St Anthony Health & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in St Anthony, Minnesota.
- Location
- 3700 Foss Road Northeast, St Anthony, Minnesota 55421
- CMS Provider Number
- 245267
- Inspections on file
- 22
- Latest survey
- July 22, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at St Anthony Health & Rehabilitation during CMS and state inspections, most recent first.
A resident with severe cognitive impairment experienced two falls, after which interventions such as PRN medications, frequent rounding, and hospice review were implemented but not added to the care plan. Staff interviews confirmed reliance on the care plan for fall interventions and acknowledged that required updates were not made, contrary to facility policy.
The facility did not maintain effective QAPI oversight, resulting in repeat deficiencies related to quality of care, care planning, and self-administration of medications. Two residents did not receive medications according to physician orders, a resident with increased care needs lacked an updated care plan, and another resident was not properly assessed for self-administration of medications. QAPI meeting minutes lacked ongoing tracking of these issues, and the facility had not been monitoring compliance with previous surveys.
A resident with multiple chronic conditions and intact cognition was found with a nebulizer and medication at bedside without a completed self-administration of medications (SAM) assessment or order. Nursing staff confirmed the absence of required documentation and care plan updates, despite facility policy mandating interdisciplinary assessment and care plan inclusion before permitting self-administration.
A resident with terminal lung cancer and other chronic conditions experienced a significant decline, becoming dependent on staff for all personal care needs. Despite clear observations and staff acknowledgment of the resident's increased dependency, the care plan and Kardex were not updated to reflect these changes, contrary to facility policy requiring care plan revisions after a change in status.
A resident with cognitive and mobility impairments who was dependent on staff for ADLs did not receive necessary nail and grooming care. The resident was observed with long, irregular fingernails and unshaven facial hair, and reported not receiving an electric razor after requesting one. Staff interviews confirmed that nail care and grooming were not performed as required, despite facility policy mandating assistance for residents unable to complete these tasks.
Two residents received medications in a manner inconsistent with current physician orders and parameters, including incorrect dosages, frequencies, and lack of required monitoring such as blood pressure and MAP. Staff were unfamiliar with certain medication parameters, and discrepancies between signed orders and the MAR were not identified or addressed, resulting in administration errors.
A resident with significant mobility limitations and multiple diagnoses did not receive range of motion (ROM) exercises as needed. The care plan lacked specific ROM interventions, and no therapy referral was made after the family requested ROM therapy for stiffness. Staff interviews and facility policy confirmed that a referral and care plan update should have occurred, but these actions were not taken.
A consulting pharmacist did not identify or report irregularities in medication administration parameters for two residents. One resident received metoprolol without required blood pressure checks, and another received hydralazine and carvedilol without proper monitoring of mean arterial pressure (MAP) as ordered. The pharmacist's monthly reviews over six months failed to detect these issues, and staff interviews confirmed that MAP is not a standard parameter in this setting.
A facility failed to properly assess a resident's capacity to consent to sexual activity, leading to an inadequate investigation of an alleged sexual abuse incident. Despite the resident's severe cognitive impairment, the facility relied on verbal consent and the absence of distress, without a comprehensive assessment. The lack of a specific policy on capacity to consent contributed to the deficiency.
A facility failed to assess a resident's capacity to consent to sexual activity, leading to a deficiency. Two residents, one with severe cognitive impairment, were found being intimate. The resident's care plan acknowledged her impairment but noted consent to a relationship. A psychiatry assessment later found she lacked capacity to consent, but this was not done before the incident. The facility's decision to allow the relationship was based on verbal consent and lack of distress, without a thorough assessment.
The facility failed to notify the Ombudsman for LTC of hospital transfers for three residents, despite their significant medical conditions. The facility's policy only required notification for discharges, not transfers, and the social services director was unaware of the need to notify the Ombudsman for hospital transfers.
The facility failed to provide written bed hold notices for three residents hospitalized for various medical conditions, including a stroke, peripheral vascular disease, and cardiorespiratory issues. Despite the facility's policy requiring such notifications, records lacked evidence of compliance, as confirmed by interviews with staff.
A facility failed to ensure a resident received routine physician visits every 60 days, as required. The resident, with diagnoses including stroke and diabetes, only had documented visits on two occasions, resulting in a gap exceeding 60 days. The facility's policy mandates visits every 30 days for the first 90 days and every 60 days thereafter, with a 10-day grace period, but the resident's record lacked evidence of compliance.
The facility failed to offer the pneumococcal vaccine series to two residents as recommended by the CDC. One resident with a history of stroke and other conditions had received PPSV23 in 2014, but there was no evidence of a decision-making process for PCV20. Another resident with respiratory failure and kidney disease had received PCV13 and PPSV23 but lacked documentation for PCV20. The DON and IP confirmed the oversight, noting that immunizations should be reviewed during care conferences.
Failure to Update Care Plan with Fall Interventions
Penalty
Summary
The facility failed to update the care plan with specific interventions following two separate falls experienced by a resident with severe cognitive impairment and significant care needs. After falls on two consecutive days, documentation indicated that interventions such as PRN medications, frequent rounding, and hospice review for medication side effects were implemented. However, these interventions were not incorporated into the resident's care plan as required. The most recent care plan revision did not reflect these new interventions, despite documentation and policy indicating that such changes should be made and communicated to staff. Interviews with facility staff, including a nursing assistant, an LPN, and an RN, confirmed that the care plan was the primary source for fall interventions and that the management team was responsible for updating it. The RN acknowledged that the new interventions following the falls should have been added to the care plan but were not. The administrator also confirmed that staff were expected to refer to the care plan for fall interventions and that management was responsible for timely updates. The facility's Post Fall Assessment policy required care plan changes to be made and communicated as appropriate, which did not occur in this instance.
Failure to Sustain Ongoing Compliance with QAPI for Repeat Deficiencies
Penalty
Summary
The facility failed to ensure its Quality Assurance Assessment and Performance Improvement Plan (QAPI) committee effectively sustained ongoing compliance regarding previously cited deficiencies. Specifically, the facility was cited for repeat deficiencies in quality of care, development and implementation of comprehensive care plans, and self-administration of medications (SAM). These deficiencies were identified during the current survey and had also been cited in a previous survey. For quality of care, the facility did not follow current physician orders and parameters for two residents reviewed for medications. In the area of care planning, the facility did not develop or maintain a care plan to ensure appropriate care for a resident with increased care needs due to decline. Regarding SAM, the facility failed to complete a self-administration of medications assessment for a resident observed with medications at bedside. Review of QAPI meeting minutes over several months showed a lack of ongoing data and tracking related to these repeat citations. The administrator confirmed that the facility had not been monitoring previous compliance with surveys and only recently began to form a plan to address and maintain compliance. The facility's QAPI policy required the development, implementation, and evaluation of corrective actions or performance improvement activities, but this was not demonstrated in practice for the cited areas.
Failure to Assess and Document Self-Administration of Medications
Penalty
Summary
The facility failed to complete a self-administration of medications (SAM) assessment for a resident who was observed with medications at bedside. The resident had intact cognition and multiple diagnoses, including cancer, malnutrition, asthma, chronic obstructive pulmonary disease, and required oxygen therapy. The resident was prescribed antipsychotic, antianxiety, antidepressant, and narcotic pain medications, as well as nebulizer treatments and supplemental oxygen. Despite these needs, there was no documentation of a SAM order or assessment in the resident's medical record, medication administration record, or care plan. During observation, a nebulizer machine with a cup two-thirds full of solution and an empty medication vial were found in the resident's room, accessible to the resident. Nursing staff confirmed that the resident did not have a SAM order or assessment and that the nebulizer should not have been left for self-administration. Facility policy requires an interdisciplinary team assessment and care plan documentation before allowing self-administration of medications, which was not completed in this case.
Failure to Update Care Plan Following Resident Decline
Penalty
Summary
A deficiency occurred when the facility failed to update the care plan for a resident experiencing a significant decline in condition. The resident, who had diagnoses including terminal lung cancer, malnutrition, asthma, and chronic lung disease, was previously independent with activities of daily living (ADLs) such as bathing, toileting, and dressing, as documented in her care plan and bedside Kardex. However, observations over several days showed the resident was increasingly dependent, remaining in bed, unresponsive to verbal stimulation, and wearing the same clothing for multiple days. Staff interviews confirmed that the resident now required assistance with all personal cares, including bathing, toileting, and dressing, due to her declining condition. Despite these changes, the care plan and Kardex were not updated to reflect the resident's increased need for assistance. Nursing staff, including the registered nurse and CNA, acknowledged that the care instructions in the Kardex were outdated and did not match the resident's current needs. The nurse manager and DON both confirmed that the care plan had not been revised to address the resident's decline, even though facility policy required care plans to be reviewed and updated upon a change in status. The facility's own policy outlined a process for reviewing and revising care plans when a resident experiences a status change, including notification of the MDS coordinator, collaboration with the interdisciplinary team, and communication of updated interventions to all staff. However, this process was not followed in the case of this resident, resulting in a care plan that did not accurately reflect her current care needs.
Failure to Provide Nail and Grooming Care for Dependent Resident
Penalty
Summary
A resident with moderate cognitive impairment, impaired mobility, and a self-care deficit requiring assistance with all activities of daily living (ADLs) did not receive appropriate nail care. The resident was observed on multiple occasions to have long, irregular fingernails that extended past the fingertips, with dark matter occasionally visible under the nails. The resident expressed dissatisfaction with the length of his fingernails, stating they sometimes got caught on his sheets, and reported being unable to shave due to not having an appropriate razor. Despite having requested an electric razor weeks prior, the resident had not received one. The care plan indicated the resident was at risk for excessive bruising and bleeding due to the use of a blood thinner, and required assistance with all ADLs, including grooming and nail care. Interviews with staff confirmed that nail care should be completed on bath days or as needed, and that assistance with grooming was expected daily. Staff acknowledged that the resident's nail care had not been performed as required, and that documentation and follow-up were lacking when care was refused or not completed. Facility policy stated that necessary services for ADLs, including bathing and grooming, would be provided for residents unable to complete these tasks. The deficiency was identified through observation, resident and staff interviews, and review of care plans and facility policy.
Failure to Follow Physician Orders and Medication Parameters for Two Residents
Penalty
Summary
The facility failed to follow current physician orders and medication parameters for two residents reviewed for medications. For one resident with moderate cognitive impairment and diagnoses including gastroparesis, malnutrition, and fecal impaction, the most recent signed physician orders specified prochlorperazine as needed for nausea, polyethylene glycol once daily, and metoprolol tartrate with instructions to hold if systolic blood pressure was less than 100. However, the medication administration record (MAR) showed these medications were administered at different dosages and frequencies, and without the specified parameters. Additionally, there was no documentation of blood pressure readings for several months, despite the requirement to monitor before administering metoprolol. Another resident, who was cognitively intact and had diagnoses including neuromyelitis optica and diabetes, had signed physician orders for tacrolimus at specific dosages, hydralazine and carvedilol with instructions to hold if mean arterial pressure (MAP) was less than 65. The MAR reflected administration of tacrolimus at a different dosage and did not include documentation of MAP or pulse prior to administration of hydralazine and carvedilol. Staff interviews revealed confusion regarding the MAP parameter, with some staff indicating they would check heart rate instead, and others acknowledging unfamiliarity with MAP calculations. The facility did not routinely compare the most recent signed physician orders with the MAR, leading to discrepancies in medication administration. The facility's policy required new orders to be entered onto the MAR and verified with the attending physician if unclear, but this process was not consistently followed. The consultant pharmacist failed to identify discrepancies during monthly medication reviews, and the director of nursing confirmed that medication parameters were not always followed and that discrepancies between signed orders and administration were not recognized. The facility did not adhere to its own procedures for reviewing and reconciling physician orders, resulting in residents receiving medications in a manner inconsistent with current orders and parameters.
Failure to Provide Range of Motion Care After Family Request
Penalty
Summary
A resident with diagnoses including neuromyelitis optica, diabetes, and encephalopathy was dependent on staff for activities of daily living such as dressing, eating, and oral hygiene. The resident's care plan noted a need for assistance with ADLs due to impaired mobility and weakness, but did not include specific interventions for range of motion (ROM) exercises. Documentation showed that the resident had been discharged from physical and occupational therapy several months prior, and no new therapy referral was made despite a significant change in condition and a family request for ROM therapy due to stiffness. Interviews with staff confirmed that ROM exercises would be documented if performed and that therapy referrals should be made following a change in condition or family request. The nurse manager and DON both acknowledged that a therapy referral should have been initiated after the family's request, and that ROM interventions should have been included in the care plan or Kardex. Facility policy required assessment of ROM and referral to therapy as appropriate, but these steps were not followed, resulting in a failure to provide necessary ROM care for the resident.
Consulting Pharmacist Failed to Identify and Report Medication Parameter Irregularities
Penalty
Summary
The consulting pharmacist failed to identify and report irregularities related to physician-ordered medication parameters for two residents during monthly drug regimen reviews. For one resident with moderate cognitive impairment and diagnoses including gastroparesis, malnutrition, and fecal impaction, physician orders required metoprolol to be held if systolic blood pressure was less than 100. However, the medication administration record showed the medication was given without documentation of blood pressure checks, and the order on the MAR did not include the hold parameter. Over the previous six months, pharmacy reviews did not identify that the blood pressure parameter was not being followed. For another resident with neuromyelitis optica and diabetes, physician orders required hydralazine and carvedilol to be held if mean arterial pressure (MAP) was less than 65. The MAR showed hydralazine was administered with blood pressure recorded instead of MAP, and carvedilol was given without any vital signs documented. The consulting pharmacist did not identify that MAP parameters were not being followed or recommend reviewing the appropriateness of using MAP as a parameter in this setting. Interviews with facility staff and the medical director confirmed that MAP is not a standard parameter in nursing homes and that the pharmacist failed to recognize and report these discrepancies during monthly reviews.
Failure to Assess Resident's Capacity to Consent
Penalty
Summary
The facility failed to thoroughly investigate an allegation of sexual abuse involving two residents, R1 and R2, by not assessing R1's capacity to consent prior to the incident. On the evening of the incident, staff found R1 and R2 being sexually intimate in R1's room. Although the residents were monitored throughout the night and an investigation was initiated, the facility did not adequately assess R1's ability to consent to sexual activity, given her severe cognitive impairment as indicated by a Brief Interview for Mental Status (BIMS) score of 4. R1's medical records and care plan indicated she had severe cognitive impairment due to dementia, requiring assistance with daily activities and communication. Despite this, the facility's investigation report noted that both residents were seen by a psychologist who found them alert and oriented, capable of making decisions about physical/sexual contact. However, a subsequent psychiatry assessment determined that R1 lacked the capacity to consent to sexual expression, contradicting the facility's earlier findings. Interviews with staff and family members further highlighted R1's confusion and memory issues, reinforcing concerns about her ability to consent. The facility's decision-making process regarding R1's capacity to consent was inconsistent and lacked a comprehensive assessment. The administrator and director of social services relied on R1's verbal consent and the absence of distress as indicators of her capacity, despite evidence of her cognitive limitations. The facility did not have a specific policy on assessing residents' capacity to consent, which contributed to the inadequate investigation and response to the incident.
Failure to Assess Capacity to Consent in Residents with Cognitive Impairment
Penalty
Summary
The facility failed to comprehensively assess a resident's capacity to consent to sexual activity, leading to a deficiency. The incident involved two residents, one with severe cognitive impairment and the other with mild cognitive impairment, who were found being sexually intimate. The facility's report to the State Agency indicated that the residents were monitored, and an investigation was initiated. However, the resident with severe cognitive impairment, identified as having a BIMS score of 4, was not appropriately assessed for capacity to consent prior to the incident. The resident's care plan acknowledged her severe cognitive impairment and directed staff to assist in removing her from dangerous situations and to communicate with her family regarding her capabilities. Despite this, the care plan also noted that the resident consented to a relationship with the other resident. A psychiatry assessment later identified that the resident lacked the capacity to consent to sexual expression, but this assessment was not conducted prior to the incident. Interviews with staff and family members revealed that the resident often exhibited confusion and memory issues, further questioning her ability to consent. The facility's administrator and social services director conducted interviews and held a care conference, ultimately deciding that the residents could maintain a relationship. However, the decision was based on the resident's verbal consent and lack of distress, rather than a thorough assessment of her cognitive capacity. The facility lacked a specific policy on assessing capacity to consent, and the deficiency was identified due to the absence of a comprehensive assessment prior to the incident.
Failure to Notify Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to notify the Ombudsman for Long Term Care (LTC) of resident transfers to the hospital for three residents reviewed for hospitalization. Resident 3, who had a significant change in their Minimum Data Set (MDS) indicating diagnoses such as cerebrovascular accident, diabetes, anemia, malnutrition, and epilepsy, was hospitalized from April 28 to May 17, 2024. However, there was no evidence in Resident 3's record that the Ombudsman for LTC was notified of this transfer. Similarly, Resident 4, with diagnoses including peripheral vascular disease, MRSA infection, and pressure ulcers, was hospitalized from March 28 to April 2, 2024, without notification to the Ombudsman. The document faxed to the Ombudsman for March 2024 also lacked this information. Resident 5, with multiple diagnoses including cardiorespiratory conditions, atrial fibrillation, cirrhosis, and respiratory failure, was hospitalized on an unspecified date, and the progress notes did not indicate notification to the Ombudsman. Additionally, Resident 5 was discharged from the facility on May 8, 2024, but the Ombudsman was not notified of this discharge either. The facility's policy on transfers and discharges, last reviewed in October 2023, only mentioned notifying the Ombudsman of discharges, not hospital transfers. During an interview, the social services director admitted to being unaware of the requirement to notify the Ombudsman of hospital transfers.
Failure to Provide Bed Hold Notices for Hospitalized Residents
Penalty
Summary
The facility failed to provide written notice of a bed hold upon transfer for hospitalization for three residents. Resident 3, who had a history of cerebrovascular accident, diabetes, anemia, malnutrition, and epilepsy, was transferred to the emergency department for a gastrostomy tube replacement and subsequently admitted to a hospital. Despite the hospitalization from April 28 to May 17, there was no evidence of a written bed hold notice in Resident 3's records. Similarly, Resident 4, with diagnoses including peripheral vascular disease and MRSA infection, was hospitalized from March 28 to April 2, but their records also lacked a written bed hold notice. Resident 5, who had multiple diagnoses including cardiorespiratory conditions and atrial fibrillation, was hospitalized, yet there was no documentation of a bed hold policy notification to the resident or responsible party. Interviews with facility staff, including the Executive Director, Social Services Director, and Director of Nursing, confirmed the absence of bed hold notifications in the residents' records. The facility's policy required that bed hold and readmission policies be provided before transferring a resident to a hospital or for therapeutic leave, with emergency transfers requiring notification within 24 hours. However, the records for Residents 3, 4, and 5 did not contain the necessary documentation, indicating a failure to adhere to the facility's policy.
Failure to Ensure Routine Physician Visits
Penalty
Summary
The facility failed to ensure that a long-term resident received routine physician visits every 60 days, as required. The resident, who had a significant change Minimum Data Set indicating diagnoses of cerebrovascular accident, diabetes, anemia, malnutrition, and epilepsy, only had documented physician visits on two occasions: 2/5/24 and 5/22/24. This resulted in a gap of more than 60 days between visits, with no evidence of a visit occurring within the required timeframe. The facility's policy mandates that physician visits occur every 30 days for the first 90 days after admission and every 60 days thereafter, with a 10-day grace period. However, the resident's clinical record lacked evidence of compliance with this policy, as confirmed by the Director of Nursing and the Infection Preventionist.
Failure to Offer Pneumococcal Vaccination
Penalty
Summary
The facility failed to ensure that two residents, identified as R3 and R9, were offered and/or provided the pneumococcal vaccine series as recommended by the CDC. R3, who had a history of cerebrovascular accident, diabetes, anemia, malnutrition, and epilepsy, had received the PPSV23 vaccine in 2014. However, there was no evidence in R3's records of shared clinical decision-making with a physician regarding the administration of the PCV20 vaccine, which should have been considered at least five years after the last pneumococcal dose. Similarly, R9, with diagnoses including acute and chronic respiratory failure and chronic kidney disease, had received PCV13 in 2016 and PPSV23 in 2018. R9's records also lacked evidence of shared clinical decision-making for the PCV20 vaccine. The director of nursing and the infection preventionist confirmed that the records for both R3 and R9 did not show that they were offered, declined, or received the PCV20 vaccine. The infection preventionist noted that immunizations should have been reviewed during care conferences to determine eligibility and offer the PCV20 vaccine, which is important for fighting pneumonia and reducing infection effects. The facility's policy, reviewed in October 2023, stated that immunizations should be provided in accordance with CDC guidelines, indicating a failure to adhere to these guidelines in the cases of R3 and R9.
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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