Providence Place
Inspection history, citations, penalties and survey trends for this long-term care facility in Minneapolis, Minnesota.
- Location
- 3720 23rd Avenue South, Minneapolis, Minnesota 55407
- CMS Provider Number
- 245271
- Inspections on file
- 36
- Latest survey
- January 12, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Providence Place during CMS and state inspections, most recent first.
Surveyors found that the facility failed to ensure two residents’ pain regimens were free from unnecessary drugs by not documenting clear indications for PRN opioid use and not recording attempts or offers of non-pharmacological interventions before administering PRN pain medications. Both residents had care plans and pain assessments indicating chronic pain that interfered with daily activities, and both reported that repositioning, ice packs, and rest helped relieve their pain in addition to PRN medications. However, medication administration records and progress notes for multiple PRN doses of acetaminophen, hydromorphone, and oxycodone lacked documentation of pain location, associated symptoms, and any non-pharmacological measures tried prior to giving the medications, including instances where opioids were given for mild pain or when pain was documented as 0/10. Interviews with an LPN, an RN, the DON, a nurse practitioner, and a pharmacist, as well as the facility’s Pain Management Program policy, all described expectations to use non-opioids first when appropriate, reserve opioids for more severe pain, and document pain assessments and non-pharmacological interventions, which were not reflected in the records reviewed.
A resident with dysphagia, cognitive impairment, and a history of choking incidents did not have speech therapy recommendations or physician orders for safe swallowing—such as upright positioning, crushing medications, and specific eating techniques—incorporated into their care plan. Despite staff and family being aware of the swallowing difficulties and receiving education, the care plan was not updated to reflect these critical interventions.
Two residents with behavioral health and substance use needs did not receive individualized care plans that incorporated recommendations from psychological services to support sobriety. Staff were unaware of or did not implement suggested interventions, resulting in ongoing substance use, unaddressed mental health needs, and repeated unsupervised departures from the facility that led to hospitalizations.
The facility did not adequately assess or address the supervision needs of residents with cognitive impairment and substance use disorders when they left the facility, resulting in multiple incidents where residents were missing for extended periods, returned intoxicated, or required hospitalization. Care plans lacked individualized interventions for community safety, and staff were unable to articulate or implement a systematic process for evaluating or mitigating risks for these residents.
A facility failed to accurately document a resident's advance directives, resulting in a mismatch between the POLST and EHR. The resident's POLST indicated a DNR status, but the EHR and physician orders showed a full code status. Staff interviews revealed reliance on the EHR for code status decisions, risking CPR against the resident's wishes. The HUC was responsible for updating records, but audits were not completed due to staffing issues.
The facility failed to provide routine personal hygiene care for several residents dependent on staff for ADLs. One resident with multiple medical conditions had long, soiled fingernails despite expressing a desire for them to be cleaned. Another resident with cognitive impairment was observed with unwanted chin hair, and staff interviews revealed inconsistencies in addressing personal hygiene. A third resident was observed in soiled clothing with long nails, and staff failed to address hygiene needs despite visible signs. Facility policies on bathing and nail care were not consistently followed.
Two residents in the facility experienced deficiencies in care related to skin conditions. One resident had dry, cracked skin on her feet that was not addressed despite her requests, and staff failed to follow care plan directives for skin observation. Another resident had a deep tissue injury and unreported skin concerns on her foot and thigh, with inconsistent documentation and lack of staff awareness. The facility's Skin Management Program Policy was not consistently followed, leading to inadequate monitoring and intervention for these residents.
A resident with a history of falls and impaired cognition experienced multiple falls due to the facility's failure to implement planned interventions. The care plan required auto-lock brakes on the wheelchair and keeping it at the bedside, but observations showed these were not consistently followed. Staff interviews revealed a lack of awareness and adherence to the care plan, contributing to the resident's repeated falls.
A resident with severe cognitive impairment and significant weight loss did not receive prescribed nutritional supplements as ordered. Despite being on a fortified diet, the facility failed to provide the necessary magic cup supplement twice daily. Observations and staff interviews revealed inconsistencies in supplement administration, with supplements remaining in the refrigerator and not being distributed. The DON expected staff to administer supplements or document refusals, but this was not consistently done.
The facility failed to implement enhanced barrier precautions (EBP) and proper hand hygiene for two residents, one with a feeding tube and another with a wound. Staff were observed providing care without necessary PPE and not performing hand hygiene between tasks, despite clear signage and facility policies. The infection preventionist confirmed the need for EBP and ongoing education efforts.
The facility failed to post complaint investigations and plans of correction for 2024 and 2025 in accessible areas. The survey results binder was placed too high for wheelchair users to reach, as confirmed by multiple residents and staff. Additionally, the binder lacked results of complaint surveys for 2024 and January 2025. The facility's policy on posting survey results was not provided.
The facility failed to protect resident privacy by leaving care sheets with sensitive information unattended on medication carts. Staff members, including an LPN and an RN, acknowledged the issue, and the DON confirmed the need for better privacy practices. The facility's privacy policy was not provided.
The facility failed to provide a dignified dining experience for residents needing assistance during mealtime on a dementia unit. Nursing assistants used the term 'feeders' in the presence of residents, which was acknowledged as inappropriate by staff, including an LPN and the DON. The facility's guidelines emphasize promoting dignity, which was not upheld in this instance.
A contracted therapy staff member at an LTC facility took unauthorized photos of a resident with cognitive impairments and shared them via text message, violating facility policy. The resident, diagnosed with paranoid schizophrenia and schizoaffective disorder, was vulnerable to abuse due to his condition. Facility leadership acknowledged the inappropriateness of the action, which breached policies protecting residents from mental abuse.
The facility failed to investigate allegations of staff-to-resident abuse involving a COTA and two residents. One resident reported a consensual relationship with the COTA, but only therapy staff were interviewed, and no facility floor staff were questioned. Text messages from the COTA to the resident included pictures of another resident, which were not addressed. The facility's policy lacked guidance on investigation procedures, contributing to the deficiency.
The facility failed to provide routine bathing, nail care, and shaving assistance for four residents who were dependent on staff for these activities of daily living. Residents were found with unkempt hair, long dirty fingernails, and overgrown facial hair, despite care plans indicating regular assistance. Staff interviews revealed inconsistencies in following care plans and documenting refusals of care.
The facility failed to ensure routine dental needs were evaluated and addressed timely for four residents, resulting in unaddressed broken dentures, missing teeth, and lack of dental appointments. Residents expressed a desire for dental care, but the facility did not take necessary follow-up actions.
The facility failed to offer or provide the pneumococcal vaccine to two residents and did not engage in shared clinical decision-making for the pneumococcal vaccine for two additional residents. The infection preventionist acknowledged awareness of the new CDC guidance but had not implemented it due to time constraints.
The facility failed to ensure that a resident participated in care conferences for care planning. The resident, with multiple diagnoses and intact cognition, reported not being invited to care conferences. Documentation was incomplete, missing critical information, and interviews revealed that the social worker did not fulfill their responsibilities in notifying the resident and completing the care conference summary.
The facility failed to ensure accurate MDS coding for two residents, leading to potential inaccuracies in care planning and federal reimbursement. One resident's wandering behaviors were not reflected in the MDS, and another resident's dental issues were not addressed, despite documentation and staff observations.
The facility failed to develop and maintain a comprehensive care plan for a resident with lymphedema, resulting in inconsistent application of compression wraps and lack of coordination between nursing and therapy staff. Observations and interviews revealed that the care plan, task list, and care guide lacked necessary information, leading to inadequate care for the resident.
The facility failed to reassess and develop interventions for a resident with a persistent skin condition and did not properly manage another resident's diabetes, leading to ongoing health issues. Nursing staff were unaware of the conditions, and no follow-up assessments were documented.
The facility failed to ensure a ROM restorative program for a resident with severe cognitive impairment and contractures, and did not complete or reassess recommended splint applications for two residents with hand contractures. Interviews and observations revealed lapses in communication and execution of care plans, leading to inadequate care.
The facility failed to maintain an appropriate communication system with an outside dialysis clinic for a resident requiring dialysis care. The resident's care plan lacked direction on coordinating with the clinic, and staff interviews revealed inconsistencies in the communication process. Dialysis Communication Records were often incomplete, and the dialysis clinic was not updated on the resident's medication holds or recent fall.
A facility failed to act on a consultant pharmacist's recommendation to update the diagnosis for a resident's antipsychotic medication. Despite the recommendation being signed by both the pharmacist and the physician, the diagnosis was not documented in the EMR, leading to staff confusion and resident frustration.
The facility failed to monitor orthostatic blood pressure for a resident on antipsychotic medication for three consecutive months. Despite orders for monthly checks, the required monitoring was not documented or completed, and the resident's care plan lacked an intervention for orthostatic hypotension. Interviews with staff confirmed the expectation for such monitoring, but the facility's records did not reflect this practice.
The facility failed to maintain a clean and sanitary environment in a resident's room and the main production kitchen. A resident's room had walls with dried human feces and other organic material, while a commercial oven in the kitchen was covered with dust, debris, and burnt food particles. Staff confirmed the issues and acknowledged lapses in cleaning schedules and reporting systems.
The facility failed to ensure call lights were accessible for three residents, compromising their ability to request assistance. Observations and interviews revealed that call lights were out of reach or unplugged, despite residents' ability to use them and staff acknowledging the importance of accessibility.
Failure to Document Indications and Non-Pharmacological Interventions Before PRN Opioid Use
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents’ drug regimens were free from unnecessary drugs by not identifying clear indications for opioid use and not documenting attempts or offers of non-pharmacological interventions prior to administering PRN pain medications. For Resident 1 (R1), the admission MDS showed intact cognition and diagnoses including end stage renal disease and a heel pressure ulcer, with a pain assessment indicating pain frequently interfered with therapy and daily activities. R1’s care plan for chronic neuropathic pain directed staff to offer non-pharmacological interventions such as rest and repositioning and to observe and document pain characteristics. Despite this, documentation showed that when R1 received PRN acetaminophen and hydromorphone, the associated progress notes consistently lacked details on pain location, associated symptoms, and whether any non-pharmacological interventions were attempted or offered before medication administration. R1 had PRN orders for both acetaminophen and hydromorphone. In January, R1 received PRN acetaminophen twice and PRN hydromorphone nine times. For the PRN acetaminophen doses, one note documented severe pain rated 8/10 and another documented moderate foot pain rated 5/10, but neither note included any record of non-pharmacological interventions being attempted or offered prior to giving the medication. For the PRN hydromorphone doses, pain ratings ranged from 0/10 to 9/10, yet the corresponding progress notes repeatedly only stated that the medication was administered and effective, without documenting pain location, symptoms, or any non-pharmacological measures tried beforehand. In one instance, hydromorphone was administered when the pain rating was documented as 0/10. During interview, R1 reported chronic pain in the knees and all over the body and stated that repositioning, ice packs, and rest helped relieve pain in addition to PRN medications, indicating that non-pharmacological measures were known to be helpful but were not reflected in the documentation. For Resident 2 (R2), the admission MDS indicated independent decision-making with diagnoses including amputation and end stage renal disease, and a pain assessment showing pain frequently interfered with day-to-day activities. R2’s care plan for pain management included an intervention to offer non-pharmacological measures and to notify the practitioner if these were unsuccessful or if the pain complaint represented a significant change. R2 had PRN orders for acetaminophen and oxycodone. In January, R2 received PRN acetaminophen twice for pain rated 10/10 and PRN oxycodone five times for pain rated between 5/10 and 7/10. The associated progress notes documented that medications were administered and, in some cases, that the resident felt better, but did not include pain location, associated symptoms, or any record of non-pharmacological interventions being attempted or offered prior to either non-opioid or opioid administration. During interview, R2 stated that pain sometimes occurred at the amputation site, in both arms, and all over the body when tired, and that repositioning, ice packs, and rest helped relieve pain along with PRN medications, again contrasting with the lack of documentation of such measures. Interviews with staff and facility leadership further highlighted the deficiency. An LPN stated that when a resident had pain, the nurse should ask about pain location and intensity, administer the requested PRN medication if multiple options were available, and document the time and pain level, with follow-up to reassess effectiveness. An RN stated that non-opioid medications should be offered first for pain less than 7/10 and opioids for pain rated 7–10/10, and that residents requesting opioids would be educated but ultimately given the requested medication, with documentation of administration and pain level and later follow-up. The DON stated that documentation for PRN pain medications should include pain location, pain scale rating, and any non-pharmacological interventions attempted prior to administration so that pain follow-up and trending could be done accurately. The nurse practitioner and pharmacist both indicated that non-opioid medications should be used first and that opioids are generally reserved for more severe pain, and the facility’s Pain Management Program policy required clear documentation of pain evaluation, interventions (including non-pharmacological measures), and post-administration pain relief. Despite these stated expectations and policies, the records for R1 and R2 showed repeated administration of PRN opioids and non-opioids without documented indication details or non-pharmacological interventions, constituting the cited deficiency.
Failure to Update Care Plan with Swallowing Safety Interventions
Penalty
Summary
The facility failed to update and implement a comprehensive care plan to address a resident's swallowing difficulties and risk of choking, despite multiple documented incidents and professional recommendations. The resident had a history of unspecified tremor, partial digestive tract removal, oropharyngeal dysphagia, and cognitive impairment, and required set-up assistance with meals. Although the resident was observed to have difficulty swallowing medications, resulting in coughing and choking episodes, the care plan only included a general intervention for eating set-up and did not reflect the specific risks or interventions needed for safe swallowing. Speech therapy evaluated the resident and provided detailed recommendations, including crushing medications, upright positioning during and after meals, slow eating, small bites and sips, thorough chewing, and specific swallowing techniques. These recommendations, as well as the physician's order to crush medications, were not incorporated into the resident's care plan or the nursing assistant care guide. Interviews with staff and family confirmed awareness of the resident's swallowing issues and the education provided, but the care plan remained incomplete, lacking the necessary interventions to address the identified risks.
Failure to Implement Individualized Behavioral Health Care Plans and Professional Recommendations
Penalty
Summary
The facility failed to develop and implement individualized behavioral health care plans for two residents with behavioral health needs, specifically neglecting to utilize recommendations from professional psychological services to support sobriety efforts. For one resident with moderate cognitive impairment, depression, and a history of substance use, the care plan acknowledged his desire for sobriety and alternative living arrangements, as well as recommendations from a psychological provider to monitor mood, encourage engagement in meaningful activities, and reinforce strengths. However, facility staff, including the community life coordinator and director of social services, were unaware of or did not implement these recommendations. The resident continued to leave the facility unsupervised, sometimes resulting in hospitalizations, and staff did not actively support his sobriety or address his psychological needs as outlined by the consulting psychologist. Another resident, who was cognitively intact but had a history of substance use disorder, depression, and loneliness, also did not receive an individualized behavioral health care plan that incorporated professional recommendations. Despite documentation from a psychologist recommending harm reduction strategies, increased engagement, and consideration of a private room to support sobriety and mental health, the facility did not implement these interventions. The resident continued to consume alcohol in her room, left the facility unsupervised, and was hospitalized for alcohol intoxication. Staff were aware of her drinking but did not establish a behavioral contract or safety plan, and were not fully informed of the psychologist's willingness to assist with harm reduction or safety planning. Facility policy required care planning interventions to address risks for residents with substance use disorders, including providing diversions, substance use treatment services, and increased monitoring. Despite this, the facility did not follow through with the necessary individualized interventions or incorporate the recommendations from psychological services into the residents' care plans. This lack of action resulted in ongoing substance use, unaddressed behavioral health needs, and repeated incidents of residents leaving the facility unsupervised and requiring hospital care.
Failure to Assess and Supervise Residents' Community Safety Needs
Penalty
Summary
The facility failed to comprehensively assess the supervision needs of residents and develop individualized, person-centered interventions to identify and mitigate risks and hazards for residents when they were out in the community and upon their return. This deficiency was evident in the cases of three residents with significant cognitive and behavioral health issues, including moderate vascular dementia, substance use disorder, and alcoholism with impaired insight and judgment. The facility did not conduct or document comprehensive community safety assessments for these residents, nor did it establish clear prevention strategies or interventions to ensure their safety while outside the facility. One resident with moderate vascular dementia and a history of substance use, psychiatric hospitalizations, and cognitive impairment repeatedly left the facility unsupervised, often without signing out or notifying staff. On multiple occasions, this resident was missing for extended periods, sometimes over 17 hours, and was found by police or returned via ambulance after hospitalizations for medical issues such as COPD exacerbation. The resident's care plan lacked interventions related to community safety, and staff interviews revealed there was no systematic process to assess or address the resident's ability to be independent in the community. Another resident with a history of alcohol and opioid abuse, psychiatric diagnoses, and repeated falls was frequently found intoxicated both inside and outside the facility. This resident left the facility independently, often without using an assistive device, and was hospitalized multiple times for alcohol-related medical issues. The care plan did not address supervision needs or interventions for community safety, and there was no evidence of comprehensive assessment or monitoring for withdrawal symptoms, nor strategies to prevent or mitigate risks associated with the resident's behavior in the community or upon return. Staff interviews confirmed the absence of a clear process for assessing community safety or implementing individualized interventions for residents at risk.
Inconsistent Documentation of Advance Directives
Penalty
Summary
The facility failed to ensure that a resident's advance directives were accurately and consistently documented in the electronic health record (EHR), Provider Order for Life-Sustaining Treatment (POLST), and physician orders. This discrepancy involved a resident, identified as R84, whose code status was not accurately documented, leading to immediate jeopardy. The POLST signed by the resident and a nurse practitioner indicated a do not resuscitate (DNR) status, while the physician's order incorrectly documented a full code status. The inconsistency in documentation was discovered during a review of R84's records, which showed conflicting information regarding the resident's code status. The admission orders and EHR banner indicated a full code status, while the POLST and progress notes confirmed a DNR status. Interviews with staff revealed that the health unit coordinator (HUC) was responsible for updating the EHR to match the POLST, but audits to ensure accuracy had not been completed due to staffing issues. Interviews with various staff members, including licensed practical nurses (LPNs) and the director of nursing (DON), highlighted the reliance on the EHR banner to determine code status in emergencies. This reliance posed a risk of performing CPR against the resident's wishes due to the mismatch in documentation. The facility's policies required that the POLST and EHR be reviewed and updated to reflect the resident's wishes, but this process was not followed, leading to the deficiency.
Removal Plan
- Corrected R84's code status on the EHR banner/provider order to DNR
- Completed a facility-wide audit to ensure there were no other code status discrepancies
- Reviewed related policies and procedures
- Provided education for all staff involved in ensuring advance directives were honored on the CPR and POLST policies/procedures and their respective roles in the process
Failure to Provide Routine Personal Hygiene Care
Penalty
Summary
The facility failed to ensure routine personal hygiene care for several residents who were dependent on staff for assistance with activities of daily living (ADLs). One resident, who had intact cognition and multiple medical conditions including multiple sclerosis and malnutrition, was observed with long, soiled fingernails despite expressing a desire for them to be cleaned. The resident's care plan required substantial assistance with personal hygiene but lacked specific instructions regarding nail care. Staff interviews revealed uncertainty about documentation and responsibility for nail care, and the resident's medical record lacked evidence of recent nail care. Another resident with moderately impaired cognition and various mental health diagnoses was observed with unwanted chin hair over several days. The resident's care plan required assistance with personal hygiene but did not address preferences for facial hair. Staff interviews indicated that chin hair should be addressed during personal care, but there was no documentation of refusals or attempts to address the issue. Similarly, a resident with severe cognitive impairment and behavioral symptoms was observed with thick chin hair, and staff interviews revealed inconsistencies in addressing and documenting personal hygiene care. A fourth resident with moderate cognitive impairment and a history of mental health issues was observed in soiled clothing with long, ungroomed nails. The resident's care plan required assistance with dressing and personal hygiene, but staff interviews indicated that personal care was not consistently offered or documented. The resident was observed in the same clothing over multiple days, and staff failed to address the resident's hygiene needs despite the presence of urine odor and visibly soiled clothing. The facility's policies required regular bathing and nail care, but these were not consistently followed or documented for the residents involved.
Failure to Address Skin Conditions in Residents
Penalty
Summary
The facility failed to ensure timely identification, assessment, and intervention for skin conditions in two residents, R103 and R158, leading to deficiencies in care. R103, who had intact cognition and was dependent on staff for mobility and dressing, expressed concerns about dry and cracked skin on her feet, which had not been addressed despite her requests. Observations revealed that staff had not been checking her feet during routine care, and there were no treatment orders or monitoring documented for her skin condition. The nursing assistant and LPN involved were unaware of the issue, and the care plan's directive to observe skin during care was not followed. R158, who was cognitively intact and at risk for pressure ulcers, had a deep tissue injury and was supposed to have regular skin assessments. However, documentation was inconsistent, and staff failed to identify and report a painful area on the bottom of her right foot and an open area on her right thigh. The resident self-administered a cream without proper hygiene, and staff were unaware of the skin concerns until prompted by the resident. The RN and nursing assistants involved did not perform thorough skin checks, and there was a lack of communication and documentation regarding the resident's skin condition and necessary interventions. The facility's Skin Management Program Policy required regular body audits and skin observations, but these were not consistently performed or documented for both residents. The lack of timely assessment and intervention for skin conditions in R103 and R158 highlights a failure in the facility's processes to monitor and address residents' skin integrity, potentially leading to complications such as infection or worsening of the conditions.
Failure to Implement Fall Interventions for Resident
Penalty
Summary
The facility failed to implement planned fall interventions for a resident identified as R125, who was at risk for falls due to moderately impaired cognition and a history of falls. R125's care plan included interventions such as auto-locking brakes on the wheelchair, gripper socks or shoes at all times, and keeping the wheelchair at the bedside when in bed. Despite these interventions, R125 experienced multiple falls between December 2024 and February 2025, often attempting to self-transfer without assistance and not using the call light. Observations revealed that R125's wheelchair was frequently not positioned next to the bed as required by the care plan, and the wheelchair did not have the specified auto-lock brakes. Staff interviews indicated a lack of consistent adherence to the care plan, with some staff unaware of the specific interventions or failing to implement them. For instance, a trained medication assistant and a nursing assistant both confirmed the absence of auto-lock brakes and the improper placement of the wheelchair, which was kept away from the bed to prevent self-transfer attempts. The director of nursing confirmed that staff were expected to follow the care plan interventions, which included keeping the wheelchair at the bedside and ensuring it had auto-lock brakes. However, the observations and interviews indicated that these interventions were not consistently implemented, contributing to the resident's repeated falls. The facility's Adverse Event policy required falls to be reviewed to ensure correct interventions, but the repeated incidents suggest a failure in this process.
Failure to Administer Nutritional Supplements as Ordered
Penalty
Summary
The facility failed to ensure that a resident, identified as R18, received the necessary nutritional supplements as ordered, which was crucial for maintaining their health. R18 had severe cognitive impairment and required assistance with eating. The resident had multiple diagnoses, including dementia, peripheral vascular disease, and chronic obstructive pulmonary disease, among others. Despite being on a fortified diet and having a significant weight loss noted over 30 and 180 days, the facility did not consistently provide the prescribed nutritional supplement, a magic cup, twice daily as recommended by the registered dietician. During observations, it was noted that R18 did not receive the magic cup supplement during breakfast, and there was confusion among staff regarding the administration of supplements. Interviews with various staff members, including a registered nurse, dietary aide, and nursing assistants, revealed inconsistencies in the delivery of the supplements. The registered nurse was unsure if R18 received the supplement, and the dietary aide confirmed that the supplements were still in the refrigerator, indicating they had not been distributed as required. The director of nursing stated that staff were expected to administer supplements as ordered or document if a resident refused them. However, the failure to provide R18 with the necessary supplements as ordered was evident, as the supplements were not given during the observed shifts. This deficiency in care was contrary to the facility's policy, which required immediate interventions for residents with undesired weight loss trends to prevent further decline.
Failure to Implement Enhanced Barrier Precautions and Hand Hygiene
Penalty
Summary
The facility failed to consistently implement enhanced barrier precautions (EBP) as recommended by the CDC to prevent the spread of multidrug-resistant organisms (MDROs) for two residents. One resident, identified as R38, had a care plan indicating the need for EBP due to an indwelling medical device, specifically a feeding tube. Despite signage indicating the requirement for gowns and gloves during high-contact care activities, nursing assistants were observed providing care without the necessary protective equipment. The nursing assistants were unaware of the EBP requirements until questioned by the surveyor, after which they sought clarification and donned the appropriate PPE. Another resident, R25, also required EBP due to a wound. During an observation, a nursing assistant was seen performing peri-care without changing gloves or performing hand hygiene between tasks, despite the presence of signage indicating the need for EBP. The nursing assistant admitted to not performing hand hygiene between glove changes due to a reaction to hand sanitizer and instead washed their hands in a different room. The registered nurse confirmed that R25 was on EBP and expected staff to adhere to the guidelines for glove and gown use during direct care. The facility's policies on hand hygiene and PPE use were not followed, contributing to the deficiencies observed. The infection preventionist confirmed the ongoing education efforts for EBP but acknowledged the lapses in adherence to the protocols. The failure to implement EBP and proper hand hygiene practices as outlined in the facility's guidelines and CDC recommendations resulted in the identified deficiencies.
Inaccessible Survey Results and Missing Complaint Investigations
Penalty
Summary
The facility failed to ensure that complaint investigations for 2024 and 2025, along with any plans of correction, were posted in prominent and accessible areas for public review. This deficiency was identified during observations and interviews conducted on February 25, 2025. The survey results binder was placed in a wire basket 60 inches off the ground, making it inaccessible to individuals in wheelchairs. Multiple residents, including those using wheelchairs, confirmed that they could not reach the binder without assistance. The facility's social services director and administrator acknowledged that the binder was not within reach for wheelchair users. Additionally, the facility administrator admitted that the survey results binder did not contain the results of any complaint surveys for 2024 and January 2025, which should have been included. The facility's policy on posting survey results was requested but not provided. The administrator was responsible for delegating the task of posting the survey results and acknowledged the oversight in the placement and content of the binder.
Failure to Protect Resident Privacy
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of residents' personal and medical records, as observed during a survey. On two separate occasions, care sheets containing sensitive information such as residents' names, room numbers, and personal care details were left unattended and face up on medication carts. This information was accessible to unauthorized personnel, including staff members and residents, who walked past the exposed documents. The care sheets included detailed personal information such as sleep/wake preferences, assistance needed with daily activities, and personal interests. During interviews, both an LPN and an RN acknowledged that the care sheets should not have been left exposed, citing concerns about privacy and HIPAA compliance. The Director of Nursing also confirmed that care sheets should be flipped over to prevent unauthorized access, noting that maintaining privacy is an ongoing challenge for the facility. Despite requests, the facility's policy on privacy practices was not provided to the surveyors.
Undignified Dining Experience for Residents Needing Assistance
Penalty
Summary
The facility failed to ensure a dignified dining experience for residents requiring assistance during mealtime on a locked dementia unit. During an observation, a nursing assistant (NA-A) was seen preparing the dining area and distributing desserts and drinks to residents. NA-A communicated with another nursing assistant (NA-N) across the room, instructing them to set up all the 'feeders' first. This term was used in the presence of residents, which was acknowledged by NA-N as inappropriate and undignified. NA-N explained that typically, residents needing assistance were served last to provide immediate help, but on this occasion, they had extra help to assist those residents first. Interviews with staff, including another nursing assistant (NA-I) and a licensed practical nurse (LPN-E), confirmed that the term 'feeders' was inappropriate and could make residents feel infantilized. The director of nursing (DON) also agreed that the term was not dignified. A care sheet indicated that six residents required assistance with eating, and the facility's Standards of Care Guidelines emphasized promoting dignity and quality of life for residents. The use of the term 'feeders' and the manner of communication during mealtime did not align with these guidelines, leading to the deficiency.
Unauthorized Photos Taken of Resident Without Consent
Penalty
Summary
The facility failed to protect a resident from potential mental abuse by allowing a contracted therapy staff member to take unauthorized pictures without consent. The resident, who had diagnoses of paranoid schizophrenia and schizoaffective disorder bipolar type, was identified as having moderately impaired cognition and physical limitations, making him susceptible to abuse. The resident's care plan noted a history of refusing care and exhibiting behaviors such as refusing to change clothes and becoming verbally and physically abusive when assisted. Despite these vulnerabilities, a contracted therapy staff member took unauthorized pictures of the resident while he was sleeping in his wheelchair, which were later shared via text message. The facility's executive director and assistant executive director acknowledged the inappropriateness of the action, as it violated the facility's policy on personal phones and communication devices. The policy explicitly prohibits taking pictures without prior approval and defines mental abuse to include unauthorized photographs. The guardian of the resident was not informed of the incident and expressed concern that the resident would become upset if he knew about the unauthorized pictures. The facility's policy also emphasizes the protection of vulnerable adults from abuse, neglect, and mistreatment, highlighting the failure to adhere to these guidelines in this incident.
Failure to Investigate Allegations of Staff-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of staff-to-resident abuse involving a certified occupational therapy assistant (COTA) and two residents. One resident, who was no longer at the facility, reported having consensual sexual relations and a relationship with the COTA. The facility's executive director (ED) admitted that during the investigation, only two therapy staff were interviewed, and no facility floor staff were questioned regarding the interactions between the resident and the COTA. Additionally, the assistant executive director (AED) confirmed that the investigation did not include interviews with facility staff, as it was deemed unnecessary due to the location of the alleged incident. Furthermore, the investigation uncovered text messages from the COTA to the resident, which included pictures of another resident. However, these pictures were not addressed or investigated further. The facility's policy on Vulnerable Adult/Maltreatment-Communication, Prevention, and Reporting required immediate reporting and investigation of such findings, but it lacked specific guidance on what should be included in the investigation. This oversight contributed to the deficiency in addressing the allegations and ensuring a comprehensive investigation.
Failure to Provide Routine Bathing, Nail Care, and Shaving Assistance
Penalty
Summary
The facility failed to ensure routine bathing, nail care, and shaving assistance for four residents who were dependent on staff for these activities of daily living. Resident R35, who had moderate cognitive impairment and required assistance with bathing, received only four showers in two months despite being care planned for two showers a week. R35 expressed frustration about not receiving regular baths and was observed with greasy, matted hair and unshaved chin hairs. Staff interviews revealed inconsistencies in following the bathing schedule and documenting refusals of care. Resident R20, who had moderately impaired vision and required maximal assistance with bathing and nail care, was found with long, dirty fingernails despite progress notes indicating regular showers and nail trims. R20 expressed dissatisfaction with the infrequent nail care, and staff confirmed that nail care was not being consistently provided or documented. Observations and interviews highlighted a lack of adherence to the care plan and the importance of nail care for infection control and resident dignity. Resident R52, who had moderately impaired cognition and required maximal assistance for personal hygiene, was also found with long, dirty fingernails despite documentation of regular bed baths and nail trims. R52 indicated a desire for nail care, and staff confirmed the nails had not been trimmed recently. Similarly, Resident R102, who required assistance with grooming, was observed with overgrown facial hair and expressed dissatisfaction with the lack of shaving assistance. Staff interviews confirmed that grooming needs were not being consistently met, and the DON emphasized the importance of honoring residents' grooming needs for their overall well-being.
Failure to Address Routine Dental Needs
Penalty
Summary
The facility failed to ensure routine dental needs were evaluated and addressed timely for four residents. Resident R92 had a broken upper partial denture that was identified during an annual evaluation by Apple Tree Dental, but no follow-up action was taken to repair the denture despite the recommendation. The resident and their family member confirmed that no discussion about fixing the denture had occurred, and the medical record lacked evidence of any subsequent dental appointments since the issue was identified over three months prior. Resident R26 had severe cognitive impairment and was missing dentures that were lost before admission to the facility. The resident's family member stated that no one at the facility had offered to help set up a dental appointment to get new dentures, despite the resident's poor dentition and the importance of wearing dentures to the resident. The medical record did not indicate that the resident had been offered, refused, or received dental services. Resident R68 had broken natural teeth and loose-fitting dentures but had not been seen by a dentist for a comprehensive assessment since 2022. The resident expressed a desire for help in setting up a dental appointment to fix the dentures, but no follow-up action was taken by the facility. The medical record lacked evidence of any dental appointments or offers for dental services since the last visit in 2022. Additionally, Resident R102, who had multiple missing teeth and difficulty chewing, had not been assisted in setting up a dental appointment for dentures, and the medical record did not contain a completed dental consent form for the resident.
Failure to Administer and Document Pneumococcal Vaccinations
Penalty
Summary
The facility failed to offer or provide the pneumococcal vaccine to two residents and did not engage in shared clinical decision-making for the pneumococcal vaccine for two additional residents. Specifically, one resident who was cognitively intact and admitted to the facility had received previous doses of the pneumococcal vaccine but was not administered the recommended PCV20 or PPSV23 dose as per CDC guidelines. Another resident with severe cognitive impairment had no record of receiving the pneumococcal vaccine and was not offered the vaccine or educated on its risks and benefits upon admission. Additionally, two other residents with varying degrees of cognitive impairment had received previous doses of the pneumococcal vaccine but lacked documentation of shared clinical decision-making regarding the administration of the PCV20 vaccine. During an interview, the infection preventionist (IP) acknowledged the expectation that residents should be offered vaccines upon admission and that consent should be obtained. The IP admitted to being aware of the new CDC guidance on shared clinical decision-making for pneumococcal vaccines but had not yet implemented it due to time constraints. The IP also conducted an audit to identify residents needing the pneumococcal vaccine but had not completed the necessary vaccinations for the identified residents. The facility's policy indicated that the pneumococcal vaccine should be offered to all residents aged 65 or older, but this was not consistently followed.
Failure to Ensure Resident Participation in Care Planning
Penalty
Summary
The facility failed to ensure that a resident and/or their representative participated in care conferences for the care planning process. The resident, who had intact cognition and multiple diagnoses including anxiety, depression, COPD, amputation of the left leg above the knee, and a right hip replacement, reported not being invited or made aware of care conferences. The facility's documentation did not indicate whether the resident was invited or included in any care conferences, and the care conference summary documents were incomplete, missing critical information such as hospital stays and medication reconciliation. Interviews with the director of social services and the social worker revealed that it was the social worker's responsibility to notify residents and their families about care conferences and to ensure that all relevant sections of the care conference summary were filled out. However, the social worker admitted that the documents were incomplete and that the required sections were not filled out. The facility's policy required documentation of attendee names, areas discussed, concerns presented, and action items for follow-up, but this was not adhered to in the case of the resident in question.
Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was accurately coded, leading to potential inaccuracies in federal reimbursement and resident care planning for two residents. One resident, diagnosed with severe cognitive impairment and Alzheimer's disease, exhibited wandering behaviors that were documented multiple times during the MDS reference period. However, these behaviors were not accurately reflected in the MDS, which indicated no wandering behaviors. Interviews with staff confirmed the resident's wandering behavior and the need for secure unit placement, which was not properly coded in the MDS. Another resident, diagnosed with multiple sclerosis, malnutrition, and depression, had issues with broken or loosely fitting dentures that were documented during the MDS reference period. Despite this, the MDS did not reflect these dental issues, and the care plan did not address the resident's dental needs. Interviews with the resident and staff revealed that the resident had not received assistance in addressing his dental issues, which had persisted for a significant period. The MDS coordinator acknowledged the discrepancies in the MDS coding for both residents after reviewing their medical records. The director of nursing emphasized the importance of accurate MDS coding for creating effective care plans. The facility's policy/procedure regarding MDS completion was requested but not provided, indicating a potential gap in procedural adherence or documentation.
Failure to Develop and Maintain Comprehensive Care Plan for Resident with Lymphedema
Penalty
Summary
The facility failed to ensure a comprehensive care plan was developed and maintained for a resident with lymphedema. The resident's care plan lacked evidence of occupational therapy (OT) for lymphedema treatment, the need for compression socks or wraps, and coordination between providers. The resident's task list and care guide also lacked information about leg compression stockings or wraps, which would have been triggered from the care plan. Observations revealed the resident's legs were swollen and dry, and compression wraps were inconsistently applied, indicating a lack of proper care and coordination among staff members. Interviews with nursing assistants, licensed practical nurses, and occupational therapists confirmed the lack of communication and coordination in the resident's care. Nursing assistants were unsure if the resident received compression socks or wraps, as it was not mentioned in their task list or care sheets. The licensed practical nurse and registered nurse verified that the care plan and electronic medical record (EMR) lacked orders for lower extremity wraps or compression socks. The occupational therapist stated that treating the resident's lymphedema was a collaborative effort, but the most recent recommendation sheet was outdated and not up to date with the current recommendations. The director of nursing (DON) and director of rehab (DOR) acknowledged the importance of collaboration between therapy and nursing for the success of treatment. However, the DON was unaware of the concern with the resident's care plan and the missing information. The facility's policy on person-centered care plans indicated that the care plan should be clear, concise, and consistent with the nursing assistant care plan, which was not the case for this resident.
Failure to Reassess Skin Condition and Manage Diabetes
Penalty
Summary
The facility failed to comprehensively reassess and develop interventions for a resident (R71) with a non-pressure skin impairment on their feet. Despite initial treatment with Ketoconazole cream, the condition persisted, and no follow-up assessment was conducted after the treatment ended. The resident reported ongoing issues with dry, flaking skin and itching, which were not adequately addressed by the nursing staff. Observations and interviews revealed that the nursing assistants and licensed practical nurses were unaware of the resident's skin condition, and no post-treatment evaluation was documented in the medical record. Additionally, the facility failed to properly manage the diabetes of another resident (R26), who had consistently elevated blood glucose levels. The resident's blood sugar levels were frequently above the acceptable range, with some readings exceeding 400 mg/dL. Despite these elevated levels, there was no evidence that the provider was consistently notified, and no adjustments were made to the resident's diabetic management plan. Interviews with nursing staff and the nurse practitioner indicated a lack of communication and follow-up regarding the resident's blood glucose trends. The facility's policies and procedures for non-pressure skin management and diabetic management were either not provided or insufficiently detailed. The lack of comprehensive reassessment and follow-up for both the skin condition and diabetes management led to ongoing health issues for the residents, highlighting significant gaps in the facility's care processes and communication protocols.
Failure to Implement ROM and Splint Programs
Penalty
Summary
The facility failed to ensure a range of motion (ROM) restorative program was completed for a resident (R46) who was on a ROM program to prevent contractures. Despite having severe cognitive impairment and being dependent on staff for all activities of daily living (ADLs), R46's care plan lacked an intervention to provide ROM to her arms. Interviews with nursing staff and the director of rehabilitation (DOR) revealed confusion about who was responsible for R46's ROM exercises, resulting in the exercises not being performed as required. The director of nursing (DON) confirmed that R46 should be on a restorative program and that the therapy team should be completing the ROM exercises, but R46 was not on the list for therapy programs, indicating a lapse in communication and execution of care plans. The facility also failed to ensure a recommended splint application was completed and reassessed as needed for two residents (R19 and R68) with contractures of the hands. R19, who had severe cognitive impairment and multiple medical conditions, was supposed to have a palm protector applied to her left hand and receive ROM exercises. However, documentation showed inconsistent application of the splint and ROM exercises, with several instances of refusal or missed therapy sessions. Interviews with staff revealed a lack of awareness and communication regarding R19's need for the splint and ROM exercises, leading to inadequate care. Similarly, R68, who had multiple sclerosis and other medical conditions, was supposed to have a left-hand splint applied every evening and removed every morning. Despite this, observations and interviews indicated that the splint was not being applied consistently, and staff were unaware of the requirement. The DOR confirmed that R68 was not on a restorative program and that there had been poor staff follow-through with the wear schedule. The DON stated that she expected staff to notify the provider, therapy, and/or the resident representative if a resident was refusing to wear a needed orthotic device, but this had not occurred in R68's case.
Failure to Maintain Communication with Dialysis Clinic
Penalty
Summary
The facility failed to implement or maintain an appropriate communication and collaboration system with an outside dialysis clinic for a resident requiring dialysis care. The resident, who had moderate cognitive impairment and several medical conditions including anemia, high blood pressure, and renal failure, was unsure of the processes used by the facility to communicate with the dialysis clinic. The resident's care plan lacked evidence or direction on how the facility would coordinate or collaborate with the offsite dialysis clinic for the resident's care. The facility's staff, including nursing assistants and registered nurses, were interviewed and revealed inconsistencies in the communication process with the dialysis clinic. The Dialysis Communication Records were often left blank and not completed, and there was no evidence that the dialysis clinic was updated on the resident's repeated medication holds for low blood pressure or a recent fall. The health unit coordinator and health information system manager also confirmed that the communication records were not consistently sent or returned completed, and there was no scanning backlog to account for the missing records. The facility's policy on dialysis care plans and treatment sheets lacked information on how or how often the care center would collaborate or coordinate care with the offsite clinic. The registered nurse clinical director acknowledged the issue and mentioned that the offsite dialysis clinic was notorious for not completing or returning the communication records. However, no prior efforts had been made to address this issue with the clinic before the survey. The deficiency highlights a significant gap in the continuity of care for the resident receiving dialysis treatment.
Failure to Update Medication Diagnosis
Penalty
Summary
The facility failed to act upon the consultant pharmacist's recommendation for a resident (R73) who was prescribed Prochlorperazine Maleate without a documented diagnosis. The resident's physician orders did not include a diagnosis for the antipsychotic medication, and the consultant pharmacist had recommended updating the diagnosis in February 2024. Despite this recommendation being signed by both the consultant pharmacist and the physician, the diagnosis was not updated in the electronic medical record (EMR). Interviews with the resident, a trained medication aide, a licensed practical nurse, and the director of nursing revealed that the staff were unaware of the reason for the medication and acknowledged the importance of having the diagnosis documented in the EMR. The director of nursing confirmed that the monthly medication regimen reviews are collected and reviewed, and any recommendations are supposed to be addressed by the facility. However, in this case, the diagnosis for Prochlorperazine was not updated in the EMR, despite the consultant pharmacist's recommendation. The resident expressed frustration and confusion about the medication, stating that the facility did not communicate with them about their medications. The facility's policy on medication regimen review was requested but not provided, indicating a potential gap in the facility's adherence to its own policies and procedures.
Failure to Monitor Orthostatic Blood Pressure for Resident on Antipsychotic Medication
Penalty
Summary
The facility failed to ensure appropriate side effect monitoring, specifically orthostatic blood pressure monitoring, for a resident on antipsychotic medication. The resident, who had severe cognitive impairment, legal blindness, and vascular dementia with psychotic disturbance, was prescribed quetiapine furmate. Despite orders for monthly orthostatic blood pressure and pulse monitoring, the facility did not complete these checks for three consecutive months. The treatment administration records for January, February, and March 2024 showed that the required monitoring was either not documented or marked as incomplete without proper follow-up or explanation in the electronic medical record. Interviews with facility staff, including a registered nurse, pharmacist, and the director of nursing, confirmed the expectation for monthly orthostatic blood pressure monitoring for residents on antipsychotic medications. However, the facility's records lacked evidence of this monitoring for the resident in question. Additionally, the resident's care plan did not include an intervention to monitor for orthostatic hypotension, despite the known risks associated with antipsychotic medications. A facility policy on antipsychotic medication use and side effect monitoring was requested but not provided.
Facility Fails to Maintain Clean and Sanitary Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in a resident's room and the main production kitchen. In the case of the resident's room, the walls were observed to have bubbling paint, torn areas, and multiple dark-brown colored smears, which were identified as dried human feces and other organic material. The issue was confirmed by a registered nurse and the maintenance and housekeeping staff, who acknowledged that the room had not been properly cleaned or repaired. The last deep cleaning of the room was recorded over a month prior, and the Tels system used for reporting maintenance and housekeeping issues had not been utilized effectively by the staff to address the problem in a timely manner. In the main production kitchen, one of the two commercial ovens was found to be in an unsanitary condition. The top of the Vulcan double-stack convection oven was covered with a thick layer of black and gray-colored dust, debris, and burnt food particles, with metallic oven racks stored directly on this soiled surface. The kitchen staff, including a cook and the nutrition service director, confirmed that the oven had not been cleaned as per the facility's cleaning schedule. The cleaning log provided lacked specific instructions for cleaning the oven, and the last recorded cleaning was nearly three weeks prior. The nutrition service director acknowledged the oversight and the potential risk of cross-contamination due to the unclean oven. The facility's policies on reporting maintenance and housekeeping issues and kitchen equipment cleanliness were not effectively followed. The Tels system, intended to alert maintenance and housekeeping of environmental concerns, was not properly utilized by the staff. Additionally, the cleaning schedule for the kitchen equipment was not adhered to, leading to the unsanitary condition of the oven. These deficiencies highlight a lack of adherence to established protocols and inadequate communication among the staff, resulting in an unsafe and unsanitary environment for residents, visitors, and staff.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to accommodate the needs of three residents by ensuring their call lights were accessible. Resident R96, who had intact cognition and multiple diagnoses including schizophrenia and morbid obesity, was observed twice with the call light out of reach. R96 expressed frustration about the call light's inaccessibility, and staff interviews confirmed that the call light should have been within reach. Similarly, Resident R114, who had severe cognitive impairment and was receiving hospice services, was observed twice with the call light out of reach while seated in a wheelchair. Both the resident and a family member indicated that the call light should be accessible, and staff interviews corroborated this requirement. The Director of Nursing acknowledged the importance of accessible call lights but noted the facility lacked a written policy on this standard of care. Resident R10, who had moderately impaired cognition and dementia, was observed twice with the call light unplugged from the wall while seated in a wheelchair. Despite being able to use the call light in the past, R10 was found repeatedly yelling for help. A nursing assistant confirmed that R10 could use the call light but was unsure why it was not used on this occasion. These observations and interviews highlight the facility's failure to ensure call lights were accessible to residents, compromising their ability to request assistance when needed.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
