Parkview Manor Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Ellsworth, Minnesota.
- Location
- 308 Sherman Avenue, Ellsworth, Minnesota 56129
- CMS Provider Number
- 245553
- Inspections on file
- 19
- Latest survey
- March 27, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Parkview Manor Nursing Home during CMS and state inspections, most recent first.
Surveyors observed that the exhaust vent above the gas stove was coated with a thick, black grease-like substance. The CDM acknowledged the buildup and stated it had not been recently noticed, while the maintenance supervisor reported the vent had been replaced months earlier but was unaware of the current accumulation. The facility could not provide a policy for cleaning kitchen vents and equipment. This issue had the potential to affect all residents receiving food from the kitchen.
A Bunn coffee warmer and glass coffee pots containing hot coffee were placed on a counter in the dining room within easy reach of residents, with no consistent staff supervision present. The hot surface and pots created a potential burn hazard, and no safety policy for the dining room was provided when requested.
Staff failed to use appropriate PPE and perform hand hygiene during blood glucose testing and insulin administration for two residents, handling blood-contaminated items with bare hands and storing them in personal pockets. Additionally, a mechanical lift was not cleaned or disinfected between use with different residents, contrary to facility policy and infection control standards.
A resident with morbid obesity, arthritis, and reduced mobility experienced significant pain and discomfort in her wheelchair, leading her to remain isolated in her room and avoid activities. Although staff were aware of her discomfort and reported it to the DON, there was no documentation of therapy assessment or interventions to address her wheelchair fit, and the care plan directives regarding pain and mobility were not followed.
The facility did not properly integrate hospice care plans with its own care plans for two residents receiving hospice services. The care plans lacked clear information on when hospice visits would occur and did not specify which services were to be provided by hospice versus facility staff. Communication issues between hospice and facility staff further contributed to confusion about care responsibilities.
The facility failed to ensure that nurse aides were properly trained in cleaning and disinfecting the whirlpool tub according to the manufacturer's instructions. Observations revealed that aides were not following correct procedures, were unaware of appropriate disinfectant use, and lacked personal protective equipment. Interviews with aides and the DON highlighted a lack of formal training and competency checks specific to the whirlpool tub, with training being conducted informally on the job.
The facility failed to implement a comprehensive assessment protocol to ensure staff competencies, with the administrator unable to locate the previous assessment and starting a new one. Interviews revealed a lack of direct skills review and incomplete annual evaluations, with the DON not conducting necessary training or competencies.
The facility failed to analyze and document data submitted to the QAPI committee, lacking documentation of goals and analysis. An interview with the DON confirmed the absence of data analysis, measurable goals, and actions to meet those goals. Additionally, there was no formal process for feedback from staff, residents, or families. The QAPI Plan policy lacked mention of measurable goals or data analysis, and there was no evidence of a review to ensure regulatory compliance.
The facility did not have evidence of a Performance Improvement Project (PIP) as part of its QAPI program, which is crucial for identifying high-risk areas. The QAPI minutes showed no PIP projects, and the DON confirmed that the new administrator opted out of participating in such projects. The QAPI Plan policy lacked guidance on identifying and measuring PIP projects, and there was no evidence of an annual review to ensure compliance with regulations.
The facility failed to ensure proper reconciliation of controlled medication counts, risking potential diversion. An RN and LPN were unable to verify documentation for the emergency kit (Ekit) containing controlled medications, and the DON confirmed that monitoring and documentation were not conducted as required. The Ekit contained medications like morphine sulfate and lorazepam, but the last documented removal was months prior, with no policy provided.
The facility failed to properly clean and disinfect a whirlpool tub, affecting two residents. Observations showed that nurse aides did not follow manufacturer guidelines and used incorrect cleaning solutions. The correct disinfectant was inaccessible due to a water heater installation, and the staff lacked formal training on proper procedures. The facility's outdated policies and training materials contributed to the deficiency.
Kitchen Exhaust Vent Found with Heavy Grease and Dirt Accumulation
Penalty
Summary
During an observation and interview in the facility kitchen, surveyors identified a large rectangular exhaust vent above the gas stove that was covered with a black, thick grease-like substance. The certified dietary manager (CDM) acknowledged the vent's condition, stating it had been cleaned by maintenance a couple of months prior and believed the buildup was likely rust and dust, but admitted she had not noticed its current appearance and agreed it needed cleaning. The maintenance supervisor reported that the vent had been replaced a couple of months ago due to rust and paint chipping, but was unaware of the extent of dirt and grease accumulation since then. He stated that the black buildup could not be wiped off and required a heavy degreaser for removal. Additionally, when requested, the facility was unable to provide a policy on cleaning vents and equipment in the kitchen. This deficiency had the potential to affect all 28 residents who received food prepared in the facility kitchen, as the vent's condition could contaminate food being prepared and served.
Unattended Hot Coffee Warmer Poses Burn Hazard in Dining Room
Penalty
Summary
A Bunn brand double element coffee warmer was observed in the dining room, switched on by a dietary staff member prior to meal service. The coffee warmer, along with glass coffee pots containing hot coffee, was placed on a counter within easy reach of residents, including those walking or using wheelchairs. The surface of the warmer was noted to be very hot, and there was no consistent staff presence in the dining room to monitor the coffee or prevent residents from attempting to serve themselves. Interviews with the certified dietary manager and the administrator confirmed that the coffee warmer was routinely used in this manner and acknowledged the potential for burns if a resident touched the hot surface or attempted to self-serve. The facility did not provide a policy for safety in the dining room when requested during the survey.
Failure to Follow Infection Control Practices During Insulin Administration and Equipment Use
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during blood glucose testing and insulin administration for two residents. An LPN was observed performing blood glucose monitoring and insulin injections without wearing gloves or performing hand hygiene. The LPN handled blood-contaminated items, such as lancets and cotton balls, with bare hands and placed these items, along with the insulin pen, into her scrub pocket. After administering insulin, the LPN disposed of the used items and cleaned the blood glucose meter only after completing the procedures, rather than between residents. The LPN acknowledged she should have worn gloves and performed hand hygiene but stated she forgot due to being nervous while observed. The DON confirmed that staff are expected to use appropriate PPE and follow infection control measures, especially when contact with blood is involved. Additionally, the facility failed to ensure mechanical lifts were cleaned and disinfected between resident use. A CNA in training was observed moving a mechanical lift from one resident's room to another without cleaning it in between. The CNA stated he was trained to clean lifts at the end of each shift, not between residents, and believed this was the facility's policy. The DON clarified that lifts are to be cleaned and disinfected after each use, regardless of the resident's precaution status, and that new staff are trained accordingly. Facility policy also requires cleaning and disinfection of reusable medical equipment between residents.
Failure to Assess and Accommodate Resident's Wheelchair Needs
Penalty
Summary
The facility failed to ensure that a resident with severe morbid obesity, arthritis, reduced mobility, and a stage II pressure ulcer was appropriately assessed by therapy for a properly fitting wheelchair. The resident, who required extensive assistance with activities of daily living and experienced pain that interfered with her daily activities, reported significant discomfort when using her wheelchair, which led her to remain in her room and avoid activities. Multiple staff members, including an activity aide and a nursing assistant, were aware that the resident was refusing to leave her room due to pain associated with her wheelchair and had reported this to the director of nursing. However, there was no documentation that the resident had been assessed for wheelchair fit or that therapy had been notified to evaluate her needs. The resident's care plan identified risks related to impaired mobility, pain, skin integrity, and limited activity involvement, with interventions to monitor and address pain and discomfort. Despite these care plan directives, the medical record and progress notes lacked evidence that the underlying cause of the resident's refusals—her discomfort in the wheelchair—had been investigated or addressed. Interviews with nursing staff and the administrator confirmed that no referral to therapy or physician notification had occurred to assess the resident for an appropriate wheelchair, and no interventions were documented to improve her comfort while seated.
Failure to Integrate Hospice and Facility Care Plans for Residents
Penalty
Summary
The facility failed to ensure that the hospice plan of care was integrated with the facility care plan for two residents who were receiving hospice services. For one resident with severe cognitive impairment, multiple chronic conditions, and a life expectancy of less than six months, the care plan only indicated that hospice visits would occur but did not specify when these visits would take place or delineate which services were to be provided by the facility versus hospice. Similarly, for another resident admitted with a cancer diagnosis and a focus on comfort care, the care plan did not clarify the division of responsibilities between the hospice agency and facility staff. During interviews, the hospice registered nurse reported communication issues with facility staff, including confusion about the roles of hospice and facility aides during bathing and assistance with positioning and dressing. The facility's policy requires care plans to describe all services provided, incorporate resident wishes and goals, and identify which professional services are responsible for each aspect of care. However, the care plans reviewed did not meet these requirements, as they lacked clear delineation of services and responsibilities between the facility and hospice agency.
Inadequate Training for Whirlpool Tub Cleaning
Penalty
Summary
The facility failed to ensure that all 25 nurse aides responsible for bathing residents were appropriately trained and deemed competent in the cleaning and disinfection of the whirlpool tub according to the manufacturer's instructions. Observations and interviews revealed that nurse aides were not following the correct procedures for cleaning and disinfecting the whirlpool tub. For instance, NA-B was observed using a Clorox Fuzion cleaner/disinfectant spray and a brush to clean the tub, but she was unaware of the correct disinfecting time or whether the disinfectant solution was coming out of the jets. Additionally, NA-B did not wear any personal protective equipment (PPE) while performing the task. Further observations and interviews with other nurse aides, such as NA-C, indicated similar issues. NA-C used a Triforce bleach solution with an overpowering smell and was unsure if it was appropriate for the whirlpool tub. She also received training from a colleague who no longer worked at the facility and was unaware of any specific training checklist or competencies for the whirlpool. NA-D and NA-E also expressed uncertainty about the training they received, with NA-E mentioning that the online courses provided were not specific to the tub used at the facility. The Director of Nursing (DON) confirmed that the facility lacked a formal checklist for training nurse aides on whirlpool cleaning and disinfection. There were no accessible records of employee training or competencies completed, and training was conducted on the job alongside colleagues. The facility's training policy from 2020 indicated that initial orientation and yearly online training would be provided, but there was no indication that the training was specific to the facility's equipment.
Failure to Implement Facility-Wide Assessment Protocol
Penalty
Summary
The facility failed to implement a comprehensive facility-wide assessment protocol to ensure staff competencies were identified and completed according to their duties. During an interview, the administrator admitted to having just discussed the facility assessment with the Director of Nursing (DON) and revealed that the assessment had only been recently updated. The administrator was unable to locate the previous assessment and had to start a new one. This indicates a lack of continuity and oversight in maintaining up-to-date assessments. Further interviews revealed that the nursing assistant (NA) reported no direct review of skills or competencies, although online training was completed. The DON acknowledged that department heads had not been completing annual evaluations, and she had not conducted any skills training or competencies with the staff, except for an annual session on mechanical lifts. The facility assessment tool reviewed on 6/24/24 identified necessary staff education and competencies, including infection control procedures, but these were not being adequately addressed or implemented.
Deficiency in QAPI Data Analysis and Documentation
Penalty
Summary
The facility failed to ensure that data submitted to the Quality Assurance Performance Improvement (QAPI) committee was properly analyzed and documented. This deficiency was identified during a review of QAPI minutes from a meeting, which revealed a lack of documentation regarding facility goals and analysis. There was no response on how the facility would meet its goals, nor was there an evaluation of whether previous goals were met or if new processes had been identified. An interview with the Director of Nursing confirmed the absence of data analysis, measurable goals, and actions to meet those goals. Additionally, there was no formal process for staff, residents, or their families to provide feedback to improve areas identified in QAPI. The QAPI Plan policy, which was undated, provided guidance for quality improvement but lacked mention of measurable goals or data analysis. There was also no evidence that the plan had been reviewed to ensure it included all required regulatory elements.
Lack of Performance Improvement Project in QAPI Program
Penalty
Summary
The facility failed to provide evidence of a Performance Improvement Project (PIP) focusing on high-risk or problem-prone areas, as required by their Quality Assurance and Performance Improvement (QAPI) program. This deficiency was identified during a review of QAPI minutes from a meeting held on June 14, 2024, which showed no PIP projects were noted. An interview with the Director of Nursing (DON) on June 25, 2024, revealed that the facility had not conducted a PIP project because the new administrator chose not to participate in such projects. The DON acknowledged the importance of PIP projects in identifying high-level areas of concern to ensure the highest care possible for residents. Additionally, the facility's QAPI Plan policy, which was undated, lacked clear guidance on how PIP projects would be identified, educated to staff and residents, and measured for goal accomplishment and compliance. There was also no evidence that the QAPI Plan had been reviewed to ensure it included all required regulatory elements.
Failure to Reconcile Controlled Medication Counts
Penalty
Summary
The facility failed to ensure that staff followed protocols for verifying controlled medication counts, which could potentially lead to medication diversion. During an observation and interview, a registered nurse (RN) was unable to find documentation that the emergency kit (Ekit) containing controlled medications had been reconciled. The RN confirmed that without reconciling the Ekit controlled medication tag number each shift, it would be impossible to know if the Ekit had been tampered with. A licensed practical nurse (LPN) also revealed that nurses did not reconcile the Ekit controlled medications stored in the locked box within the medication cart. The LPN was unable to verify the tag number on the Ekit controlled medication box, indicating a lack of proper documentation and monitoring. The director of nursing (DON) confirmed that the Ekit controlled medication tag should be monitored and documented each shift, but was unable to find any documentation of this in the narcotic book. The DON discovered that the Ekit tag number had been transferred to a new non-narcotic book without proper documentation or signatures. The DON acknowledged that the tag numbers for the Ekit controlled medication had not been monitored or documented in the non-narcotic book either. A review of the Ekit controlled medication list showed several medications, including morphine sulfate and lorazepam, but the last documented removal was several months prior, with no policy on controlled medications provided.
Inadequate Cleaning and Disinfection of Whirlpool Tub
Penalty
Summary
The facility failed to ensure proper cleaning and disinfection of a whirlpool tub, affecting two residents who used it for bathing. Observations revealed that two nurse aides, NA-B and NA-C, did not follow the manufacturer's guidelines for cleaning the tub. NA-B used a Clorox Fuzion cleaner/disinfectant spray and scrubbed the tub without wearing personal protective equipment (PPE). She was unaware of the correct disinfecting procedure and whether the solution was effective. NA-C used a Triforce bleach solution, which had an overpowering smell, and was also unaware of the correct cleaning procedure. The facility's housekeeping supervisor and director of nursing (DON) confirmed that the correct disinfectant solution was not being used due to a water heater blocking access to the compartment where the solution should be added. The maintenance director acknowledged that the disinfectant solution had expired and was not being used, leading to only water being dispensed when the DISINFECT button was pressed. The DON admitted that there was no formal training or documentation for staff on the proper use and cleaning of the whirlpool tub. The facility's policies and training materials were outdated and not specific to the current equipment and procedures. The Triforce solution used was not intended for whirlpool tubs and required a different application method than what was being practiced. The lack of proper training and adherence to manufacturer guidelines resulted in inadequate cleaning and disinfection of the whirlpool tub, potentially compromising infection control measures.
Latest citations in Minnesota
A resident with dry eye syndrome and degenerative eye disease had orders for cyclosporine ophthalmic emulsion and Refresh Tears, both scheduled at the same time. Medication records and direct observation showed a TMA instilled cyclosporine drops in both eyes and immediately followed with Refresh Tears in both eyes without waiting between medications. This practice conflicted with referenced professional guidance recommending several minutes between multiple eye drops and with the medical provider’s recommendation to wait fifteen minutes between the two ophthalmic medications. No facility policy on ophthalmic medication administration was provided when requested.
A resident with severe cognitive impairment, impaired mobility, and high fall risk was care planned to have wheelchair footrests in place at all times, with staff ensuring proper positioning and monitoring for leaning during transport. A NA transported the resident in a manual wheelchair from the shower without the footrests, and while going through the doorway the wheelchair struck the door frame, causing the resident, who was leaning forward, to fall out. The resident sustained a T12 fracture, head injury with concussion, abrasions and contusions, and multiple right-hand lacerations requiring sutures, and the DON confirmed the care plan had not been followed.
A high‑risk, immobile resident with MS and prior heel DTI developed an avoidable unstageable coccygeal pressure ulcer after staff failed to consistently assess and document skin status, did not transfer or timely provide ordered pressure‑relieving mattresses, and did not reliably perform q2h repositioning. The resident was repeatedly left on a bedpan for prolonged periods despite early reports of this issue, and the toileting care plan was not revised to a bedside commode until after the coccygeal wound had significantly worsened. Wound assessments lacked complete measurements and staging, changes in wound size and color were not promptly recognized as deterioration or reported to providers, and recommended interventions from a wound NP (including an air mattress and offloading) were not promptly implemented. As a result, the coccygeal ulcer rapidly progressed to a large, necrotic, malodorous wound requiring hospital transfer and surgical debridement.
A resident with spastic hemiplegia, muscle weakness, and moderate cognitive impairment was observed using bilateral bed grab bars for bed mobility and transfers, but the care plan did not address grab bar or side rail use. Review of the EMR showed no completed bed mobility device or side rail assessment to determine the necessity or safety of the grab bars, and no documentation that risks and benefits were discussed or that informed consent was obtained. An LPN and the ADON stated that a bed mobility device assessment is required before grab bars are installed and confirmed that no such assessment existed for this resident.
A resident with bilateral heel pressure ulcers and multiple comorbidities received wound care during which an RN removed dressings from both heels, cleansed both wounds, and wiped each heel without changing gloves or performing hand hygiene between wounds or after disposing of soiled dressings. This practice conflicted with the facility’s written wound care procedure, which requires glove removal and hand hygiene after dressing removal and after wound cleansing. In interviews, the RN, NP, and DON/IP acknowledged that hand hygiene and glove changes are expected between dirty and clean tasks and between separate wounds to prevent infection.
A resident with MS, neurogenic bladder, mobility limitations, and existing pressure injuries was identified as dependent for toileting hygiene and at risk for pressure ulcers, yet the care plan lacked an individualized toileting/incontinence plan and a defined repositioning schedule. Despite a new coccyx pressure ulcer and documentation that interventions such as increased repositioning and incontinent care were needed, the care plan was not revised for a period of time to reflect these changes. During this time, the resident sometimes fell asleep on a bedpan and remained on it until staff removed it, and staff were not initially informed that the bedpan should no longer be used. The DON later acknowledged that the care plan revisions for turning, repositioning, and toileting were delayed until after the resident’s coccyx ulcer had significantly worsened.
A resident with diabetes, Crohn’s disease, bowel incontinence, and a history of MASD on the right gluteus developed an open, painful lesion on the right gluteal area that was documented over time without complete wound characteristics, clear etiology, or timely provider notification. Wound care orders were written for a stage 3 pressure ulcer on the left buttocks, while staff reported the wound was only on the right side and applied the left‑sided orders to the right gluteal wound in the absence of specific right‑side treatment orders. The DON acknowledged discomfort with staging the wound, lack of early physician notification, and confusion over wound classification, despite a facility policy requiring comprehensive wound assessment, consistent measurement, and provider notification when treatment orders are absent.
A resident with diabetes, chronic leg ulcer, kidney transplant, and a documented gluteal wound was care-planned for Enhanced Barrier Precautions (EBP), with posted instructions requiring gown and gloves for high-contact care such as transfers and wound care. During a telehealth wound assessment, the DON donned a gown and initially performed hand hygiene but then applied gloves without hand hygiene, removed a soiled dressing from the resident’s gluteal area, discarded it, removed gloves, and applied new gloves again without performing hand hygiene between glove changes. On another occasion, during use of a sit-to-stand lift, an NA wore gown and gloves, but the DON handled the lift harness, the resident’s clothing, and assisted with the transfer and repositioning while wearing a gown but no gloves, despite EBP requirements for transfers. The DON stated EBP was only needed for catheter or wound care and not for transfers, contradicting the posted EBP instructions and facility policy.
A resident with severe dementia, psychiatric disorders, and high dependence for ADLs was verbally abused during evening care when a NA, frustrated with the resident’s crying and resistance, loudly ridiculed her as acting like a two-year-old, threatened to hit her back if struck, told her she would be sent to a locked unit, and questioned who would want to care for her when she cried like a baby. Multiple staff witnessed the loud, stern, and intimidating tone and reported it to an LPN, who recognized it as verbal abuse but did not immediately remove the NA from duty or promptly report the allegation per policy, allowing the NA to continue working on the unit. Following this incident, the resident demonstrated increased crying, combativeness, resistance to care, wandering, self-isolation, and refusal of food, fluids, and medications above baseline, with documentation of significant emotional distress and subsequent ED evaluation for aggressive behaviors and poor intake.
A resident with dementia, bilateral above‑knee amputations, vascular disease, and severe protein‑calorie malnutrition developed a wound on an amputation stump that had a dressing dated several days before any documentation or treatment orders appeared in the record. Although bath audits and nursing notes initially reported no skin issues, a later assessment described a full‑thickness stage 4 ulcer/diabetic ulcer on the stump with exposed bone, erythema/edema, slough, and moderate serosanguineous drainage. Nursing staff interviews showed no one could identify who first discovered the wound or applied the initial dressing, and there was no evidence that the wound was assessed, the provider notified, or standing orders implemented when it was first present, despite facility expectations that new wounds be promptly evaluated and reported.
Failure to Follow Professional Standards for Ophthalmic Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice for administering ophthalmic medications to a resident with dry eye syndrome and degenerative eye disease. The resident was cognitively intact, required assistance with ADLs, and had physician orders for cyclosporine ophthalmic emulsion 0.05% one drop in both eyes twice daily and Refresh Tears ophthalmic solution one drop in both eyes four times daily for dry eyes. The administration summary showed that both eye medications were scheduled for the same time and were documented as being given at the same time on multiple dates. During a medication pass observation, a trained medication aide administered the ordered oral medications, then applied gloves and instilled one drop of cyclosporine in each eye, immediately followed by one drop of Refresh Tears in each eye, without any waiting period between the two medications. The surveyors referenced guidance from the American Academy of Allergy, Asthma, and Immunology stating that when more than one eye drop is ordered, three to four minutes should be allowed between drops in the same eye, and five to fifteen minutes should be allowed between different eye medications to prevent dilution. Interviews with the DON, pharmacy consultant, and medical provider confirmed that best practice and the provider’s recommendation were to wait between administration of cyclosporine and Refresh Tears, with the medical provider specifying a fifteen-minute interval. The facility did not provide a policy on ophthalmic medications when requested. The observed practice and documented administration times demonstrated that staff did not follow these professional standards or the medical provider’s recommended interval between the two eye medications.
Failure to Follow Wheelchair Transport Care Plan Leads to Fall With Injuries
Penalty
Summary
The deficiency involves the facility’s failure to implement care-planned fall prevention interventions for a resident at high risk for falls, resulting in a fall with injury. The resident had diagnoses including aphasia, dysphagia, muscle weakness, traumatic brain injury, and impaired mobility, with severe cognitive impairment documented on the MDS and dependence on staff for transfers and wheelchair transport. A care plan addressing wheelchair transport safety and positioning directed staff to ensure the resident was fully positioned and supported in the wheelchair prior to transport, verify footrests were in place prior to transport, and monitor for leaning, sliding, or unsafe positioning. An additional care-planned approach required wheelchair pedals to be on at all times. On the date of the incident, a nursing assistant transported the resident in a manual wheelchair from the shower room to the resident’s room without the foot pedals in place, contrary to the care plan. While being wheeled through the doorway, the wheelchair struck the door frame, causing the chair to stop and the resident, who had begun leaning forward, to fall out of the wheelchair onto the floor. Progress notes and ED documentation identified that the resident sustained a T12 vertebral fracture, a head injury with concussion, an abrasion and contusion to the head, a bruise to the left knee, and multiple lacerations to the right hand requiring sutures. The nursing assistant later acknowledged awareness that the foot pedals should have been on but did not apply them because the transport was only from the shower to the room. The DON confirmed that the resident’s care plan had not been followed when the fall occurred.
Failure to Implement and Update Pressure Ulcer Prevention and Treatment Led to Avoidable Unstageable Coccygeal Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, monitor, and implement individualized pressure ulcer prevention and treatment interventions for multiple high‑risk residents, resulting in an avoidable, unstageable coccygeal pressure ulcer for one resident that required surgical debridement and hospitalization. The resident had primary progressive multiple sclerosis, hereditary spastic paraplegia, obesity, and pre‑existing pressure‑related deep tissue injury to the left heel, and was identified as high risk for pressure ulcers on the Braden Scale due to constant moisture, chairfast status, very limited mobility, inadequate nutrition, and friction/shear risk. Hospital records on readmission documented irritant contact dermatitis of the bilateral gluteal cleft with specific cleansing and barrier cream orders, and facility documentation showed the resident could not reposition in bed or chair and required assist of two and a full‑body mechanical lift for transfers. Despite this, the admission/readmission skin assessment and weekly skin checks lacked measurements and detailed wound characteristics for the heel ulcer and gluteal dermatitis, and the care plan did not include comprehensive, individualized interventions beyond generic repositioning and wound care orders. After a new coccyx pressure ulcer was identified and documented as a stage 2 lesion, the facility failed to promptly and accurately update the care plan and implement recommended pressure‑relieving interventions. The wound nurse practitioner on 3/5 ordered coccyx wound care, an air mattress, pressure offloading, and a dietician consult, but the care plan was not revised and there was no evidence that an air mattress was placed on the bed for nearly two weeks. The environmental services director later confirmed that when the resident was moved to a new room, the gel mattress was not transferred, and the air mattress requested on 3/17 was not actually placed until the following day, despite being marked as completed. During this period, TAR documentation showed gaps in the every‑2‑hour repositioning order, and staff interviews revealed that CNAs were unaware of which residents were on repositioning programs, were not consistently repositioning residents, and had not received recent education on pressure ulcer prevention. The DON and RN case manager acknowledged that the coccyx wound increased in size and changed color between assessments, that the bed lacked the ordered gel mattress, and that the physician was not notified of the wound’s deterioration at that time. The facility also failed to timely modify toileting and incontinence care practices despite knowledge that the resident was being left on a bedpan for extended periods. The DON reported hearing before an IDT meeting that the resident had fallen asleep on a bedpan for an undetermined amount of time, but the care plan was not revised to discontinue bedpan use and implement a bedside commode until after the coccyx wound had significantly worsened. CNAs confirmed that the resident sometimes fell asleep on the bedpan and that they were not informed she should no longer use it until after the sore had worsened. Subsequent wound assessments documented rapid progression of the coccyx wound from a small stage 2 ulcer to a large, malodorous, necrotic wound with eschar, slough, erythema, and purulent drainage, ultimately classified as an unstageable pressure ulcer. The DON, NP, PA, and medical director all indicated that the lack of a pressure‑relieving mattress, failure to adjust pressure‑reducing interventions, and prolonged time on a bedpan likely contributed to the development and deterioration of the resident’s pressure ulcer, which was determined to be avoidable and resulted in hospitalization and surgical debridement. Additional documentation and interviews showed systemic assessment and communication failures related to pressure ulcer management. Weekly skin checks and wound assessments often omitted complete measurements, staging, and wound characteristics, and changes in wound size and appearance were not consistently recognized as deterioration or communicated to providers. The DON acknowledged that a 3/12 assessment showing increased wound size and purple discoloration should have been identified as a deep tissue injury and reported to the physician, but this did not occur. When nursing later documented foul odor, increased pain, and expanding necrotic tissue, telemedicine and PA responses deferred in‑person evaluation and ED transfer despite earlier recommendations that the resident be sent to the ED if an in‑person provider could not assess the wound. The NP ultimately found a large, malodorous, purulent wound with expanding eschar and ordered transfer to the hospital, where imaging and surgical findings confirmed a large necrotic sacral wound requiring extensive debridement. Throughout this sequence, the facility did not consistently follow its own pressure ulcer protocols, did not ensure ordered pressure‑relieving equipment was in place, and did not promptly revise care plans or interventions in response to known risk factors and documented wound changes. The report also notes that other residents reviewed for pressure ulcers were affected by similar failures in monitoring and individualized intervention, though detailed narratives focus primarily on this resident. Staff interviews revealed that CNAs relied on paper care guides that did not clearly identify residents on repositioning programs or at risk for skin breakdown, and that they were unaware of some residents’ special mattress orders or toileting restrictions. The DON and medical director stated that residents at risk for pressure ulcers should have immediate pressure‑relieving interventions and that existing ulcers require ongoing evaluation to prevent deterioration, but the documented practices for this resident did not align with those expectations. These combined actions and inactions—insufficient assessment detail, delayed or missing care plan revisions, failure to implement ordered support surfaces and repositioning, and delayed response to wound deterioration—constituted the deficiency in providing appropriate pressure ulcer care and preventing new ulcers from developing.
Failure to Assess, Care Plan, and Obtain Consent for Bed Grab Bar Use
Penalty
Summary
The deficiency involves the facility’s failure to follow required procedures before installing and using bed grab bars for a resident. The resident had diagnoses including spastic hemiplegia affecting the left side and muscle weakness, and an admission MDS indicating moderate cognitive impairment. During observation, the resident was seen in a power chair with bilateral grab bars on the bed and reported using them to roll in bed and for transfers. The resident’s care plan, dated 1/23/26, documented a need for assistance with bed mobility and independence with transfers but did not mention or address the use of grab bars or side rails. Review of the electronic medical record showed no completed grab bar/side rail or bed mobility device assessment to determine the necessity of the grab bars or whether the resident could safely use them. There was also no evidence that the resident or the resident’s representative had been educated on the risks of having a grab bar on the bed or that informed consent had been obtained. In interviews, an LPN and the ADON both stated that a bed mobility device assessment was required to determine need and safety prior to installing grab bars, and both confirmed that no such assessment was present in the resident’s record.
Failure to Perform Hand Hygiene and Change Gloves During Wound Care
Penalty
Summary
Surveyors observed that a registered nurse (RN) and a nurse practitioner (NP) did not follow the facility’s established infection control practices during wound care for one resident. During a wound treatment, the RN wore gloves while removing the dressing from the resident’s left heel, then removed the dressing from the right heel, sprayed both wounds with wound cleanser, wiped the left heel with gauze, and then used a clean gauze pad to wipe the right heel. The RN did not remove her gloves or perform hand hygiene after disposing of the soiled dressings or between cleaning the left and right heel wounds, contrary to the facility’s written wound care procedure, which requires glove removal and hand hygiene after removing the previous dressing and again after cleaning the wound. The resident’s admission MDS documented diagnoses including multiple rib fractures, heart failure, dementia, anxiety, and the presence of a pressure ulcer, and indicated the resident was cognitively intact and required staff assistance with care and transfers. The resident’s care plan identified pressure ulcers on both heels requiring wound care. In interviews, the RN, NP, and the DON/infection prevention nurse each stated that gloves should be changed when moving from dirty to clean areas and that hand hygiene is expected after glove removal and between wounds to prevent infection, confirming that the observed practice did not align with facility policy or expected infection control standards.
Failure to Timely Revise Care Plan for Toileting and Skin Integrity
Penalty
Summary
The deficiency involves the facility’s failure to timely revise and individualize a resident’s care plan to address toileting and incontinence needs in relation to impaired skin integrity. The resident had diagnoses including primary progressive multiple sclerosis, hereditary spastic paraplegia, obesity, and a pressure-induced deep tissue injury to the left heel. A Significant Change MDS identified the resident as dependent for toileting hygiene, with lower extremity range-of-motion limitations, wheelchair use, dependence for transfers, occasional urinary incontinence, intact cognition, and at risk for pressure ulcers with existing unhealed pressure injuries and MASD. The resident’s skin-focused care plan, revised on various dates, included skin inspections, wound care orders, weekly skin checks, pressure ulcer care to the left heel, nutritional supplements, and a gel mattress, but did not include an individualized toileting or incontinence plan. On a weekly skin check dated 3/3/26, nursing staff identified a new Stage 2 pressure ulcer on the coccyx and contact dermatitis on both gluteal folds. An IDT Final Post Review Follow Up dated 3/10/26 (signed 3/23/26) documented that a new skin issue had occurred and that interventions after the incident included wound care treatment orders, increased repositioning, and increased incontinent care. However, the resident’s care plan from 3/3/26 through 3/16/26 did not show revisions reflecting increased incontinence care or a repositioning schedule, and the care plan was not updated to include these elements until 3/17/26. During this period, the care plan still lacked an individualized toileting plan despite the resident’s identified incontinence and new coccyx pressure ulcer. Progress notes on 3/17/26 documented that the resident’s coccyx wound had declined, with an evaluation describing a deteriorating wound characterized as a Kennedy terminal ulcer/End of Life, staged as a Stage 4 pressure ulcer, in-house acquired, with increased size, exudate, odor, pain, and surrounding erythema. On that same date, the skin focus care plan was revised to include prompt incontinence care and keeping the skin clean and dry, and the elimination focus care plan was revised to address incontinence due to neurogenic bladder with use of a bedside commode offered every 2–3 hours. A nursing assistant reported that when working with the resident, the resident would sometimes fall asleep on the bedpan and forget to ask staff to remove it, and that she was not aware the resident was not supposed to use the bedpan until after the sore had worsened. The DON stated that the resident’s care plan had not been revised earlier to include a turning and repositioning schedule or toileting changes, and that it should have been revised as soon as staff learned the resident was falling asleep on the bedpan, rather than waiting until after the pressure ulcer worsened.
Failure to Assess and Notify Provider for Right Gluteal Wound
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess and appropriately manage a non‑pressure skin issue on a resident’s right gluteal area, and to notify the physician in a timely manner. The resident had diagnoses including diabetes, Crohn’s disease, and a kidney transplant, and the MDS indicated occasional bowel incontinence, no pressure ulcers, and no moisture‑associated skin damage at that time. Earlier documentation identified a resolved MASD to the right gluteus, and a progress note later described a sacral wound with creams applied, noting that sores were still open and painful during application, but without any measurements, wound characteristics, or evidence of physician notification. Subsequent wound assessments documented an open lesion on the right gluteus with specific measurements on multiple dates, but did not identify the wound type or other characteristics, and the record did not show physician notification or treatment orders for the right gluteal lesion. Provider orders in place initially addressed cleansing the buttocks and applying barrier cream, and later included a detailed wound care order for a stage 3 pressure ulcer documented on the left buttocks. However, the resident’s record did not contain a specific treatment order for the right gluteal wound, despite the ongoing documentation of an open lesion in that area. Interviews revealed confusion and inconsistency in wound identification and classification. The DON stated that the right gluteal wound was documented as an open lesion because she did not feel comfortable determining the wound type, and acknowledged that the physician should have been notified when the wound was first identified. The DON was unaware that the NP had documented the wound as being on the left buttocks and as a stage 3 pressure ulcer, while the RN reported that the wound had never been on the left buttocks and that she had been applying the left‑sided wound orders to the right gluteal area because there was no open area on the left. The resident reported a recurring painful area on the right buttocks and chronic stool leakage since prior anal fistula surgery. The facility’s own wound treatment policy required comprehensive assessment of wound etiology and characteristics, consistent measurement and documentation, and provider notification in the absence of treatment orders, which were not followed for this resident’s right gluteal wound. The deficiency centers on the lack of a comprehensive wound assessment for the right gluteal lesion, incomplete documentation of wound characteristics, failure to clearly determine and document the wound etiology, and failure to notify the physician and obtain appropriate treatment orders when the wound was identified and remained open. These actions and inactions resulted in a discrepancy between the documented wound location and type and the actual clinical presentation, as well as a period during which the right gluteal wound had no specific, clearly ordered treatment despite being open and painful.
Failure to Perform Hand Hygiene and Implement Enhanced Barrier Precautions During Wound Care and Transfers
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper hand hygiene during wound care and to consistently implement Enhanced Barrier Precautions (EBP) for a resident requiring such measures. The resident had diagnoses including diabetes, a non-pressure chronic ulcer of the right lower leg, and a kidney transplant, and a wound assessment documented an open lesion on the right gluteal area. The resident’s care plan and a sign posted outside the room specified that EBP, including gown and gloves, were required for high-contact care activities such as dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, catheter care, and wound care. During one observation, the DON performed hand hygiene and donned a gown before entering the resident’s room for a telehealth wound assessment. Inside the room, the DON went into the bathroom, applied gloves without performing hand hygiene, removed the resident’s brief, and removed a foam dressing from the right gluteal area that had stool on one corner. After discarding the soiled dressing, the DON removed gloves and then applied new gloves without performing hand hygiene between glove changes. When questioned, the DON stated that hand hygiene should be done when hands or gloves are visibly soiled and before and after removing or applying gloves, and acknowledged that hand hygiene had not been performed each time gloves were removed and reapplied. In a separate observation, the resident was transferred using a sit-to-stand mechanical lift while EBP requirements were not fully followed. An NA entered the room wearing a gown and gloves with the lift, and the DON applied the lift harness under the resident’s arms and cinched the waist strap, encountering the resident’s clothing, while not wearing gloves. After the transfer to bed, the DON pulled down the resident’s pants and removed the harness while touching the resident’s clothes. Following wound care by a CNP-WOC, the DON again assisted the resident by sitting the resident on the edge of the bed, applying the lift harness, and adjusting the resident’s pants and shirt while wearing a gown but no gloves. The DON stated that EBP was only needed for catheter or wound care and not for transfers, and only upon reading the posted EBP sign acknowledged that EBP was required for all high-contact resident care activities, including transfers.
Failure to Protect Resident From Verbal Abuse and Delay in Removing Alleged Perpetrator
Penalty
Summary
The deficiency involves the facility’s failure to protect a vulnerable resident from mental abuse and to respond appropriately to an allegation of abuse. The resident had severe cognitive impairment, Alzheimer’s disease, dementia, anxiety, depression, psychotic disorder, and significant functional dependence, including frequent incontinence and the need for extensive assistance with ADLs and transfers. Her care plan identified behavioral and mood issues such as wandering, yelling, combative behavior, and calling staff names, with interventions including calm approaches, emotional support, redirection, and monitoring for emotional distress and mood/behavior changes. She was identified as a vulnerable adult, with instructions to monitor for signs of emotional distress and to follow the facility’s abuse reporting policy. On the evening in question, while the resident was crying on the phone with her son and expressing a desire to leave, NA-A and NA-B entered to provide evening care using an EZ stand lift. After the resident ended the phone call, multiple staff reported that NA-A spoke to the resident in a loud, stern, and frustrated tone, telling her to stop crying and that she was acting like a two-year-old. When the resident swatted at NA-A, NA-A stated, “If you hit me, I’m going to hit you back,” and later told the resident she was “in trouble now.” Staff reported that NA-A told the resident she would be sent to a locked unit so she could not get out, and questioned who would want to care for her when she cried like a baby, and that nobody would want to keep working with her. NA-C described NA-A yelling commands such as “HOLD ON!” and “Stop crying! Where would you be if you were not here? Probably lying on the floor,” and felt NA-A was obviously upset and overwhelmed. These statements were made in the presence of the resident while she was already distressed and crying. Following this interaction, the resident exhibited crying, yelling, combativeness, resistance to care, wandering into other residents’ rooms, self-isolation, and refusal of food, fluids, and medications above her prior baseline, as documented in behavior charts, target behavior monitoring, and nursing progress notes. Staff documented that she cried most of the morning, was very restless, difficult to redirect, hit and pinched staff, called staff names, and refused care and meals. She required repeated redirection, 1:1 attention, and non-pharmacological interventions, and was ultimately sent to the ED for evaluation of combativeness and emotional distress, where she was treated for dementia with aggressive behavior and hypoglycemia related to poor intake. The report identifies that the resident’s actual response and the reasonable person concept showed serious psychosocial harm, including increased crying and combative behavior above baseline, fear/anxiety manifested as combativeness, resistance to care and social interaction, and self-isolation. The facility also failed to immediately remove the alleged perpetrator from resident care and to promptly report and investigate the allegation in accordance with its abuse policy. After NA-B and NA-C reported to LPN-A that NA-A had yelled at and threatened the resident, LPN-A acknowledged it as verbal abuse but did not initiate immediate protective measures or timely reporting. LPN-A stated she believed she had 24 hours to report because there was no injury, despite facility policy requiring reporting within two hours. NA-A remained on the unit and continued working until the end of her shift, including after staff had clearly communicated their concerns to LPN-A. TMA and NA staff described uncertainty about their authority to remove NA-A and reliance on the nurse to act, while the DON later informed LPN-A that NA-A should have been removed from the floor to prevent further danger to residents. The Immediate Jeopardy was determined to have begun when NA-A’s derogatory, intimidating, and threatening statements were made and continued while she remained on duty with access to the resident and other vulnerable residents.
Failure to Timely Assess and Treat Newly Discovered Stump Wound
Penalty
Summary
The deficiency involves the facility’s failure to provide timely treatment and care for a newly discovered wound on a resident’s above‑knee amputation stump. The resident was admitted with diagnoses including unspecified dementia with behavioral disturbances, vascular dementia, bilateral above‑knee amputations, vascular disease, reduced mobility, and severe protein‑calorie malnutrition, and had no documented ulcers or skin problems on admission or on the most recent MDS. A weekly bath audit on 3/17/26 documented only non‑tender lymph nodes on the right upper hip and did not identify any open areas. However, when the wound was later assessed, the dressing on the stump was dated 3/16/26, indicating that a wound and dressing existed at that time, even though no corresponding assessment, provider notification, or treatment orders were documented. On 3/23/26, nursing staff documented a new skin issue above the resident’s knee at the amputation site, describing a stage 4 pressure ulcer/injury with full‑thickness skin and tissue loss, exposed bone, erythema/edema, and moderate serosanguineous exudate. The wound measured 1.56 cm by 1.64 cm, with 20–29% granulation tissue and 80% slough. A progress note and skin issues assessment on that date confirmed the wound characteristics and staging, and the NP, after reviewing a picture, determined the wound to be a diabetic ulcer with peripheral vascular disease and severe protein‑calorie malnutrition as contributing factors. On that same date, the NP was notified, antibiotic therapy (doxycycline) was ordered for possible cellulitis, and specific wound care orders were initiated, with documentation on the MAR that these treatments were carried out beginning 3/23/26. Multiple interviews with nursing staff revealed that no one could identify who discovered the wound or who applied the initial dressing dated 3/16/26, and there was no documentation of a wound assessment, provider notification, or interim treatment between 3/16/26 and 3/22/26. Several RNs and LPNs who worked shifts from 3/16/26 through 3/20/26 stated they did not notice a wound on the stump and that, per their usual practice, they would have contacted the provider and initiated treatment if they had found one. One LPN recalled seeing a band‑aid with a date on the stump but could not recall the date, and another LPN stated she did not see the wound because she was not looking for one. The facility’s standing orders required staff to assess all wounds daily, change dressings every three days and as needed, treat with normal saline or non‑cytotoxic cleanser and appropriate dressings, and notify the provider the next business day when a new wound or injury was found. Despite these expectations, the wound identified by the dated dressing on 3/16/26 was not assessed, reported, or treated according to orders and facility policy until 3/23/26.
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