Southside Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Minneapolis, Minnesota.
- Location
- 2644 Aldrich Avenue South, Minneapolis, Minnesota 55408
- CMS Provider Number
- 24E507
- Inspections on file
- 18
- Latest survey
- April 6, 2026
- Citations (last 12 mo.)
- 28 (1 serious)
Citation history
Health deficiencies cited at Southside Care Center during CMS and state inspections, most recent first.
The facility failed to employ a registered dietician, affecting all 11 residents receiving food. Interviews revealed inconsistencies in menu adherence and a lack of dietician involvement. The facility was between dieticians, with nursing staff completing nutritional assessments in the absence of a registered dietician. The facility policy allowed for dietary orders to be delegated to a qualified dietitian under physician supervision, but this was not being followed.
The facility failed to ensure proper sanitization of dishware and appropriate food storage, affecting all residents. The dish machine's temperatures fluctuated and did not consistently meet required levels, and food items were found undated and improperly stored. Staff did not consistently follow infection control techniques, such as hand hygiene between tasks.
The facility administration failed to provide adequate oversight and staffing, affecting resident care. The RN-A, acting as both DON and administrator, was overwhelmed due to the lack of an ADON replacement. The facility also lacked a registered dietitian and had issues with infection prevention training, MDS assessments, and PASARR processes. The QAPI and QAA processes were informal, with acknowledged room for improvement.
The facility failed to submit accurate staffing data to CMS for Q4 2024, with discrepancies between reported and actual nursing coverage. The DON admitted to reporting lower numbers due to payroll system limitations, despite having 24-hour coverage on the dates in question.
The facility failed to implement an effective QAPI plan, lacking formal processes for identifying and addressing quality deficiencies. The QAA committee meetings were not attended by the medical director, and the DON also served as the administrator, impacting the program's effectiveness. Meeting minutes focused on resident activities but did not address critical issues like falls. Staff interviews revealed reliance on informal feedback without structured evaluation mechanisms. The facility owner acknowledged the need for improvement in the QAPI process.
The facility's QAPI committee failed to effectively implement action plans to correct quality deficiencies, including MDS assessment inaccuracies, unmet resident activity needs, lack of trauma-informed care, and food sanitation issues. Meeting minutes lacked documentation on performance indicators and tracking of adverse events. Staff interviews revealed informal processes for addressing deficiencies, and the facility's owner acknowledged the need for improvement in the QAPI process.
The QA committee at the facility did not have all required members attending quarterly meetings, as the medical director was absent. Additionally, the facility lacked a trained infection preventionist after the previous one retired, and no staff were enrolled in specialized training. The facility's owner recognized the need for improvement in QAPI processes.
The facility failed to maintain proper infection control during laundry services, affecting all 11 residents. The head of housekeeping and laundry services used the same gloves to handle soiled and clean laundry without wearing a gown, contrary to facility policy. The RN expected staff to change gloves and perform hand hygiene before handling clean laundry.
The facility failed to ensure the acting infection preventionist (IP), the DON, had completed specialized training in infection prevention and control. The DON confirmed the lack of training, and no other staff were enrolled in such training. This deficiency had the potential to affect all 11 residents in the facility.
The facility failed to accurately code the MDS for several residents, leading to deficiencies in care assessments. One resident's activity preferences were inaccurately reported, while another's PASARR status was incorrectly coded, resulting in a lack of necessary mental health services. Staff interviews revealed a lack of understanding of the PASARR process and the importance of accurate MDS assessments.
The facility failed to complete Level II PASARRs for four residents with mental illness diagnoses before admission, as required. The director of nursing and staff were unaware of the process, leading to incomplete assessments and unmet mental health care needs.
The facility failed to serve food according to a menu and did not review changes with a dietician, affecting five residents with specific dietary needs. A resident with diabetes was non-compliant with their diet, while another with cardiac issues was not on a therapeutic diet. Staff interviews revealed inconsistencies in dietary practices, with the head cook admitting the menu was not always followed. The facility was between dieticians, leading to a lack of professional oversight in dietary management.
A facility failed to complete a comprehensive assessment for a resident, R7, using the RAI process, omitting her PTSD diagnosis despite documented trauma history. The MDS and care plan lacked documentation of her trauma and PRN antipsychotic use. Staff interviews revealed a lack of adherence to RAI guidelines, impacting R7's trauma-informed care.
A facility failed to incorporate PASARR level II recommendations into a resident's care plan. The resident, with a history of schizophrenia and other conditions, reported hallucinations and delusions, but her care plan lacked documentation of recommended services. Staff interviews revealed a lack of understanding of the PASARR process, and the facility could not provide relevant policies when requested.
A facility failed to review and revise a resident's activities care plan with input from the resident or their representative. The resident, with mild cognitive impairment, had preferences for activities like word find puzzles and music, but these were not documented in the care plan. Staff interviews revealed a lack of understanding and training regarding the activities care plan, and the facility's policy to incorporate resident preferences was not followed.
A resident with a history of depression, alcohol dependence, and cancer was discharged from an LTC facility without a proper discharge plan, leading to uncertainty about whether their medical and mental health needs could be met at the new location. The facility failed to document the discharge process adequately, and the resident was taken to a facility that had closed, with no communication established with the receiving facility.
A resident with mild cognitive impairment and mental health diagnoses was not provided with individualized activities, despite preferences for arts and crafts and group settings. The facility's care plan lacked documentation of specific activity preferences, and staff did not solicit input from the resident. Observations showed a lack of consistent arts and crafts offerings, and interviews revealed gaps in assessing and documenting activity preferences.
A facility failed to properly monitor a resident's blood pressure before administering Midodrine, a medication with specific hold parameters. The resident, with a history of orthostatic hypotension, was given the medication without a prior blood pressure check, contrary to the prescribed order. Interviews revealed inconsistencies in monitoring practices, and the need for clarification on medication orders was acknowledged by the DON.
A facility failed to identify and document triggers for a resident with a history of trauma, leading to a lack of a comprehensive trauma-informed care plan. The resident's care plan focused on behavioral triggers unrelated to her trauma history, despite staff awareness of her past trauma. The facility's policy on trauma-informed care was not followed, resulting in inadequate documentation and integration of the resident's trauma history into her care plan.
A facility failed to ensure a PRN psychotropic medication order for a resident included an end date or documented clinical rationale. The resident, with diagnoses of depression and alcohol dependence, received frequent PRN olanzapine without an end date or rationale for extending beyond 14 days. Interviews with staff highlighted the importance of adhering to the 14-day limit for such medications. The nurse practitioner confirmed the absence of an end date and stated no request for a rationale was received, although they believed the dose was appropriate.
The facility failed to accurately post nurse staffing information, omitting actual hours worked by RNs and LPNs. Discrepancies were found between posted staffing data and actual hours worked, confirmed by the DON. This affected all residents or visitors reviewing the information.
The facility failed to provide individualized non-pharmacological interventions for two residents with mental health disorders, leading to self-harm and hospitalizations. One resident, with a history of anxiety and self-injurious behavior, repeatedly used hot towels to self-soothe, resulting in burns. The care plan lacked specific interventions, and staff did not consistently offer PRN medications or alternative coping strategies. Another resident with schizoaffective disorder also lacked individualized behavior interventions. The facility lacked a policy for mental health management, contributing to these deficiencies.
Facility Lacks Registered Dietician, Affecting Nutritional Services
Penalty
Summary
The facility failed to employ a registered dietician or other qualified clinical nutrition professional to carry out the functions of a facility registered dietician, potentially affecting all 11 residents receiving food from the kitchen. Interviews revealed that the head cook, C-B, noted inconsistencies in menu adherence, with eggs not being served daily as planned, and other cooks not following the menu, complicating food ordering and usage. C-B also mentioned a lack of involvement from the registered dietician, who they believed had quit. The facility administrator and director of nursing, RN-A, acknowledged the absence of a dietician, stating that the newly hired dietician was not as involved as the previous one and that they were in the process of contracting a new dietician. Further interviews indicated that the facility was between dieticians, as the previous dietician had retired or resigned, with the last day being 5/31/24. RN-A confirmed that nursing staff completed nutritional assessments in the absence of a registered dietician, and C-B made menu changes as needed. The facility policy allowed for dietary orders to be delegated to a qualified dietitian under physician supervision, but this was not being followed due to the lack of a dietician. The certified physician assistant, CPA-B, stated they were not involved in nutritional assessments or diet orders, highlighting the gap in professional oversight in the facility's food and nutrition services.
Deficiencies in Dishware Sanitization and Food Storage
Penalty
Summary
The facility failed to ensure proper sanitization of dishware and appropriate food storage, affecting all 11 residents. During an initial tour, the head cook was observed not performing hand hygiene after removing gloves and handling dishes. The dish machine's wash and rinse temperatures fluctuated and did not consistently meet the required temperatures for proper sanitization. Additionally, the dish machine had mechanical issues, such as a door that did not close completely and a side panel that was not secured. Food storage practices were also inadequate. Items in the kitchen refrigerator, such as orange juice and milk, were undated, and a cup of juice was uncovered and unlabeled. The kitchen freezer contained opened and unlabeled tater tots and fish. In the dry storage area, cereal bags were not properly secured. The downstairs storage area had unlabeled chicken and cauliflower with white flaky crusts, indicating spoilage. A head of lettuce in the refrigerator was discolored and should not have been used. Staff did not consistently follow infection control techniques. A resident's personal water bottle was placed in the dish machine, which did not reach the required wash temperature. Staff were observed not washing hands between handling dirty and clean dishes. The facility's policies required labeling of opened food items and proper hand hygiene, which were not adhered to, contributing to the deficiencies observed.
Inadequate Oversight and Staffing Issues in Facility Administration
Penalty
Summary
The administration of the facility failed to provide adequate oversight, training, and guidance for appropriate resident care, which affected various aspects of the facility's operations. The facility did not have a replacement for the assistant director of nursing (ADON) after their retirement, leaving the registered nurse (RN)-A, who also served as the director of nursing (DON) and administrator, overwhelmed with responsibilities. This lack of staffing support hindered RN-A's ability to effectively manage both nursing and administrative duties, including the training of new staff and the handling of new admissions. The facility also failed to employ a registered dietitian or qualified clinical nutrition professional, as the hired dietitian believed the role could be performed virtually, which was not feasible due to technology issues. Additionally, RN-A was acting as the infection preventionist without specialized training in infection prevention and control, a fact that the facility's owner was unaware of. The facility's policy required relevant staff to be trained in infection control, but this was not adequately implemented. Furthermore, the facility had issues with the Minimum Data Set (MDS) assessments, as RN-B, who was responsible for these assessments, was new to the role and received insufficient training from RN-A. The facility also had deficiencies in the Pre-Admission Screening and Resident Review (PASARR) process, as some residents were admitted without completed assessments. The Quality Assurance and Performance Improvement (QAPI) and Quality Assurance and Assessment (QAA) processes were not formalized, and the facility's owner acknowledged the need for improvement in communication and time allocation for RN-A's dual roles.
Inaccurate Staffing Data Submission to CMS
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) for the fourth quarter of 2024. The review of the facility's payroll-based journal (PBJ) staffing data report revealed that the facility did not have licensed nursing coverage 24 hours a day on multiple dates throughout the quarter. However, the facility's schedules indicated that there was indeed licensed nursing coverage for those dates, suggesting discrepancies between the reported data and the actual staffing levels. During an interview, the Director of Nursing (DON), who was also the administrator, acknowledged responsibility for submitting the PBJ data and admitted that the reported data were sometimes lower than actual staffing levels. This was attributed to the inability to report staff who had been discharged from the payroll system. The DON verified that there was licensed nursing coverage for the dates in question and stated that any inaccuracies in the reported data were unintentional. A policy regarding the reporting of PBJ data was requested but not provided.
Deficient QAPI Implementation and Oversight
Penalty
Summary
The facility failed to implement an effective Quality Assurance and Performance Improvement (QAPI) plan, which is essential for maintaining acceptable levels of performance and ensuring continual improvement in care and services. The facility's policy required a Quality Assessment and Assurance (QAA) committee to meet quarterly, consisting of key personnel such as the administrator, medical director, director of nursing (DON), program director, and consulting pharmacist. However, the medical director did not attend any of the QAA meetings, as evidenced by the absence of their signature on the meeting sign-in sheets. Additionally, the director of nursing was also serving as the administrator, which may have impacted the effectiveness of the QAPI program. The facility's QAA meetings lacked formal processes for identifying and addressing quality deficiencies, and there was no evidence of systematic data collection or analysis to identify high-risk or problem-prone areas. The facility's QAA meeting minutes revealed a focus on a quality improvement project aimed at enhancing resident activities and participation, but there was no mention of addressing falls or falls with injury, which are critical issues in long-term care settings. Interviews with staff indicated that the QAA process relied heavily on informal feedback and lacked structured mechanisms for evaluating health outcomes and resident safety. The facility owner acknowledged the need for improvement in the QAPI process and expressed reliance on the DON/administrator for updates on survey results and plans of correction. Overall, the facility's failure to implement a robust QAPI plan and ensure governing body oversight had the potential to affect all residents in the facility.
Ineffective QAPI Committee and Quality Deficiencies
Penalty
Summary
The facility failed to ensure the effectiveness of its Quality Assessment and Assurance (QAA) and Quality Assurance Process Improvement (QAPI) committee in implementing appropriate action plans to correct quality deficiencies identified in previous surveys. These deficiencies included inaccuracies in Minimum Data Set (MDS) assessments, activities not meeting the interests and needs of each resident, lack of trauma-informed care, food sanitation issues, and failure to implement a QAPI plan and maintain a QAPI committee with improvement projects. The report indicates that these deficiencies had the potential to affect all residents residing in the facility. The review of the Certification and Survey Provider Enhanced Reporting (CASPER) system report showed that the facility had several deficiencies with a survey exit date of 11/30/23, including repeat deficiencies from a previous survey dated 10/22. The QAPI meeting minutes from various dates in 2024 and 2025 lacked documentation on how the facility developed, monitored, and evaluated performance indicators for improvement activities. Additionally, the minutes did not document how the facility identified, reported, and tracked adverse events, high-risk, high-volume, and problem-prone concerns. Interviews with facility staff revealed that correcting quality deficiencies was not a formal process and was not always included in the meeting minutes. The facility's RN-A acknowledged that the QAA committee could improve in comparing itself to benchmarks and tracking improvement projects. The facility's owner confirmed the need for improvement in the QAPI process and relied on RN-A for updates about survey results and the facility's plan of correction. The facility's policy indicated that the QAA committee should meet quarterly to develop an ongoing quality assurance program and implement plans of action to correct identified quality deficiencies.
QA Committee Lacks Required Members and Infection Control Training
Penalty
Summary
The Quality Assurance (QA) committee at the facility failed to ensure that all required members attended the quarterly meetings, as mandated by the facility's Quality Assessment and Assurance (QAA) program policy. The policy specified that the committee should include the administrator, medical director, director of nursing (DON), program director, and consulting pharmacist. However, the review of the QA meeting sign-in sheets revealed that the medical director did not attend any of the meetings throughout the year. Additionally, the sign-in sheets showed that a registered nurse (RN)-A was identified as both the DON and administrator, indicating a potential overlap in roles. Further interviews and document reviews highlighted additional issues within the facility's QA processes. RN-A reported that the facility's infection preventionist had retired and that no staff member had completed or was enrolled in specialized training for infection prevention and control. Despite attempts to interview the medical director, no response was received. RN-A mentioned that the certified physician assistant (CPA)-B attended the meetings as a continuity person, and information from the meetings was relayed to the medical director's designee. The facility's owner acknowledged the need for improvement in the Quality Assurance and Performance Improvement (QAPI) processes.
Infection Control Deficiency in Laundry Services
Penalty
Summary
The facility failed to maintain proper infection control practices during laundry services, potentially affecting all 11 residents. During an observation, the head of housekeeping and laundry services, identified as HK-D, was seen wearing gloves but no gown while handling laundry detergent, Clorox Bleach, and soiled linens. HK-D placed linens and bed sheets from a bag on the floor into the washing machine and folded clean washcloths using the same gloves. HK-D stated that wearing a gown was unnecessary for loading dirty laundry. However, the facility's policy required gowns to be available and used while sorting linens to prevent cross-transmission and adhere to standard precautions. When interviewed, the RN who was also the administrator and director of nursing, expected staff to wear gloves when handling soiled laundry and to change gloves and perform hand hygiene before touching clean laundry. The RN acknowledged that staff should avoid contact between dirty laundry and their body or arms and suggested that staff could be more careful by wearing gowns when handling dirty laundry.
Inadequate Training for Acting Infection Preventionist
Penalty
Summary
The facility failed to ensure that the acting infection preventionist (IP) had completed specialized training in infection prevention and control, which is a requirement for the role. The Director of Nursing (DON), who was serving as the acting IP, confirmed during an interview that he had not completed any specialized training in infection prevention and control. Additionally, no other staff members were currently enrolled in or scheduled for any specialized infection control education. The facility's policy on infection prevention, revised in July 2024, outlines that relevant staff should be trained in infection control upon hire and periodically thereafter. However, the facility did not adhere to this policy, as evidenced by the lack of specialized training for the acting IP. This deficiency had the potential to affect all 11 residents residing in the facility, as the infection control program was not being overseen by a qualified individual.
Inaccurate MDS Coding and PASARR Process Deficiencies
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was accurately coded for several residents, leading to deficiencies in their care assessments. For one resident, the MDS inaccurately reported her activity preferences, despite her having mild cognitive impairment and being able to communicate her preferences. The registered nurse admitted to not interviewing the resident about her activity preferences and instead relied on staff interviews, which led to a gap in understanding and an incomplete care plan that did not address the resident's activity needs. Another resident's MDS was inaccurately coded regarding her Level II PASARR status. Despite having a history of mental illness and being referred for a Level II PASARR, the MDS indicated she was not considered to have a serious mental illness. The facility lacked documentation of the services recommended under the Level II PASARR evaluation, and the registered nurse admitted to not knowing what services should have been provided, indicating a lack of understanding of the PASARR process. Additional deficiencies were noted for other residents, including inaccurate coding of PASARR status and medication use. One resident's MDS did not reflect her use of antianxiety and anticonvulsant medications, and another resident's MDS failed to document her PRN use of antipsychotic medication. The facility also failed to complete required Level II PASARR assessments before admitting residents, leading to a lack of necessary mental health services. Interviews with facility staff revealed a lack of knowledge and understanding of the PASARR process and the importance of accurate MDS assessments for developing appropriate care plans.
Failure to Complete Level II PASARR Prior to Admission
Penalty
Summary
The facility failed to ensure that a Level II Pre-Admission Screening and Resident Review (PASARR) was completed prior to admission for four out of five residents who required it for mental illness. Resident 7 was admitted without a completed Level II PASARR, despite the Minnesota Senior Linkage Line indicating it was necessary. The Hennepin County supervisor confirmed that the assessment was not completed due to a lack of documentation from the facility. The registered nurse responsible for the Minimum Data Set (MDS) was unaware of the PASARR requirements and relied on the director of nursing, who also lacked understanding of the process. Resident 9 was admitted with a primary diagnosis of bipolar disorder, and the preadmission screening indicated a Level II assessment was required. However, the director of nursing admitted that the PASARR process fell through the cracks after a nurse who previously handled it retired. The medical record for Resident 9 lacked evidence of a completed Level II assessment, indicating a failure to meet the resident's mental health care needs. Resident 10 was admitted with diagnoses of bipolar disorder and post-traumatic stress disorder, and the preadmission screening required a Level II assessment. The director of nursing mistakenly believed the process was completed, but no Level II assessment was found. Resident 11 was admitted with similar mental health diagnoses, and the PASARR process was initiated only after admission. The director of nursing acknowledged the importance of completing PASARRs prior to admission to determine necessary services, but the facility did not have a policy in place to ensure compliance.
Facility Fails to Follow Menu and Review Dietary Changes with Dietician
Penalty
Summary
The facility failed to serve food according to a menu and did not review changes to the menu with a qualified dietician or other qualified nutrition professional. The facility also did not ensure that the menu met the nutritional needs of residents with specific dietary requirements, such as a cardiac diet. This deficiency affected five residents who were reviewed for dietary recommendations. The head cook admitted that the menu was not always followed, and there was confusion about the involvement of a registered dietician, as the previous dietician had left, and a new one had not yet been fully integrated. Resident 1 had mild cognitive impairment and several diagnoses, including diabetes mellitus and hyperlipidemia, and was on a no concentrated sweets diet. However, the resident's behavior sheet indicated non-compliance with the diet. Resident 2, with intact cognition and diagnoses including atrial fibrillation and hypertension, was supposed to be on a cardiac, consistent carbohydrate diet, but the MDS did not indicate a therapeutic diet. Resident 3, with intact cognition and diagnoses including orthostatic hypotension and hyperlipidemia, was on a regular diet with increased sodium. Resident 5, with intact cognition and diagnoses including diabetes mellitus, was also on a no concentrated sweets diet. Resident 10, admitted with intact cognition and at risk for malnutrition, was on a regular diet. Interviews with staff revealed inconsistencies in dietary practices. The head cook stated that other cooks did not follow the menu, making it difficult to manage food ordering and usage. The facility administrator acknowledged the lack of a dietician's involvement and stated that the facility was between dieticians. The registered nurse confirmed that residents were not following their prescribed diets, and the facility was not adhering to the menu. The facility's policy indicated that dietary orders could be delegated to a qualified dietician, but this was not being practiced due to the absence of a dietician.
Deficiency in Comprehensive Assessment and Trauma-Informed Care
Penalty
Summary
The facility failed to ensure a comprehensive assessment was completed and implemented using the Resident Assessment Instrument (RAI) process for a resident identified as R7. Upon admission, R7's Minimum Data Set (MDS) did not include a diagnosis of post-traumatic stress disorder (PTSD), despite her history of trauma being documented in other assessments. The Care Area Assessments (CAAs) for R7 identified her use of psychotropic medications and non-pharmacologic interventions but lacked documentation of her PRN use of olanzapine and her history of trauma. Additionally, the CAAs did not indicate if referrals to other disciplines were warranted. R7's care plan, while addressing her depression and behavioral management, did not document her history of trauma or the use of PRN antipsychotic medication. Interviews with facility staff revealed a lack of awareness and adherence to the RAI utilization guidelines, which are crucial for determining a resident's functional status and guiding further assessments. The registered nurse responsible for completing R7's MDS expressed hesitancy in reporting a PTSD diagnosis due to its absence in the primary or secondary diagnosis list, despite being aware of R7's trauma history. The facility's failure to accurately capture and document R7's trauma history and related triggers in her care plan and MDS assessments led to a deficiency in providing trauma-informed care. Interviews with the resident and staff highlighted the absence of discussions regarding R7's triggers and past trauma, which are essential for her psychosocial well-being. The facility's policies on comprehensive care planning and MDS or RAI were requested but not provided, indicating potential gaps in procedural adherence and staff training.
Failure to Incorporate PASARR Recommendations into Care Plan
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASARR) program by not incorporating recommendations from the PASARR level II determination into the care plan for one resident. The resident, who had a history of schizophrenia, alcohol dependence in remission, insomnia, history of cocaine abuse, and encephalopathy, was not considered by the state to have a serious mental illness or intellectual disability according to her Minimum Data Set (MDS). However, she reported hallucinations and delusions during the lookback period. The Care Area Assessments (CAAs) triggered several areas of concern, but lacked documentation on whether referrals to other disciplines were warranted. The resident's care plan and behavioral management care plan did not include documentation of services recommended under her level II PASARR evaluation. Interviews with facility staff revealed a lack of understanding and awareness regarding the PASARR process. A registered nurse (RN-B) admitted to inaccurately coding the MDS and being unaware of what a PASARR was. The director of nursing (RN-A) also expressed uncertainty about the services recommended under the level II PASARR and admitted to not having read the PASARR evaluation. The facility was unable to provide a PASARR policy or a policy pertaining to MDS accuracy when requested. This lack of coordination and documentation indicates a deficiency in the facility's compliance with PASARR requirements.
Failure to Review and Revise Activities Care Plan
Penalty
Summary
The facility failed to review and revise the activities care plan with input from a resident and/or their representative. The resident, who was reviewed for activities, had a Brief Interview for Mental Status (BIMS) score indicating mild cognitive impairment and was able to communicate effectively. Despite this, the Minimum Data Set (MDS) reported that the interview for daily and activity preferences was not conducted because the resident was rarely/never understood, and no family or significant other was available. The resident's Care Area Assessment (CAA) indicated a preference for certain activities, such as word find puzzles and listening to music, but these preferences were not documented in the care plan. The care plan, revised on a specific date, identified the resident's risk for not meeting emotional, intellectual, physical, and social needs due to cognitive deficits and other conditions. However, it lacked documentation of the resident's activity preferences. Interviews with staff revealed that the registered nurse responsible for the MDS assessments did not interview the resident about activity preferences and acknowledged a gap in understanding regarding the activities care plan. The facility's director of nursing and administrator confirmed that the training provided to the registered nurse on the MDS process could have been more robust. The facility's policy directed staff to incorporate resident preferences into activities, but a comprehensive care plan policy was not provided.
Inadequate Discharge Planning for Resident with Complex Needs
Penalty
Summary
The facility failed to adequately plan and evaluate the discharge needs of a resident, leading to a discharge to an unknown location without ensuring the resident's medical, mental health, and medication needs could be met. The resident, who had a history of major depressive disorder, alcohol dependence, and cancer, was discharged to a location where it was unclear if their needs could be accommodated. The facility did not have an active discharge plan in place, and the resident did not want a referral to a local contact agency. The resident's care plan did not include discharge planning and indicated the need for pain management, assistance with scheduling medical appointments, and follow-up with oncology staff. Despite these needs, the resident was discharged with all medications, and staff dropped them off at an address that was later found to be a closed facility. The facility's registered nurse and director of nursing stated that the discharge was self-directed by the resident, who did not provide details about the social worker or the discharge location. Interviews with facility staff revealed that the discharge process was not properly documented, and there was no discharge summary available for the resident. The facility's registered nurse acknowledged that the discharge happened faster than desired and without the usual procedures, such as filling out a discharge summary and ensuring communication with the receiving facility. The resident's psychiatric office and chemical counselor were not informed of the discharge, and the facility did not have a policy related to discharge available for review.
Failure to Provide Individualized Activities for Resident
Penalty
Summary
The facility failed to provide individualized activities for a resident with mild cognitive impairment and multiple mental health diagnoses, including anxiety, bipolar disorder, schizophrenia, and mild intellectual disabilities. The resident's Minimum Data Set (MDS) indicated a preference for participating in favorite activities and group settings, yet the Care Area Assessment (CAA) noted a lack of interest in activities other than word find puzzles. The resident's care plan aimed to maintain involvement in cognitive and social activities but lacked documentation of specific activity preferences. Observations and interviews revealed that the resident expressed a desire for more arts and crafts activities, which were not consistently offered according to the activities participation logs and calendars. The resident reported that staff did not solicit input on activity preferences and mentioned a lack of supplies for crafts due to budget constraints. Despite the presence of various games and books in the facility, the resident noted the absence of a craft bucket and expressed interest in both structured group activities and independent options. Interviews with facility staff, including the Health Unit Coordinator (HUC) and Registered Nurse (RN), highlighted gaps in assessing and documenting the resident's activity preferences. The HUC confirmed that the resident enjoyed word puzzles and bingo but had not recently updated the resident's activity preferences. The RN acknowledged a lack of an activities care plan focus and expressed uncertainty about the MDS process. The resident's medical doctor emphasized the importance of activities in managing the resident's mental health, noting that engaging in activities could distract from psychosis and improve mood.
Failure in Blood Pressure Monitoring and Medication Administration
Penalty
Summary
The facility failed to ensure appropriate blood pressure monitoring and medication administration for a resident diagnosed with orthostatic hypotension, hyperlipidemia, depression, and schizophrenia. The resident was prescribed Midodrine HCL with specific instructions to hold the medication if blood pressure was 110 mmHg or higher, and to administer it if the resident exhibited symptoms of hypotension. However, during a medication administration observation, the registered nurse (RN) did not check the resident's blood pressure before giving the medication, which was against the prescribed order. The RN admitted to normally checking the blood pressure before and after medication administration to assess effectiveness, but failed to do so on this occasion. Further interviews revealed inconsistencies in the facility's practice regarding blood pressure monitoring. The licensed practical nurse (LPN) and certified physician assistant (CPA) both indicated that blood pressure should be checked before administering medication with hold parameters. The consultant pharmacist had previously recommended clarifying the frequency of blood pressure checks due to the twice-daily administration of Midodrine, but there was no evidence of follow-up on this recommendation. The director of nursing acknowledged the need to clarify the medication order and confirmed that the resident's blood pressure had not reached 110 mmHg or above, indicating a lack of adherence to the prescribed monitoring protocol.
Failure to Implement Trauma-Informed Care Plan
Penalty
Summary
The facility failed to identify and document triggers to avoid potential re-traumatization and did not develop a comprehensive care plan with individualized trauma-informed approaches for a resident with a history of trauma. The resident, who had intact cognition and no hallucinations or delusions, was diagnosed with depression and alcohol dependence but did not have a PTSD diagnosis on her Minimum Data Set (MDS). Her Care Area Assessments (CAAs) for psychosocial well-being and mood state identified the use of psychotropic medications and non-pharmacologic interventions but lacked documentation of triggers or referrals to other disciplines. A comprehensive trauma-informed care assessment identified specific triggers such as loud male voices and yelling, but these were not included in the resident's care plan. Instead, the care plan focused on behavioral triggers related to sleep apnea, insomnia, and stress from medical appointments, without addressing the resident's history of trauma. Interviews with facility staff revealed that while the resident's trauma history was known, it was not adequately documented or integrated into her care plan. The facility's policy on trauma-informed care required assessments upon admission and collaboration with residents and their support systems to develop individualized interventions. However, the policy was not followed, as evidenced by the lack of documentation and integration of the resident's trauma history and triggers into her care plan. Interviews with staff indicated a misunderstanding of the policy requirements and a failure to capture necessary information in the MDS within the required timeframe.
Failure to Document End Date or Rationale for PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a PRN psychotropic medication order for a resident included an end date or a documented clinical rationale. The resident, who had intact cognition and no hallucinations or delusions, was diagnosed with depression and alcohol dependence. The resident's medication administration record showed frequent administration of PRN olanzapine without an end date or clinical rationale for extending the order beyond the 14-day limit. Interviews with the consultant pharmacist and certified physician assistant highlighted the importance of adhering to the 14-day limit for PRN psychotropic medications to ensure appropriate use and monitoring for adverse effects. The nurse practitioner responsible for the resident's psychotropic medication management confirmed the absence of an end date for the PRN olanzapine order and stated that no request for a clinical rationale to extend the order had been received. The nurse practitioner expressed a belief that the resident was on an appropriate dose of olanzapine and would have provided a clinical rationale if requested. The facility's failure to provide a policy on psychotropic drug use further contributed to the deficiency.
Inaccurate Nurse Staffing Information Posted
Penalty
Summary
The facility failed to ensure that the posted nurse staffing information accurately displayed the actual hours worked by licensed staff for each shift on a daily basis. This deficiency was identified through interviews and document reviews, which revealed discrepancies between the posted staffing information and the actual hours worked by registered nurses (RNs) and licensed practical nurses (LPNs). The weekly staffing posts for the periods from 1/1/25 to 1/28/25 included the facility's name, date, census, and total hours for RNs, LPNs, and trained medication assistants (TMAs), but lacked the actual worked hours for RNs and LPNs. Further investigation showed that the facility schedules for the periods from 1/1/25 to 1/31/25 indicated actual hours worked per shift that contradicted the total hours posted on the weekly staffing posts. During interviews, the director of nursing (DON), who was also the administrator, confirmed responsibility for the weekly staffing posts and acknowledged the discrepancies. Despite a request for a policy pertaining to staffing posts, no such policy was provided. This failure had the potential to affect all 11 residents or visitors who wished to review the staffing information.
Failure to Implement Individualized Behavioral Interventions
Penalty
Summary
The facility failed to develop and implement individualized non-pharmacological interventions to manage behaviors for two residents with mental health disorders. One resident, who had a history of anxiety and self-injurious behavior, was admitted with multiple mental health diagnoses, including borderline personality disorder and generalized anxiety disorder. Despite being cognitively intact and independent in mobility and activities of daily living, the resident experienced episodes of anxiety that led to self-harm using hot towels. The care plan lacked specific interventions to prevent such behaviors, and the facility did not consistently offer PRN medications or alternative coping strategies. The resident's care plan was not updated with individualized interventions to prevent self-harm, and there was no comprehensive assessment to determine triggers or behavior patterns. The facility's documentation revealed multiple instances where the resident attempted to use hot towels to self-soothe, resulting in burns and hospitalizations. Interviews with staff indicated a lack of awareness of non-pharmacological options and an over-reliance on PRN medications, which were not always offered proactively. The facility's administrator acknowledged the shortcomings in offering PRN medications and the lack of individualized care plans. Another resident with schizoaffective disorder also lacked individualized behavior interventions in their care plan. The facility did not have a policy or procedure related to mental health or behavioral management, which contributed to the deficiencies in care. Interviews with staff and family members highlighted the need for better management of anxiety and sleep disturbances, as well as the importance of offering PRN medications based on observed behaviors rather than waiting for resident requests.
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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