St Anthony Park Home Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Paul, Minnesota.
- Location
- 2237 Commonwealth Avenue, Saint Paul, Minnesota 55108
- CMS Provider Number
- 245063
- Inspections on file
- 21
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at St Anthony Park Home Inc during CMS and state inspections, most recent first.
Surveyors found that during a COVID-19 outbreak, staff did not consistently follow source-control requirements despite posted signs stating masks were required. An LPN, a laundry assistant, and multiple NAs were observed either not wearing masks or wearing them under their chins while in resident rooms, common areas with residents, and at the nurse’s station near other staff. Some staff stated they were unsure about mask requirements or avoided masks due to discomfort, even though they acknowledged that masks were supposed to cover the nose and mouth when around residents. The IP confirmed that all staff were required to wear masks in resident care areas and at the nurse’s desk, and facility policy referenced signage and PPE use during an outbreak.
The facility did not ensure that the low-temperature commercial dishwasher was monitored for sanitizer concentration every shift, as only the morning shift checked and documented the PPM using Hydrion strips. The policy lacked clear frequency requirements, and evening staff did not perform or record checks, resulting in inconsistent verification of dishware sanitization for all individuals consuming food from the kitchen.
Staff failed to follow infection control protocols, including proper hand hygiene and glove use during personal care for a resident with multiple health conditions, and used a damaged blood glucose machine that could not be adequately disinfected. Additionally, a Norovirus outbreak affecting multiple residents was not reported to the state agency as required by law.
The facility did not implement an effective antibiotic stewardship program, failing to track or review the appropriateness of prophylactic antibiotic use for all residents. A resident remained on cephalexin for UTI prophylaxis without documented review for continued need, and staff interviews confirmed that neither the infection preventionist nor the consulting pharmacist were monitoring the duration or necessity of prophylactic antibiotics as required by facility policy.
Staff entered a resident's shared room without knocking or announcing themselves, causing the resident to feel vulnerable, despite facility policy requiring respect for private space. Additionally, all residents were served meals on hard plastic trays in the dining room without being offered a choice or having their preferences assessed, and no individualized care plans reflected dining preferences. Facility leadership confirmed that resident input on meal service was not sought or documented.
The facility did not obtain or document informed consent, including discussion of risks and benefits, before administering psychotropic medications to four residents with varying cognitive and medical conditions. Medical records lacked signed consent forms and evidence of education or notification to residents or their representatives. Nursing staff interviews revealed uncertainty about who was responsible for obtaining consent, and no policy on residents' rights regarding medications was provided.
A resident assessed as unable to self-administer medications was routinely left to take her levothyroxine unsupervised, without a physician's order for self-administration. Nursing staff did not observe the resident taking the medication and relied on the medication's absence from the cup as evidence of administration, contrary to facility policy and assessment findings.
A resident with memory impairment and behavioral symptoms was administered PRN psychotropic medications without consistent documentation of symptoms or evidence that non-pharmacological interventions were attempted first. Staff interviews confirmed that such interventions and documentation are required, but records showed multiple instances where medications were given without these steps being followed.
A resident with memory impairment and end-stage illness did not have a comprehensive, accessible hospice care plan in place. The facility's care plan was generic and referred staff to a hospice binder, which lacked specific details about hospice services. Staff interviews revealed that the hospice care plan was kept in the hospice agency's electronic system and was not available to facility staff, resulting in a lack of clear guidance for the resident's care.
The facility did not adequately coordinate with a hospice agency to ensure consistent care and comfort for a resident at the end of life, as care plans and visit schedules were incomplete and communication was lacking. Additionally, another resident on anticoagulant therapy with visible bruising was not properly assessed or monitored, with insufficient documentation and follow-up on skin concerns.
A resident with cognitive impairment and multiple comorbidities developed a sacral pressure ulcer, but staff did not perform a comprehensive reassessment or update interventions to promote healing. Care continued as before, with inconsistent wound care and no documented review of nutrition or additional preventive measures. Staff interviews confirmed a lack of interdisciplinary evaluation and documentation, despite facility policy requiring reassessment after changes in condition.
A resident with severe cognitive impairment and functional limitations in all extremities was not assessed for, nor provided with, a nursing functional maintenance program to maintain or improve range of motion. The care plan and medical records lacked documentation of the resident's ROM status or interventions, and staff interviews confirmed that no ROM activities were being performed or directed, despite facility policy requiring such care.
A resident with severe cognitive impairment and chronic pain did not receive ongoing pain assessments or timely interventions despite frequent non-verbal signs of pain. Staff failed to document regular pain assessments, and agency staff were unfamiliar with the resident's pain behaviors. The facility lacked a process to ensure regular pain assessment for nonverbal residents on scheduled pain medications, resulting in a deficiency.
A resident with multiple medical conditions and impaired cognition was provided with grab bars on their bed without comprehensive assessment or documentation of alternatives attempted prior to installation. Staff interviews and document reviews revealed missing information regarding risk/benefit discussions and family notification, and evaluation forms lacked details on alternatives considered or tried before grab bar use.
A resident with intact cognition was repeatedly denied their preference for fried eggs with runny yolks, despite the facility having pasteurized eggs available and other residents being served such eggs. Staff interviews revealed confusion and lack of a clear policy, and the resident's care plan did not document any reason for the restriction. The facility failed to accommodate the resident's meal choice, impacting their quality of life.
The facility did not make the most recent recertification survey and complaint investigation results, including those with immediate jeopardy findings, readily available for residents, staff, or visitors to review. A resident was unaware of where to find these results, and the administrator confirmed the required documents were missing from the designated binder, contrary to facility policy.
The facility did not maintain a surety bond sufficient to cover the total amount of resident personal funds held, as the bond was set at $50,000 while the total resident fund balance exceeded $91,000. Two residents accounted for a significant portion of the funds, and the facility's policy did not address surety bond requirements.
A resident with severe cognitive impairment and at risk for elopement was found outside the facility due to a malfunctioning WanderGuard system. Staff failed to check the device's functionality and did not adhere to the required monitoring protocols, leading to the resident's unsupervised departure.
A high-temperature commercial dishwasher in an LTC facility failed to reach the required sanitization temperature of 180°F, as observed during a kitchen tour. Dietary staff were unable to read the temperature gauges due to a hard white film, leading to inaccurate temperature logs. The dietary manager confirmed the dishwasher's failure to reach the necessary temperature, posing a risk for foodborne illnesses. The facility's policy required staff to check the gauges for proper sanitization, which was not followed.
The facility failed to provide dignified care by not responding promptly to a resident's call light, not knocking before entering residents' rooms, and not ensuring a dignified dining experience. A resident with hemiplegia waited over 30 minutes for assistance after activating a call light. Staff entered rooms without knocking, affecting residents with impaired cognition. Additionally, residents dependent on staff for eating were left waiting with meals on trays before receiving assistance.
A resident with Alzheimer's and depression was not provided a Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) after Medicare A coverage ended. The facility's occupational therapist confirmed the coverage ended and attempted to inform the resident's POA, who declined to sign the Notice of Medicare Non-Coverage (NOMNC). The facility's policy required issuing a non-coverage notice and SNF ABN, but this was not followed.
A resident with severe cognitive impairment and multiple medical conditions reported missing dresses, but the grievance was not documented in the facility's log. Interviews revealed that the typical process for addressing such issues was not followed, and the administrator was unaware of the report. The facility's policy requires immediate reporting of misappropriation of property, which was not adhered to in this instance.
A resident with severely impaired cognition and at risk for pressure ulcers was not repositioned or checked for incontinence as per their care plan, which required these actions every 2-3 hours. Observations showed the resident remained in a wheelchair for over five hours without repositioning. Nursing staff cited being short-staffed as a reason for not following the care plan, despite facility policies requiring adherence to individualized schedules for pressure injury prevention.
The facility failed to assess and implement interventions for a resident with wandering behaviors and did not update fall prevention strategies for another resident at high risk for falls. Despite incidents indicating potential elopement and falls, the care plans were not updated, and staff were unaware of necessary interventions, leading to deficiencies in resident safety.
A facility failed to provide trauma-informed care for a resident with PTSD, bipolar disorder, and anxiety. The care plan lacked specific interventions and objectives to address her PTSD and potential triggers. Staff interviews revealed a lack of awareness about the resident's PTSD and triggers, despite the facility's policy emphasizing individualized care plans for trauma survivors.
A facility failed to act on a pharmacist's recommendation for a GDR of a resident's antipsychotic medication. The resident, who was cognitively intact and required assistance with daily activities, had been on quetiapine since March 2022. Despite recommendations in April and July 2024, no action was taken. Interviews revealed that a change in providers and pending psychosocial reviews contributed to the inaction.
A facility failed to document non-pharmacological interventions before administering PRN narcotic medication to a resident with post-surgical pain. Despite a care plan including ice and rest, the resident's records showed multiple instances of narcotic use without attempts at non-drug interventions. Staff interviews confirmed a lack of implementation and documentation of these interventions.
A resident with dementia and severely impaired cognition was prescribed quetiapine for agitation without documented signs of psychosis or behavioral symptoms. Despite the care plan suggesting non-pharmacological interventions, staff observed no behaviors justifying the antipsychotic use. Interviews with staff and a review of records confirmed the absence of behaviors that would present a danger, questioning the appropriateness of the diagnosis used to justify the medication.
A resident admitted to a care center reported losing their dentures prior to admission, but the facility failed to assess or offer a dental appointment to address this need. Despite the resident's expressed desire for new dentures, the admission assessment and subsequent care plan did not result in any action to coordinate dental care. Interviews with staff revealed a lack of communication and follow-up, leading to a deficiency in managing the resident's oral hygiene.
A facility failed to provide timely pneumococcal vaccinations to a resident, as per CDC guidelines. The resident, with a history of Alzheimer's and other conditions, consented to the vaccine, but records were not updated to reflect this. The ADON acknowledged the oversight, and the DON stated that the issue would have been caught in the next audit. This deficiency could impact all 80 residents.
A resident with severe cognitive impairment and dependency on staff for all ADLs had a bruise on the chest that was not reported to the state agency in a timely manner. The bruise was discovered by the resident's son and reported to facility staff, but it was not documented or monitored properly. Interviews revealed that the bruise was not entered into the risk management section of the EMR, and the provider was not notified. The facility's policy required such incidents to be reported and investigated, which was not done.
The facility failed to provide adequate personal and incontinence care for two residents. One resident, with moderate cognitive impairment, had long and soiled fingernails due to a lack of routine nail care. Another resident, with severe cognitive impairment, was not repositioned or checked for incontinence for over five hours, contrary to care plan requirements. Staff cited being short-staffed as a reason for the lapse in care, and recent changes in documentation may have contributed to the oversight.
Failure to Enforce Mask Use During COVID-19 Outbreak
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to improper use of personal protective equipment (PPE), specifically masks, during a COVID-19 outbreak. CDC guidance dated 6/24/2024 recommended source control, including use of respirators or well-fitting masks, for individuals residing or working on a unit experiencing COVID-19 or other respiratory infection outbreaks. Signs posted at the front door and in the elevator instructed that masks were required for staff. Despite this, multiple staff members were observed either not wearing masks at all or wearing them improperly (under the chin) while in resident care areas, common areas with residents, and at the nurse’s desk in close proximity to others. On several occasions during the survey day, an LPN, laundry assistant, and multiple NAs were observed without masks or with masks worn under their chins while around residents or other staff. One LPN stated he did not know if he should be wearing a mask. The laundry assistant, who reported delivering laundry to all resident rooms, stated she was not wearing a mask because it made her face break out, and later acknowledged she had been informed she needed to wear a mask whenever around residents. Other staff members acknowledged that masks were required and should cover the nose and mouth when around residents or other people, yet were observed not following this requirement. The infection preventionist stated that all staff were required to wear masks in resident care areas and at the nurse’s desk, and the facility’s undated COVID-19 policy indicated signage would be posted regarding an outbreak, PPE, and source control.
Inadequate Monitoring of Dishwasher Sanitizer Levels
Penalty
Summary
The facility failed to ensure that the low-temperature sanitization commercial dishwasher in the main production kitchen was adequately monitored for effective chemical concentration and dishware sanitization. Observations revealed that the dishwasher, which uses sodium hypochlorite as a sanitizer, was only checked once daily for proper sanitizer concentration using Hydrion strips, rather than every shift as required. Documentation showed that only a single reading per day was recorded, and consistent PPM (parts per million) checks were only documented starting from 5/21, with no additional readings for other shifts. Dietary staff confirmed that only the morning shift performed the check, and evening staff did not conduct or document any PPM checks. Interviews with dietary aides and the dietary manager confirmed that the practice was to check the machine only once per day, and the facility's policy did not specify the frequency for PPM testing. The policy required dish machines to be checked prior to meals for proper functioning and appropriate temperatures, but lacked clear direction on how often to test sanitizer concentration. This deficiency had the potential to affect all residents, staff, and visitors consuming food from the kitchen, as effective sanitization of dishware was not consistently verified.
Infection Control Failures and Unreported Norovirus Outbreak
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices in several key areas. During personal care for a resident with multiple comorbidities and impaired mobility, a nursing assistant was observed removing soiled incontinence products and then applying clean items without changing gloves or performing hand hygiene between tasks. The assistant exited the room to retrieve a clean gown, again without hand hygiene, and only washed hands after completing all care and removing gloves. The facility's own policy required hand hygiene after glove removal, before and after direct resident contact, and when moving from contaminated to clean body sites, but these steps were not followed. Additionally, a blood glucose monitoring device used for multiple residents was found to be in poor repair, with a crack in the plastic housing, white buildup, and a missing battery cover replaced with tape. The nurse using the device was unsure how long it had been damaged, and the unit manager questioned whether it could still be properly disinfected. The device was not immediately removed from service, despite the facility's policy and manufacturer instructions requiring equipment to be cleanable and disinfected after each use. The facility also failed to report a suspected Norovirus outbreak to the state agency as required by Minnesota law. Over a period of several weeks, 14 residents exhibited symptoms consistent with Norovirus, and isolation precautions were implemented. However, the infection preventionist did not report the outbreak, stating she was unaware of the reporting requirement. The director of nursing later confirmed that the outbreak should have been reported, in accordance with facility policy and state regulations.
Failure to Monitor and Review Prophylactic Antibiotic Use
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program, specifically lacking protocols and a system to monitor the appropriateness of antibiotic use, including prophylactic antibiotics. Document review and staff interviews revealed that the facility was not tracking or reviewing the ongoing use of prophylactic antibiotics for any residents, and this deficiency had the potential to affect all 72 residents. The Antibiotic Surveillance and Symptom Tracker report did not include prophylactic antibiotic tracking, and the infection preventionist confirmed that she was not monitoring or able to identify residents on prophylactic antibiotics. The consulting pharmacist reviewed antibiotics for appropriate dosing but did not assess the duration of use, leaving this responsibility to the provider, while the infection preventionist relied on pharmacy review without understanding the process. For one resident reviewed for oral antibiotic use, the medical record showed an ongoing order for cephalexin for UTI prophylaxis without documentation of review for continued appropriateness. The resident reported being started on cephalexin by a urologist after multiple UTIs but was unclear on the intended duration. The assistant director of nursing and the nurse practitioner both confirmed that the continued use of the antibiotic had not been reviewed since admission, with the nurse practitioner stating she would not review the medication until the resident transitioned to long-term care. Facility policy required monthly chart reviews and pharmacy oversight for antibiotic use, but these processes were not being followed for prophylactic antibiotics.
Failure to Ensure Dignified Room Entry and Dining Experience
Penalty
Summary
Staff failed to honor a resident's right to a dignified existence and self-determination by not knocking or announcing themselves before entering a resident's shared room. On multiple occasions, a nursing assistant entered the room without knocking, and the resident confirmed not hearing a knock and expressed feeling vulnerable as a result. Interviews with other staff, including a registered nurse and the assistant director of nursing, confirmed that the expectation was for staff to knock and announce themselves before entering, in accordance with the facility's policy on dignity, which requires staff to respect residents' private space and request permission before entry. Additionally, the facility did not provide a dignified dining experience for residents. Observations revealed that meals were consistently served to all residents in the dining rooms on hard plastic trays, with food, drinks, and utensils left on the trays rather than being placed on the tables. Staff reported that this was the standard practice, and no efforts were made to remove items from the trays or offer residents a choice in how their meals were served. Some staff believed serving on trays was more dignified, but could not explain why, and dietary management acknowledged that while some residents preferred trays, others did not, yet no individualized assessments or care plan updates were made to reflect resident preferences. Interviews with dietary management and facility leadership confirmed that resident preferences regarding meal service had not been assessed or discussed in resident council meetings, and no documentation existed of such discussions. The facility lacked a policy on dignified dining and had not updated care plans to reflect individual preferences for meal service, despite recognizing the importance of a home-like, dignified dining experience for residents.
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain and document informed consent, including an explanation of risks and benefits, for the use of psychotropic medications for four residents. For each resident, medical records showed administration of psychotropic medications such as lorazepam, haloperidol, quetiapine, duloxetine, citalopram, and sertraline, but lacked evidence of signed consent forms or documentation that the risks, benefits, and alternatives were discussed with the resident or their representative prior to starting the medications. In several cases, there was also no documentation of education provided regarding the medications. Residents affected included individuals with varying degrees of cognitive impairment and complex medical histories, such as memory impairment, hallucinations, depression, dementia, and other chronic conditions. Some residents were on hospice care or had significant behavioral symptoms, while others were cognitively intact but still did not have documented consent for psychotropic medication use. Medication administration records confirmed that these medications were given as ordered, and progress notes did not reflect any discussion or education about the medications. Interviews with nursing staff, including LPNs, RNs, the ADON, and the DON, revealed a lack of clarity regarding responsibility for obtaining consent and providing education about psychotropic medications. Staff indicated that direct care nurses rarely, if ever, obtained consent or discussed risks and benefits, and there was no consistent process in place. The facility was unable to provide a policy on residents' rights regarding medications when requested.
Failure to Safely Administer Medication to Non-Authorized Resident
Penalty
Summary
A resident with diagnoses including Alzheimer's disease, hypertension, anemia, and arthritis was assessed as cognitively intact and independent in activities of daily living, but had a care plan indicating impaired cognition and a Self Administration of Medications Assessment (SAM) stating she was not able to self-administer medications. Despite this, nursing staff routinely left levothyroxine at the resident's bedside for her to take on her own, without direct supervision and without a physician's order for self-administration. The resident reported that she sometimes dropped the medication on the floor and did not always inform staff, and staff confirmed they did not observe her taking the medication but assumed it was taken if it was no longer in the cup. The facility's policy required an interdisciplinary team assessment and a physician's order for self-administration of medications, neither of which were in place for this resident. Interviews with nursing staff and the DON confirmed that the expectation was for nurses to administer medications as ordered and not to leave medications at the bedside unless there was an order for self-administration. The failure to follow these procedures resulted in the resident self-administering medication despite being assessed as unable to do so safely.
Failure to Document Non-Pharmacological Interventions Prior to PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that symptoms of potential psychiatric distress were consistently recorded and that non-pharmacological interventions were attempted and documented prior to the administration of as-needed (PRN) psychotropic medications for a resident. The resident in question had both long-term and short-term memory impairment, experienced hallucinations, and exhibited behaviors such as yelling, cursing, accusations, and physical aggression. The care plan for this resident included multiple non-pharmacological interventions, such as redirection and providing a calm environment, and directed staff to monitor and record occurrences of target behaviors and interventions. Despite these directives, documentation revealed multiple instances where PRN psychotropic medications, including haloperidol and lorazepam, were administered without clear evidence that non-pharmacological interventions were attempted first. For example, on one occasion, haloperidol was given for agitation and yelling, but the record did not indicate what, if any, non-pharmacological measures were tried beforehand. On another occasion, lorazepam and Dilaudid were administered at nearly the same time, but the documentation lacked details on the symptoms presented, the rationale for giving both medications, and any non-pharmacological interventions attempted prior to medication administration. Interviews with staff confirmed that non-pharmacological interventions should be attempted and documented before administering PRN psychotropic medications, and that symptoms and interventions should be clearly recorded. The assistant director of nursing acknowledged the lack of consistent documentation regarding symptoms and non-pharmacological interventions in the resident's medical record, confirming that this was an area needing improvement.
Lack of Comprehensive Hospice Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident receiving hospice services. The resident, who had both long-term and short-term memory impairment, exhibited hallucinations and rejection of care behaviors, and was identified as being at the end stage of life and receiving hospice or palliative care. The care plan in place was generic, listing interventions such as calling hospice for new physician orders and coordinating with hospice, but lacked specific details regarding the frequency and nature of hospice services to be provided. References in the care plan directed staff to a hospice binder at the nursing station for further information, but this binder only contained general documents such as a POLST, emergency contact information, and summary notes from hospice staff visits, without a detailed or individualized hospice care plan. Interviews with facility staff and hospice personnel revealed that the hospice care plan was maintained in the hospice agency's electronic record system, which was not accessible to facility staff, and a printed copy was not available in the resident's binder. Staff were unclear about the specifics of hospice services being provided, with one LPN unable to recall seeing a hospice aide or a care plan in the binder, and the hospice nurse confirming that the care plan was not shared with the facility. The assistant director of nursing verified that the facility's care plan was generic and that the hospice care plan was not provided prior to the survey, resulting in a lack of a comprehensive, accessible care plan to promote continuity of care for the resident.
Failure to Coordinate Hospice Care and Monitor Bruising in Residents
Penalty
Summary
The facility failed to coordinate care with an outside hospice agency for a resident receiving end-of-life services. The resident had significant cognitive impairment, including memory loss, hallucinations, and rejection of care behaviors, and was identified as being at the end stage of life. The care plan indicated the use of hospice services but lacked specific details about the frequency and nature of hospice visits and interventions. The hospice binder at the nursing station contained incomplete and outdated information, including missing calendars for upcoming visits and insufficient documentation of the services provided. Staff interviews revealed uncertainty about when hospice staff would visit, lack of communication regarding medication renewals, and an absence of a readily available hospice care plan for facility staff. Both facility and hospice staff acknowledged the lack of a set schedule and the need for better communication and documentation. Additionally, the facility failed to assess and appropriately monitor developing bruising for a resident on anticoagulant therapy. The resident had multiple medical conditions, including peripheral vascular disease, dementia, and a history of hip fracture, and required significant assistance with activities of daily living. The care plan addressed anticoagulant use and skin integrity but did not include specific interventions to prevent bruising. Observations showed the resident had visible bruising and a scab with drainage on the hands, but documentation in the electronic health record and risk management system lacked consistent assessment and follow-up on the bruising. Staff interviews indicated that bruises were addressed on a case-by-case basis, and there was no clear documentation or monitoring process in place for the resident's bruising. Facility policies required coordination with hospice providers and monitoring for complications in residents on anticoagulants, but these were not fully implemented. The lack of clear communication, documentation, and follow-up contributed to the deficiencies in care coordination with hospice and in the assessment and monitoring of bruising for residents at risk.
Failure to Reassess and Update Interventions After Pressure Ulcer Development
Penalty
Summary
The facility failed to comprehensively reassess a resident after the development of an in-house acquired pressure ulcer, resulting in a lack of additional or modified interventions to promote healing and prevent complications. The resident, who had significant cognitive impairment, hallucinations, and care rejection behaviors, was identified as being at risk for pressure ulcers but had no ulcers at the time of the last formal assessment. Despite the development of a sacral pressure ulcer, documentation showed that the care plan and interventions remained largely unchanged, with staff continuing previous repositioning routines and applying various topical treatments without a documented comprehensive review. Observations and interviews revealed that staff were unsure of any new or additional interventions beyond the use of an air mattress and topical creams. There was inconsistency in wound care products used, and staff could not articulate a clear plan for wound management or prevention of further injury. The resident's nutritional status was not reassessed or addressed, despite wound care notes recommending optimization of nutrition. The medical record lacked evidence of interdisciplinary team involvement or a comprehensive evaluation of the resident's risk factors and needs after the ulcer developed. Interviews with nursing and hospice staff confirmed that no comprehensive reassessment or interdisciplinary review was conducted following the onset of the pressure ulcer. The assistant director of nursing acknowledged that such reviews were not routinely performed for pressure ulcer development and that documentation of interventions and risk reassessment was lacking. The facility's own policy required reassessment upon changes in condition, but this was not followed in the case of the resident who developed the pressure ulcer.
Failure to Assess and Implement ROM Maintenance Program
Penalty
Summary
The facility failed to comprehensively assess and implement a nursing functional maintenance program to maintain or improve range of motion (ROM) for a resident with severely impaired cognition and functional limitations in all extremities. The resident's quarterly MDS indicated severe cognitive impairment and dependence on staff for all ADLs, with documented functional limitations in ROM, but no restorative nursing program was in place during the look-back period. The care plan did not address the resident's current ROM status or include specific interventions or exercises to prevent further decline. Medical records lacked an assessment of the resident's ROM status or any interventions to maintain ROM. Interviews with staff revealed that nursing assistants were not instructed to perform ROM activities with the resident, and nursing and therapy staff were unaware of any functional maintenance program or assessment for the resident. The therapy department stated they would assist if consulted, but such consultations were not routine. The assistant director of nursing confirmed that the resident had not been assessed for a maintenance program and that such programs were typically initiated only after therapy discharge or upon provider order, not as a preventive measure. The facility's policy required nursing personnel to be trained in rehabilitative care, including ROM exercises, but this was not implemented for the resident in question.
Failure to Provide Ongoing Pain Assessment and Timely Intervention for Nonverbal Resident
Penalty
Summary
A resident with severe cognitive impairment and a history of Alzheimer's disease, thoracic spine pain, and chronic pain was not provided with ongoing pain assessments or timely interventions when exhibiting signs of pain. The resident was dependent on staff for all activities of daily living and communication of needs, as indicated in her care plan. Despite being on a scheduled regimen of pain medications, including fentanyl patches, oxycodone, and acetaminophen, there was no documentation of as-needed (PRN) pain medications being administered during the review period, nor were regular pain assessments recorded in the progress notes. Observations revealed that the resident frequently exhibited non-verbal signs of pain, such as loud moaning, which were audible from the hallway. Staff, including agency nursing assistants, were seen passing by or briefly entering the resident's room without providing pain interventions or conducting assessments. Interviews with staff indicated a lack of familiarity with the resident's pain behaviors and an absence of nonpharmacological interventions. The nurse on duty confirmed that pain assessments were not routinely completed, and the last recorded pain score was several months prior. The facility's policy required weekly pain assessments for residents with stable chronic pain and more frequent assessments for acute pain. However, the assistant director of nursing acknowledged that there was no process in place to ensure regular pain assessments for nonverbal residents on scheduled pain medications. The lack of timely assessment and intervention for the resident's pain, despite clear signs and a documented need, led to the deficiency.
Failure to Assess and Document Alternatives Prior to Bed Rail Use
Penalty
Summary
The facility failed to comprehensively assess and attempt alternatives before the use of bed rails for a resident who had grab bars affixed to their bed. The resident had moderately impaired cognition and multiple diagnoses, including peripheral vascular disease, arthritis, hip fracture, dementia, Parkinson's Disease, and depression. Documentation showed that the resident required varying levels of assistance with mobility and activities of daily living. Although the care plan and order summary indicated the use of grab bars to promote independence, the quarterly Bed Rail/Assist Bar Evaluation noted that no bed rail or assist bar was in use at the time of assessment, and there was a lack of documentation regarding risk and benefit discussions with the resident or their representative. Observations confirmed that the resident used two grab bars during care, and interviews with staff revealed that assessments were completed but documentation of alternatives tried and family notification was missing. Review of evaluation forms and informed consent documents showed that sections for alternatives attempted and resident/representative notification were left blank. Staff acknowledged inconsistencies in completing assessments and documentation, and while there was a signed consent form, it did not include details about alternatives trialed or considered.
Failure to Honor Resident Meal Preferences for Fried Eggs
Penalty
Summary
The facility failed to honor a resident's meal preference for fried eggs with runny yolks, despite the availability of pasteurized eggs, which are permitted under federal regulations for such preparations. The resident, who had intact cognition and no delusional thinking, repeatedly requested fried eggs but was consistently denied this choice by management. Observations confirmed that the resident was served hard-boiled eggs instead, while other residents were seen consuming eggs with runny yolks in the dining room. The dietary manager's progress note documented informing the resident that only fully cooked eggs would be served, but did not provide a rationale for this restriction, even though pasteurized eggs were available in the facility. Interviews with staff, including a cook and the assistant director of nursing, revealed confusion and lack of consensus regarding the policy for serving fried eggs. The cook confirmed that pasteurized eggs were available and believed it was acceptable to serve fried eggs using them, but stated that the facility owner did not allow it, without providing a clear reason. The assistant director of nursing acknowledged that the interdisciplinary team had discussed the issue but had not reached a decision, and recognized the importance of resident choice in meal options. The resident's nutritional care plan did not address the restriction on fried eggs, nor did it provide any clinical justification for denying the resident's preference. The facility was unable to produce a policy on meal choices when requested. The lack of documentation, clear rationale, and consistent practice regarding resident meal preferences led to the deficiency in accommodating resident choice and promoting quality of life.
Survey Results Not Accessible to Residents and Public
Penalty
Summary
The facility failed to ensure that the most recent recertification survey and subsequent complaint investigation results were readily available and accessible within the care center. According to the CMS Aspen Central Office database, the most recent standard recertification survey and an abbreviated complaint survey, which included immediate jeopardy findings, had been completed, but their results were not present in the public binder intended for such documents. During an interview, a resident who regularly attended the monthly resident council meeting stated they were unsure where the most recent state agency survey results were kept. A tour of the care center revealed that the only binder labeled for annual survey results did not contain the most recent survey or complaint investigation results. The administrator confirmed that this binder was the sole location for posting survey results and acknowledged that the most recent documents were missing due to an oversight. Facility policy required that the most recent standard survey and state-approved plan of correction be kept in a 3-ring binder in an area frequented by most residents, such as the main lobby or activity room, but this was not followed.
Inadequate Surety Bond Coverage for Resident Personal Funds
Penalty
Summary
The facility failed to ensure that resident personal fund accounts were protected with a surety bond sufficient to cover the total balance of all resident funds held by the facility. During an interview, the administrative assistant reported that the total amount of resident funds was $91,117.79. However, documentation provided by the administrator showed that the facility's surety bond only covered up to $50,000, which was less than the total amount of resident funds on hand. The administrator explained that the bond amount was based on a 12-month average balance and acknowledged that a recent property sale by a resident had increased the total balance significantly, with two residents accounting for more than $58,000 of the total funds. Further document review included a resident statement showing a balance of $20,995.70 for one resident after a large bank credit, and a trial balance listing 166 residents with accounts at the facility. The facility's policy on deposit of resident funds stated that personal funds would be safeguarded but did not include information about maintaining a resident trust fund surety bond. The lack of adequate surety bond coverage had the potential to affect all residents with positive account balances.
Failure to Supervise Resident at Risk for Elopement
Penalty
Summary
The facility failed to provide adequate supervision for a resident (R1) at risk for elopement, resulting in an immediate jeopardy situation. R1, who had severe cognitive impairment and was diagnosed with Alzheimer's disease, traumatic brain injury, and dementia, was found half a block away from the facility. The resident was supposed to be monitored with a WanderGuard management system, which was intended to trigger alarms when the resident approached a door. However, the WanderGuard did not function properly, and staff failed to check its placement and functionality as required. On the day of the incident, R1 was seen leaving the facility with a nurse, but the WanderGuard alarm did not sound, indicating a malfunction. The deficiency was further compounded by staff errors, including a licensed practical nurse (LPN) who admitted to not checking or replacing the WanderGuard as documented in the electronic medical record. Additionally, there was a lack of communication among staff regarding R1's elopement risk and the need for thirty-minute checks. The facility's policy required weekly checks of the WanderGuard's function, but the manufacturer's manual recommended daily checks, which were not followed. This oversight allowed R1 to leave the facility unnoticed, highlighting a significant lapse in supervision and adherence to safety protocols.
Removal Plan
- The facility reviewed and revised their current policy on WanderGuards.
- The facility reviewed all residents with WanderGuards to ensure bracelets were working correctly by checking function.
- The facility completed staff education on the WanderGuard policy.
Dishwasher Temperature Deficiency in LTC Facility
Penalty
Summary
The facility failed to ensure proper sanitization of dishware used for meal preparation and resident service due to a malfunctioning high-temperature commercial dishwasher. During a kitchen tour, it was observed that the dishwasher did not reach the required final rinse temperature of 180°F, as indicated by the machine's specifications. Dietary staff were unable to read the temperature gauges due to a hard white film covering them, and the temperature logs were inaccurately recorded. The dietary manager confirmed that the dishwasher was not reaching the necessary temperature, posing a risk for foodborne illnesses. Further investigation revealed that the dishwasher had been serviced recently, but it still failed to reach the required temperature during multiple cycles. The administrator was informed of the issue and planned to use paper and plastic products until the dishwasher was fixed. The facility's Cleaning Dishes/Dish Machine policy, dated 2017, required staff to check the dish machine gauges to ensure proper sanitization temperatures, which was not adhered to due to the unreadable gauges and inaccurate log entries.
Deficiencies in Resident Dignity and Care
Penalty
Summary
The facility failed to address a resident's needs in a respectful and dignified manner when a resident, identified as R34, used a call light for assistance. R34, who had intact cognition and diagnoses of hemiplegia and hemiparesis following a stroke, required staff assistance for transfers using an EZ stand medium harness. On the day of observation, R34's call light was activated at 12:51 p.m., but it was not answered until 1:23 p.m., despite multiple staff members being present in the vicinity. The resident expressed frustration over the long wait times for call light responses, which he stated occurred frequently. Additionally, the facility did not ensure that staff knocked on residents' doors and introduced themselves before entering, affecting residents R68, R76, and R74. Observations showed that staff entered these residents' rooms without knocking or announcing themselves, which was acknowledged by the staff involved. This lack of respect for privacy and dignity was confirmed by the assistant director of nursing and the director of nursing, who stated that knocking and announcing oneself is expected to prevent startling residents, especially those with dementia. The facility also failed to provide a dignified dining experience for residents R21, R31, and R68. These residents, who had severely impaired cognition and were dependent on staff for eating, were observed sitting with their meals on hard plastic trays for extended periods before receiving assistance. Staff interviews confirmed that meals were served on trays for convenience, and residents who required assistance often had to wait while other trays were distributed. This practice was acknowledged by the director of nursing, who stated that residents should be served meals simultaneously and assisted promptly.
Failure to Provide SNFABN After Medicare A Coverage Ends
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN; CMS-10055) upon the termination of Medicare A coverage for a resident who remained in the nursing home after Medicare A coverage ended. The resident, who had intact cognition and diagnoses of Alzheimer's disease and depression, was discharged from Medicare Part A services on 7/23/24. The facility's records indicated that the resident's primary payer changed from Medicare Part A to private pay on 7/24/24. A Notice of Medicare Non-Coverage (NOMNC) form was issued, indicating the final day of skilled nursing services was 7/23/24 due to a decrease in tube feeding. However, the form lacked a signature or date from the resident or their representative, and there was a note indicating multiple unsuccessful attempts to obtain the signature of the resident's family member/power of attorney (POA), who demonstrated a lack of understanding of the document. The occupational therapist (OT) responsible for providing NOMNCs and SNF ABNs confirmed that Medicare Part A skilled coverage ended on 7/23/24 and that the final day of skilled services was on that date. The OT recalled having an initial conversation about the non-coverage on 7/19/24 and multiple conversations with the POA, who declined to sign the form. However, there was no supporting documentation of these conversations aside from the note on the NOMNC. The OT stated that no SNF ABN was provided to the resident or their representative, as they believed it was not necessary after the discharge from Medicare Part A services. The facility's policy required issuing a non-coverage notice in advance of the last covered day and providing the SNF ABN before services that do not meet Medicare coverage criteria, but this was not followed in this case.
Failure to Address Resident's Grievance on Missing Clothing
Penalty
Summary
The facility failed to respond to and resolve a grievance regarding missing clothing for a resident with severe cognitive impairment and multiple medical conditions, including hemiplegia, vascular dementia, and major depressive disorder. The resident, who was dependent on assistance for daily activities, reported missing dresses to an LPN, but this grievance was not documented in the facility's grievance log. The facility's grievance policy requires that any resident, family member, or appointed representative may file a grievance concerning care, treatment, or theft of property, and staff are encouraged to guide residents on how to file such grievances. Interviews with the social worker and administrator revealed that the typical process for addressing missing items involves searching the resident's room, contacting the laundry, and discussing the issue during daily IDT meetings. However, the administrator was unaware of the progress note indicating the resident's report of missing dresses and stated that grievance forms are sometimes part of the process for reporting missing personal items. The facility's policy also mandates immediate reporting of any alleged misappropriation of resident property to the administrator, but this procedure was not followed in this case.
Failure to Implement Pressure Ulcer Prevention Care Plan
Penalty
Summary
The facility failed to consistently implement assessed and care-planned interventions for preventative skin care for a resident identified as R31, who was at risk for developing pressure ulcers. R31 had severely impaired cognition and was dependent on staff for all activities of daily living, including bed mobility and hygiene needs. The care plan for R31 included interventions such as repositioning every 2-3 hours and checking and changing incontinence briefs on the same schedule. However, observations revealed that R31 was left seated in a wheelchair in the dining room for over five hours without being repositioned or checked for incontinence. Interviews with nursing assistants confirmed that R31 had not been repositioned or changed since before breakfast, despite the expectation to do so every 2-3 hours. The nursing assistants cited being short-staffed and having a lot of work as reasons for not adhering to the care plan. The assistant director of nursing and the director of nursing both stated that the expectation was to check and change incontinent residents and reposition them every 2-3 hours, as per the care plan. The facility's policy on the prevention of pressure injuries required repositioning residents at risk of pressure injuries on an individualized schedule determined by the interdisciplinary care team. Despite this policy, the facility did not adhere to the care plan for R31, leading to a deficiency in providing appropriate pressure ulcer care and prevention.
Deficiencies in Resident Safety and Fall Prevention
Penalty
Summary
The facility failed to adequately assess and implement interventions for a resident, R330, who exhibited potential wandering behaviors. Upon admission, R330 was noted to have cognitive impairments and was initially assessed as low risk for elopement. However, the resident was found wandering on a different floor near the facility's entrance, indicating a potential risk for elopement. Despite this incident, there was no comprehensive reassessment or implementation of interventions such as a wanderguard device to mitigate the risk of wandering or elopement. The care plan for R330 lacked updates or interventions following the wandering episode, and staff interviews revealed a lack of awareness and communication regarding the resident's wandering behavior. Another deficiency was identified in the facility's handling of fall interventions for a resident, R64, who was at high risk for falls due to impulsivity and a history of falls. R64 experienced an unwitnessed fall because his walker was not within reach, and the incident report did not document any new fall interventions based on a root cause analysis. Observations showed R64 walking without his walker and not being reminded by staff to use it, despite his care plan indicating he required assistance with ambulation. Interviews with staff revealed a lack of implementation of fall prevention strategies and an outdated care plan that did not reflect R64's current needs for reminders to use his walker. The facility's policies on resident elopement and fall risk management were not effectively followed, as evidenced by the lack of timely reassessment and intervention implementation for both residents. The staff's failure to document and communicate necessary interventions contributed to the deficiencies observed. The facility's policies lacked specific guidelines on evaluating and care-planning for wandering behaviors, and the fall risk management policy was not adhered to, resulting in inadequate prevention measures for R64.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to comprehensively assess and develop a person-centered care plan for a resident with PTSD, bipolar disorder, anxiety disorder, and fibromyalgia. The resident's admission Minimum Data Set identified her with moderately impaired cognition and a history of trauma related to military service. Despite this, the care plan lacked specific interventions, measurable objectives, and timeframes to address her PTSD and potential triggers. The resident expressed that no one had discussed her past trauma or triggers with her, and she desired to work with a social worker to identify these triggers. Interviews with staff, including nursing assistants, a registered nurse, and a social worker, revealed a lack of awareness regarding the resident's PTSD and potential triggers. The staff confirmed that the care plan did not include documentation or interventions related to the resident's PTSD, aside from a reference to the diagnosis in the PASARR screening. The facility's policy on trauma-informed care emphasized the need for individualized care plans to address past trauma, but this was not reflected in the resident's care plan.
Failure to Act on Pharmacist's Recommendations for Medication Review
Penalty
Summary
The facility failed to act upon the consultant pharmacist's recommendation for a resident reviewed for unnecessary medications. The resident, who was cognitively intact and required assistance with daily activities, had been prescribed quetiapine for hallucinations. The consultant pharmacist recommended a gradual dose reduction (GDR) assessment, as the medication had been active since March 2022. Despite the recommendations made in April and July 2024, there was no documentation showing that the recommendations were addressed. Interviews with the assistant director of nursing (ADON) and director of nursing (DON) revealed that the facility switched providers in April, and the new nurse practitioner requested detailed psychosocial reviews before making any changes to residents' psychotropic medications. The ADON acknowledged that the psychosocial reviews were pending, and the DON confirmed that the pharmacist's recommendations for April and July were not completed. The facility's policy required a GDR to be attempted within the first year of antipsychotic medication use and annually thereafter, unless clinically contraindicated.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Use
Penalty
Summary
The facility failed to ensure that non-pharmacological interventions were attempted and documented before administering as-needed (PRN) narcotic medication to a resident, identified as R4, who was reviewed for unnecessary medication use. R4, who had intact cognition, was admitted with a care plan indicating potential pain due to recent hip surgery. The care plan included interventions such as ice, rest, and pain medications to manage pain. However, the facility did not document attempts to use these non-pharmacological interventions before administering hydromorphone, a narcotic, despite the resident's openness to trying such methods. R4's medical records showed multiple instances where hydromorphone was administered for high pain levels without documentation of any non-pharmacological interventions being offered or attempted. The Medication Administration Record (MAR) indicated that the narcotic was given six times in August, with pain levels ranging from eight to ten out of ten. Progress notes consistently lacked information on physical symptoms or non-pharmacological interventions prior to medication administration, despite the care plan and medical provider's efforts to reduce narcotic use. Interviews with staff, including a nursing assistant and registered nurses, revealed a lack of awareness and implementation of non-pharmacological interventions for R4. Staff members acknowledged that such interventions should be attempted and documented before administering PRN narcotics, but this was not reflected in practice. The facility's policy on as-needed narcotic management was not provided, indicating a potential gap in procedural guidance.
Inappropriate Use of Antipsychotic Medication
Penalty
Summary
The facility failed to provide an appropriate indication for the continued use of antipsychotic medication for a resident diagnosed with dementia, anxiety, depression, and a stroke. The resident, who had severely impaired cognition and was receiving hospice services, was prescribed quetiapine for agitation despite having no documented signs of psychosis or behavioral symptoms during the look-back period. The care plan indicated the resident had behavioral problems related to dementia, but staff were instructed to use non-pharmacological interventions such as reassurance and distraction. However, the Medication Administration Record and Behavior Monitoring reports showed no behaviors were observed that would justify the use of antipsychotic medication. Interviews with facility staff, including nursing assistants and a registered nurse, revealed that the resident was mostly sleeping, nonverbal, and did not exhibit any behaviors or signs of agitation. The nurse practitioner, who had been working with the resident since April, acknowledged that there was no documentation of behaviors that would present a danger to the resident or others. The nurse practitioner and the assistant director of nursing both reviewed the medical record and confirmed the absence of active behaviors or signs of agitation, questioning the appropriateness of the diagnosis used to justify the antipsychotic medication. The facility's policy on Medication Monitoring and Management did not address indications for antipsychotic use, contributing to the deficiency. The consultant pharmacist had recommended clarifying the diagnosis for the antipsychotic use, but the provider's response did not align with the documented observations of the resident's condition. The lack of documented behaviors and the absence of a clear indication for the antipsychotic medication use led to the deficiency identified by the surveyors.
Failure to Address Resident's Dental Care Needs
Penalty
Summary
The facility failed to ensure that a resident's need for routine dental care was assessed and addressed, leading to a deficiency in oral hygiene management. The resident, who was admitted to the care center from an acute care hospital, reported losing their dentures prior to admission. Despite this, the facility did not assess or offer a dental appointment to address the resident's need for new dentures, which the resident expressed a desire for due to difficulty in chewing without them. Upon admission, the resident's oral status was noted to include the use of an upper denture and a partial lower denture, with potential issues such as broken or loose-fitting dentures. However, the admission assessment lacked information on the resident's last dental visit or any current needs or desires for dental care. The resident's care plan, initiated nearly a month after admission, identified potential oral health problems related to denture fit but did not result in any immediate action to coordinate dental care. Interviews with facility staff revealed a lack of communication and follow-up regarding the resident's dental needs. Nursing staff and the medical records coordinator were unaware of any dental appointments being scheduled or concerns being raised. The assistant director of nursing acknowledged the oversight and the absence of documentation in the resident's medical record regarding dental care needs or appointments. The facility's policy on dental services, which outlines the provision of routine and emergency dental care, was not adhered to in this case.
Failure to Administer Pneumococcal Vaccine Timely
Penalty
Summary
The facility failed to ensure that recommended pneumococcal immunizations were offered and/or provided in a timely manner to a resident, as outlined by the CDC guidelines. The resident, who was admitted to the facility in March 2024, had a history of Alzheimer's disease, anemia, high blood pressure, kidney failure, anxiety, and depression. Despite consenting to receive the pneumococcal vaccination, the resident's electronic health record did not reflect that the PCV-20 vaccine was offered or administered, as per CDC recommendations. The assistant director of nursing (ADON), who was responsible for infection prevention, acknowledged that the resident's immunization records were not updated, and the vaccination may have been overlooked. The facility's policy required that residents be assessed for pneumococcal vaccine eligibility prior to or within five days of admission, and vaccines should be offered within thirty days unless contraindicated. However, the ADON admitted that the resident initially refused the vaccination but later consented, and this change was not updated in the tracking log. The director of nursing (DON) mentioned that a formal audit system was in place to check and update vaccination statuses, but the oversight was not caught until the survey. This deficiency had the potential to affect all 80 residents in the facility.
Failure to Report Potential Abuse in a Timely Manner
Penalty
Summary
The facility failed to report an allegation of potential abuse in a timely manner to the state agency for a resident with severely impaired cognition and dependency on staff for all activities of daily living. The resident's care plan indicated a risk for abuse due to cognitive impairment and dementia. A bruise was discovered on the resident's chest by the resident's son, who reported it to the facility staff. However, the facility did not document or monitor the bruise adequately, nor did they report it to the state agency as required. Interviews with facility staff revealed that the bruise was not entered into the risk management section of the electronic medical record, and the provider was not notified of the injury. The assistant director of nursing and the director of nursing were aware of the bruise but did not assess it or report it to the state agency. The facility's policy required all reports of resident abuse, including injuries of unknown origin, to be reported to local, state, and federal agencies and thoroughly investigated, which was not followed in this case.
Deficiencies in Personal and Incontinence Care
Penalty
Summary
The facility failed to provide routine personal care, specifically nail care, for a resident identified as R6. R6, who has moderate cognitive impairment and is dependent on staff for personal hygiene, was observed with long and soiled fingernails. Despite R6's care plan indicating a need for assistance with personal hygiene, there was no specific mention of nail care. Interviews with staff revealed that nail care was expected to be performed during scheduled bath days, but recent changes in documentation forms may have led to this task being overlooked. The facility's policy requires nail care to be recorded, but R6's medical records lacked evidence of nail care being offered or performed. Another deficiency was noted in the care of a resident identified as R31, who has severe cognitive impairment and is dependent on staff for all activities of daily living, including incontinence care. Observations showed that R31 remained in the same position in a wheelchair for over five hours without being repositioned or checked for incontinence. Interviews with nursing assistants confirmed that R31 had not been repositioned or provided with incontinence care as required by the care plan, which mandates checks every 2-3 hours. Staff cited being short-staffed as a reason for the lapse in care. The facility's policies on activities of daily living and incontinence care were not adhered to, resulting in deficiencies in the care provided to R6 and R31. The lack of documentation and adherence to care plans contributed to these deficiencies, highlighting a failure to ensure that residents received necessary personal hygiene and incontinence care. The facility's policies require regular checks and documentation, but these were not consistently followed, leading to the observed deficiencies.
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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