Presbyterian Homes Of Arden Hills
Inspection history, citations, penalties and survey trends for this long-term care facility in Arden Hills, Minnesota.
- Location
- 3220 Lake Johanna Boulevard, Arden Hills, Minnesota 55112
- CMS Provider Number
- 245424
- Inspections on file
- 19
- Latest survey
- August 19, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Presbyterian Homes Of Arden Hills during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of falls was not provided scheduled toileting or adequate supervision as outlined in her care plan. She was left unsupervised in her room, attempted to toilet herself, and was found on the bathroom floor with a head laceration requiring emergency care and hospitalization. Staff interviews and documentation confirmed that the care plan was not followed, leading to the incident.
A resident with multiple chronic conditions experienced a significant decline in a pressure ulcer, but facility staff delayed consulting the physician and transferring the resident to the hospital for debridement. Despite the MD's recommendation for immediate hospital transfer, staff waited for the NP to assess the wound, resulting in a delay of over 24 hours before the resident received necessary care.
Staff did not wear required gowns, only gloves, while assisting a resident with an indwelling catheter and on enhanced barrier precautions during a transfer. Despite facility policy and signage directing the use of both gowns and gloves for high-contact care, staff acknowledged forgetting to wear gowns during the observed event.
The facility failed to properly dispose of and store food in two of four serving kitchens. Observations revealed expired and improperly stored food items, including an opened box of cream of wheat without a use-by date and milk past its best used by date. Uncovered and undated beverages were also found. Staff interviews indicated a lack of adherence to food storage policies, with no clear method for checking expiration dates.
The facility failed to implement proper infection control measures for residents with COVID-19, as staff did not consistently use required PPE or perform hand hygiene. A resident with severe cognitive impairment and two cognitively intact residents were not provided with appropriate TBP, as staff entered their rooms without necessary protective gear. Additionally, a resident requiring personal care did not receive proper hand hygiene practices from staff, who failed to change gloves and wash hands after handling soiled items.
The facility failed to report allegations of neglect and verbal abuse involving two residents. One resident was left unattended, missing breakfast and morning care, while another was verbally threatened by a nursing assistant. Despite witnessing and acknowledging these incidents, the facility did not file the required vulnerable adult reports.
A resident with severe cognitive impairment and limited mobility did not receive proper positioning with a pillow to prevent pressure ulcers, as required by their care plan. Despite clear instructions and signage, staff failed to consistently place a pillow under the resident's left elbow, as observed during multiple instances. Interviews with staff revealed a lack of adherence to the care plan, which was confirmed by the DON.
A resident with chronic respiratory failure did not receive proper oxygen maintenance as per physician's orders. Observations revealed outdated oxygen tubing and improper handling of the nasal cannula, which was placed in the resident's nose after being on the floor. Staff interviews highlighted inconsistencies in following the facility's oxygen equipment maintenance policy.
A resident with a history of trauma and diagnoses of major depressive and anxiety disorder did not receive trauma-informed care at the facility. Despite a preference for female caregivers and a documented history of trauma, the facility failed to assess potential triggers or offer specialized services. Interviews revealed that the resident had not been assessed for triggers, and her trauma history was known to the facility. The facility's policy on trauma-informed care was not followed, as assessments and documentation of offered services were lacking.
A resident with cognitive impairment and delusional disorder did not receive their prescribed Seroquel due to unavailability. Despite multiple refill requests, the medication was not delivered on time, resulting in a missed dose. Facility staff and the pharmacist cited issues with refill timing and delivery processes.
Two residents in an LTC facility experienced medication administration errors, leading to a 7.69% error rate. One resident did not receive their prescribed Seroquel due to unavailability, while another received Synthroid after breakfast, contrary to instructions to take it on an empty stomach. The facility's processes for medication reordering and administration timing contributed to these errors.
Failure to Provide Scheduled Toileting and Supervision Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when staff failed to provide adequate supervision and scheduled toileting for a resident with a history of falls and severe cognitive impairment. The resident's care plan required supervision, regular toileting every three hours, and that she be kept in common areas for monitoring. Despite these interventions being documented, staff did not follow the care plan on the day of the incident, resulting in the resident not being toileted between 4:51 a.m. and 9:29 p.m., with a significant gap in care during the evening hours. On the day of the incident, the resident was last toileted at 4:30 p.m. and was observed at the nurse's station and dining room throughout the afternoon and early evening. However, she was allowed to return to her room unsupervised at approximately 8:22 p.m. Staff did not redirect her to the common area or provide the scheduled toileting. Shortly after, staff found her on the bathroom floor with a head laceration, which required emergency medical attention and resulted in hospitalization. The resident was unable to use the call light and had a history of attempting to self-transfer, which increased her risk for falls. Interviews with staff and review of documentation confirmed that the care plan was not followed, specifically regarding scheduled toileting and supervision. Staff acknowledged that the resident should have been toileted and kept within sight, and that failure to do so likely contributed to her attempting to toilet herself, leading to the fall and injury. The facility's own investigation and camera footage corroborated that the resident was not provided the required supervision or assistance as outlined in her care plan.
Delay in Physician Notification and Treatment for Pressure Ulcer
Penalty
Summary
The facility failed to immediately consult with a resident's physician regarding a significant change in the resident's condition, specifically the deterioration of a pressure ulcer. The resident, who had a history of atrial fibrillation, chronic kidney disease stage 3, spinal stenosis, and sarcoidosis, was noted to have a worsening sacral ulcer with redness, odor, and drainage. The medical director (MD) assessed the wound and recommended immediate hospital transfer for debridement. However, facility staff delayed this action, waiting for orders from the nurse practitioner (NP), who wanted to assess the wound personally the following day. This resulted in a delay of more than 24 hours before the resident was sent to the hospital, despite the MD's recommendation for urgent care. Interviews with facility staff revealed that it was protocol to obtain orders from the NP even when the MD had already given a recommendation for hospital transfer. The MD was not informed that the NP disagreed with his recommendation, and the facility administrator expressed a preference for direct hospital or wound clinic admission rather than emergency room transfer. The facility's policy required staff to notify practitioners of significant changes in a resident's condition, but this was not followed in a timely manner, leading to a delay in necessary treatment for the resident's rapidly deteriorating pressure ulcer.
Failure to Use Proper PPE During Enhanced Barrier Precautions
Penalty
Summary
Staff failed to follow proper personal protective equipment (PPE) protocols for a resident on enhanced barrier precautions (EBPs) who had an indwelling catheter and required extensive assistance with care. The resident's care plan and signage on the door directed staff to wear gowns and gloves during high-contact care activities, including transfers. During an observed transfer, three staff members, including two nursing assistants and a registered nurse, only wore gloves and did not don gowns while assisting the resident with a transfer using a mechanical lift. After the transfer, they removed their gloves, sanitized their hands, and exited the room. Interviews with the involved staff confirmed that they were aware the resident was on EBPs and acknowledged that gowns should have been worn during the transfer, but they forgot to do so. The infection preventionist and the director of nursing both stated that staff are expected to wear gowns and gloves for high-contact care with residents on EBPs, including transfers. The facility's policy also required targeted use of gowns and gloves for residents with indwelling medical devices during high-contact care activities.
Improper Food Storage and Disposal in Serving Kitchens
Penalty
Summary
The facility failed to ensure proper disposal and storage of food items in two of the four serving kitchens reviewed. During an observation of the 3rd floor serving kitchen, it was found that an opened box of instant cream of wheat had no use-by date, and an unopened box had a best if used by date that was not adhered to. The server responsible for the kitchen was unsure about the usability of the opened box and acknowledged that both boxes should have been removed. Similarly, in the 2nd floor serving kitchen, two containers of skim milk were found, one of which was past its best used by date by six days. The server in this kitchen admitted that the milk should have been checked and disposed of, but due to busyness, this was overlooked. Additionally, in the 4 north serving kitchen, uncovered and undated glasses of milk and apple juice were found in the refrigerator, prepared for the evening shift. The server was unaware of the requirement to cover the beverages and began covering them upon realization. Interviews with the lead server and the Assistant Dietary Director revealed that there was an expectation for staff to check food items daily and ensure proper labeling and storage. However, the facility's policy on safe food storage did not specify a method for checking expiration dates, contributing to the oversight.
Failure to Implement Proper Infection Control Measures
Penalty
Summary
The facility failed to ensure appropriate transmission-based precautions (TBP) for three residents who tested positive for COVID-19. Resident R69, with severe cognitive impairment and dementia, was observed to be in quarantine with a sign indicating the need for droplet precautions, including gown, gloves, eye protection, and an N-95 respirator. However, a nursing assistant (NA-A) entered R69's room without a gown or eye protection, only wearing personal eyeglasses, and assisted with breakfast. NA-A acknowledged not wearing a gown, believing it was only necessary for close contact care. Similarly, residents R108 and R4, both cognitively intact and diagnosed with COVID-19, were observed under TBP. NA-B entered their rooms without donning an N-95 respirator or eye protection, leaving the doors open while delivering meals. NA-B admitted to not wearing the required protective equipment, thinking it was only needed for close contact care. The infection preventionist and the Director of Nursing (DON) confirmed that staff were expected to wear all required personal protective equipment (PPE) when entering rooms of residents with COVID-19. Additionally, the facility failed to ensure proper hand hygiene during personal care for resident R46, who was incontinent and required assistance. NA-B did not perform hand hygiene or change gloves after removing R46's soiled brief and before placing a clean one. NA-B acknowledged the oversight, stating they should have performed hand hygiene and exchanged gloves. The facility's policies on COVID-19 precautions and hand hygiene were not followed, contributing to the deficiencies observed.
Failure to Report Allegations of Neglect and Verbal Abuse
Penalty
Summary
The facility failed to report allegations of potential neglect and verbal abuse to the state agency for two residents. One resident, who had cognitive and functional deficits, was left unattended in bed for several hours, missing breakfast and morning care. This resident required extensive assistance for all activities of daily living and was at risk for developing pressure ulcers. The incident was captured on video, but no written follow-up was completed, and the resident's skin was not assessed for potential pressure injuries. Another resident, who had dementia and required assistance with eating, was verbally threatened by a nursing assistant. The nursing assistant told the resident to stop crying or they would stop feeding them. This incident was witnessed by a registered nurse who intervened and reported the encounter to the nursing assistant's supervisor. However, there was no indication that a vulnerable adult report was filed for this incident. Interviews with facility staff revealed that the incidents were not reported to the state agency as required. The administrator acknowledged that a vulnerable adult report should have been completed for both residents. The facility's policy on abuse prevention outlines the need for immediate reporting and investigation of suspected abuse, but these steps were not followed in these cases.
Failure to Provide Proper Positioning for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as R30, received appropriate positioning with a pillow to prevent pressure ulcers and aid in comfort associated with contractures. R30 had severely impaired cognitive skills, impairments in range of motion, and was dependent on staff for all activities of daily living. The care plan indicated that R30 was at risk for impaired skin integrity and required a pillow under the left elbow while in bed and in the chair. However, during multiple observations, R30 was found without the necessary pillow under the left elbow, contrary to the care plan instructions. Interviews with staff, including nursing assistants and registered nurses, revealed inconsistencies in the application of the care plan. Staff members were either unaware or did not adhere to the requirement of placing a pillow under R30's left elbow, despite signage in the room and care plan directives. The director of nursing confirmed that staff were not following the plan of care, emphasizing the importance of the pillow for preventing skin issues and aiding with contractures. The facility's policy required staff to review care plans and complete personal care as indicated, which was not followed in this instance.
Improper Maintenance of Supplemental Oxygen
Penalty
Summary
The facility failed to ensure proper maintenance of supplemental oxygen for a resident with chronic respiratory failure and hypoxia. The resident required extensive assistance with daily activities and had a physician's order to maintain oxygen saturation levels above 88% using 1 to 4 liters of oxygen via nasal cannula, with tubing changes every week. However, during an observation, it was noted that the resident's oxygen tubing and bubbler were dated over a week old, and the nasal cannula was found on the floor before being placed back in the resident's nose by a nursing assistant. Interviews with staff revealed inconsistencies in the understanding and implementation of oxygen equipment maintenance protocols. A registered nurse confirmed that the oxygen tubing should have been changed weekly and should not have been used after falling on the floor. The Director of Nursing acknowledged the lack of a backup plan for changing oxygen tubing when the designated staff member was unavailable. The facility's policy, which was not followed, stated that oxygen tubing should not touch the floor and should be changed weekly.
Failure to Provide Trauma-Informed Care for Resident with History of Trauma
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for a resident with a history of trauma. The resident, who had intact cognition and diagnoses of major depressive and anxiety disorder, was noted to socially isolate herself and required assistance with toileting and mobility. Despite having a documented history of trauma and a preference for female caregivers, the facility did not assess potential triggers to prevent re-traumatization or offer specialized services. The resident's care plan and medical records lacked documentation of such assessments or services being offered or refused. Interviews revealed that the resident had not been assessed for triggers, and her son had informed the facility of her trauma history upon admission. The household coordinator acknowledged that the LTC Psychosocial assessment should have included questions about past trauma and triggers, and that services like ACP should have been offered and documented. The director of nursing confirmed that household coordinators were responsible for completing assessments for trauma-informed care and documenting any offered services. The facility's policy emphasized the importance of assessing residents with a history of trauma to provide appropriate treatment and minimize re-traumatization, which was not adhered to in this case.
Failure to Administer Prescribed Medication Due to Refill Delays
Penalty
Summary
The facility failed to provide medication as ordered for a resident with cognitive impairment and diagnoses of dementia and delusional disorder. The resident was prescribed Seroquel, an antipsychotic medication, to be taken daily at bedtime. However, the medication was not administered on a specific date because it was unavailable. The medication administration record confirmed the absence of the dose, and a nursing progress note indicated that follow-up with the pharmacy was needed. Despite multiple refill requests submitted by the facility, the medication was not delivered in time, resulting in a missed dose. Interviews with facility staff revealed that the medication was re-ordered when the supply was low, but the delivery was delayed. The trained medication assistant noted that the last dose was given the previous day, and the pharmacy had been contacted for a refill. The Director of Nursing acknowledged the issue and mentioned ongoing efforts to improve the medication delivery process. The pharmacist explained that the initial refill request was too early due to insurance restrictions, and subsequent requests were made closer to the depletion date. Despite these efforts, the medication was not available in the emergency kit, leading to the missed administration.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to prevent medication errors for two residents, resulting in a medication error rate of 7.69%. One resident, who had cognitive impairment and diagnoses of dementia and delusional disorder, did not receive their prescribed Seroquel on a specific date because the medication was not available. The trained medication assistant (TMA) responsible for administering the medication stated that the Seroquel had been reordered the previous day but had not yet arrived. The facility's process involved sending a fax to the pharmacy for refills, with the latest delivery expected between 8:00 and 9:00 p.m. However, if the medication was not on that delivery, it would arrive the following morning. The registered nurse (RN) mentioned that medications should be reordered when there was about a week's worth left, but Seroquel was not included in the emergency kit, leading to the missed dose. Another resident, who was cognitively intact with diagnoses of Parkinson's disease and hypothyroidism, received their Synthroid medication after breakfast, contrary to the pharmacy's instructions to administer it on an empty stomach. The TMA acknowledged that the medication was given after breakfast and stated that while they tried to follow the directions, it was not always administered before breakfast. The medication was scheduled as an 8:00 a.m. dose, which allowed for a larger window of administration. The Director of Nursing (DON) expected staff to follow the medication instructions listed from the pharmacy, and the consultant pharmacist confirmed that Synthroid is better absorbed on an empty stomach. The facility's policy directed that medications ordered to be given on an empty stomach should be administered at least 30 minutes prior to a meal.
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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