Rochester Restorative Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Rochester, Minnesota.
- Location
- 501 Eighth Avenue Southeast, Rochester, Minnesota 55904
- CMS Provider Number
- 245184
- Inspections on file
- 32
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 46 (1 serious)
Citation history
Health deficiencies cited at Rochester Restorative Care Center during CMS and state inspections, most recent first.
A resident with COPD and asthma, who was oxygen dependent and had moderate cognitive impairment, was self-administering Ventolin and Dulera inhalers without a comprehensive assessment or a physician's order. Staff were aware of the resident's actions for at least two weeks, but no assessment was completed as required by facility policy.
The facility did not maintain accurate and complete medical records for two residents, resulting in discrepancies between physician orders, treatment records, and progress notes for oxygen therapy and antibiotic administration. Staff failed to consistently document changes in orders and care provided, and there was no clear process for integrating outside medical records into the facility's EHR.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
The facility did not review or update its assessment to specify the minimum number of direct care and licensed staff needed to meet residents' needs, including staffing hours per resident day (PPD) and the division between licensed and direct care staff. Staffing decisions were made daily based on census and acuity, but the assessment lacked a formalized plan, potentially affecting all residents.
The facility failed to maintain a documented plan describing the process for conducting QAPI and QAA activities, as required. Surveyors found no evidence of a structured approach or written procedures for these quality initiatives.
The facility did not set up an ongoing quality assessment and assurance group, resulting in the lack of a formal process to review quality deficiencies and develop corrective plans of action.
The QAA group did not include all required members and failed to meet at least quarterly, as shown by facility records and documentation.
The facility did not allow a resident or the resident's legal representative to access or purchase copies of the resident's records, as required.
A resident was admitted without a plan being created or implemented to address their most immediate needs within 48 hours. The facility did not ensure that a comprehensive assessment and plan were completed in the required timeframe, resulting in the resident's immediate needs not being systematically addressed.
A deficiency was cited when a resident's care plan did not include all necessary needs, lacked measurable timetables, and failed to specify actions, resulting in incomplete planning and documentation for the resident's care.
The facility did not complete the care plan within 7 days of the comprehensive assessment, and the care plan was not prepared, reviewed, and revised by a team of health professionals as required.
Surveyors found that appropriate care was not consistently provided to residents who were continent or incontinent of bowel/bladder, including improper catheter care and insufficient measures to prevent UTIs.
Annual performance evaluations were not completed for four nursing assistants employed for over a year. Staff interviews indicated a lack of awareness about receiving reviews, and the DON confirmed that these evaluations had not been performed. Requested policies on performance reviews were also not provided.
The facility failed to ensure proper dishwashing sanitization and monitoring, as a dietary aide was observed using a dish machine with incorrect chemical levels. Additionally, expired food was found in a unit refrigerator meant for residents' personal food, despite policies requiring regular cleaning and labeling. The dietary manager and registered dietician confirmed the expectations for sanitization and food storage, which were not met.
The facility failed to ensure proper use of PPE for two residents on enhanced barrier precautions (EBP). A resident with a gastrostomy tube was administered medication without the nurse wearing a gown, and the necessary EBP signage was missing. Another resident with a pressure ulcer received care without the nurse donning a gown, despite EBP signage being present. These lapses indicate non-compliance with the facility's infection prevention protocols.
Two residents were found with medications in their rooms without proper assessment or authorization for self-administration. One resident had Voltaren gel without a physician's order or care plan for self-administration, while another had glucose tablets, aspirin, and iron without a self-administration order. The DON confirmed the lack of necessary orders and assessments, indicating non-compliance with facility policy.
The facility failed to notify resident representatives after two residents experienced falls and were transferred to the hospital. One resident, who was cognitively intact, was not able to have her emergency contact informed despite her request. Another resident with mild cognitive impairment had a similar issue, with the facility failing to make adequate attempts to contact the emergency contact. The facility's policy required immediate notification, but this was not followed, leading to dissatisfaction and concern from the residents' representatives.
A facility failed to complete a baseline care plan for a newly admitted resident requiring post-op orthopedic after-care. The resident's MDS assessment showed moderate impaired cognition and a need for ADL assistance. Neither the resident nor their family received a care plan, and the DON confirmed the required form was incomplete. The facility's policy lacked guidance on baseline care plan development.
A facility failed to develop a comprehensive care plan for a resident with urinary retention and an indwelling urinary catheter. The resident's care plan did not include necessary details about the urinary catheter, leg bag, or drainage bag, despite these being documented needs. The RN responsible for care plans acknowledged the oversight, and the DON confirmed the expectation for these elements to be included in the care plan.
A resident with a history of Alzheimer's and cardiovascular issues did not receive consistent application of prescribed compression wraps for edema management. Observations and interviews revealed that staff were often unaware of the requirement or unsure of their responsibilities, leading to missed applications and increased swelling. The Director of Nursing confirmed the need for daily application, but a policy on edema prevention and treatment was not provided.
Two residents at an LTC facility experienced multiple falls due to inadequate assessment and intervention. One resident, with a history of falls and Alzheimer's, had seven falls over three months, with inconsistent interventions and poor communication among staff. Another resident, admitted for rehabilitation, fell three times in a week, with incomplete incident reports and lack of root cause analysis. The facility's fall prevention policy was not effectively implemented, leading to missed opportunities to prevent future falls.
A resident with urinary retention and an indwelling catheter did not have their leg bag switched to a urinary drainage bag at night, contrary to the facility's catheter care policy. Observations and staff interviews confirmed the oversight, which could lead to urine backflow and potential infection. The facility's policy required the use of a drainage bag at night to ensure proper urine drainage.
The facility failed to maintain the second-floor tub/shower room in good repair and sanitary conditions, affecting 30 residents. Missing tiles exposed wood and plaster, creating an unsanitary environment. The corporate maintenance director and facility maintenance director were unaware of the issue, and a housekeeper could not recall reporting it. A maintenance policy was requested but not provided.
The facility failed to serve meals at a warm and palatable temperature, affecting residents' quality of life and nutritional intake. Observations showed meal trays left unattended, leading to food temperatures below safe levels. Residents reported dissatisfaction with cold meals, and staff acknowledged the issue, citing a broken plate warmer and insufficient staff as contributing factors.
The facility failed to maintain proper food temperatures, leading to resident complaints about cold meals. Observations showed that meal trays were distributed late, and nursing staff did not check temperatures before serving. Dietary management confirmed that recorded temperatures were unacceptable, with some hot foods below the required standards. The facility's policy required food to be served at safe and appetizing temperatures, but practices did not align with these standards.
A resident with chronic respiratory failure did not receive oxygen as per physician orders, leading to a significant drop in oxygen saturation and shortness of breath. The resident's oxygen was set incorrectly, and the nasal cannula was not properly placed. Staff interviews revealed a lack of understanding of oxygen delivery protocols, contributing to the deficiency.
Failure to Assess Resident for Self-Administration of Inhalers
Penalty
Summary
The facility failed to complete a comprehensive assessment for self-administration of medications for a resident with chronic obstructive pulmonary disease (COPD) and asthma, who was oxygen dependent and had moderately impaired cognition. The resident's care plan included interventions for respiratory impairment, and physician orders specified the use of Ventolin and Dulera inhalers. Despite these orders, the resident was found to be self-administering both inhalers, keeping them in her pocket, and had not received a comprehensive assessment to determine her ability to safely self-administer these medications. There was also no physician order authorizing self-administration, as required by facility policy. Multiple staff members, including RNs, were aware that the resident had been self-administering her inhalers for at least two weeks, but no assessment had been completed. The resident reported keeping the inhalers on her person for quick access and had informed staff of her desire to self-administer, but was told the inhalers should be kept in the medication cart. The DON confirmed that no self-administration assessment had been completed, and the facility's policy required both a prescriber's order and an interdisciplinary team determination of safety before allowing self-administration of medications.
Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to maintain complete, accurate, and readily accessible medical records for two residents. For one resident with chronic obstructive pulmonary disease and asthma, there were discrepancies between physician orders, treatment administration records (TAR), and progress notes regarding oxygen therapy. The physician ordered a change from 3 liters per minute (L/min) to 2 L/min of oxygen, but this change was not transcribed into the official physician orders. The TAR continued to reflect administration of 3 L/min, while progress notes documented administration of 2 L/min on several occasions. Additionally, refusals of oxygen therapy were not consistently documented, and notifications to the physician were based on verbal reports rather than written documentation. Nursing staff and the director of nursing acknowledged that the medical record was inaccurate due to these inconsistencies. For another resident with chronic kidney disease, cellulitis, diabetes, and heart failure, there was a lack of documentation regarding the discontinuation of an antibiotic prescribed after a hospital visit. The hospital after visit summary included an order for Augmentin, but the facility's electronic health record (EHR) showed a verbal order for the medication with a start and stop date, without any corresponding written order or physician note explaining the discontinuation. Staff interviews revealed uncertainty about the process for retrieving and incorporating outside medical records into the facility's EHR, and the director of nursing confirmed that the record did not address the discontinuation of the antibiotic. The facility's medical record policy required documentation according to the resident's level of care and for any unusual activity, event, or change in assistance. However, the lack of accurate transcription of physician orders, inconsistent documentation of care provided, and unclear processes for integrating external medical records led to incomplete and inaccurate records for the residents involved.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Identify and Document Minimum Staffing Requirements in Facility Assessment
Penalty
Summary
The facility failed to review and update its facility-wide assessment to identify the minimum or baseline number of direct care and licensed staff required to meet residents' needs during both routine operations and emergencies. The assessment did not specify staffing hours per resident day (PPD) goals or the breakdown between licensed and direct care staff necessary to provide care based on residents' diagnoses, assessed needs, and comprehensive care plans. The assessment process described was fluid and based on daily evaluations by the nursing department and interdisciplinary team, but lacked concrete staffing numbers or ratios. The special memory care unit was noted to require special staffing considerations, but no specific minimums were documented. Interviews with staff revealed that daily staffing decisions were made based on the DON's direction and current census, with a general target of 3.3 to 3.4 PPD, but without a formalized or documented staffing plan in the facility assessment. The scheduler and DON both confirmed that the assessment did not identify the number or type of staff needed for each shift. Additionally, the facility assessment policy was requested but not provided. This deficiency had the potential to affect all 51 residents in the facility.
Lack of QAPI and QAA Process Plan
Penalty
Summary
The facility did not have a plan that describes the process for conducting Quality Assurance and Performance Improvement (QAPI) and Quality Assessment and Assurance (QAA) activities. This deficiency was identified based on the absence of documentation or evidence outlining the procedures or steps the facility uses to carry out these required quality activities.
Failure to Establish Ongoing Quality Assessment and Assurance Group
Penalty
Summary
The facility failed to establish an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. This inaction resulted in the absence of a systematic process for identifying, reviewing, and addressing quality issues within the facility. As a result, there was no formal mechanism in place to ensure that quality deficiencies were consistently identified or that appropriate corrective actions were developed and implemented.
QAA Group Lacked Required Members and Quarterly Meetings
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) group was composed of the required members and that meetings were held at least quarterly. This deficiency was identified through review of facility records and documentation, which showed that the QAA group did not consistently meet the mandated membership requirements and did not convene at the required frequency.
Failure to Provide Access to Resident Records
Penalty
Summary
The facility failed to ensure that each resident or the resident's legal representative was able to access or purchase copies of all the resident's records. This deficiency was identified based on the facility's actions or inactions that did not provide residents or their legal representatives with the required access to their records as mandated.
Failure to Develop and Implement Immediate Needs Plan Within 48 Hours of Admission
Penalty
Summary
A plan to address the resident's most immediate needs within 48 hours of admission was not created or implemented. This deficiency occurred due to the facility's failure to ensure that a comprehensive assessment and plan were developed and put into place promptly after the resident's admission. The lack of timely planning resulted in the resident's immediate needs not being systematically identified or addressed within the required timeframe.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the facility's failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This deficiency was observed through review of the resident's records and care plans, which did not contain all necessary elements to ensure comprehensive care as required.
Failure to Timely Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Deficient Continence and Catheter Care Leading to UTI Risk
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not consistently provided to residents in these areas. Specific failures included inadequate attention to the needs of residents with continence or incontinence issues, improper catheter care, and insufficient measures to prevent UTIs. These findings indicate that the facility did not meet the required standards for ensuring proper continence management, catheter maintenance, and infection prevention for its residents.
Failure to Complete Annual Performance Evaluations for Nursing Assistants
Penalty
Summary
The facility failed to complete annual performance evaluations for four out of five nursing assistants who had been employed for over one year. Staff records for these nursing assistants showed hire dates ranging from 1996 to 2024, but no annual performance evaluations were provided upon request. Interviews with the nursing assistants revealed that they did not recall receiving annual performance reviews, and the DON confirmed that she was responsible for conducting these evaluations but had not completed them for the identified staff. Additionally, the facility was unable to provide policies regarding performance reviews when requested.
Dishwashing and Food Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper dishwashing sanitization levels and monitoring during the dishwashing process. During a kitchen tour, a dietary aide was observed placing dishes through a dish machine, with the wash dial indicating a temperature of 130 degrees Fahrenheit and the rinse dial at 140 degrees Fahrenheit. The dietary aide stated that the dish machine sanitized dishes with hot water and used test strips to check chemical levels after dishwashing. However, the test strips did not change color, indicating a failure in the sanitization process. The dietary manager confirmed that the dish machine used chemical sanitization, not temperature, and acknowledged ongoing issues with the dish machine. Additionally, the facility failed to ensure expired food was identified and removed from a unit refrigerator storing residents' personal food. A refrigerator on the second floor was observed with a sign indicating it was cleaned weekly, and all items must be labeled with the resident's name and date. However, the refrigerator contained several expired food items, including a plastic container with red sauce and pasta, an ice-cream sandwich, miracle whip, yogurt, cantaloupe, a piece of lemon pie, and pizza. The registered nurse confirmed the presence of expired food and removed it from the refrigerator. The facility's policies on ware washing and food storage were not adhered to, as evidenced by the failure to maintain proper dishwashing sanitization levels and the presence of expired food in the refrigerator. The dietary manager and registered dietician confirmed the expectations for checking chemical levels during dishwashing and ensuring expired food was not present in unit refrigerators. The director of nursing and district dietary manager also acknowledged the deficiencies in cleaning and monitoring the refrigerator.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure proper use of personal protective equipment (PPE) for two residents, R54 and R23, who were on enhanced barrier precautions (EBP). R54, who had severe cognitive impairment and a gastrostomy tube, was observed during a medication administration without the registered nurse (RN-A) donning a gown as required. The nurse confirmed that R54 was on EBP due to the g-tube, but the necessary signage indicating EBP was missing from the resident's door. Additionally, the trained medication aide (TMA-A) was unaware of R54's EBP status, indicating a lack of communication and adherence to protocols. R23, who had a stage 2 pressure ulcer and was on EBP, was assisted by RN-E without wearing a gown during peri care. Although the EBP sign was present on R23's door, RN-E admitted to forgetting to wear the gown during the care process. The infection preventionist (RN-B) confirmed that R23 was on EBP due to skin alterations and reiterated the expectation for staff to wear gowns and gloves during high-contact care activities. The facility's policy on enhanced barrier precautions, dated 8/8/24, requires signage on resident doors and the availability of PPE outside rooms for residents with wounds or indwelling medical devices. The policy also mandates that staff be aware of which residents require EBP before providing care. However, the observations and interviews revealed lapses in adherence to these protocols, leading to deficiencies in infection prevention and control measures.
Failure to Assess Residents for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that two residents, who were observed to have medications in their rooms, were appropriately assessed and deemed safe to self-administer medications. Resident 6, diagnosed with rheumatoid arthritis and dementia, had a tube of Voltaren gel in her room without a physician's order for self-administration or an assessment for safe self-administration documented in her electronic medical record (EMR). During an interview, Resident 6 mentioned that she did not apply the medication herself, indicating a lack of self-administration. The care plan for Resident 6 did not include self-administration of medication. Resident 49, with a history of stroke, type 1 diabetes, and dementia, was found with several medications in his room, including glucose tablets, aspirin, and iron, without a self-administration order or assessment in the EMR. Although Resident 49 stated he brought the medications from home and did not use them anymore, the presence of these medications in his room was not in compliance with the facility's policy. The Director of Nursing confirmed the absence of self-administration orders for both residents and acknowledged that the medications should not have been in their rooms without proper authorization and assessment.
Failure to Notify Resident Representatives After Falls
Penalty
Summary
The facility failed to notify resident representatives following falls and subsequent hospital transfers for two residents. Resident R20, who had a history of falls and was cognitively intact, experienced a fall resulting in a femur fracture. Despite R20's request to notify her emergency contact, FM-A, the facility did not make the notification. FM-A only learned of the incident when R20 contacted her from the emergency department. The administrator and director of nursing were aware of the policy to notify resident representatives but did not follow through, citing R20's ability to make her own decisions, despite her being in considerable pain and unable to contact FM-A herself. Resident R164, who had mild cognitive impairment and a history of falls, was also not properly notified. After a fall that led to a hospital transfer, FM-B, R164's emergency contact, was not informed by the facility. The facility's documentation indicated an attempt to contact FM-B, but no follow-up was made when there was no answer. The director of nursing acknowledged that staff should have made additional attempts to contact FM-B or informed the next shift to try again. The facility's policy required immediate notification of resident representatives in the event of an accident involving injury or a significant change in condition. However, in both cases, the facility failed to adhere to this policy, resulting in a lack of communication with the residents' emergency contacts during critical situations. This oversight led to dissatisfaction and concern from the residents' representatives, who were not able to provide support during the hospital transfers.
Failure to Complete Baseline Care Plan for New Resident
Penalty
Summary
The facility failed to complete a baseline care plan for a newly admitted resident, identified as R164, who had been admitted for post-operative orthopedic after-care following neck surgery. The resident's admission Minimum Data Set (MDS) assessment indicated moderate impaired cognition, clear speech, and a need for assistance with activities of daily living (ADLs), as the resident did not walk independently. Despite these needs, neither the resident nor their family member received a copy of a baseline care plan after admission. Upon review of the resident's electronic medical record and paper chart, it was found that a baseline care plan was not documented. A carbonless form titled Baseline Care Plan Summary was found in the paper chart with only the resident's name and room number filled in, leaving the rest of the form blank. The Director of Nursing (DON) confirmed that this form was intended for documenting the baseline care plan and acknowledged that it had not been completed. Additionally, the facility's Comprehensive Care Plan policy did not include language about developing a baseline care plan and providing a summary to residents or their representatives.
Failure to Develop Comprehensive Care Plan for Resident with Urinary Catheter
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident (R163) who was reviewed for urinary catheter use. The resident's facesheet indicated a diagnosis of urinary retention, and the Minimum Data Set (MDS) assessment showed dependency on staff for most activities of daily living and the presence of an indwelling urinary catheter. Despite these documented needs, the care plan dated 1/27/25 did not include the resident's urinary retention, the use of an indwelling Foley catheter, leg bag, or urinary drainage bag. During interviews, the registered nurse (RN-C) responsible for updating care plans acknowledged the omission, stating it was a mistake and that she would correct it immediately. The Director of Nursing (DON) also confirmed that the urinary retention and catheter use should have been included in the care plan to ensure staff were aware of the necessary care interventions. The facility's policy requires a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet the resident's needs, which was not adhered to in this case.
Failure to Apply Compression Wraps for Edema Management
Penalty
Summary
The facility failed to comprehensively assess and provide ongoing treatment for a resident (R5) who required leg wraps to prevent and treat edema. R5 had a history of multiple medical conditions, including Alzheimer's disease and impaired cardiovascular status, and was prescribed low stretch compression wraps for both legs. However, the facility's records indicated that the compression wraps were not applied consistently, with several instances of missed applications due to the resident sleeping or other undocumented reasons. Additionally, R5 refused the wraps multiple times, but there were no documented reattempts to apply them. Observations and interviews revealed that R5 was often found without the prescribed compression wraps, and staff members were either unaware of the requirement or unsure of their responsibilities regarding the application of the wraps. Family members expressed concerns about the lack of care, noting increased swelling in R5's legs and the absence of necessary interventions such as massaging and moisturizing before applying the wraps. Staff interviews highlighted a lack of communication and understanding of roles, with some staff believing that only nurses could apply the wraps, while others thought nursing assistants could do so. The Director of Nursing confirmed the presence of an order for bilateral leg wraps and stated that staff should apply them daily and remove them at bedtime. The DON also mentioned that residents who refuse care should be approached a minimum of three times. Despite these expectations, the facility's policy on edema prevention and treatment was not provided, indicating a possible gap in procedural guidance. The deficiency was further compounded by the lack of consistent documentation and follow-up on R5's care needs.
Inadequate Fall Prevention and Intervention for Residents
Penalty
Summary
The facility failed to adequately assess and implement interventions to prevent falls for two residents, R5 and R164, who were at risk for accidents. R5, who had a history of falls and multiple medical conditions including Alzheimer's disease and impaired mobility, experienced seven falls over a period of three months. Despite these incidents, the facility's interventions were inconsistent and not effectively communicated to staff. Observations revealed that R5's room lacked a 'call don't fall' sign, and necessary items were not within reach, contributing to the resident's attempts to self-transfer and subsequent falls. R164, admitted for short-term rehabilitation following neck surgery, also experienced multiple falls within a week of admission. The facility's response to these falls was inadequate, as incident reports were incomplete, and the interdisciplinary team (IDT) failed to conduct thorough root cause analyses or implement new interventions. The lack of communication and follow-up on fall incidents resulted in missed opportunities to address the underlying causes and prevent future falls. The facility's fall prevention and management policy was not effectively implemented, as evidenced by the failure to conduct timely fall risk assessments and update care plans with appropriate interventions. The director of nursing acknowledged the shortcomings in the facility's response to falls, highlighting a need for improved communication and adherence to established protocols to ensure resident safety.
Failure to Switch Catheter Leg Bag to Drainage Bag at Night
Penalty
Summary
The facility failed to provide appropriate management of an indwelling catheter for a resident diagnosed with urinary retention. The resident, who was dependent on staff for most activities of daily living, had an indwelling urinary catheter. Observations revealed that the resident's leg bag was not switched to a urinary drainage bag at night, as required by the facility's catheter care policy. This oversight was noted during multiple observations, where the resident was found with a leg bag in place, which was not changed to a urinary drainage bag at night. Interviews with staff, including an LPN and a nursing assistant, confirmed that the catheter should have been connected to a urinary drainage bag at night to ensure proper urine drainage and prevent backflow, which could lead to a urinary tract infection. The Director of Nursing also acknowledged the importance of switching to a urinary drainage bag at night to prevent urine backflow. The facility's catheter care policy, revised in March 2023, clearly stated that leg bags should be removed and replaced with a bedside drainage bag at night, which was not adhered to in this case.
Deficiency in Tub/Shower Room Maintenance
Penalty
Summary
The facility failed to maintain the second-floor tub/shower room in good repair and sanitary conditions for the 30 residents who could potentially use the area. During an observation, it was noted that a wall partially enclosing the shower area was missing six tiles, exposing wood and plaster. The corporate maintenance director was unaware of the missing tiles and acknowledged the unsanitary and non-homelike environment. A housekeeper was aware of the issue but could not recall to whom it was reported. The facility maintenance director, new to the position, was also unaware of the missing tiles and was dealing with a backlog of repairs. A policy on building maintenance was requested but not provided.
Failure to Serve Meals at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to ensure that meals were served at a warm and palatable temperature, affecting the quality of life and nutritional intake for residents on the second floor. Three residents, each with specific dietary needs and cognitive impairments, reported that their meals were consistently served cold. Observations confirmed that meal trays were left unattended on the second floor for extended periods, leading to food temperatures significantly below the recommended safe levels. The dietary manager acknowledged that the food should be served at temperatures closer to 135 degrees Fahrenheit, but the facility's plate warmer had been out of service for two weeks, contributing to the issue. Interviews with residents and staff revealed that the lack of sufficient staff to deliver meal trays promptly was a contributing factor. Residents expressed dissatisfaction with the temperature of their meals, and the registered dietician confirmed concerns about food safety and palatability due to the low temperatures. The facility's policy stated that food should be prepared and served at safe and appetizing temperatures, but this was not adhered to, as evidenced by the observations and resident feedback.
Deficiency in Food Temperature Maintenance
Penalty
Summary
The facility failed to ensure that food was maintained at proper temperatures, resulting in complaints from six residents about receiving cold meals. Observations and interviews revealed that residents consistently received meals that were lukewarm or cold, regardless of whether they dined in their rooms or the dining room. Specific instances included a resident receiving lunch at 2:00 p.m. with food that was not as ordered and often cold, and another resident who found the food cold but did not request reheating. During observations, it was noted that meal trays were distributed late, and nursing staff did not check food temperatures before serving. A Licensed Practical Nurse (LPN) mentioned that trays sometimes arrived late, and dietary staff did not pass out trays, leaving this task to nursing staff. The LPN also noted that hot plates were rarely used, and food was often reheated in microwaves before serving. Temperature checks conducted by dietary staff showed that food items were below the required temperature standards, with some hot foods measuring significantly below the minimum 135 degrees Fahrenheit. Interviews with dietary management confirmed that the temperatures recorded were unacceptable. The dietary account manager stated that food was taken from the oven to the steam table, but space limitations affected temperature maintenance. Observations showed that food was plated without lids, and cold items were placed on warm plates. The facility's policy required food to be served at safe and appetizing temperatures, but the practices observed did not align with these standards, leading to dissatisfaction among residents.
Failure to Deliver Oxygen According to Physician Orders
Penalty
Summary
The facility failed to ensure that oxygen was delivered according to physician orders for a resident with chronic respiratory failure and other related conditions. The resident was supposed to receive continuous oxygen at 1 liter per minute (LPM) via nasal cannula, as per physician orders. However, during an observation, the resident was found with the oxygen concentrator set at 2 LPM, and the nasal cannula was not properly placed in the resident's nose. Additionally, the resident's head of bed was not elevated as required by the care plan. When the resident was transferred to a wheelchair, the oxygen saturation dropped significantly, and the resident experienced shortness of breath, prompting staff to increase the oxygen to 3 LPM, which was not in accordance with the physician's order. Interviews with staff revealed a lack of understanding and adherence to the oxygen delivery protocol. Nursing assistants were not aware of the importance of continuous oxygen delivery and were not trained to titrate oxygen levels, although they were involved in tasks that required temporary removal of oxygen. The facility's oxygen policy emphasized the necessity of oxygen for survival, yet the staff's actions did not align with this policy, leading to a deficiency in providing safe and appropriate respiratory care for the resident.
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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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