Renvilla Health Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Renville, Minnesota.
- Location
- 205 Southeast Elm Avenue, Renville, Minnesota 56284
- CMS Provider Number
- 245554
- Inspections on file
- 15
- Latest survey
- December 10, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Renvilla Health Center during CMS and state inspections, most recent first.
A resident with multiple complex medical conditions was admitted with several wounds, including a blister on the right fourth toe that was not included in the physician's wound care orders. Nursing staff observed worsening conditions of the toes, such as maceration, drainage, and discoloration, but did not notify the physician or update treatment orders. The primary care physician was not informed about these wounds, and facility policy requiring physician notification for new skin issues was not followed.
Two residents with significant skin integrity issues did not have all necessary wound care and preventive interventions incorporated into their care plans. One resident with multiple wounds and complex medical conditions had no wound care interventions documented in the care plan, while another resident's care plan did not consistently reflect physician orders for heel protectors, and heel boots were not always in place as required.
A resident with multiple comorbidities and numerous wounds was admitted without specific wound care orders or clear documentation in the care plan. Nursing staff provided wound care to the resident's toes without physician orders and failed to notify the physician of worsening wound conditions, despite observations of drainage, discoloration, and foul odor. The lack of timely physician notification and incomplete documentation led to the resident's wounds deteriorating, requiring hospitalization and surgical intervention.
A resident with multiple risk factors for skin breakdown developed an open area on the coccyx that was not promptly identified or comprehensively assessed by staff. Nursing assistants discovered the wound, but the nurse was not called at the time, and a subsequent assessment by an LPN revealed the open area had not been previously documented or treated according to facility policy.
The facility failed to maintain sanitary conditions in the kitchen, affecting all 39 residents. Expired and unlabeled food items were found, and the walk-in freezer had significant frost buildup. Interviews revealed a lack of adherence to food safety protocols due to staff turnover and absence of a structured system for checking expired foods and completing cleaning tasks. The facility's policies lacked specific systems to ensure compliance, leading to these deficiencies.
The facility failed to implement a comprehensive assessment protocol to ensure staff competencies and solicit input from residents and representatives. The assessment document highlighted changes that were not executed, and competencies for dietary staff were incomplete. Interviews revealed gaps in implementation, with the administrator acknowledging the lack of required input and incomplete competencies.
The facility's QAPI program lacked documentation of measurable goals and data analysis for various initiatives, including bowel incontinence management and employee recruitment. Despite data submission from departments, there was no evidence of goal-setting or analysis in QAPI meeting minutes from February, March, and July 2024. Issues such as falls and dementia care also lacked documented goals and action plans, as confirmed by the administrator.
A resident's lisinopril dosage was not properly reconciled, leading to the administration of an incorrect dose. The TMA used a medication card with 10 mg tablets, despite the EMR showing a 5 mg order. The facility's procedures for handling medication changes were not followed, as the incorrect card was not removed, and the pharmacy was not notified.
The facility failed to ensure accurate medication labeling and dosage for two residents, leading to potential medication errors. One resident received an incorrect dosage of Lisinopril due to a lack of communication about a dosage change. Another resident had discrepancies in Gabapentin and Lidoderm patch orders and labels. The facility's policies for medication order transcription and communication were not followed.
Failure to Notify Physician of New and Worsening Wounds
Penalty
Summary
The facility failed to notify the physician of new wounds for a resident with multiple complex medical conditions, including heart disease, diabetes, chronic kidney disease, and a left below-knee amputation. Upon admission, the resident was found to have fourteen wounds, including a blister on the right fourth toe that was not included in the physician's orders for wound care. Nursing staff observed maceration, drainage, and discoloration of the toes during dressing changes, but did not notify the physician about these wounds or their changes in appearance. Documentation shows that wound care orders were only in place for four of the fourteen wounds, and the remaining wounds, including those on the toes, were not addressed with new physician orders. Interviews with nursing staff revealed that they assumed the physician was already aware of the wounds or that wound care was being managed by others, leading to a lack of direct communication with the physician regarding the new or worsening wounds. The resident's primary care physician confirmed not being informed about the wounds since admission and did not assess the toes during a visit, as they were wrapped. Facility policy required staff to notify the physician and responsible party of new skin integrity issues, but this protocol was not followed in this case.
Failure to Incorporate Skin Integrity Interventions into Care Plans
Penalty
Summary
The facility failed to incorporate appropriate skin integrity interventions into the care plans for two residents who were reviewed for skin conditions. One resident was admitted with multiple complex medical diagnoses, including a history of myocardial infarction, chronic atrial fibrillation, diabetes, stage 5 chronic kidney disease, and a left below-knee amputation. This resident required maximum assistance with activities of daily living and had a stage two pressure ulcer on admission, as well as a total of fourteen wounds identified during the facility's skin/wound assessment. Despite these findings, the resident's care plan did not include documentation of wounds, wound care, or interventions aimed at preventing further deterioration of skin integrity. Another resident was admitted with diagnoses including non-pressure chronic ulcers on both lower legs, varicose veins with ulceration, a stage 3 pressure ulcer on the left heel, and localized edema. The care plan for this resident did identify some skin integrity issues and listed interventions such as use of an air mattress, encouragement of nutrition and hydration, heel protection, and regular repositioning. However, physician orders for heel protectors were not consistently reflected in the care plan, and documentation indicated that heel boots were not in place at times due to drainage and odor, with pillows being used instead. Interviews with staff and administration confirmed that not all interventions for prevention and management of skin breakdown were included in the care plans, as required by facility policy.
Failure to Initiate, Monitor, and Notify Physician of Resident Wounds
Penalty
Summary
The facility failed to initiate, monitor, and notify the physician regarding multiple wounds for a resident who was admitted with significant comorbidities and impaired skin integrity. Upon admission, the resident had numerous wounds, including a blister on the right 4th toe, abrasions, a stage 2 pressure ulcer, and a left below-knee amputation site. The initial wound assessment documented these wounds, but there was no corresponding physician order for wound care to the right 4th digit toe, and the care plan did not specify wound locations, treatments, or interventions for the identified wounds. Throughout the resident's stay, nursing staff provided wound care to the toes without physician orders, and documentation was inconsistent or incomplete. Several nurses and nursing assistants described the wounds as macerated, draining, and discolored, with some noting foul odor and difficulty separating the toes due to drainage. Despite these observations, staff did not notify the physician of the wounds' condition or deterioration, assuming the physician was already aware or that orders were not needed for all treatments. Progress notes indicated worsening wound conditions, including purulent drainage and discoloration, but lacked details on treatments applied or physician notification. The lack of timely physician notification and absence of specific wound care orders resulted in the resident's wounds worsening, ultimately leading to hospitalization and surgical intervention for wet gangrene and peripheral vascular disease. Interviews with staff and the resident's primary care physician confirmed that the physician was not informed about the wounds, and wound care orders were not entered into the medication administration record. Facility policy required notification of the provider and initiation of treatment orders for new or worsening wounds, but these steps were not followed for this resident.
Failure to Identify and Assess Pressure Ulcer
Penalty
Summary
The facility failed to identify and comprehensively assess a pressure ulcer for one resident with multiple risk factors, including a recent femur fracture, type 2 diabetes, incontinence, and substantial assistance required for activities of daily living. The resident's care plan noted skin integrity impairment and interventions such as encouraging nutrition, hydration, and prompt treatment of skin breaks. Despite a Braden scale score indicating risk, a skin and wound evaluation did not identify an open area on the coccyx the day before the deficiency was observed. During care, nursing assistants discovered an open spot with fresh blood on the resident's coccyx, but the nurse was not called to assess the area at that time, as the resident was leaving for an appointment and declined further evaluation. The following day, an LPN was unaware of the wound until informed and then measured the area as 0.5 cm x 0.5 cm, confirming it was open. The LPN stated that wounds should be photographed, covered, and have a dressing order entered, with ongoing assessment on bath days and daily checks by nursing assistants. However, the wound had not been properly identified, assessed, or documented prior to this, and a nursing assistant reported that a nurse had previously been dismissive when informed of the wound. The facility's policy required prompt monitoring and addressing of skin integrity issues, but this was not followed in the resident's case.
Deficiencies in Kitchen Sanitation and Food Safety Protocols
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which had the potential to affect all 39 residents. During an inspection, several expired food items were found, including Parmesan Pepper Corn Pasta Salad, mustard, sun-dried raisins, minced garlic, dressing, smoothie mix, cheese, and pepperoni. Additionally, there were multiple unlabeled and undated food items in the walk-in cooler, such as a bowl with a white creamy substance, a plastic squeeze bottle with a solid white substance, and a glass jar with a yellow creamy consistency. The walk-in freezer had significant frost buildup, and the stove and surrounding areas were observed to be unclean. Interviews with kitchen staff revealed a lack of awareness and adherence to food safety protocols. Cook-A admitted uncertainty about the contents of unlabeled bottles and acknowledged that the kitchen had experienced significant staff turnover, which impacted their ability to maintain cleanliness and check for expired foods. The dietary manager confirmed the findings and admitted that there was no system in place to ensure staff were checking for expired foods or completing necessary cleaning tasks. The director of dietary services, who oversees multiple facilities, had previously discussed the need for audits and competencies with the dietary manager but had not followed up on their implementation. The facility's policies on labeling foods and using sanitary practices were reviewed and found to lack specific systems to ensure compliance. The administrator expected the dietary manager to have a system in place to ensure all kitchen duties were completed, including cleaning, removal of expired foods, and appropriate labeling. However, the absence of a structured system led to the observed deficiencies, as evidenced by the incomplete cleaning sign-off sheets and the lack of audits or competencies to verify adherence to food safety protocols.
Failure to Implement Comprehensive Facility Assessment Protocol
Penalty
Summary
The facility failed to implement a comprehensive facility-wide assessment protocol to ensure staff competencies were identified and completed according to their respective duties. The assessment did not solicit input from staff, residents, representatives, or family members, which is a requirement. The facility assessment document, dated 8/8/24, highlighted changes that were supposed to be implemented, including feedback solicitation through questionnaires, suggestion boxes, and meetings. However, these changes had not been executed at the time of the survey. The assessment also failed to include competencies for all staff, as evidenced by the lack of completed competencies for two dietary staff members. Interviews with the dietary manager and the administrator revealed gaps in the implementation of the assessment protocol. The dietary manager admitted that competencies for the dietary staff were only completed annually and were not available for the two staff members in question. The administrator acknowledged that the facility had not yet implemented the required input from residents or representatives, as the regulation had just come into effect. The facility had discussed these changes internally but had not taken steps to gather input or complete the necessary competencies, as highlighted in the assessment document.
Lack of Measurable Goals and Data Analysis in QAPI Program
Penalty
Summary
The facility failed to provide evidence of measurable goals and documentation of analysis and evaluation of data submitted to the Quality Assurance Performance Improvement (QAPI) committee. During the review of the QAPI meeting minutes from February, March, and July 2024, it was identified that the facility departments were submitting data to the committee. However, there was a lack of documentation of measurable goals and analysis of the data. For instance, the Quality Improvement Incentive Program (QIIP) for bowel incontinence did not have documented measurable goals or evidence of data analysis by the QAPI committee. Similarly, the Performance-Based Incentive Payment Program (PIIP) for employee recruitment and retention lacked an action plan and data analysis. In the QAPI meeting minutes from March 2024, the same issues persisted. The QIIP for bowel incontinence continued without measurable goals or data analysis documentation. The PIIP for employee recruitment and retention also lacked an action plan and data analysis. Additionally, new tasks such as performance reviews in the UKG system were introduced, but there was no documentation of how the facility would achieve compliance or if revisions were needed. By July 2024, the facility still had not documented measurable goals or analyzed data for identified problems such as falls and dementia care. For example, the problem of falls in April was identified, but there was no documentation of measurable goals or data analysis. Similarly, tasks related to dementia care education lacked an assigned person, completion date, and follow-up action plan. An interview with the administrator confirmed the lack of measurable goals and analysis of information during the QAPI meetings.
Medication Administration and Reconciliation Deficiency
Penalty
Summary
The facility failed to appropriately administer and accurately reconcile a resident's medication, specifically lisinopril, which is used for high blood pressure. During an observation, a trained medication aid (TMA) was preparing to administer morning medications and was found to be using a medication card that contained 10 mg tablets of lisinopril, despite the electronic medical record (EMR) displaying a current order for 5 mg. The TMA admitted to administering 10 mg of lisinopril daily and was unaware of any change in the dosage. The medication card had no label indicating a change in order and was improperly stored with other current medications. Interviews with the TMA, a licensed practical nurse (LPN), and the director of nursing (DON) revealed that the procedure for handling medication order changes was not followed. The order for lisinopril had changed the day before, but the medication card with the incorrect dose was not removed from the cart, and the pharmacy was not notified to provide the correct dose. The facility's policy required that medication orders be entered into the EMR, the pharmacy be notified of changes, and the medication card be updated or removed as necessary. However, these steps were not completed, leading to the potential for medication errors.
Medication Labeling and Dosage Errors
Penalty
Summary
The facility failed to ensure accurate labeling of medications for two residents, leading to potential medication errors. For one resident, the physician's order for Lisinopril was for 5 mg daily, but the medication card contained 10 mg tablets without any label indicating a change in dosage. The trained medication aid confirmed administering the incorrect dosage due to a lack of notification about the change. Similarly, the licensed practical nurse was unaware of the dosage change, indicating a failure in communication and process adherence. Another resident had a physician order for Gabapentin 100 mg capsules, but the medication card contained 300 mg capsules with incorrect administration instructions. Additionally, there was a discrepancy in the order and pharmacy label for a Lidoderm patch. The director of nursing confirmed that the medication card should have been updated, and the pharmacy notified, but this process was not followed. The facility's policies required proper transcription and communication of medication orders, which were not adhered to in these cases.
Latest citations in Minnesota
A resident with dry eye syndrome and degenerative eye disease had orders for cyclosporine ophthalmic emulsion and Refresh Tears, both scheduled at the same time. Medication records and direct observation showed a TMA instilled cyclosporine drops in both eyes and immediately followed with Refresh Tears in both eyes without waiting between medications. This practice conflicted with referenced professional guidance recommending several minutes between multiple eye drops and with the medical provider’s recommendation to wait fifteen minutes between the two ophthalmic medications. No facility policy on ophthalmic medication administration was provided when requested.
A resident with severe cognitive impairment, impaired mobility, and high fall risk was care planned to have wheelchair footrests in place at all times, with staff ensuring proper positioning and monitoring for leaning during transport. A NA transported the resident in a manual wheelchair from the shower without the footrests, and while going through the doorway the wheelchair struck the door frame, causing the resident, who was leaning forward, to fall out. The resident sustained a T12 fracture, head injury with concussion, abrasions and contusions, and multiple right-hand lacerations requiring sutures, and the DON confirmed the care plan had not been followed.
A high‑risk, immobile resident with MS and prior heel DTI developed an avoidable unstageable coccygeal pressure ulcer after staff failed to consistently assess and document skin status, did not transfer or timely provide ordered pressure‑relieving mattresses, and did not reliably perform q2h repositioning. The resident was repeatedly left on a bedpan for prolonged periods despite early reports of this issue, and the toileting care plan was not revised to a bedside commode until after the coccygeal wound had significantly worsened. Wound assessments lacked complete measurements and staging, changes in wound size and color were not promptly recognized as deterioration or reported to providers, and recommended interventions from a wound NP (including an air mattress and offloading) were not promptly implemented. As a result, the coccygeal ulcer rapidly progressed to a large, necrotic, malodorous wound requiring hospital transfer and surgical debridement.
A resident with spastic hemiplegia, muscle weakness, and moderate cognitive impairment was observed using bilateral bed grab bars for bed mobility and transfers, but the care plan did not address grab bar or side rail use. Review of the EMR showed no completed bed mobility device or side rail assessment to determine the necessity or safety of the grab bars, and no documentation that risks and benefits were discussed or that informed consent was obtained. An LPN and the ADON stated that a bed mobility device assessment is required before grab bars are installed and confirmed that no such assessment existed for this resident.
A resident with bilateral heel pressure ulcers and multiple comorbidities received wound care during which an RN removed dressings from both heels, cleansed both wounds, and wiped each heel without changing gloves or performing hand hygiene between wounds or after disposing of soiled dressings. This practice conflicted with the facility’s written wound care procedure, which requires glove removal and hand hygiene after dressing removal and after wound cleansing. In interviews, the RN, NP, and DON/IP acknowledged that hand hygiene and glove changes are expected between dirty and clean tasks and between separate wounds to prevent infection.
A resident with MS, neurogenic bladder, mobility limitations, and existing pressure injuries was identified as dependent for toileting hygiene and at risk for pressure ulcers, yet the care plan lacked an individualized toileting/incontinence plan and a defined repositioning schedule. Despite a new coccyx pressure ulcer and documentation that interventions such as increased repositioning and incontinent care were needed, the care plan was not revised for a period of time to reflect these changes. During this time, the resident sometimes fell asleep on a bedpan and remained on it until staff removed it, and staff were not initially informed that the bedpan should no longer be used. The DON later acknowledged that the care plan revisions for turning, repositioning, and toileting were delayed until after the resident’s coccyx ulcer had significantly worsened.
A resident with diabetes, Crohn’s disease, bowel incontinence, and a history of MASD on the right gluteus developed an open, painful lesion on the right gluteal area that was documented over time without complete wound characteristics, clear etiology, or timely provider notification. Wound care orders were written for a stage 3 pressure ulcer on the left buttocks, while staff reported the wound was only on the right side and applied the left‑sided orders to the right gluteal wound in the absence of specific right‑side treatment orders. The DON acknowledged discomfort with staging the wound, lack of early physician notification, and confusion over wound classification, despite a facility policy requiring comprehensive wound assessment, consistent measurement, and provider notification when treatment orders are absent.
A resident with diabetes, chronic leg ulcer, kidney transplant, and a documented gluteal wound was care-planned for Enhanced Barrier Precautions (EBP), with posted instructions requiring gown and gloves for high-contact care such as transfers and wound care. During a telehealth wound assessment, the DON donned a gown and initially performed hand hygiene but then applied gloves without hand hygiene, removed a soiled dressing from the resident’s gluteal area, discarded it, removed gloves, and applied new gloves again without performing hand hygiene between glove changes. On another occasion, during use of a sit-to-stand lift, an NA wore gown and gloves, but the DON handled the lift harness, the resident’s clothing, and assisted with the transfer and repositioning while wearing a gown but no gloves, despite EBP requirements for transfers. The DON stated EBP was only needed for catheter or wound care and not for transfers, contradicting the posted EBP instructions and facility policy.
A resident with severe dementia, psychiatric disorders, and high dependence for ADLs was verbally abused during evening care when a NA, frustrated with the resident’s crying and resistance, loudly ridiculed her as acting like a two-year-old, threatened to hit her back if struck, told her she would be sent to a locked unit, and questioned who would want to care for her when she cried like a baby. Multiple staff witnessed the loud, stern, and intimidating tone and reported it to an LPN, who recognized it as verbal abuse but did not immediately remove the NA from duty or promptly report the allegation per policy, allowing the NA to continue working on the unit. Following this incident, the resident demonstrated increased crying, combativeness, resistance to care, wandering, self-isolation, and refusal of food, fluids, and medications above baseline, with documentation of significant emotional distress and subsequent ED evaluation for aggressive behaviors and poor intake.
A resident with dementia, bilateral above‑knee amputations, vascular disease, and severe protein‑calorie malnutrition developed a wound on an amputation stump that had a dressing dated several days before any documentation or treatment orders appeared in the record. Although bath audits and nursing notes initially reported no skin issues, a later assessment described a full‑thickness stage 4 ulcer/diabetic ulcer on the stump with exposed bone, erythema/edema, slough, and moderate serosanguineous drainage. Nursing staff interviews showed no one could identify who first discovered the wound or applied the initial dressing, and there was no evidence that the wound was assessed, the provider notified, or standing orders implemented when it was first present, despite facility expectations that new wounds be promptly evaluated and reported.
Failure to Follow Professional Standards for Ophthalmic Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice for administering ophthalmic medications to a resident with dry eye syndrome and degenerative eye disease. The resident was cognitively intact, required assistance with ADLs, and had physician orders for cyclosporine ophthalmic emulsion 0.05% one drop in both eyes twice daily and Refresh Tears ophthalmic solution one drop in both eyes four times daily for dry eyes. The administration summary showed that both eye medications were scheduled for the same time and were documented as being given at the same time on multiple dates. During a medication pass observation, a trained medication aide administered the ordered oral medications, then applied gloves and instilled one drop of cyclosporine in each eye, immediately followed by one drop of Refresh Tears in each eye, without any waiting period between the two medications. The surveyors referenced guidance from the American Academy of Allergy, Asthma, and Immunology stating that when more than one eye drop is ordered, three to four minutes should be allowed between drops in the same eye, and five to fifteen minutes should be allowed between different eye medications to prevent dilution. Interviews with the DON, pharmacy consultant, and medical provider confirmed that best practice and the provider’s recommendation were to wait between administration of cyclosporine and Refresh Tears, with the medical provider specifying a fifteen-minute interval. The facility did not provide a policy on ophthalmic medications when requested. The observed practice and documented administration times demonstrated that staff did not follow these professional standards or the medical provider’s recommended interval between the two eye medications.
Failure to Follow Wheelchair Transport Care Plan Leads to Fall With Injuries
Penalty
Summary
The deficiency involves the facility’s failure to implement care-planned fall prevention interventions for a resident at high risk for falls, resulting in a fall with injury. The resident had diagnoses including aphasia, dysphagia, muscle weakness, traumatic brain injury, and impaired mobility, with severe cognitive impairment documented on the MDS and dependence on staff for transfers and wheelchair transport. A care plan addressing wheelchair transport safety and positioning directed staff to ensure the resident was fully positioned and supported in the wheelchair prior to transport, verify footrests were in place prior to transport, and monitor for leaning, sliding, or unsafe positioning. An additional care-planned approach required wheelchair pedals to be on at all times. On the date of the incident, a nursing assistant transported the resident in a manual wheelchair from the shower room to the resident’s room without the foot pedals in place, contrary to the care plan. While being wheeled through the doorway, the wheelchair struck the door frame, causing the chair to stop and the resident, who had begun leaning forward, to fall out of the wheelchair onto the floor. Progress notes and ED documentation identified that the resident sustained a T12 vertebral fracture, a head injury with concussion, an abrasion and contusion to the head, a bruise to the left knee, and multiple lacerations to the right hand requiring sutures. The nursing assistant later acknowledged awareness that the foot pedals should have been on but did not apply them because the transport was only from the shower to the room. The DON confirmed that the resident’s care plan had not been followed when the fall occurred.
Failure to Implement and Update Pressure Ulcer Prevention and Treatment Led to Avoidable Unstageable Coccygeal Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, monitor, and implement individualized pressure ulcer prevention and treatment interventions for multiple high‑risk residents, resulting in an avoidable, unstageable coccygeal pressure ulcer for one resident that required surgical debridement and hospitalization. The resident had primary progressive multiple sclerosis, hereditary spastic paraplegia, obesity, and pre‑existing pressure‑related deep tissue injury to the left heel, and was identified as high risk for pressure ulcers on the Braden Scale due to constant moisture, chairfast status, very limited mobility, inadequate nutrition, and friction/shear risk. Hospital records on readmission documented irritant contact dermatitis of the bilateral gluteal cleft with specific cleansing and barrier cream orders, and facility documentation showed the resident could not reposition in bed or chair and required assist of two and a full‑body mechanical lift for transfers. Despite this, the admission/readmission skin assessment and weekly skin checks lacked measurements and detailed wound characteristics for the heel ulcer and gluteal dermatitis, and the care plan did not include comprehensive, individualized interventions beyond generic repositioning and wound care orders. After a new coccyx pressure ulcer was identified and documented as a stage 2 lesion, the facility failed to promptly and accurately update the care plan and implement recommended pressure‑relieving interventions. The wound nurse practitioner on 3/5 ordered coccyx wound care, an air mattress, pressure offloading, and a dietician consult, but the care plan was not revised and there was no evidence that an air mattress was placed on the bed for nearly two weeks. The environmental services director later confirmed that when the resident was moved to a new room, the gel mattress was not transferred, and the air mattress requested on 3/17 was not actually placed until the following day, despite being marked as completed. During this period, TAR documentation showed gaps in the every‑2‑hour repositioning order, and staff interviews revealed that CNAs were unaware of which residents were on repositioning programs, were not consistently repositioning residents, and had not received recent education on pressure ulcer prevention. The DON and RN case manager acknowledged that the coccyx wound increased in size and changed color between assessments, that the bed lacked the ordered gel mattress, and that the physician was not notified of the wound’s deterioration at that time. The facility also failed to timely modify toileting and incontinence care practices despite knowledge that the resident was being left on a bedpan for extended periods. The DON reported hearing before an IDT meeting that the resident had fallen asleep on a bedpan for an undetermined amount of time, but the care plan was not revised to discontinue bedpan use and implement a bedside commode until after the coccyx wound had significantly worsened. CNAs confirmed that the resident sometimes fell asleep on the bedpan and that they were not informed she should no longer use it until after the sore had worsened. Subsequent wound assessments documented rapid progression of the coccyx wound from a small stage 2 ulcer to a large, malodorous, necrotic wound with eschar, slough, erythema, and purulent drainage, ultimately classified as an unstageable pressure ulcer. The DON, NP, PA, and medical director all indicated that the lack of a pressure‑relieving mattress, failure to adjust pressure‑reducing interventions, and prolonged time on a bedpan likely contributed to the development and deterioration of the resident’s pressure ulcer, which was determined to be avoidable and resulted in hospitalization and surgical debridement. Additional documentation and interviews showed systemic assessment and communication failures related to pressure ulcer management. Weekly skin checks and wound assessments often omitted complete measurements, staging, and wound characteristics, and changes in wound size and appearance were not consistently recognized as deterioration or communicated to providers. The DON acknowledged that a 3/12 assessment showing increased wound size and purple discoloration should have been identified as a deep tissue injury and reported to the physician, but this did not occur. When nursing later documented foul odor, increased pain, and expanding necrotic tissue, telemedicine and PA responses deferred in‑person evaluation and ED transfer despite earlier recommendations that the resident be sent to the ED if an in‑person provider could not assess the wound. The NP ultimately found a large, malodorous, purulent wound with expanding eschar and ordered transfer to the hospital, where imaging and surgical findings confirmed a large necrotic sacral wound requiring extensive debridement. Throughout this sequence, the facility did not consistently follow its own pressure ulcer protocols, did not ensure ordered pressure‑relieving equipment was in place, and did not promptly revise care plans or interventions in response to known risk factors and documented wound changes. The report also notes that other residents reviewed for pressure ulcers were affected by similar failures in monitoring and individualized intervention, though detailed narratives focus primarily on this resident. Staff interviews revealed that CNAs relied on paper care guides that did not clearly identify residents on repositioning programs or at risk for skin breakdown, and that they were unaware of some residents’ special mattress orders or toileting restrictions. The DON and medical director stated that residents at risk for pressure ulcers should have immediate pressure‑relieving interventions and that existing ulcers require ongoing evaluation to prevent deterioration, but the documented practices for this resident did not align with those expectations. These combined actions and inactions—insufficient assessment detail, delayed or missing care plan revisions, failure to implement ordered support surfaces and repositioning, and delayed response to wound deterioration—constituted the deficiency in providing appropriate pressure ulcer care and preventing new ulcers from developing.
Failure to Assess, Care Plan, and Obtain Consent for Bed Grab Bar Use
Penalty
Summary
The deficiency involves the facility’s failure to follow required procedures before installing and using bed grab bars for a resident. The resident had diagnoses including spastic hemiplegia affecting the left side and muscle weakness, and an admission MDS indicating moderate cognitive impairment. During observation, the resident was seen in a power chair with bilateral grab bars on the bed and reported using them to roll in bed and for transfers. The resident’s care plan, dated 1/23/26, documented a need for assistance with bed mobility and independence with transfers but did not mention or address the use of grab bars or side rails. Review of the electronic medical record showed no completed grab bar/side rail or bed mobility device assessment to determine the necessity of the grab bars or whether the resident could safely use them. There was also no evidence that the resident or the resident’s representative had been educated on the risks of having a grab bar on the bed or that informed consent had been obtained. In interviews, an LPN and the ADON both stated that a bed mobility device assessment was required to determine need and safety prior to installing grab bars, and both confirmed that no such assessment was present in the resident’s record.
Failure to Perform Hand Hygiene and Change Gloves During Wound Care
Penalty
Summary
Surveyors observed that a registered nurse (RN) and a nurse practitioner (NP) did not follow the facility’s established infection control practices during wound care for one resident. During a wound treatment, the RN wore gloves while removing the dressing from the resident’s left heel, then removed the dressing from the right heel, sprayed both wounds with wound cleanser, wiped the left heel with gauze, and then used a clean gauze pad to wipe the right heel. The RN did not remove her gloves or perform hand hygiene after disposing of the soiled dressings or between cleaning the left and right heel wounds, contrary to the facility’s written wound care procedure, which requires glove removal and hand hygiene after removing the previous dressing and again after cleaning the wound. The resident’s admission MDS documented diagnoses including multiple rib fractures, heart failure, dementia, anxiety, and the presence of a pressure ulcer, and indicated the resident was cognitively intact and required staff assistance with care and transfers. The resident’s care plan identified pressure ulcers on both heels requiring wound care. In interviews, the RN, NP, and the DON/infection prevention nurse each stated that gloves should be changed when moving from dirty to clean areas and that hand hygiene is expected after glove removal and between wounds to prevent infection, confirming that the observed practice did not align with facility policy or expected infection control standards.
Failure to Timely Revise Care Plan for Toileting and Skin Integrity
Penalty
Summary
The deficiency involves the facility’s failure to timely revise and individualize a resident’s care plan to address toileting and incontinence needs in relation to impaired skin integrity. The resident had diagnoses including primary progressive multiple sclerosis, hereditary spastic paraplegia, obesity, and a pressure-induced deep tissue injury to the left heel. A Significant Change MDS identified the resident as dependent for toileting hygiene, with lower extremity range-of-motion limitations, wheelchair use, dependence for transfers, occasional urinary incontinence, intact cognition, and at risk for pressure ulcers with existing unhealed pressure injuries and MASD. The resident’s skin-focused care plan, revised on various dates, included skin inspections, wound care orders, weekly skin checks, pressure ulcer care to the left heel, nutritional supplements, and a gel mattress, but did not include an individualized toileting or incontinence plan. On a weekly skin check dated 3/3/26, nursing staff identified a new Stage 2 pressure ulcer on the coccyx and contact dermatitis on both gluteal folds. An IDT Final Post Review Follow Up dated 3/10/26 (signed 3/23/26) documented that a new skin issue had occurred and that interventions after the incident included wound care treatment orders, increased repositioning, and increased incontinent care. However, the resident’s care plan from 3/3/26 through 3/16/26 did not show revisions reflecting increased incontinence care or a repositioning schedule, and the care plan was not updated to include these elements until 3/17/26. During this period, the care plan still lacked an individualized toileting plan despite the resident’s identified incontinence and new coccyx pressure ulcer. Progress notes on 3/17/26 documented that the resident’s coccyx wound had declined, with an evaluation describing a deteriorating wound characterized as a Kennedy terminal ulcer/End of Life, staged as a Stage 4 pressure ulcer, in-house acquired, with increased size, exudate, odor, pain, and surrounding erythema. On that same date, the skin focus care plan was revised to include prompt incontinence care and keeping the skin clean and dry, and the elimination focus care plan was revised to address incontinence due to neurogenic bladder with use of a bedside commode offered every 2–3 hours. A nursing assistant reported that when working with the resident, the resident would sometimes fall asleep on the bedpan and forget to ask staff to remove it, and that she was not aware the resident was not supposed to use the bedpan until after the sore had worsened. The DON stated that the resident’s care plan had not been revised earlier to include a turning and repositioning schedule or toileting changes, and that it should have been revised as soon as staff learned the resident was falling asleep on the bedpan, rather than waiting until after the pressure ulcer worsened.
Failure to Assess and Notify Provider for Right Gluteal Wound
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess and appropriately manage a non‑pressure skin issue on a resident’s right gluteal area, and to notify the physician in a timely manner. The resident had diagnoses including diabetes, Crohn’s disease, and a kidney transplant, and the MDS indicated occasional bowel incontinence, no pressure ulcers, and no moisture‑associated skin damage at that time. Earlier documentation identified a resolved MASD to the right gluteus, and a progress note later described a sacral wound with creams applied, noting that sores were still open and painful during application, but without any measurements, wound characteristics, or evidence of physician notification. Subsequent wound assessments documented an open lesion on the right gluteus with specific measurements on multiple dates, but did not identify the wound type or other characteristics, and the record did not show physician notification or treatment orders for the right gluteal lesion. Provider orders in place initially addressed cleansing the buttocks and applying barrier cream, and later included a detailed wound care order for a stage 3 pressure ulcer documented on the left buttocks. However, the resident’s record did not contain a specific treatment order for the right gluteal wound, despite the ongoing documentation of an open lesion in that area. Interviews revealed confusion and inconsistency in wound identification and classification. The DON stated that the right gluteal wound was documented as an open lesion because she did not feel comfortable determining the wound type, and acknowledged that the physician should have been notified when the wound was first identified. The DON was unaware that the NP had documented the wound as being on the left buttocks and as a stage 3 pressure ulcer, while the RN reported that the wound had never been on the left buttocks and that she had been applying the left‑sided wound orders to the right gluteal area because there was no open area on the left. The resident reported a recurring painful area on the right buttocks and chronic stool leakage since prior anal fistula surgery. The facility’s own wound treatment policy required comprehensive assessment of wound etiology and characteristics, consistent measurement and documentation, and provider notification in the absence of treatment orders, which were not followed for this resident’s right gluteal wound. The deficiency centers on the lack of a comprehensive wound assessment for the right gluteal lesion, incomplete documentation of wound characteristics, failure to clearly determine and document the wound etiology, and failure to notify the physician and obtain appropriate treatment orders when the wound was identified and remained open. These actions and inactions resulted in a discrepancy between the documented wound location and type and the actual clinical presentation, as well as a period during which the right gluteal wound had no specific, clearly ordered treatment despite being open and painful.
Failure to Perform Hand Hygiene and Implement Enhanced Barrier Precautions During Wound Care and Transfers
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper hand hygiene during wound care and to consistently implement Enhanced Barrier Precautions (EBP) for a resident requiring such measures. The resident had diagnoses including diabetes, a non-pressure chronic ulcer of the right lower leg, and a kidney transplant, and a wound assessment documented an open lesion on the right gluteal area. The resident’s care plan and a sign posted outside the room specified that EBP, including gown and gloves, were required for high-contact care activities such as dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, catheter care, and wound care. During one observation, the DON performed hand hygiene and donned a gown before entering the resident’s room for a telehealth wound assessment. Inside the room, the DON went into the bathroom, applied gloves without performing hand hygiene, removed the resident’s brief, and removed a foam dressing from the right gluteal area that had stool on one corner. After discarding the soiled dressing, the DON removed gloves and then applied new gloves without performing hand hygiene between glove changes. When questioned, the DON stated that hand hygiene should be done when hands or gloves are visibly soiled and before and after removing or applying gloves, and acknowledged that hand hygiene had not been performed each time gloves were removed and reapplied. In a separate observation, the resident was transferred using a sit-to-stand mechanical lift while EBP requirements were not fully followed. An NA entered the room wearing a gown and gloves with the lift, and the DON applied the lift harness under the resident’s arms and cinched the waist strap, encountering the resident’s clothing, while not wearing gloves. After the transfer to bed, the DON pulled down the resident’s pants and removed the harness while touching the resident’s clothes. Following wound care by a CNP-WOC, the DON again assisted the resident by sitting the resident on the edge of the bed, applying the lift harness, and adjusting the resident’s pants and shirt while wearing a gown but no gloves. The DON stated that EBP was only needed for catheter or wound care and not for transfers, and only upon reading the posted EBP sign acknowledged that EBP was required for all high-contact resident care activities, including transfers.
Failure to Protect Resident From Verbal Abuse and Delay in Removing Alleged Perpetrator
Penalty
Summary
The deficiency involves the facility’s failure to protect a vulnerable resident from mental abuse and to respond appropriately to an allegation of abuse. The resident had severe cognitive impairment, Alzheimer’s disease, dementia, anxiety, depression, psychotic disorder, and significant functional dependence, including frequent incontinence and the need for extensive assistance with ADLs and transfers. Her care plan identified behavioral and mood issues such as wandering, yelling, combative behavior, and calling staff names, with interventions including calm approaches, emotional support, redirection, and monitoring for emotional distress and mood/behavior changes. She was identified as a vulnerable adult, with instructions to monitor for signs of emotional distress and to follow the facility’s abuse reporting policy. On the evening in question, while the resident was crying on the phone with her son and expressing a desire to leave, NA-A and NA-B entered to provide evening care using an EZ stand lift. After the resident ended the phone call, multiple staff reported that NA-A spoke to the resident in a loud, stern, and frustrated tone, telling her to stop crying and that she was acting like a two-year-old. When the resident swatted at NA-A, NA-A stated, “If you hit me, I’m going to hit you back,” and later told the resident she was “in trouble now.” Staff reported that NA-A told the resident she would be sent to a locked unit so she could not get out, and questioned who would want to care for her when she cried like a baby, and that nobody would want to keep working with her. NA-C described NA-A yelling commands such as “HOLD ON!” and “Stop crying! Where would you be if you were not here? Probably lying on the floor,” and felt NA-A was obviously upset and overwhelmed. These statements were made in the presence of the resident while she was already distressed and crying. Following this interaction, the resident exhibited crying, yelling, combativeness, resistance to care, wandering into other residents’ rooms, self-isolation, and refusal of food, fluids, and medications above her prior baseline, as documented in behavior charts, target behavior monitoring, and nursing progress notes. Staff documented that she cried most of the morning, was very restless, difficult to redirect, hit and pinched staff, called staff names, and refused care and meals. She required repeated redirection, 1:1 attention, and non-pharmacological interventions, and was ultimately sent to the ED for evaluation of combativeness and emotional distress, where she was treated for dementia with aggressive behavior and hypoglycemia related to poor intake. The report identifies that the resident’s actual response and the reasonable person concept showed serious psychosocial harm, including increased crying and combative behavior above baseline, fear/anxiety manifested as combativeness, resistance to care and social interaction, and self-isolation. The facility also failed to immediately remove the alleged perpetrator from resident care and to promptly report and investigate the allegation in accordance with its abuse policy. After NA-B and NA-C reported to LPN-A that NA-A had yelled at and threatened the resident, LPN-A acknowledged it as verbal abuse but did not initiate immediate protective measures or timely reporting. LPN-A stated she believed she had 24 hours to report because there was no injury, despite facility policy requiring reporting within two hours. NA-A remained on the unit and continued working until the end of her shift, including after staff had clearly communicated their concerns to LPN-A. TMA and NA staff described uncertainty about their authority to remove NA-A and reliance on the nurse to act, while the DON later informed LPN-A that NA-A should have been removed from the floor to prevent further danger to residents. The Immediate Jeopardy was determined to have begun when NA-A’s derogatory, intimidating, and threatening statements were made and continued while she remained on duty with access to the resident and other vulnerable residents.
Failure to Timely Assess and Treat Newly Discovered Stump Wound
Penalty
Summary
The deficiency involves the facility’s failure to provide timely treatment and care for a newly discovered wound on a resident’s above‑knee amputation stump. The resident was admitted with diagnoses including unspecified dementia with behavioral disturbances, vascular dementia, bilateral above‑knee amputations, vascular disease, reduced mobility, and severe protein‑calorie malnutrition, and had no documented ulcers or skin problems on admission or on the most recent MDS. A weekly bath audit on 3/17/26 documented only non‑tender lymph nodes on the right upper hip and did not identify any open areas. However, when the wound was later assessed, the dressing on the stump was dated 3/16/26, indicating that a wound and dressing existed at that time, even though no corresponding assessment, provider notification, or treatment orders were documented. On 3/23/26, nursing staff documented a new skin issue above the resident’s knee at the amputation site, describing a stage 4 pressure ulcer/injury with full‑thickness skin and tissue loss, exposed bone, erythema/edema, and moderate serosanguineous exudate. The wound measured 1.56 cm by 1.64 cm, with 20–29% granulation tissue and 80% slough. A progress note and skin issues assessment on that date confirmed the wound characteristics and staging, and the NP, after reviewing a picture, determined the wound to be a diabetic ulcer with peripheral vascular disease and severe protein‑calorie malnutrition as contributing factors. On that same date, the NP was notified, antibiotic therapy (doxycycline) was ordered for possible cellulitis, and specific wound care orders were initiated, with documentation on the MAR that these treatments were carried out beginning 3/23/26. Multiple interviews with nursing staff revealed that no one could identify who discovered the wound or who applied the initial dressing dated 3/16/26, and there was no documentation of a wound assessment, provider notification, or interim treatment between 3/16/26 and 3/22/26. Several RNs and LPNs who worked shifts from 3/16/26 through 3/20/26 stated they did not notice a wound on the stump and that, per their usual practice, they would have contacted the provider and initiated treatment if they had found one. One LPN recalled seeing a band‑aid with a date on the stump but could not recall the date, and another LPN stated she did not see the wound because she was not looking for one. The facility’s standing orders required staff to assess all wounds daily, change dressings every three days and as needed, treat with normal saline or non‑cytotoxic cleanser and appropriate dressings, and notify the provider the next business day when a new wound or injury was found. Despite these expectations, the wound identified by the dated dressing on 3/16/26 was not assessed, reported, or treated according to orders and facility policy until 3/23/26.
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