to a resident with diagnoses of anxiety and depression, who was cognitively intact and dependent on staff for most activities of daily living. The resident reported to the social services director (SSD) that $100 in cash was missing from her billfold, which she kept in her recliner. The SSD documented limited interviews with four nursing staff and the resident's family member, but did not interview other relevant staff such as housekeeping, laundry, or activities personnel, nor did she document her interview with the resident. The documentation provided was incomplete, lacking dates, full names, titles, and proper authentication. The SSD admitted that the investigation was not thorough and that documentation was insufficient. The facility's policy required immediate and comprehensive investigation of suspected abuse, neglect, or exploitation, including interviewing all involved persons and providing complete documentation. However, the investigation did not include all potentially involved staff or residents, and the documentation did not meet facility policy standards. The assistant administrator and director of nursing were aware of the missing money and the incomplete investigation.
Inaccurate Coding of Antipsychotic Medication Use on MDS
Penalty
Summary
The facility failed to accurately code the use of antipsychotic medication on Section N of the Minimum Data Set (MDS) for one resident. The resident, who had a diagnosis of schizophrenia and diabetes mellitus, was documented in the care plan and medication administration record as receiving olanzapine, an antipsychotic medication, for management of schizophrenia. However, the quarterly MDS assessment indicated that the resident had not received any antipsychotic medications since admission. During an interview, the DON confirmed that she completed the MDS and acknowledged that Section N was inaccurately coded, as it should have reflected the resident's ongoing antipsychotic medication use. The facility's policy requires accurate assessments reflective of the resident's status at the time of assessment by qualified staff.
Dirty Fan Used in Dish Drying Area
Penalty
Summary
The facility failed to ensure that a fan blowing directly on clean dishes in the kitchen was free of dust and debris, which had the potential to affect all 18 residents. During an observation, a dietary aide was seen washing dishes and allowing them to air dry near a dishwasher while a small oscillating fan, visibly covered in dust and debris, was blowing directly onto the clean, wet dishes. The dietary aide acknowledged the fan was dirty and was unsure who was responsible for cleaning it or when it was last cleaned. Interviews with the dietary director, infection preventionist, assistant administrator, and administrator revealed that none were aware of the fan's condition or its use in the dish drying area. The dietary director believed the fan had been cleaned recently but noted that the air conditioner contributed to dust buildup. The infection preventionist and assistant administrator both stated they were unaware of the fan's use and expressed concerns about its appropriateness in the clean dish area. The facility's dish machine policy specifically prohibited the use of air circulation devices, such as fans, in the dish drying area.
Failure to Assess and Monitor Pressure Ulcer Resulting in Worsening Condition
Penalty
Summary
The facility failed to comprehensively assess, monitor, and provide appropriate interventions for a resident who developed a pressure ulcer, resulting in the progression of a stage 2 pressure ulcer to a stage 3. The resident, who had a history of edema and was at risk for pressure injuries, initially developed a small stage 2 ulceration on the right medial 4th toe. Podiatry provided specific wound care orders, including keeping the foot dry and maintaining the dressing, but documentation shows that these orders were not consistently followed. The treatment administration record indicated that the daily wound care order was discontinued after only one day, and there was no documentation that the wound had healed at that time. Nursing staff interviews revealed a lack of consistent wound assessment and monitoring. LPNs and RNs could not recall the specifics of the wound care provided, and there was confusion about the location and status of the ulcer. Weekly skin checks were reportedly performed, but staff admitted to not always checking between the toes, where the ulcer was located. The resident's care plan and facility policies required regular assessment and documentation of wounds, but there was no evidence of wound assessment or measurement for several months. The wound was eventually found to have deteriorated to a stage 3 pressure ulcer with significant slough and maceration, and the podiatrist noted that the wound had worsened since the initial evaluation. Communication failures were also evident, as the medical doctor had not received updates on the wound's status between the initial and follow-up evaluations. Staff interviews indicated that the wound was not consistently reported or documented, and there was no clear protocol for monitoring the wound after it was considered healed. The director of nursing confirmed that there was no documentation of the wound being healed and that a scabbed wound would not be considered healed. Facility policies required evidence-based wound care and ongoing assessment, but these were not followed, leading to the resident's pressure ulcer worsening.
Failure to Monitor Post-Contrast Renal Risk and Inadequate Wound Assessment
Penalty
Summary
The facility failed to comprehensively assess and monitor a resident following a CT scan with contrast dye, despite the resident's significant risk factors for acute renal failure. The resident had multiple comorbidities, including hemiplegia, heart failure, renal failure, diabetes, and morbid obesity, and was dependent on staff for all activities of daily living. Although there was a physician order for the resident to drink a specified amount of water daily before the dye study to protect kidney function, the order was transcribed incorrectly as 'encourage' rather than 'drink,' and there was no documentation or monitoring of the resident's actual fluid intake. Additionally, staff did not monitor or document urine output, and there was no evidence that the physician was notified of the resident's elevated temperature or significant weight gain, both of which could indicate fluid overload or infection. Staff interviews revealed a lack of awareness and communication regarding the need to monitor fluid intake and the risks associated with the CT scan with contrast. Nursing assistants and LPNs were not informed about the fluid order or the importance of monitoring intake and output, and there was confusion about the resident's care needs. The director of nursing acknowledged the error in transcribing the order and the lack of monitoring, and also noted that changes in the resident's condition were not documented in a timely manner. The resident's condition deteriorated over several days, with symptoms including wheezing, decreased appetite, and minimal fluid intake, but appropriate assessments and notifications were delayed. Ultimately, the resident was transferred to the hospital with severe acute kidney injury and died due to acute and chronic kidney failure. The facility also failed to comprehensively assess, monitor, and treat wounds for another resident with non-pressure skin concerns. Documentation showed inconsistent and incomplete wound assessments, with missing measurements and lack of weekly evaluations as required by the care plan and facility policy. There was confusion among staff regarding the nature and management of the wound, and the physician was not promptly informed of the wound's location and severity. The wound persisted for several months, with ongoing drainage and changes in treatment orders, but without consistent documentation or communication. The facility's policies required weekly comprehensive wound assessments and timely physician notification for changes, but these were not consistently followed.
Failure to Administer Timely Medications
Penalty
Summary
The facility failed to administer provider-ordered medications in a timely manner for a resident who was admitted with multiple diagnoses, including a fracture of the left ulna, chronic kidney disease stage 3A, diabetes, urinary tract infection, and atherosclerotic heart disease. The resident had completed an antibiotic course but continued to experience symptoms such as fever, chills, and confusion. On November 4th, the provider ordered Rocephin and a Z-Pak to be administered, which were available in the facility's Emergency Medication Kit (E-Kit). However, the registered nurse on duty did not process or administer these medications, despite knowing they were available in the E-Kit. The Director of Nursing, who came on duty the following morning, also did not administer the medications, although she processed the orders for the pharmacy. The physician confirmed that the medications should have been administered promptly after the order was faxed to the facility. The facility's policy on medication orders requires that medications be administered only upon signed orders and documented appropriately, but this process was not followed, leading to the deficiency.
Improper Thawing of Frozen Meat in Facility Kitchen
Penalty
Summary
The facility failed to adhere to proper food preparation safety requirements, specifically in the thawing of frozen meat, which could potentially lead to foodborne illness. During an observation, it was noted that oven-roasted turkey breast and a pork product were being thawed together in a water bath in the middle section of a three-section sink. However, there was no continuous running cold water to minimize or prevent the risk of foodborne illness, as required by safety standards. The dietary aide interviewed confirmed that staff training had been completed, and they were taught that a cold-water bath was an appropriate technique for thawing frozen meat. This technique and the facility's training were corroborated by the dietary manager. According to the FDA's Food Code 2022, proper thawing should occur under refrigeration or completely submerged under running water at a temperature of 70 degrees F or below, with sufficient water velocity to agitate and float off loose particles, ensuring the food temperature does not rise above 41 degrees F.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices, as evidenced by multiple observations of staff not performing hand hygiene and not using personal protective equipment (PPE) as required. A nursing assistant (NA-B) was observed entering and exiting resident rooms without performing hand hygiene, despite facility policy requiring it upon entering and exiting resident rooms. Additionally, NA-B did not wear a gown or gloves when assisting a resident (R2) with a bed bath, despite a sign on the door indicating the need for enhanced barrier precautions (EBP) due to the resident's indwelling urinary catheter. Further observations revealed that mechanical lifts used for resident transfers were not sanitized after use. NA-B and another nursing assistant (NA-A) used a mechanical lift for transferring R2 without wearing the required PPE and did not sanitize the lift afterward. The lift was then left at the nurse's station and later used for another resident without being cleaned, increasing the risk of infection spread. NA-A confirmed the oversight and acknowledged the expectation to sanitize equipment immediately after use. Additionally, an agency staff member (NA-F) was observed using an N95 mask without being fit-tested for the specific brand used at the facility, which is a requirement for proper protection. The director of the long-term care staffing agency confirmed that the agency did not provide N95 fit training. These lapses in infection control practices were acknowledged by the facility's leadership, who stated that staff were expected to follow facility policies for hand hygiene, equipment cleaning, and PPE use.
Deficiencies in Cleaning and Maintenance for TBP Residents
Penalty
Summary
The facility failed to maintain cleanliness and proper sanitation in the rooms of residents on transmission-based precautions (TBP), affecting several residents. Housekeeping staff did not clean these rooms, and nursing staff were expected to do so but were not adequately trained or informed about the cleaning procedures and supplies. Observations revealed that shared bathrooms and over-bed tables were soiled with substances resembling feces, and nursing assistants admitted to not having received proper training for cleaning these areas. The infection preventionist was unsure of who was responsible for cleaning TBP rooms, acknowledging the need for regular cleaning and disinfecting. Additionally, the facility failed to maintain the environment in good repair, particularly in the west unit tub room. The flooring was in disrepair, with chipped paint and missing tiles, creating an uneven and potentially unclean surface. The environmental services director was aware of the flooring condition but had not addressed it, and there was no policy on facility upkeep and maintenance. These deficiencies were noted during interviews and observations, highlighting a lack of clarity and responsibility in maintaining a safe and clean environment for residents.
Deficiency in Personal Hygiene Care for Residents
Penalty
Summary
The facility failed to provide routine personal hygiene care, including oral care and bathing, for two residents who were dependent on staff for their activities of daily living (ADLs). One resident, identified as R80, had diagnoses including chronic kidney disease, fibromyalgia, and anxiety, and was under transmission-based precautions for COVID-19. Despite being dependent on staff for bathing and requiring assistance for oral care, R80 did not receive a bath as scheduled and was not offered a bed bath as an alternative. Additionally, R80 reported not being offered assistance with brushing teeth, and there was a lack of oral care supplies in the room. Another resident, R26, who had intact cognition and was receiving hospice care, also did not receive adequate personal hygiene care. R26 was in quarantine due to COVID-19 and had not been bathed since being placed in isolation. Despite needing substantial assistance with personal hygiene, R26 was not offered a bed bath during the quarantine period, which lasted 10 days. Staff interviews revealed a lack of awareness regarding the facility's policy for bathing residents with COVID-19, and it was noted that 10 days without a bath was too long, especially for a hospice patient. The facility's policies on resident showers and bed baths, as well as oral care, were reviewed and indicated that residents should be assisted with bathing to maintain proper hygiene. However, there was no specific policy available for residents with COVID-19 regarding bathing. The Director of Nursing (DON) stated that residents in isolation should receive weekly bed baths unless refused, and other hygiene care should be provided twice daily. The lack of documentation and adherence to these policies contributed to the deficiency in care for both residents.
Failure to Implement Bowel Movement Protocol for Resident
Penalty
Summary
The facility failed to implement the bowel movement (BM) protocol for a resident with severe cognitive impairment, congestive heart failure, kidney failure, and diabetes. The resident was dependent on staff for toileting and frequently incontinent of bowel and bladder. Despite having a physician's order for milk of magnesia to be given every 24 hours as needed for constipation, and standing orders for escalating interventions if no BM occurred over several days, the resident went five days without a BM before receiving milk of magnesia on the fifth day. Interviews revealed that a Licensed Practical Nurse (LPN) was aware of an alert system in the electronic medical record (EMR) that notified staff if a resident went longer than 48 hours without a BM, but another LPN was not familiar with this system. The Director of Nursing (DON) expected nursing staff to monitor and utilize standing orders to prevent constipation. However, the facility did not provide a policy regarding the management of bowel elimination when requested.
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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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