Redeemer Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Minneapolis, Minnesota.
- Location
- 625 West 31st Street, Minneapolis, Minnesota 55408
- CMS Provider Number
- 245520
- Inspections on file
- 23
- Latest survey
- June 5, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Redeemer Health Care Center during CMS and state inspections, most recent first.
The facility did not follow infection control protocols in three key areas: a resident's wheelchair had damaged armrests that could not be properly cleaned, personal laundry was transported in an uncovered cart, and transmission-based precautions were not promptly implemented for a resident with gastrointestinal symptoms. Staff interviews confirmed awareness of these lapses and the inability to maintain proper infection prevention practices.
Two residents had inaccurate medication information coded in their MDS assessments. One was incorrectly documented as receiving insulin when only Ozempic was administered, and another was coded as receiving both an antiplatelet and an anticoagulant when only aspirin was given. MDS coordinators and the DON confirmed these errors, and a facility policy on MDS was not provided when requested.
The facility did not ensure that final PASARR determinations were obtained and documented for two residents with schizoaffective disorder, despite policy requiring these approvals to be uploaded into the medical record. The process for receiving these determinations had changed, and the facility had not adapted, resulting in missing documentation.
A resident with a history of pressure ulcers and heart failure developed persistent dry, flaky skin that was not consistently treated according to physician orders. Although a topical cream was prescribed, it was often unavailable and not substituted as directed, with staff inconsistently applying alternative products and failing to document treatments or notify providers. This resulted in the resident's dry skin condition remaining unimproved over several weeks.
A resident with severe cognitive impairment and multiple complex diagnoses did not have a required quarterly care conference completed, resulting in a lack of participation by the resident and their guardian in the care planning process. The social services department did not follow up after unsuccessful attempts to contact the guardian, and the care conference was not documented as required by facility policy.
A resident with a history of DVT, PE, stroke, diabetes, and other conditions experienced an unresponsive episode that was assessed by an LPN, but the provider was not notified as required by facility policy. Staff interviews confirmed that notification and documentation should have occurred following this significant change in condition.
A resident with impaired cognition and partial natural teeth, dependent on staff for ADLs, did not receive routine oral hygiene as required by their care plan. Staff failed to document or provide oral care, with one nursing assistant incorrectly assuming the resident had no real teeth. Observation revealed poor oral condition, and the nurse manager confirmed oral care should have been provided and documented.
Staff failed to consistently perform hand hygiene and use appropriate PPE when caring for residents on Enhanced Barrier Precautions, including instances where a nursing assistant wore the same mask all day, a physical therapist did not sanitize hands or don a gown before assisting a resident, and another assistant did not perform hand hygiene when delivering a meal tray, despite clear facility policies and posted instructions.
The facility failed to ensure the QAPI committee was effective in maintaining action plans to correct a deficiency related to self-administration of medications, resulting in a recurrence of the issue. The QAPI minutes lacked consistent documentation and follow-up on medication administration audits, leading to the deficiency being identified again during the current survey.
The facility failed to ensure proper hand hygiene during medication administration and catheter care, and did not ensure proper use of PPE for a resident on enhanced barrier precautions. An LPN and a nursing assistant did not follow infection control protocols, as confirmed by the DON.
The facility failed to ensure proper SAM assessments for residents, leading to medications being left at the bedside without appropriate orders or supervision. One resident with multiple diagnoses had medications at his bedside without a current SAM assessment or order. Another resident with cognitive loss had medications left on the dining table without supervision. A third resident with intact cognition had medications at his bedside despite SAM assessments indicating he was not safe to self-administer.
A resident with moderate cognitive impairment and a history of falls was found with an inaccessible call light, despite care plans and facility policies requiring it to be within reach. Staff confirmed the oversight, and a missing clip was later attached to the call light cord.
A resident with Alzheimer's and dementia was administered Tamiflu without notifying or gaining consent from the designated healthcare POA. The facility's staff failed to document the notification, leading to dissatisfaction from the family member.
A resident was left uncovered and undressed with the privacy curtain and room door open during personal care, leading to exposure and embarrassment. Staff interviews and observations confirmed the failure to follow privacy protocols, despite the facility's Resident Rights policy emphasizing the need for privacy.
The facility failed to ensure a baseline care plan was reviewed and provided timely for a resident with multiple diagnoses, including end-stage renal disease and diabetes mellitus. The resident was not included in any planning or informed about the expectations for her stay or discharge planning. The Licensed Social Worker confirmed that an initial care conference was not held as required by the facility's policy.
A resident with significant medical conditions and chronic skin issues was not properly assessed or monitored for multiple non-healing and bleeding skin lesions. Despite being dependent on staff for care, the resident's care plan did not identify their recurrent skin lesions, and staff failed to document and treat these conditions adequately, leading to inadequate treatment and monitoring.
The facility failed to ensure that pressure-reducing air mattresses were operational for two residents at risk for pressure ulcers. One resident was found lying on a deflated mattress, while another was observed on a non-functional mattress with a significant indentation. Nursing staff confirmed the necessity of these mattresses for preventing skin breakdown, but they were not properly maintained.
A facility failed to ensure post-dialysis assessment and monitoring for a resident with multiple diagnoses, including kidney failure. Despite having physician orders and a care plan, the medical records lacked documentation of post-dialysis monitoring on several dates. Staff interviews revealed inconsistencies in performing and documenting these assessments, particularly during evening shifts. The Director of Nursing confirmed the deficiency, highlighting the importance of monitoring for complications post-dialysis.
A facility failed to provide medically related social services and obtain mental health counseling for a resident with major depressive disorder and inappropriate tendencies towards staff. Despite a care plan and provider note recommending psychiatric services, the resident did not receive the necessary support due to a breakdown in the referral process and misfiled documents in the electronic health record.
The facility failed to conduct comprehensive trauma assessments for six residents with a history of traumatic events, resulting in care plans that did not address trauma-related goals and interventions. Despite documented histories of abuse and trauma, the facility did not identify potential triggers or provide appropriate interventions, leaving residents vulnerable to retraumatization and inadequate care.
Infection Control Failures in Environmental Cleaning, Linen Handling, and Precaution Implementation
Penalty
Summary
The facility failed to adhere to infection control standards in several areas, as observed and confirmed through staff interviews. In one instance, a resident with multiple diagnoses including traumatic brain injury, diabetes, aphasia, dementia, and other conditions was found to have a wheelchair with cracked and peeling vinyl armrests, exposing foam and metal. Multiple staff members, including a nursing assistant, medication aide, nurse manager, DON, infection control preventionist, and housekeeper, all acknowledged that the damaged armrests could not be properly cleaned and posed an infection control concern due to their inability to be disinfected effectively. Additionally, the facility did not ensure that personal laundry was transported in a manner that prevented contamination. A laundry aide was observed leaving a laundry cart uncovered and unattended in a hallway, with personal laundry visible and accessible. The aide later acknowledged that the cart should have been covered to prevent contamination, as per facility policy, which requires linen to be handled and transported in a way that avoids exposure and contamination. The facility also failed to implement timely transmission-based precautions (TBP) for a resident who exhibited symptoms of a possible gastrointestinal illness, including multiple episodes of nausea and vomiting. Despite these symptoms being documented in the resident's progress notes, staff did not initiate TBP or use additional personal protective equipment beyond gloves until the infection control preventionist reviewed the case the following day. The facility's policy and CDC guidelines require TBP to be implemented for residents with suspected communicable diseases, but this was not done promptly.
Inaccurate MDS Coding of Medications for Two Residents
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for two residents, resulting in incorrect documentation of medications received. For one resident, the admission MDS indicated receipt of an insulin injection, but the physician order report showed the resident was only receiving Ozempic, a GLP-1 receptor agonist, which should not be classified as insulin or a high-risk hypoglycemic medication according to the Resident Assessment Instrument (RAI) Manual. The MDS coordinator confirmed the resident was not receiving insulin and expressed uncertainty about how to code Ozempic, indicating a lack of reference to the RAI Manual at the time of coding. For another resident, the admission MDS documented receipt of both an antiplatelet and an anticoagulant medication, but the physician order report only listed aspirin, which should be coded solely as an antiplatelet. The MDS coordinator acknowledged the error, confirming the resident was not on an anticoagulant. The director of nursing agreed that the MDS coding for both residents was inaccurate. Additionally, a facility policy on MDS was requested but not provided.
Failure to Obtain and Document Final PASARR Determinations
Penalty
Summary
The facility failed to ensure that a Level I Pre-admission Screening (PAS) and, when indicated, a Level II Pre-admission Screening and Resident Review (PASARR) were completed for two residents with mental health diagnoses. Both residents had intact cognition and were diagnosed with schizoaffective disorder, one with auditory hallucinations and the other with an acute exacerbation. Documentation in their medical records showed that while a PAS notice was present, there was no evidence that a final PASARR determination had been received from the lead agency for either resident. The director of nursing confirmed during an interview that the final PASARR determinations could not be found in the medical records for these residents. The facility's policy required that copies of PASARR approvals be uploaded into each resident's medical record, but this was not done. The process for obtaining final determinations had recently changed from fax to electronic requests, and the facility had not been following the new procedure, resulting in the missing documentation.
Failure to Consistently Treat and Document Dry Skin Condition
Penalty
Summary
A deficiency occurred when a resident with a history of pressure ulcers, heart failure, and hemiparesis developed dry, itchy, and visibly flaky skin on his arms and legs. The resident's care plan included interventions to moisturize dry skin, and a physician's order directed the application of CeraVe cream twice daily. However, observations and interviews revealed that the prescribed cream was not consistently applied, and the resident reported that staff were not regularly treating his dry skin as ordered. Review of the Medication Administration Record (MAR) showed that the CeraVe cream was frequently not administered, with staff documenting 'Drug/Item Unavailable' on multiple occasions. Despite the lack of CeraVe, there was no documentation of an alternative cream being used, even though the physician's order allowed for an alternative topical cream. Staff interviews confirmed inconsistent application of lotion, uncertainty about which products were being used, and a lack of communication regarding the unavailability of the prescribed product. The medical record lacked evidence of provider notification, order clarification, or attempts to obtain the prescribed cream after insurance denial. Nursing leadership confirmed that the CeraVe was not available and that staff had been using A&D ointment instead, without updating the provider or the MAR to reflect this substitution. There was no documentation of what products were actually applied, and the facility's policy did not provide clear guidance for treating non-wound skin concerns like dry skin. The lack of consistent treatment and documentation resulted in the resident's ongoing dry skin condition, with no evidence of improvement over several weeks.
Failure to Ensure Resident and Guardian Participation in Care Planning
Penalty
Summary
The facility failed to ensure that a resident and their guardian participated in the development and implementation of the resident's person-centered plan of care. According to the report, the resident had severely impaired cognition and multiple diagnoses, including traumatic brain injury, diabetes, aphasia, dementia, seizures, depression, bipolar disorder, and psychotic disorder. The resident was dependent on staff for several activities of daily living. The resident's family member was identified as the emergency contact, guardian, and primary financial contact. Review of the electronic medical record showed that the required quarterly care conference, which should coincide with the Minimum Data Set (MDS) assessment, was not completed for the resident in March. The last documented care conference was in January, and attempts to contact the guardian were made but not followed up. Interviews with the DON and social services staff confirmed that care conferences are expected to be held in conjunction with MDS assessments and that documentation should be present in the resident's record. The social services staff acknowledged responsibility for scheduling and documenting care conferences and stated that the March care conference was missed, likely due to a lack of follow-up after an initial attempt to contact the guardian. Facility policy requires quarterly care conferences and assigns responsibility for coordination and documentation to the social services department.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to notify a physician of a significant change in condition for a resident with a complex medical history, including deep vein thrombosis, pulmonary embolism, stroke, diabetes, schizoaffective disorder, and cancer. The resident experienced an unresponsive episode observed by a nursing assistant, after which an LPN conducted an assessment. The assessment documented that the resident regained responsiveness within seconds, was able to answer questions, follow commands, and denied headache. However, there was no documentation that the provider was notified of this unresponsive episode, and the resident's care plan did not include a history of such episodes. Interviews with facility staff confirmed that the nurse in charge and the nurse practitioner were not informed of the incident, and both indicated that provider notification would have been expected according to facility procedures. The facility's policy required staff to notify the provider of significant changes in a resident's condition and to document this communication. The lack of provider notification and documentation following the unresponsive episode constituted a failure to follow established protocols for change of condition.
Failure to Provide Routine Oral Hygiene for Dependent Resident
Penalty
Summary
The facility failed to ensure that routine oral hygiene was provided for a resident who was dependent on staff for activities of daily living. The resident had moderately impaired cognition, required substantial assistance with oral care, and had a care plan indicating the need for extensive staff assistance due to having full upper dentures and natural lower teeth with some missing. Review of documentation showed no record of oral care being provided over a one-month period. The resident reported that staff were supposed to help with brushing teeth twice daily but had not been doing so, and that previously staff would leave a basin and toothbrush but no longer did even that. A nursing assistant assigned to the resident stated she did not provide oral care because she believed the resident had no real teeth, despite the resident having remaining lower teeth. Observation confirmed the resident had yellowed lower teeth with visible white/yellow matter around the edges. The unit nurse manager confirmed that oral hygiene was the standard of care and should be performed preferably twice daily, and that documentation should be present in the point of care charting, which was not found. A policy on oral care was requested but not provided.
Failure to Ensure Proper Hand Hygiene and PPE Use Under Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure proper hand hygiene and use of personal protective equipment (PPE) for multiple residents under Enhanced Barrier Precautions (EBP). For one resident with an indwelling catheter and pressure ulcers, a nursing assistant donned gloves and a gown but continued to wear the same surgical mask throughout the day, contrary to posted EBP instructions. The signage on the resident's door clearly outlined the required sequence for donning and doffing PPE and emphasized the need for hand hygiene before entering and after leaving the room. Another resident with an ostomy and kidney insufficiency was assisted by a physical therapist who did not perform hand hygiene or don a gown before entering the room, despite EBP signage. The therapist only donned gloves after entering and failed to perform hand hygiene upon exit. The therapist later acknowledged not following the required procedures and recognized the importance of these measures in preventing infection spread. A third resident with a suprapubic catheter and a wound was served a meal tray by a nursing assistant who did not perform hand hygiene before or after entering the room, despite EBP signage and recent training. The assistant believed hand hygiene was unnecessary since no direct care was provided. Interviews with the infection preventionist, director of nursing, and registered nurse confirmed that staff were expected to follow EBP protocols, including hand hygiene and appropriate PPE use, as outlined in facility policies.
Failure to Maintain Effective QAPI Committee
Penalty
Summary
The facility failed to ensure the Quality Assurance Process Improvement (QAPI) committee was effective in maintaining appropriate action plans to correct a quality deficiency identified during a previous survey related to self-administration of medications (SAM). This resulted in a deficiency identified during the current survey. Specifically, the facility did not complete SAM assessments to allow residents to safely administer their own medications for three residents observed with medications at their bedside. During the review of the QAPI minutes for the first quarter of 2023, it was noted that the facility had been cited for F755 related to a resident not being monitored for medication administration. The minutes indicated that education was completed, a whole house sweep was conducted to check for medications in rooms, and medication administration audits were performed. However, the subsequent QAPI minutes for the second, third, and fourth quarters of 2023 lacked consistent documentation and follow-up on medication administration audits, which were crucial for addressing the identified deficiency. In an interview, the administrator acknowledged that QAPI meetings were held quarterly and would transition to monthly. The administrator also mentioned that performance improvement projects (PIPs) were ongoing, but there was a lack of consistent monitoring and documentation in the QAPI minutes regarding the SAM assessments. This inconsistency in maintaining and following through with action plans led to the recurrence of the deficiency related to self-administration of medications during the current survey.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure proper hand hygiene during medication administration for two residents. An LPN administered medications to two residents without sanitizing hands between each administration. The LPN also handled medication cups and other items without performing hand hygiene. The Director of Nursing (DON) confirmed that staff are expected to sanitize hands between medication administrations to prevent the spread of infection. The facility also failed to ensure proper hand hygiene during suprapubic catheter care for one resident. An LPN did not change gloves or sanitize hands between removing a dirty dressing and cleaning the catheter site. The DON confirmed that staff are expected to change gloves and sanitize hands to prevent infection at the catheter site. Additionally, the facility failed to ensure proper use of personal protective equipment (PPE) for a resident on enhanced barrier precautions. A nursing assistant did not don a gown or gloves when entering the resident's room and assisting with care. The DON and infection preventionist confirmed that staff are expected to follow enhanced barrier precautions, including wearing gowns and gloves for high-contact care activities.
Failure to Ensure Proper Self-Administration of Medications Assessment
Penalty
Summary
The facility failed to ensure a self-administration of medications (SAM) assessment was completed for residents to safely administer their own medications. Resident 66, who had multiple diagnoses including traumatic brain injury and major depressive disorder, was observed with medications at his bedside without a current SAM assessment or order. The resident's care plan did not address SAM, and staff confirmed that medications should not be left at the bedside without the appropriate order and assessment in place. Additionally, the resident's inhaler and capsules were found at the bedside without supervision, contrary to facility policy and staff statements that an order and assessment were required for SAM. Resident 6, who was cognitively intact but had a care plan indicating cognitive loss and dementia, was observed with medications left on the dining table in front of her without supervision. The resident's SAM assessment indicated she did not want to self-administer medications, and her physician orders lacked SAM documentation. The director of nursing verified that the resident should be supervised during medication pass and that medications should not be left with the resident on the dining table. Resident 73, who had intact cognition and multiple diagnoses including diabetes and high blood pressure, was observed with medications at his bedside without staff present. Although the resident had a care plan indicating he wished to self-administer certain medications, his SAM assessments indicated he was not safe to administer his own medications. Staff were unaware of the resident's SAM status and left medications at the bedside, contrary to the facility's policy requiring both an assessment and a provider's order for SAM.
Failure to Ensure Call Light Accessibility
Penalty
Summary
The facility failed to ensure the call light was accessible for a resident (R39) who had moderate cognitive impairment and required substantial assistance with most activities of daily living. R39's care plan and falls risk assessment both indicated that the call light should be within reach to prevent falls. However, during an observation, the call light was found on the floor under R39's bed, making it inaccessible. R39 attempted to reach the call light but was unable to do so, which posed a risk given his history of falls and cognitive impairment. Interviews with staff confirmed that the call light should have been within R39's reach. A nursing assistant noted that the call light cord was missing a clip, which was later retrieved and attached. The registered nurse and director of nursing both stated that the expectation was for call lights to be accessible to residents who could use them. The facility's policy also indicated that call lights should be placed within reach at all times. Despite these guidelines, the call light was not accessible to R39, leading to a deficiency in accommodating the resident's needs and preferences.
Failure to Notify and Gain Consent for Medical Treatment
Penalty
Summary
The facility failed to contact the designated representative and gain consent for medical treatment for a resident with Alzheimer's disease and dementia. The resident, who had altered levels of consciousness and was rarely or never understood, was administered Tamiflu prophylactically due to an influenza outbreak in the facility. The resident's care plan indicated that staff should notify the provider and representative of any changes, but the electronic health record lacked documentation that the family member was informed about the administration of Tamiflu. Interviews with the family member and staff revealed that the family member, who was the healthcare power of attorney (POA), was not notified or asked for consent before the administration of Tamiflu. The family member expressed dissatisfaction with the lack of communication and decision-making by the staff. The director of nursing acknowledged the mistake, stating that the facility did not have the POA paperwork at the time, which led to the oversight in notifying the family member.
Failure to Ensure Resident Privacy During Personal Care
Penalty
Summary
The facility failed to ensure the privacy of a resident during personal care activities. The resident, who was cognitively intact and dependent on staff for various activities, reported feeling exposed and embarrassed when a nursing assistant left them uncovered and undressed with the privacy curtain open. The resident's roommate's family entered the room during this time, further compromising their privacy. Observations confirmed that the resident was left visible from the hallway, uncovered, and with the privacy curtain and room door open, despite a sign requesting the door to be closed completely. Interviews with staff revealed inconsistencies in following privacy protocols. Nursing assistants stated that privacy curtains should be pulled during care and residents should be covered if staff needed to leave the room. However, the incident showed a failure to adhere to these practices. The registered nurse confirmed the oversight, and the director of nursing emphasized that residents should not be left exposed unless it was their personal preference. The facility's Resident Rights policy supports the need for privacy in treatment and personal care, which was not upheld in this case.
Failure to Provide Timely Baseline Care Plan
Penalty
Summary
The facility failed to ensure a baseline care plan was reviewed and provided timely for a resident who was admitted and readmitted multiple times. The resident, who had diagnoses including end-stage renal disease, diabetes mellitus, and bipolar disorder, was not included in any planning or informed about the expectations for her stay or discharge planning. The resident denied having a care conference or being invited to one, and was not provided with any information regarding her care verbally or in writing. During an interview, the Licensed Social Worker (LSW) and Social Service Director confirmed that an initial care conference should be held by day 7, but this was not done for the resident. The LSW verified that a 48-hour care plan was not given to the resident and no care conference was held. The facility's policy indicated that care conferences should be held within 21 days of admission and quarterly thereafter, but this was not adhered to in this case.
Failure to Accurately Assess and Monitor Skin Lesions
Penalty
Summary
The facility failed to accurately assess and monitor multiple non-healing and bleeding skin lesions, lacerations, and scabs for a resident (R40) who was cognitively intact and had significant medical conditions including heart failure, peripheral vascular disease, kidney failure, diabetes, and a lower limb amputation. Despite being dependent on staff for showers, dressing, personal hygiene, and transfers, and being at risk for pressure ulcers, R40's care plan did not identify their recurrent skin lesions on their arms, legs, and chest, nor did it include appropriate interventions for these conditions. The care plan instructed licensed staff to complete visual body observations weekly and notify the provider and family of any new areas of concern, but this was not effectively carried out as evidenced by the lack of documentation and monitoring of R40's numerous current open areas and scabs on their arms and chest. Observations and interviews revealed that R40 had multiple small, circular superficial lesions on both upper extremities, which were not properly assessed or treated. On several occasions, R40 was found with soiled and improperly applied dressings, and numerous sores and scabs in various states of healing on their arms and chest. R40 reported that staff only applied regular moisturizing lotion to their sores and did not assess or treat them adequately. Nursing assistants and registered nurses confirmed that they observed R40's skin issues but did not consistently document or monitor them, and there was confusion about whether R40 had any special creams or lotions for their sores. The facility's director of nursing (DON) and other nursing staff acknowledged that weekly head-to-toe skin assessments were supposed to be completed and documented, and any new concerns should have been added to the wound management form. However, R40's chronic skin issues were not consistently recorded or monitored, and their care plan did not reflect these ongoing concerns. The facility's Skin Integrity policy required licensed nurses to complete visual head-to-toe skin inspections and document any skin alterations, but this was not effectively implemented for R40, leading to inadequate treatment and monitoring of their skin conditions.
Failure to Ensure Operational Pressure-Reducing Air Mattresses
Penalty
Summary
The facility failed to ensure that pressure-reducing air mattresses were properly operational for two residents, leading to a deficiency in pressure ulcer care. Resident R39, who had moderate cognitive impairment and was at risk for developing pressure ulcers, was observed lying on a deflated air mattress that was not plugged in. Nursing staff confirmed that the air mattress was required but was not operational due to the bed's position, which prevented the pump from reaching the outlet. This oversight was noted during multiple observations and interviews with nursing staff, who acknowledged the necessity of the air mattress for preventing skin breakdown. Similarly, Resident R87, who also had moderate cognitive impairment and was at risk for pressure ulcers, was observed multiple times lying on an air mattress that was not turned on. The mattress had a significant indentation, indicating it was not functioning correctly. Nursing staff confirmed that the air mattress should be operational whenever the resident was in bed to prevent skin breakdown. The facility's policy on skin integrity emphasized the importance of appropriate treatment plans and interventions to prevent skin injuries, which were not followed in these cases.
Failure to Ensure Post-Dialysis Monitoring
Penalty
Summary
The facility failed to ensure post-dialysis assessment and monitoring for a resident who required hemodialysis. The resident, who had diagnoses including kidney failure, high blood pressure, diabetes, heart failure, and peripheral vascular disease, did not receive the necessary post-dialysis monitoring of their access site, shunt bruit and thrill, and vital signs. Despite having physician orders and a care plan in place, the medical records lacked documentation of these assessments on multiple dates when the resident returned from dialysis treatments. Interviews with staff revealed that while pre-dialysis assessments were conducted, post-dialysis assessments were not consistently performed or documented, particularly when the resident returned to the facility in the evening shift. The Director of Nursing confirmed that the facility's policy required ongoing assessment and monitoring for complications before and after each dialysis treatment. However, a review of the resident's medical record indicated that staff were not completing the necessary post-dialysis assessments. This oversight was acknowledged by the Director of Nursing, who emphasized the importance of ensuring the shunt was functioning properly and monitoring for excessive bleeding or other complications. The lack of post-dialysis monitoring represents a significant deficiency in the care provided to the resident.
Failure to Provide Mental Health Counseling
Penalty
Summary
The facility failed to provide medically related social services and/or obtain mental health counseling for a resident diagnosed with major depressive disorder and inappropriate tendencies towards staff. The resident's quarterly MDS indicated moderate cognitive impairment and a need for assistance with most ADLs. Despite a care plan identifying the resident's risk for mood and behavioral disturbances and a provider note recommending a referral to in-house psychiatric services, the resident did not receive the necessary mental health support. The resident expressed feelings of sadness due to the loss of his wife and reported not being offered any psychological or grief support, which he felt would be helpful. Interviews with facility staff revealed a breakdown in the referral process. The registered nurse and health unit coordinator indicated that referrals to psychiatric services were typically made by the social worker based on nursing communication or provider orders. However, the social worker admitted to incorrectly assuming the resident was already receiving psychiatric services based on misfiled documents in the electronic health record. The social worker and other staff members acknowledged that the resident should have had a psychiatric referral and that all offers and refusals should be documented. The facility's policy on ancillary services was not followed, leading to the resident not receiving the necessary mental health support.
Failure to Conduct Comprehensive Trauma Assessments
Penalty
Summary
The facility failed to ensure comprehensive trauma assessments were completed for six residents with a history of traumatic events. These residents included individuals with diagnoses such as cerebral palsy, mood disorder, anxiety, traumatic brain injury, dementia, and major depressive disorder. Despite the presence of documented histories of abuse and trauma, the facility did not conduct thorough trauma assessments to identify potential triggers and appropriate interventions to maintain the residents' mental and psychosocial well-being. For instance, one resident reported a history of abuse by her father and an incident involving a staff member making inappropriate sexual requests, yet no comprehensive trauma assessment was completed following the allegation. Another resident with a history of traumatic brain injury and recent rape expressed discomfort with male caregivers, but the facility did not complete a trauma assessment to address her needs. Similarly, other residents with documented histories of abuse and trauma, including childhood and spousal abuse, were not provided with comprehensive trauma assessments. This lack of assessment resulted in care plans that did not address trauma-related goals and interventions, leaving residents vulnerable to retraumatization and inadequate care. Interviews with staff and family members revealed a lack of awareness and training regarding trauma-informed care. Direct care staff were not informed about residents' trauma histories, and care plans did not include specific interventions to mitigate the risks of retraumatization. The facility's policy on trauma-informed care emphasized the importance of identifying trauma histories and developing appropriate care plans, but this was not consistently implemented, leading to deficiencies in the care provided to residents with a history of trauma.
Self-audit
Pick a level of detail and, optionally, what to focus on — then generate a survey-ready checklist distilled from the most recent citations.
Beta · AI-generated — for reference only, not professional advice. Verify against current CMS guidance before relying on it. Assisto accepts no responsibility for how this checklist is used.
Citations used to create this checklist
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.
Self-audit
Pick a level of detail and, optionally, what to focus on — then generate a survey-ready checklist distilled from the most recent citations.
Beta · AI-generated — for reference only, not professional advice. Verify against current CMS guidance before relying on it. Assisto accepts no responsibility for how this checklist is used.
Citations used to create this checklist
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
