Rochester Rehabilitation And Living Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Rochester, Minnesota.
- Location
- 1900 Ballington Boulevard Nw, Rochester, Minnesota 55901
- CMS Provider Number
- 245626
- Inspections on file
- 32
- Latest survey
- March 27, 2026
- Citations (last 12 mo.)
- 9 (1 serious)
Citation history
Health deficiencies cited at Rochester Rehabilitation And Living Center during CMS and state inspections, most recent first.
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 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 was not protected from a significant medication error, as required, with no further details provided regarding the circumstances or contributing factors.
The facility experienced a systemic failure in medication management, resulting in over 79 medication errors in six weeks and actual harm to two residents, including a cardiac ICU admission and ongoing CHF exacerbation. The QAPI program did not identify, analyze, or address these errors, and meeting records showed no focus on medication error rates or pharmacy service quality.
The facility did not ensure its QAPI committee identified or responded to lapses in wound assessments for surgical wounds, resulting in inconsistent documentation and a worsening infection for a resident that delayed treatment. Despite being informed of the issue, the DON did not escalate concerns or initiate corrective action, and the facility's quality plans did not address skin-related issues.
Multiple residents experienced harm due to staff failing to follow physician orders, monitor and document changes in condition, and communicate findings to providers. This included not obtaining daily weights for a resident with respiratory and cardiac issues, not monitoring or reporting abnormal urine in residents with catheters or nephrostomies, and not assessing or reporting low blood pressure and falls in a resident with cardiac diagnoses. Staff interviews revealed confusion about protocols, lack of training, and inconsistent documentation.
The facility did not complete required MDS assessments in a timely or comprehensive manner for several residents, including those with severe cognitive and neurological conditions. Multiple assessment sections were left incomplete, and there was no documentation explaining the delays. Staff interviews confirmed that MDS assessments were overdue and not finished as required.
Two residents with PICC lines and receiving IV antibiotics were not placed on enhanced barrier precautions as required by facility policy. Staff did not use PPE or post EBP signage, and medical orders lacked EBP instructions, despite both residents having conditions that warranted these precautions. Interviews confirmed that EBP should have been initiated for these residents but was not implemented.
Two residents who had previously received PPSV23 and PCV13 vaccines were not offered or provided the PCV20 vaccine as recommended by CDC guidelines. The DON, responsible for infection control and vaccine eligibility assessment, acknowledged that these residents were eligible but had not been educated or offered the vaccine, and documentation of shared clinical decision-making was lacking.
A resident with an infection requiring daily IV antibiotics requested an earlier administration time to avoid being awakened late at night. Despite communicating this preference to both an LPN and an RN, neither staff member initiated the facility's SBAR process to request the change, and the nurse practitioner was not informed. The resident continued to receive the medication at the late hour, and no policy regarding resident choices was provided when requested.
A resident with severe cognitive impairment and incontinence was diagnosed with a UTI and started on antibiotics after family concerns prompted testing. The facility did not notify the resident's representative of the diagnosis or medication changes, and there was no documentation of such notification, despite facility policy requiring immediate communication and recordkeeping.
A resident with multiple cardiac conditions and a recent surgical history was admitted and only received a generic care plan, without person-centered interventions as required. Staff confirmed that individualized interventions, such as monitoring vital signs and cardiac symptoms, were not documented within the required timeframe, despite facility policy mandating a resident-specific care plan within 48 hours of admission.
A resident with severe cognitive impairment and an indwelling catheter was observed multiple times with the catheter drainage bag positioned at the same level as the pelvis, contrary to care plan instructions and facility policy requiring the bag to be kept below bladder level. Staff interviews revealed inconsistent practices regarding catheter bag placement, and both the MD and DON confirmed the correct procedure was not followed.
Two residents receiving IV antibiotics via PICC lines did not have their dressings changed or dated according to facility policy, with dressings observed to be peeling and IV tubing undated. Staff and leadership confirmed expectations for weekly dressing changes and daily tubing replacement, but these were not consistently followed, as shown by observations and documentation.
A resident with a history of post-surgical pain did not receive appropriate pain management, as staff failed to administer pain medication, provide non-pharmacological interventions, or notify the provider despite repeated reports of moderate to severe pain. Pain assessments were missed or not acted upon, and facility policy for pain management was not followed.
A resident with a history of osteomyelitis and pyelonephritis was ordered to have weekly bloodwork while receiving IV antibiotics, but laboratory results from two completed tests were not filed in the medical record or communicated to the infectious disease provider. The DON confirmed that the results from the outside laboratory had not been received or included in the resident's chart, which was not in accordance with facility policy.
A resident with a Foley catheter due to urinary retention did not receive timely follow-up with urology, leading to prolonged catheter use without reassessment. The facility lacked specific medical orders for catheter size and change schedule, increasing infection risk. Staff interviews confirmed the absence of necessary orders and missed appointments, highlighting a deficiency in care management.
A resident with a history of blood clots and cardiac issues did not receive a prescribed dose of Lovenox, a significant medication error that was not reported to the state agency. The resident's INR remained below the therapeutic range, and the facility's policy on reporting such errors was not followed.
Two residents in the facility experienced significant medication errors related to anticoagulant administration. One resident did not receive warfarin and Lovenox as ordered due to missed INR checks and late medication orders, while another resident missed a warfarin dose due to premature discontinuation. Staff interviews revealed a lack of communication and documentation regarding these errors, and the facility's policy on medication errors was not adequately followed.
A resident's stage 1 pressure ulcer deteriorated to an unstageable ulcer due to the facility's failure to comprehensively assess and monitor the wound. The ulcer was not properly assessed or treated for 18 days, leading to increased pain and the need for antibiotic treatment. Staff interviews revealed lapses in communication and documentation, and the facility's policy for wound care was not followed.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a pressure ulcer, despite the care plan indicating the need for gown and glove use during high-contact care activities. Observations revealed that staff did not perform hand hygiene or use protective gear during transfers and toileting. Interviews confirmed staff were unaware of the EBP requirements, leading to a deficiency in infection control practices.
A resident reported being pushed and pinched by a nursing assistant, resulting in bruises. The incident was not reported to the administrator and State Agency within the required two-hour timeframe. The LPN noted bruising but did not document it, and the DON was informed two days later, contrary to facility policy.
The facility failed to implement enhanced barrier precautions (EBP) for three residents with wounds, as required by their infection prevention policy. Despite physician orders for wound care, staff only wore gloves and did not use additional PPE such as gowns. There were no signs or precaution carts by the residents' doors to indicate the need for EBP. The infection preventionist and director of nursing confirmed the oversight, acknowledging the risk of transmission of multi-drug resistant organisms.
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 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.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident received a significant medication error, but does not provide further details regarding the specific actions, inactions, or events that led to the deficiency. No additional information about the residents involved or their medical conditions at the time of the incident is included in the report.
Systemic Failure in Medication Management and QAPI Oversight
Penalty
Summary
The facility failed to ensure its Quality Assessment and Performance Improvement (QAPI) plan and program effectively identified, analyzed, and addressed adverse events and quality deficiencies, specifically related to medication management. Over a six-week period, there were more than 79 medication errors, with actual harm occurring to two residents: one required cardiac ICU admission and another experienced ongoing congestive heart failure (CHF) exacerbation. The facility lacked systems to prevent medication errors, notify providers, and investigate incidents, resulting in a widespread failure in medication management. Further review of facility records, including QAPI plans and meeting minutes from April to July 2025, revealed no focus on medication errors, no mention of medication error rates, and no evidence of quality activities to monitor or improve pharmacy services. The interim administrator confirmed that the QAPI minutes did not address medication errors, despite facility policy requiring root cause analysis and performance improvement plans when deficiencies are identified.
Failure to Identify and Address Deficiencies in Wound Assessment and Management
Penalty
Summary
The facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI) committee identified, investigated, analyzed, and responded to deficiencies in wound assessments, specifically for non-pressure (surgical) wounds. Over a period of several weeks, three residents with surgical wounds did not have consistent or comprehensive wound assessments completed. For example, one resident with a surgical wound on her left foot did not have a comprehensive wound assessment documented for nearly two weeks, while another resident had a gap of over two weeks between wound assessments. A third resident also lacked documentation of a comprehensive wound assessment for a surgical wound during the review period. These lapses resulted in at least one resident developing a worsening infection in a wound, which delayed necessary treatment and care. Despite being informed by the certified wound nurse practitioner that wound assessments were not being completed consistently, the DON did not bring these concerns to the quality team or initiate an action plan to address the issue. The QAPI committee had been monitoring pressure-related skin issues but was not addressing non-pressure related skin concerns. At the time of the survey, the facility's quality action plans did not include any measures for assessing or monitoring skin-related issues, and the QAPI committee had not yet developed or implemented a plan to address the identified deficiencies in wound management.
Failure to Follow Physician Orders and Monitor Changes in Condition
Penalty
Summary
The facility failed to follow physician orders, complete assessments, monitor or implement appropriate interventions, and recognize changes in condition for multiple residents, resulting in significant harm. For one resident with complex respiratory and cardiac conditions, staff did not obtain daily weights as ordered, failed to monitor for fluid retention, and did not consistently follow oxygen therapy orders. The resident experienced labored breathing and a significant weight gain, which was not identified or reported to the provider in a timely manner. Staff interviews revealed confusion and lack of a reliable system for obtaining and documenting daily weights, and the nurse practitioner was unable to assess the effectiveness of diuretic therapy due to missing weight data. Oxygen orders were not entered into the electronic medical record until several days after admission, and staff administered oxygen at incorrect settings based on resident or staff preference rather than physician orders. Another resident with a nephrostomy and history of kidney infections was not properly monitored for changes in urine output or color. Staff failed to document or notify the provider when dark red urine was observed in the nephrostomy bag over several days, and there was no documentation of an episode of unresponsiveness and lethargy. The resident was ultimately sent to the emergency room for evaluation and treatment of a kidney and bladder infection after the nurse practitioner observed the abnormal urine. Staff interviews indicated a lack of training on nephrostomy care and inconsistent documentation and communication regarding changes in condition. A third resident with an indwelling catheter and history of urinary retention and uropathy was not properly monitored for signs of infection. Staff observed blood in the catheter bag but did not document the finding or notify the provider, and the nurse practitioner was unaware of the change until after the resident was sent to the emergency room and diagnosed with a urinary tract infection. Additional deficiencies were identified in the care of a resident with cardiac conditions, where staff failed to monitor blood pressure before administering cardiac medications, did not complete full sets of vital signs after falls, and did not promptly notify the provider of significant changes in condition, including multiple episodes of hypotension and falls. Staff interviews revealed gaps in knowledge regarding monitoring protocols and documentation requirements.
Removal Plan
- Provided re-education and competency testing to licensed nursing staff on the facility's policies/procedures pertaining to change of condition, notification of changes, physician's orders, congestive heart failure, nephrostomy, COPD and catheters to include standards of documentation.
- Developed and implemented an auditing system for monitoring.
Failure to Complete Timely and Comprehensive MDS Assessments
Penalty
Summary
The facility failed to accurately and timely complete comprehensive assessments of residents' needs, strengths, goals, life history, and preferences, as required by federal regulations. For five residents reviewed, the Minimum Data Set (MDS) assessments were either not completed within the required timeframes or were left incomplete, with multiple sections missing critical information such as hearing, speech, vision, behavior, and bladder and bowel status. The residents affected included individuals with severe cognitive impairment, progressive neurological conditions, and other complex medical diagnoses. In several cases, the electronic medical records did not contain documentation explaining the delays or omissions in completing the MDS assessments. Interviews with facility staff confirmed that the MDS assessments were behind schedule and not finished as required. A consultant was brought in to assist with the backlog, but several assessments remained incomplete or overdue. The facility's own policy requires the interdisciplinary team to complete resident assessments in accordance with federal requirements, but this process was not followed, resulting in deficiencies in the assessment and documentation of residents' functional status and care needs.
Failure to Implement Enhanced Barrier Precautions for Residents with PICC Lines
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for two residents who had peripherally inserted central catheter (PICC) lines and were receiving intravenous antibiotic infusions. Both residents were admitted with prosthesis infections and had PICC lines inserted prior to admission. Observations revealed that neither resident had EBP signage or personal protective equipment (PPE) available in their rooms, and nursing staff did not use PPE when administering medications. Medical orders for both residents did not include instructions for EBP, and there was no evidence that EBP was initiated upon admission as required by facility policy. Interviews with facility staff, including a nurse practitioner, RN, and the director of nursing, confirmed that EBP should have been implemented for residents with PICC lines, in accordance with the facility's infection prevention and control policy. The policy specifies that EBP precautions, including clear signage and PPE availability, are required for residents with devices such as PICC lines. Despite this, the necessary precautions were not in place for either resident, as confirmed by staff and direct observation.
Failure to Offer Recommended Pneumococcal Vaccination Series
Penalty
Summary
The facility failed to ensure that two of five residents reviewed for immunizations were offered and/or provided the recommended pneumococcal vaccination series according to CDC guidelines. Both residents had previously received PPSV23 and PCV13 vaccines, but their records lacked evidence of shared clinical decision-making with their physicians regarding the administration of the PCV20 vaccine at least five years after their last pneumococcal dose. There was also no documentation that these residents were offered or received the PCV20 vaccine as recommended. The Director of Nursing (DON), who is responsible for the infection control program and ensuring residents are assessed for vaccine eligibility upon admission, acknowledged that these residents were eligible for the PCV20 vaccine but had not been educated about the risks and benefits or offered the vaccine. The facility's policy stated that residents would be offered pneumococcal immunizations in accordance with CDC recommendations, but this was not followed for the two residents in question.
Failure to Facilitate Resident Choice in Medication Administration Timing
Penalty
Summary
A resident with an intact cognitive status and a diagnosis of right knee prosthesis infection requiring daily intravenous (IV) Ertapenem requested that the timing of her antibiotic infusion be changed from late at night to earlier in the evening. The resident reported that the current schedule required her to be awakened at 11 p.m. for the infusion and again an hour later when it was completed, which disrupted her sleep. She communicated her preference to nursing staff, specifically to an LPN and an RN, but neither initiated the facility's standard process for medication change requests, which involves completing a Situation Background Assessment Recommendation (SBAR) report. Both the LPN and RN informed the resident that the medication time could not be changed without provider or pharmacist approval, but did not document or escalate the request as required. The nurse practitioner confirmed that the antibiotic administration time could have been adjusted to the resident's preference and was unaware of the request due to lack of communication via SBAR. The director of nursing stated that anyone could complete an SBAR for such requests, but no SBAR was found for this resident. The facility also failed to provide a policy regarding resident choices when requested. As a result, the resident continued to receive the medication at the undesired late hour.
Failure to Notify Resident Representative of Change in Condition and Treatment
Penalty
Summary
The facility failed to notify the resident's representative in a timely manner following changes to provider orders for a resident who was severely cognitively impaired and incontinent. The resident's care plan included monitoring for signs and symptoms of urinary tract infection (UTI) and reporting findings to the medical provider. After the family expressed concerns about increased confusion and requested a urinalysis, a urine sample was eventually obtained, and the resident was diagnosed with a UTI. An order for antibiotics was initiated, and sensitivities confirmed the continued use of the prescribed medication. Despite these significant changes in the resident's condition and treatment, there was no documentation in the progress notes that the resident's representative was notified after the urinalysis results, the UTI diagnosis, or the initiation of new medication orders. The family member reported not receiving updates about the resident's urine status or treatment and only learned about the antibiotic regimen after inquiring in person. The facility's policy required immediate notification and documentation of such changes, but this was not followed in this instance.
Failure to Implement Person-Centered Cardiac Care Plan Interventions
Penalty
Summary
The facility failed to implement person-centered interventions for a resident with significant cardiac diagnoses following admission. The resident, who was cognitively intact and had recently undergone surgical repair of spinal stenosis, had multiple cardiac conditions including atrial fibrillation, early ventricular depolarization, atherosclerosis of the aorta, bilateral carotid artery stenosis, and hypertensive heart disease. The admission care area assessment (CAA) identified the need for monitoring, medications, and treatments for these cardiac conditions, as well as for a pacemaker, but did not specify any person-centered interventions tailored to the resident's needs. Interviews with facility staff, including an LPN, RN, and the DON, confirmed that while a generic care plan was auto-generated upon admission, no resident-specific interventions were entered within the required 48-hour timeframe. The facility's policy requires the interdisciplinary team to create an individualized care plan with specific interventions within 48 hours of admission, but this was not completed for the resident in question. Staff acknowledged that the resident's significant cardiac history and recent surgery warranted individualized interventions, such as ongoing blood pressure and vital sign monitoring, medication parameters, and monitoring for cardiac symptoms, none of which were documented in the care plan.
Improper Catheter Drainage Bag Positioning
Penalty
Summary
The facility failed to ensure proper management of an indwelling urinary catheter for a resident with severe cognitive impairment, multiple sclerosis, neurogenic bladder, and a history of recurrent urinary tract infections. The resident was dependent on staff for all activities of daily living and had a care plan specifying that the catheter drainage bag should be kept below the bladder level, the tubing should be free of kinks, and the catheter should be secured to avoid tension. The care plan also required staff to monitor for signs and symptoms of infection and to follow specific protocols for catheter and drainage bag care. Despite these interventions, observations revealed that the resident's catheter drainage bag was repeatedly found hanging on the armrest of the wheelchair at a level equal to the resident's pelvis, rather than below the bladder as required. Interviews with nursing assistants indicated inconsistent practices, with some staff placing the bag on the side or under the wheelchair, and others clipping it to prevent dragging. The medical director and DON both confirmed that the drainage bag should be kept below bladder level to ensure proper drainage and prevent urine reflux. Facility policy also required the drainage bag to be kept below the bladder to reduce the risk of catheter-associated urinary tract infection.
Failure to Ensure Timely PICC Line Dressing and IV Tubing Changes
Penalty
Summary
The facility failed to ensure proper management of peripherally inserted central catheters (PICC) for two residents receiving intravenous (IV) antibiotics. For one resident with a right knee prosthesis infection, the PICC line dressing had not been changed for ten days, as indicated by the date on the dressing and confirmed by the resident, despite the facility policy requiring dressing changes every seven days or sooner if compromised. The dressing was observed to be peeling, and the IV medication tubing lacked a date indicating when it was last changed. The resident expressed concern about the condition of both the dressing and the tubing. Documentation showed that site care was not recorded as completed until two days after the observation, and there was no physician order for dressing changes in the resident's records. A second resident with a left knee prosthesis infection also had a PICC line with an undated dressing that was peeling at multiple corners, and the IV tubing was not dated. This resident's orders specified dressing changes every seven days and as needed, but the observed condition of the dressing did not meet these requirements. Interviews with nursing staff and facility leadership confirmed that the expectation was for dressings to be changed every seven days and for IV tubing to be replaced every 24 hours, with dressings to be dated at the time of change. However, these standards were not consistently followed, as evidenced by the observations and documentation reviewed during the survey.
Failure to Identify and Treat Resident Pain Following Surgery
Penalty
Summary
The facility failed to identify and treat pain for a resident following admission after spinal surgery. The resident had a history of pain in both hips and lower back related to surgery and post-surgical treatment. The care plan indicated the potential for post-surgical pain and called for administration of pain medication as ordered, with pain monitoring every shift and documentation of non-pharmacological interventions. However, the resident did not have any active pain medication orders, and the medication administration record showed no pain medication was given. Non-pharmacological interventions were also not documented as provided, and pain assessments were missed or not acted upon, even when the resident reported moderate to severe pain. Throughout several days, the resident reported increasing pain to nursing staff, including specific pain scores and descriptions of worsening symptoms affecting participation in physical therapy. Despite these reports, staff did not administer pain medication, offer non-pharmacological interventions, or notify the provider in a timely manner. The director of nursing confirmed that staff did not follow the facility's pain management policy, which requires provider notification and implementation of non-pharmacological interventions when pain is reported. Facility standing orders for pain management were requested but not provided.
Failure to File Laboratory Reports in Medical Record
Penalty
Summary
The facility failed to ensure that clinical laboratory reports were filed into the medical record for one resident who had diagnoses of osteomyelitis and pyelonephritis. After being discharged from the hospital, the resident was ordered to receive weekly bloodwork while on intravenous antibiotics. Although laboratory tests were completed on two occasions, a review of the resident's medical record showed that the laboratory results were not present in the chart, nor was there documentation that the results were faxed to the infectious disease provider. The DON confirmed that the laboratory results from the outside laboratory had not been received or filed in the resident's medical record, contrary to the facility's laboratory services policy, which requires that laboratory reports be dated and filed in the resident's clinical record.
Failure to Manage Indwelling Catheter for Resident
Penalty
Summary
The facility failed to assess and manage the removal of an indwelling urinary catheter for one resident, identified as R6, which was necessary to restore urinary continence. R6 had a Foley catheter inserted during a hospital stay due to acute urinary retention and was discharged with instructions for a follow-up with urology. However, the facility did not ensure that this follow-up appointment occurred, and there was no rescheduling of the missed appointment. This oversight led to the prolonged use of the catheter without reassessment, increasing the risk of infection and other complications. R6's care plan and medical orders lacked specific details regarding the size of the Foley catheter and the schedule for changing it. Interviews with nursing staff, including a registered nurse and a licensed practical nurse, confirmed the absence of a current medical order specifying these details. The Director of Nursing acknowledged the missed urology appointment and the importance of assessing R6 for catheter removal to help restore continence. The facility's policy on incontinence management and indwelling urinary catheter care emphasizes the importance of timely assessment and intervention to prevent complications such as catheter-associated urinary tract infections. Despite these guidelines, the facility did not follow through with the necessary steps to ensure R6's catheter was managed appropriately, resulting in a deficiency in care.
Failure to Report Significant Medication Error
Penalty
Summary
The facility failed to report a significant medication error involving a resident who was at risk for blood clotting complications due to several cardiac diagnoses and a genetic blood clotting factor. The resident, who had a history of blood clots, was supposed to receive Lovenox injections as part of their anticoagulation management. However, the order for Lovenox was not initiated on the specified date, and the resident missed a morning dose, which was considered a significant medication error. The resident's Nurse Practitioner had ordered Lovenox to be administered twice daily until the resident's INR was greater than 2.0. Despite this, the medication was not given as ordered, and the resident's INR remained below the therapeutic range. The resident was not informed of the medication error, which they expressed a desire to be notified about. The nurse manager and regional nurse consultant acknowledged the error and recognized that it should have been reported to the state agency, but it was not. The facility's policy on resident protection emphasizes the importance of reporting incidents of neglect, including medication errors, to the appropriate authorities. The policy outlines procedures for reporting and documenting such incidents to ensure resident safety. However, in this case, the failure to report the medication error to the state agency was a deviation from the facility's established procedures, resulting in a deficiency in the care provided to the resident.
Failure to Administer Anticoagulants as Ordered
Penalty
Summary
The facility failed to follow physician orders and properly administer anticoagulant medications, resulting in significant medication errors for two residents. For one resident, identified as R1, the facility did not check the INR as ordered by the physician, leading to a delay in resuming warfarin dosing. This resident, with a history of atrial fibrillation, bioprosthetic mitral valve, and Factor 5 Leiden syndrome, did not receive warfarin on multiple occasions due to missed INR checks and late medication orders. Additionally, the resident did not receive Lovenox injections as ordered, with one instance being due to the medication not being available in the facility's Omnicell system. Another resident, identified as R2, also experienced medication errors related to anticoagulant administration. The resident's warfarin dose was discontinued prematurely, resulting in a missed dose. This resident, with a diagnosis of atrial fibrillation, had an INR that was subtherapeutic, indicating that the anticoagulation therapy was not within the therapeutic range. The facility's failure to administer the correct dosage of warfarin contributed to this issue. Interviews with facility staff revealed a lack of communication and documentation regarding these medication errors. Nurses and other staff members were not consistently aware of the errors, and there was no system in place to notify physicians or residents of missed doses. The facility's policy on medication errors was not adequately followed, as evidenced by the absence of completed medication error reports for the incidents involving both residents.
Failure to Monitor and Treat Pressure Ulcer
Penalty
Summary
The facility failed to comprehensively assess and monitor a resident's pressure ulcer, leading to its deterioration from a stage 1 to an unstageable pressure ulcer. The resident, who was admitted with a stage 1 pressure ulcer on the left buttock, did not receive a comprehensive assessment or ongoing monitoring until 18 days later when the ulcer was found to be unstageable. The initial assessment lacked measurements, a description of the pressure area, presence of pain, and a treatment plan. This lack of proper assessment and monitoring resulted in the ulcer becoming unstageable, causing pain and requiring antibiotic treatment. The facility's records show that the resident's care plan was not revised until 13 days after the unstageable ulcer was identified, and no immediate interventions were implemented until four days after the wound was discovered. During this period, the wound was not treated or monitored, and the resident experienced increased pain and warmth in the area. The facility's standing orders did not include a treatment for unstageable pressure ulcers, and the staff failed to follow the facility's policy for wound assessments and monitoring. Interviews with staff revealed that the facility did not perform full body skin assessments as required, and there was a lack of communication and documentation regarding the resident's condition. The interim director of nursing acknowledged that the facility's policy was not followed, and the facility had not reviewed other residents who might have been affected by similar deficiencies. The failure to properly assess, monitor, and treat the resident's pressure ulcer resulted in actual harm, as the ulcer deteriorated and required medical intervention.
Failure to Implement Enhanced Barrier Precautions for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a pressure ulcer, which is an infection control intervention designed to reduce the transmission of multidrug-resistant organisms. The resident, who had a diagnosis of dementia and a recent urinary tract infection, was identified as being at risk for pressure ulcers and had an unstageable pressure ulcer on the coccyx. Despite the care plan indicating the need for gown and glove use during high-contact care activities, such as dressing, bathing, and toileting, these precautions were not followed by the staff. During observations, it was noted that nursing assistants and licensed practical nurses did not perform hand hygiene or use gowns and gloves while transferring the resident from the bed to a wheelchair and during toileting. The staff members involved were unaware of the requirement to use EBP, and interviews with them confirmed the lack of adherence to the infection control protocols. The signage indicating the need for EBP was present, but staff failed to follow the instructions. Interviews with the interim director of nursing and registered nurses confirmed that EBP should have been used for the resident due to the pressure ulcer. The facility's policy on Enhanced Barrier Precautions, revised recently, clearly outlined the need for gown and glove use during high-contact activities for residents with wounds or indwelling medical devices. However, the staff did not comply with these guidelines, leading to a deficiency in infection control practices.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to report an accusation of abuse to the administrator and State Agency within the required two-hour time frame. This deficiency involved a resident who reported being pushed, turned hard, and pinched by a nursing assistant. The incident was initially reported to a Licensed Practical Nurse (LPN) by the resident, who also had visible bruises. The LPN conducted a skin inspection and noted bruising but did not document it in the medical record. The LPN claimed to have reported the incident to the Director of Nursing (DON) on the same day, but the DON stated she was only informed two days later. The resident involved had a medical history of vertebrogenic low back pain, mild intellectual disabilities, and anxiety disorder. She was dependent on staff for activities of daily living and used a walker and wheelchair for mobility. The resident's skin checks prior to the incident showed no issues, but a subsequent check revealed multiple bruises on her arms and abdomen. During an interview, the resident identified a faint bruise as a pinch mark from the nursing assistant and expressed emotional distress over the incident. Interviews with staff revealed discrepancies in the reporting process. The LPN stated she informed the DON about the incident, but the DON denied receiving such a report until two days later. The facility's policy requires immediate reporting of abuse allegations to the supervisor and state agencies, but this protocol was not followed. The delay in reporting and lack of documentation contributed to the deficiency identified by the surveyors.
Failure to Implement Enhanced Barrier Precautions for Residents with Wounds
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for three residents (R2, R3, and R4) who required infection prevention measures due to their medical conditions. R2 had an open wound on the abdominal wall, R3 had a non-pressure chronic wound on the left heel, and R4 was receiving orthopedic aftercare following a surgical amputation. Despite physician orders for wound care, none of the orders included directions for EBP. Observations and interviews revealed that staff only wore gloves during dressing changes and did not use additional personal protective equipment (PPE) such as gowns. Furthermore, there were no signs or precaution carts by the residents' doors to indicate the need for EBP. The infection preventionist confirmed that R2, R3, and R4 were not placed on EBP, which posed a risk of transmission of multi-drug resistant organisms or other bacteria or viruses. The director of nursing acknowledged that according to facility policy, any resident with a wound should be placed in EBP, but this was not done for the three residents. The facility's Infection Prevention and Control Manual required gown and glove use for residents with wounds during high-contact care activities, along with clear signage and precaution carts outside resident rooms, which were not implemented 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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