St Marks Living
Inspection history, citations, penalties and survey trends for this long-term care facility in Austin, Minnesota.
- Location
- 400 15th Avenue Southwest, Austin, Minnesota 55912
- CMS Provider Number
- 245369
- Inspections on file
- 26
- Latest survey
- March 2, 2026
- Citations (last 12 mo.)
- 6 (1 serious)
Citation history
Health deficiencies cited at St Marks Living during CMS and state inspections, most recent first.
The facility failed to ensure safe mechanical lift transfers and comprehensive fall analysis for multiple residents. A resident with multiple comorbidities and a high fall risk, who required 2-person assist and a large harness with a sit-to-stand lift, previously fell from the lift when a NA transferred the resident alone; the incident was not fully assessed for sling size or used to revise the care plan for the resident’s tendency to fall asleep in the lift. Later, two NAs attempted to transfer this resident using an XL harness instead of the ordered large size and initially did not cinch the torso strap until prompted by a surveyor, despite staff acknowledging that failure to cinch could allow a resident to fall. Another resident assessed as needing a large sling for a total lift was found sitting on an XL sling, with the care plan and Kardex conflicting with the sizing assessment, and staff relying on outdated paper guides. A third resident with brain cancer and prior falls had multiple falls where root cause analysis forms were incomplete or not linked to specific, timely interventions, and care plan changes (such as toileting programs and equipment changes) were delayed or not clearly tied to identified causes.
The facility failed to provide ongoing comprehensive RN assessment and individualized pressure-relief interventions for three residents at risk for or with pressure ulcers. One resident with MS and multiple comorbidities developed a facility-acquired stage 2 sacral ulcer that progressed to stage 3 while weekly skin assessments lacked detailed wound characteristics, repositioning orders were not reassessed, staff relied on the resident to self-reposition in a wheelchair, and a prescribed foam dressing was omitted from transcribed orders. A second resident with multiple serious diagnoses and buttock scarring had incomplete wound documentation, was found on a deflated air mattress with an improperly placed foam dressing, and developed a new open right-buttock wound. A third resident with a stage 2 buttock ulcer had orders for frequent offloading, but there was no documented reassessment of repositioning frequency, and wound assessments were minimal and inconsistent. Staff interviews and facility policy review showed that required weekly comprehensive RN wound assessments, including accurate staging, measurements, and evaluation of pressure-relief measures, were not being completed for residents with pressure ulcers.
A resident with complex cardiac and renal conditions was given another resident’s full set of morning medications when an agency TMA entered the wrong room and failed to verify identity or follow the rights of medication administration, leading to unresponsiveness, hypotension, and acute kidney injury requiring hospitalization. During observation of other medication passes, an RN misread an order for an oral antifungal as “swish and spit” instead of the ordered “swish and swallow,” and another resident with heart failure, Parkinson’s disease, dementia, and hospice services received an extra scheduled dose of lorazepam when a TMA assumed there was a PRN order and did not verify the MAR. Multiple TMAs and an RN demonstrated incomplete understanding of the rights of medication administration, and medication pass audits and competencies had been performed by an unlicensed administrator without formal medication training and by LPNs, despite facility policy requiring verification of resident identity and triple-checking the right resident, medication, dose, time, and route.
The facility’s QAPI committee consistently collected monthly data on falls, pressure ulcers, and medication errors but did not perform root cause analyses, prioritize high-risk or recurring issues, develop PIPs, or document action plans or follow-up. During this period, multiple falls occurred, including one involving improper use of a sit-to-stand lift harness after a prior lift-related fall, and another resident’s falls were not comprehensively investigated or addressed with targeted interventions. A resident sustained actual harm when given another resident’s medication, leading to unresponsiveness, hypotension, hospitalization, and acute kidney injury. Three residents with pressure ulcers were not adequately monitored or assessed, and one developed a sacral Stage 2 ulcer that progressed to Stage 3. The medical director and administrator acknowledged that QAPI meetings focused on data review without documented discussion, analysis, or implementation of action plans, despite the facility’s written QAPI plan requiring such activities.
A resident with multiple serious diagnoses, including CHF, CKD, Afib, and a history of syncope, experienced a brief syncopal episode during a transfer when a TMA assisted the resident to stand with a gait belt. The resident went limp, was lowered back into a recliner, then became alert and responsive, and nursing staff, including two LPNs and an RN manager, responded. Although staff acknowledged this was a change in condition that required documentation and provider notification, one LPN did not obtain vital signs, did not notify the provider, and did not write a nursing note, and there was no documentation that the physician was notified at the time of the event. The DON and the MD both later stated the provider should have been notified immediately, and the facility’s change of condition policy required physician notification for status changes.
A resident with heart failure, prior mini-strokes, and on anticoagulant therapy was mistakenly given another resident’s medications by a TMA, after which the resident became unresponsive and was sent to the ED. Although an incident report and a brief progress note were completed, the LPN who repeatedly assessed the resident and obtained multiple sets of vital signs after the error did not document these assessments or vital signs in the EHR. This lack of documentation conflicted with facility policy requiring complete, accurate, and objective charting of services provided, changes in condition, and events or incidents involving the resident.
The facility did not comprehensively assess or monitor non-pressure related skin injuries for three residents, including a resident on anticoagulant therapy who developed significant bruising after hitting bed rails, and two residents who sustained bruises and hematomas after falls. Care plans were not updated to reflect new injuries, protective interventions were not implemented or documented, and ongoing monitoring and physician notifications were lacking, contrary to facility policy and professional standards.
The facility failed to properly assess and address fall risks for three residents, including not updating care plans, not completing root cause analyses, and not ensuring interventions such as call light accessibility and staff assistance were implemented. In one case, a resident with dementia and a history of falls continued to self-transfer without staff intervention, while another resident's call light was left out of reach, preventing them from requesting help. Documentation and monitoring of interventions were incomplete or inaccurate, resulting in repeated deficiencies in fall prevention.
A resident with urinary retention and other comorbidities suffered harm after an LPN inserted a larger indwelling catheter without confirming urine return, inflated the balloon in the urethra, and failed to monitor for complications. The resident experienced pain, hematuria, and a urinary tract infection, requiring hospitalization. Staff did not follow proper catheter protocols, failed to document physician orders, and did not assess or monitor the resident after the procedure.
Staff did not consistently use gowns and gloves for high-contact care activities or perform proper hand hygiene for several residents with wounds, catheters, or other conditions requiring enhanced barrier precautions. Despite posted signage and facility policy, staff were observed providing care and moving between residents without following required infection prevention protocols.
A resident with advanced dementia and malnutrition, dependent on staff for eating, was left sitting unattended with her meal for an extended period while staff intermittently assisted her and prioritized other tasks. Staff and facility leadership acknowledged that best practice is to sit and engage with residents needing assistance during meals to ensure dignity and respect.
A resident with multiple chronic conditions had significant gaps in their medical record, including missing physician orders, hospital discharge summaries, and outpatient provider notes. Staff interviews revealed inconsistent processes for obtaining and uploading external medical records, with some nurses lacking access and the HUC depending on nursing staff to provide documents. The facility's EHR policy did not outline procedures to ensure records were complete and accurate, resulting in incomplete documentation.
Improper Mechanical Lift Use and Inadequate Fall Root Cause Analysis
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe use of sit-to-stand and total body mechanical lifts, including correct sling/harness sizing, proper strap application, and adherence to care plans and manufacturer instructions. One resident (R4), with diagnoses including heart failure, chronic kidney disease, pancreatic cancer, diabetes, osteoarthritis, and a history of falls, was assessed as high fall risk and required assistance of two staff with a sit-to-stand lift using a large harness for all transfers. Despite this, on a prior date R4 experienced a witnessed fall from a sit-to-stand lift when a nursing assistant transferred the resident alone, contrary to the care plan, and the resident slipped out of the harness and fell to the floor, later reporting left shoulder pain. The facility’s documentation of that incident did not identify the sling size used, did not show a comprehensive assessment to determine the correct sling size for subsequent transfers, and the care plan was not revised to address the resident’s tendency to fall asleep in the lift. On a later observation, two nursing assistants (NA-C and NA-D) prepared to transfer R4 from bed to shower chair using a sit-to-stand lift with an extra-large (XL) harness draped over the lift, which they both believed was the correct size. Neither had a resident care guide in the room identifying the correct harness size. After the surveyor intervened and prompted verification, NA-D checked the resident care guide and discovered R4 was supposed to use a large harness, not an XL, and had to obtain the correct size from another unit because it was not available on R4’s wing. During the same transfer, after the large harness was applied and R4 was raised to standing, the torso strap was not cinched until the surveyor intervened and instructed the staff to tighten it. NA-C acknowledged she knew the torso strap needed to be cinched as the resident stood and that failure to do so could allow a resident to fall out of the lift, but stated she had overlooked this step. Staff also reported they had not received any re-education on proper mechanical lift use or following care plans since initial orientation. A second resident (R9), with diagnoses including heart failure, chronic respiratory failure, and chronic kidney disease, required total mechanical lift transfers and had been assessed via a sling/harness sizing assessment as needing a large sling. However, the resident’s care plan and Kardex directed staff to use an XL sling, conflicting with the sizing assessment. During observation, R9 was seated in a wheelchair on top of a sling whose size markings were washed off; a trained medication aide identified the sling as XL based on its color coding and confirmed via the Kardex that the resident was supposed to be in a large sling. The aide stated the resident could have fallen out of the oversized sling. The DON later confirmed that staff had been using the paper nurse aide care guide to verify sling size and that R9 had not been transferred with the correct sling size. The facility also failed to comprehensively investigate and analyze falls for root cause and to implement appropriate, person-centered interventions for another resident (R3) with malignant brain neoplasm, heart failure, osteoporosis, moderate cognitive impairment, and a history of falls. R3’s fall care plan included general interventions such as following the fall protocol, routine safety checks, anticipating needs, and reviewing past falls to determine causes, but subsequent fall incident documentation and root cause analysis worksheets were incomplete or lacked clear causal analysis and corresponding interventions. After an unwitnessed bathroom fall assisted by a family member, the root cause section was left blank, and the only care plan revision was to encourage family not to transfer the resident and to ask staff for assistance. Later falls, including one where the resident was found on the bathroom floor without a walker and another where the resident independently walked to the bathroom and lost balance, identified factors such as brain cancer, weakness, and self-transfers, but did not show comprehensive analysis or immediate interventions to mitigate further falls. One intervention, placing a dycem mat in the wheelchair seat, lacked a documented rationale linked to the identified causal factors. The DON acknowledged that comprehensive causal analyses had not been completed for each of R3’s falls and that toileting, identified as a root cause, was not addressed in the care plan until several days after repeated falls. The immediate jeopardy began when NA-C and NA-D had to be stopped from using the wrong harness size for R4 and failed to cinch the torso strap during a sit-to-stand transfer, despite R4’s prior fall from a sit-to-stand lift and existing care plan requirements. The medical director stated that any resident being transferred using a mechanical lift without the care plan and/or policy being followed had the likelihood to cause serious harm, serious injury, or death in the event of a fall from the lift.
Removal Plan
- The facility identified all residents who use a sit-to-stand lift, assessed each resident for the correct harness size needed, and educated each member of the nursing staff who will or may use the sit-to-stand lift.
- The facility assessed R4 and all residents using mechanical lifts for proper transfer method, correct sling/harness size, and care plan accuracy.
- The facility verified sling/harness size for each resident through therapy documentation, direct measurement, manufacturer guidelines, and care plan accuracy.
- The facility reviewed and updated the mechanical lift transfer policy to require sling/harness size documented in the care plan and Kardex, require 2-assist transfers when indicated, require staff verification of sling size prior to transfer, and require cinching of waist/middle straps before elevation.
- The facility updated care plans to specifically identify type of lift, assist level, and sling/harness size.
- The facility updated the Kardex to match the care plan.
- The facility updated care sheets to match the care plan.
- The facility provided education to all licensed nurses and other certified individuals on manufacturer recommendations, proper sling application, proper strap placement and cinching, when sit-to-stand lifts are contraindicated, and always following the care plan.
Failure to Provide Comprehensive Pressure Ulcer Assessment and Pressure-Relief Interventions
Penalty
Summary
The deficiency involves the facility’s failure to provide comprehensive, ongoing assessment and individualized pressure-relief interventions for residents at risk for or with pressure ulcers, resulting in actual harm to one resident whose facility-acquired stage 2 pressure ulcer deteriorated to stage 3. For one resident with multiple sclerosis, diabetes, heart failure, neurogenic bladder and bowel, and chronic kidney disease, the Braden assessments identified moderate risk and the care plan called for heel elevation, pressure-reducing surfaces, and turning/repositioning in bed and chair. Despite repeated weekly skin assessments documenting “redness to bottom/skin breakdown” over several weeks, these assessments lacked wound location, measurements, type, or other characteristics. When a stage 2 pressure ulcer on the left buttock was first documented, there was a delay in obtaining a specific wound treatment order, and once ordered, subsequent skin assessments continued to list the wound as a stage 2 ulcer with unchanged measurements and minimal description, even after a nurse practitioner later documented that the ulcer had progressed to stage 3 with detailed measurements and wound characteristics. From the time the stage 2 ulcer was identified until the nurse practitioner documented stage 3 status, the record did not show that existing pressure-relief interventions were evaluated for effectiveness or that new interventions were added. The resident’s repositioning schedule in bed and chair was not reassessed for appropriateness, and there was no comprehensive assessment of skin tolerance to pressure over time. Staff interviews revealed that direct care staff were unaware of the ordered frequency for repositioning in the wheelchair and relied on the resident to self-reposition, even though the resident reported sometimes being unable to feel when her buttocks were getting sore due to MS and sometimes forgetting to reposition. The resident’s ROHO cushion had been placed backwards on multiple occasions, and the resident stated that this worsened her bottom when not placed correctly. Documentation also showed that a foam dressing ordered by the nurse practitioner was omitted from the transcribed treatment orders, and treatments were carried out without the foam dressing, while weekly skin assessments continued to record the wound as a healing stage 2 ulcer with the same measurements and no detailed characteristics. Two additional residents with buttock wounds and pressure injury risk also did not receive weekly comprehensive RN wound assessments as required by facility policy. One resident with heart failure, chronic kidney disease, pancreatic cancer, diabetes, and a history of falls had old scarring on the buttocks and was admitted with a buttock wound. Orders were in place for foam dressings and daily assessment, and a nurse practitioner later identified a stage 2 pressure injury to the left medial buttock and incontinence-associated dermatitis with multiple small open wounds. However, subsequent skin assessments lacked full wound descriptions, did not address all wounds identified by the nurse practitioner, and there was a period where no comprehensive wound assessment was documented. During observation, this resident was found lying on a completely deflated, unplugged air mattress with no other barrier between the bedframe and mattress, and staff were unsure how long the mattress had been deflated or when the resident was last repositioned. A new open wound was observed on the right buttock with macerated edges and a foam dressing stuck to the brief instead of the wound. Another resident with heart failure, chronic respiratory failure, and chronic kidney disease had a documented stage 2 pressure ulcer on the left buttock and was assessed as moderate risk on the Braden Scale. The care plan called for turning and repositioning every two hours in bed and chair, pressure-relieving surfaces, and laying the resident down between meals to offload the buttocks. A nurse practitioner ordered a silicone bordered foam dressing and frequent repositioning/offloading, but there was no documentation of a comprehensive assessment to determine the appropriate repositioning frequency or any revision of the existing every-two-hour schedule. Serial skin assessments showed the wound measurements remaining the same for several weeks with minimal description, and when the wound later deteriorated with increased size, the assessment still lacked detailed wound characteristics. A separate weekly wound observation tool documented a stage 2 pressure ulcer with different measurements, indicating inconsistent documentation. Interviews with nursing staff and management confirmed that weekly comprehensive RN wound assessments were not being performed for residents with pressure ulcers, that staff were unclear about who was responsible for staging and comprehensive assessment, and that the DON later recognized that required RN comprehensive assessments, including full wound descriptions and evaluation of pressure-relief measures, had not been completed for these residents. Overall, the deficiency centers on the facility’s failure to ensure that residents with or at risk for pressure ulcers received consistent, comprehensive RN wound assessments, accurate staging and measurement, timely and correctly transcribed treatment orders, and individualized reassessment of pressure-relief interventions. This failure was evidenced by incomplete and inaccurate skin assessments, lack of documented evaluation of repositioning schedules and pressure-relief devices, staff unawareness of ordered repositioning frequencies, improper use of pressure-relieving equipment such as ROHO cushions and air mattresses, and the absence of weekly comprehensive RN wound assessments despite facility policy requiring them.
Significant Medication Error and Multiple Medication-Pass Failures
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors by not adhering to the rights of medication administration. One resident with diagnoses including heart failure, transient cerebral ischemic attacks, renal insufficiency/failure, and use of anticoagulants was inadvertently given another resident’s full set of morning medications by a trained medication aide (TMA) who was agency staff and unfamiliar with the resident. The TMA prepared medications for the intended resident, verified that resident’s picture and room number in the EHR, but then entered the wrong room and did not verify the room number or the resident’s identity before administering the medications. The TMA administered multiple medications not prescribed to this resident, including antihypertensives, diuretics, antiplatelet, antidepressant, anticonvulsant/mood stabilizer, diabetic medication, and others, and only realized the error when attempting to give an inhaler that the resident stated she did not take. Following administration of the wrong medications, the resident initially had stable vital signs but later became unresponsive, with no response to verbal commands and only a grimace to sternal rub, prompting transfer to the emergency department. Hospital documentation identified accidental drug ingestion, hypotension secondary to accidental drug ingestion, blurry vision, orthostatic hypotension, and an acute kidney injury with elevated creatinine. The resident experienced symptomatic orthostatic hypotension with dizziness and blurry vision on standing and required interventions such as compression wraps, abdominal binder, hydration, and titration of midodrine. The medical director considered this a significant medication error and stated that the resident’s hypotension and acute kidney injury were likely caused by receiving medications not prescribed to her. Additional deficiencies were identified in the facility’s medication administration practices for other residents. One resident with heart failure and GERD was observed during a medication pass when an RN misread an order for an oral antifungal as “swish and spit” instead of the ordered “swish and swallow,” and the RN acknowledged this as a medication error. Another resident with heart failure, Parkinson’s disease, dementia, and hospice services had an order for scheduled lorazepam 1 mg three times daily; this resident received an extra dose of lorazepam when a TMA assumed there was an as-needed order and did not verify the physician’s orders before administering the additional dose. Multiple staff interviews revealed that TMAs and an RN had incomplete or unclear understanding of the rights of medication administration, and that medication pass audits and competencies had been conducted by an administrator who was not a licensed nurse and had no formal training in medication administration, as well as by LPNs, contrary to the DON’s statement that such competencies should have been done by an RN. The facility’s own policy required verification of resident identity and triple-checking the label for right resident, medication, dosage, time, and route, which was not followed in these instances. The facility’s failure to ensure that staff consistently followed the rights of medication administration, verified resident identity, and accurately read and followed physician orders led to a significant medication error causing actual harm to one resident and additional medication errors for two other residents. Staff interviews confirmed lapses in performing the required checks and in understanding all components of the rights of medication administration, despite recent audits and competencies. The documented events show that the facility did not effectively implement its own medication administration policy, resulting in residents receiving medications that were incorrect in recipient, route, or dose.
Failure of QAPI Process to Address Falls, Med Errors, and Pressure Ulcers
Penalty
Summary
The facility failed to ensure its QAPI committee identified, investigated, analyzed, and responded to high-risk issues related to falls, medication errors, and pressure ulcers, despite consistently collecting data on these events. From May 2025 through January 2026, the facility tracked numbers of falls, pressure ulcers, and medication errors each month, but the documentation did not include root cause analyses, prioritization of high-risk or recurring issues, development of performance improvement projects, implementation of corrective actions, or monitoring of interventions for effectiveness. QAPI records for these months showed counts of falls, pressure ulcers of various stages, and medication errors, but repeatedly noted no documented discussion or action plans, and often lacked information on whether pressure ulcers were facility-acquired or present on admission. The deficiency was further evidenced by specific care failures cited under related tags. For falls and safety, staff used the wrong size harness for a sit-to-stand mechanical lift transfer for one resident after that resident had previously fallen from a sit-to-stand lift and sustained minor injuries. The facility also failed to comprehensively investigate and analyze falls for root cause and to implement appropriate interventions to prevent or reduce the risk of future falls for another resident. For medication administration, one resident experienced a significant medication error when staff did not observe the rights of medication administration and gave the resident another resident’s medication, resulting in the resident becoming unresponsive, requiring hospitalization for hypotension, and developing an acute kidney injury. For pressure ulcer care, the facility failed to monitor, comprehensively assess, and develop and implement individualized interventions to prevent or mitigate the risk of pressure ulcers and prevent deterioration for three residents reviewed for pressure ulcers. One of these residents developed a Stage 2 sacral pressure ulcer that deteriorated to a Stage 3 ulcer. Interviews with the medical director and the administrator confirmed that, although the QAPI committee met monthly and reviewed data on wounds, falls, and medication errors, there were no current action plans addressing these issues, no minutes documenting discussions over the last four quarters, and no evidence that adverse outcomes were being analyzed and acted upon as outlined in the facility’s own written QAA/QAPI plan.
Failure to Notify Physician After Resident Syncopal Episode
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of a resident’s change in condition following a syncopal episode. The resident had multiple significant diagnoses, including pneumonia, acute respiratory failure, chronic heart failure, chronic kidney disease, atrial fibrillation, and syncope, and the admission MDS indicated no cognitive deficits. On 4/3/26, a trained medication assistant (TMA-A) assisted the resident to stand with a gait belt; upon rising, the resident leaned forward, went limp, and was lowered back into a recliner. The resident then opened his eyes and spoke. TMA-A immediately called for assistance via walkie talkie, and LPN-A, LPN-B, and the RN nurse manager (RN-NM) responded. A health status note later documented that the resident had passed out for a few seconds during the transfer and that a nurse was notified and evaluated the resident. Despite this documented change in condition, there was no indication in the resident’s record that the physician was notified on the day of the event. LPN-A reported that when she entered the room the resident was alert, and she left because it was the end of her shift, stating that a provider should be updated any time a resident has a change in condition. LPN-B stated she responded to the call, found the resident alert and following commands, but did not check vital signs, did not notify the provider, and did not complete a nursing note, explaining there was a lot going on that shift; she also acknowledged that a note and provider notification should occur with a change in condition. RN-NM stated that when she entered, the resident was alert and LPN-B was obtaining vital signs, and confirmed there was no nurse’s note or provider notification documented, despite the resident not having had such an episode previously at the facility. The DON stated the provider should have been notified the day of the event because it was a significant change from baseline, and the physician later reported learning of the dizziness episode days afterward during routine rounds, stating she would have wanted immediate notification. The facility’s Change of Condition policy instructed staff to notify the physician in the event of a status change.
Failure to Document Assessments After Significant Medication Error
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete, accurate, and readily accessible medical record for a resident who experienced a significant medication error. The resident had diagnoses including heart failure, transient cerebral ischemic attacks, and use of anticoagulants, and was documented on the admission MDS as having moderate cognitive impairment and taking an anticoagulant. On the date of the incident, a progress note recorded that a trained medication aide notified the nurse that the resident had been given another resident’s medications by mistake. A medication error incident report documented that the resident had inadvertently received another resident’s medications and subsequently became unresponsive, requiring transfer to the emergency department. A later progress note described the resident as unresponsive, with eyes closed and not responding to verbal commands, and only a facial grimace in response to a sternal rub, along with recorded vital signs and the decision to call an ambulance. During interview, the LPN on duty stated that she had taken the resident’s vital signs multiple times and performed assessments after the medication error but did not enter any of these vital signs or assessments into the electronic health record. The DON confirmed that these vital signs and assessments should have been documented in the resident’s record to ensure it was complete and accurate, consistent with the facility’s Charting and Documentation Policy, which requires documentation of services provided, changes in condition, and events or incidents involving the resident, and specifies that documentation must be objective, complete, and accurate.
Failure to Assess and Monitor Non-Pressure Skin Injuries and Implement Interventions
Penalty
Summary
The facility failed to comprehensively assess and monitor non-pressure related skin impairments for three residents reviewed for injuries, and did not ensure appropriate interventions were in place to reduce bruising for a resident at risk due to anticoagulant therapy. One resident with diagnoses including heart failure, diabetes, and atrial fibrillation was on anticoagulant medication and had a care plan identifying risk for bruising. Despite documentation of a large bruise on the right upper arm after hitting bed rails, there was no evidence of ongoing monitoring or assessment of the bruise, nor were protective pads placed on the bed rails as recommended. Additionally, new bruising observed on the left forearm was not communicated to the physician, and protective sleeves were not included in the care plan or consistently used. Another resident with chronic kidney disease experienced an unwitnessed fall resulting in multiple bruises on the lower back. The initial assessment documented the presence and size of the bruises but lacked comprehensive details such as units of measurement, specific locations, and characteristics. The care plan was not updated to reflect the injuries, and there was no evidence of ongoing monitoring or documentation of the bruises' progression. Nursing staff interviews confirmed a lack of clear protocol for monitoring bruises, and the DON acknowledged that comprehensive assessments and care plan updates were not completed as expected. A third resident with a history of falls and other chronic conditions sustained a hematoma on the forehead and a skin tear after a fall. The records did not show a comprehensive assessment or ongoing monitoring of the hematoma or bruise. Observations confirmed the presence of a healing bruise, but documentation was incomplete regarding color, pain, and progression. The DON confirmed that physician notification and monitoring orders were not present in the records, and the facility's own policy requiring comprehensive skin assessments and documentation was not followed.
Failure to Assess, Implement, and Monitor Fall Prevention Interventions
Penalty
Summary
The facility failed to comprehensively assess and evaluate the causal factors for falls and did not develop or monitor the effectiveness of appropriate interventions to reduce the risk of falls for three residents. For one resident with dementia, muscle weakness, and a history of falls, the care plan required staff assistance for transfers and toileting, but the resident frequently self-transferred and toileted independently. Staff interviews revealed that the resident rarely used the call light for assistance, and staff were aware of her self-transferring but did not address it or reassess her needs. The fall investigation documentation was incomplete, with missing root cause analysis and lack of follow-up on intervention effectiveness. The care plan and fall risk assessments were not updated to reflect the resident's actual behaviors and risks, and interventions such as 'call, don't fall' signage were not appropriate for her cognitive status. Another resident with heart failure, diabetes, and atrial fibrillation, who required maximum assistance for transfers and was on anticoagulant therapy, experienced a fall resulting in minor injuries. The fall record and care plan did not include a comprehensive analysis or root cause of the fall, and the intervention implemented was limited to signage. During observation, the resident's call light was found out of reach, and the resident was unable to request assistance when needed, directly contradicting the care plan intervention to keep the call light within reach. A third resident with a history of falls and severe cognitive impairment also experienced deficiencies in the implementation of fall prevention interventions. The facility failed to ensure that identified interventions were consistently implemented and did not reassess or monitor the effectiveness of interventions after falls occurred. Across all cases, documentation was incomplete, care plans were not updated to reflect current risks and needs, and staff did not consistently follow or reassess interventions, leading to repeated deficiencies in fall prevention and supervision.
Improper Catheter Insertion and Monitoring Leads to Resident Harm
Penalty
Summary
A deficiency occurred when a resident with a history of urinary retention, diabetes mellitus, and chronic kidney disease experienced improper insertion of an indwelling urinary catheter. The resident had a care plan in place to prevent catheter-related trauma, with interventions including care per orders, proper positioning of catheter and tubing, and monitoring for signs of urinary tract infection. Despite these interventions, the resident's catheter was changed to a larger size following complaints of leakage, but the process was not properly documented or assessed. There was no physician order documented for the catheter flush or the size change, and the assessment of catheter placement and the resident's tolerance to the procedure was not completed. The nurse who inserted the new catheter did not confirm urine return before inflating the balloon, which is a critical step to ensure proper placement in the bladder. The nurse also lacked competency training for catheter insertion and was unaware of the correct procedure. After the catheter was inserted, the resident experienced significant pain, hematuria, and eventually developed a urinary tract infection. Staff failed to monitor the resident's urinary output, pain, and catheter patency following the procedure, and there was a lack of communication among staff regarding the resident's condition and the absence of urine return after catheter insertion. Subsequent medical evaluation revealed that the catheter balloon had been inflated within the urethra, causing urethral perforation, hematuria, and infection. The resident required hospitalization, intravenous antibiotics, and urology consultation. Documentation and interviews confirmed that staff did not follow proper catheter insertion protocols, did not obtain necessary physician orders, and did not perform or document ongoing assessments or monitoring after the procedure, all of which contributed to the resident's harm.
Failure to Implement Enhanced Barrier Precautions and Hand Hygiene
Penalty
Summary
The facility failed to ensure that enhanced barrier precautions (EBP), specifically the use of gown and gloves during high-contact resident care activities, were consistently implemented for residents requiring these precautions. Observations revealed that staff did not use gowns or gloves when providing care to residents with wounds, foley catheters, or other conditions necessitating EBP, despite signage indicating the need for such precautions. For example, a nursing assistant provided feeding assistance and removed clothing protectors for residents with wounds and catheters without donning the required protective equipment or performing hand hygiene before or after care. In another instance, a licensed practical nurse repositioned a foley catheter bag and applied lotion to a resident's feet, initially using only gloves and not a gown, before later donning both for a transfer. Additionally, the facility did not ensure proper hand hygiene practices were followed. Staff were observed failing to perform hand hygiene before and after direct resident contact, after removing gloves, and when moving between residents or care activities. These lapses occurred even though the facility's policies and posted signage required such practices, and both the infection preventionist and director of nursing confirmed that their expectations were for staff to adhere to EBP and hand hygiene protocols. The facility was unable to provide a copy of its Enhanced Barrier Precaution Policy when requested.
Failure to Provide Dignified Dining Experience for Non-Communicative Resident
Penalty
Summary
A resident with Alzheimer's disease and malnutrition, who was unable to communicate needs due to advanced dementia and required extensive assistance with eating, was observed during breakfast sitting at a table with other residents. The resident was not feeding herself and was intermittently assisted by a nursing assistant who stood while feeding her a spoonful of oatmeal before leaving to assist other residents. The nursing assistant returned only briefly to provide another bite before leaving again, resulting in the resident sitting unattended for an extended period with her meal in front of her. Interviews with staff confirmed that the usual practice was to sit with the resident and provide attentive, uninterrupted assistance during meals, but on this occasion, staff were passing trays and only provided sporadic help. The facility's social services director and administrator both stated that staff should sit with residents needing assistance and engage with them to ensure a dignified and respectful dining experience. The facility's policy also states that residents have the right to be treated with respect, kindness, and dignity.
Incomplete and Inaccurate Medical Records Due to Gaps in EHR Integration
Penalty
Summary
The facility failed to maintain a complete, accurate, and readily accessible medical record for a resident with a history of urinary retention, diabetes mellitus, and chronic kidney disease. Multiple gaps were identified in the resident's electronic health record (EHR), including missing physician orders for an indwelling urinary catheter, absent hospital history and physical or discharge summaries following hospitalizations, and lack of documentation from an outpatient urology visit. Staff interviews revealed uncertainty and inconsistency in the process for obtaining, reviewing, and uploading external medical records into the facility's EHR. Some nurses did not have access to outside medical records, and the health unit coordinator (HUC) relied on nursing staff to provide documents for scanning, which did not always occur. The facility's policy on electronic health records did not specify procedures for ensuring the completeness and accuracy of resident records. The director of nursing (DON) confirmed that only a portion of nurses could access external EHRs and that there was no established policy or procedure for integrating this information into the facility's records. As a result, important medical information, such as orders and provider notes, was not consistently included in the resident's chart, leading to incomplete and inaccurate documentation.
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A resident with dry eye syndrome and degenerative eye disease had orders for cyclosporine ophthalmic emulsion and Refresh Tears, both scheduled at the same time. Medication records and direct observation showed a TMA instilled cyclosporine drops in both eyes and immediately followed with Refresh Tears in both eyes without waiting between medications. This practice conflicted with referenced professional guidance recommending several minutes between multiple eye drops and with the medical provider’s recommendation to wait fifteen minutes between the two ophthalmic medications. No facility policy on ophthalmic medication administration was provided when requested.
A resident with severe cognitive impairment, impaired mobility, and high fall risk was care planned to have wheelchair footrests in place at all times, with staff ensuring proper positioning and monitoring for leaning during transport. A NA transported the resident in a manual wheelchair from the shower without the footrests, and while going through the doorway the wheelchair struck the door frame, causing the resident, who was leaning forward, to fall out. The resident sustained a T12 fracture, head injury with concussion, abrasions and contusions, and multiple right-hand lacerations requiring sutures, and the DON confirmed the care plan had not been followed.
A high‑risk, immobile resident with MS and prior heel DTI developed an avoidable unstageable coccygeal pressure ulcer after staff failed to consistently assess and document skin status, did not transfer or timely provide ordered pressure‑relieving mattresses, and did not reliably perform q2h repositioning. The resident was repeatedly left on a bedpan for prolonged periods despite early reports of this issue, and the toileting care plan was not revised to a bedside commode until after the coccygeal wound had significantly worsened. Wound assessments lacked complete measurements and staging, changes in wound size and color were not promptly recognized as deterioration or reported to providers, and recommended interventions from a wound NP (including an air mattress and offloading) were not promptly implemented. As a result, the coccygeal ulcer rapidly progressed to a large, necrotic, malodorous wound requiring hospital transfer and surgical debridement.
A resident with spastic hemiplegia, muscle weakness, and moderate cognitive impairment was observed using bilateral bed grab bars for bed mobility and transfers, but the care plan did not address grab bar or side rail use. Review of the EMR showed no completed bed mobility device or side rail assessment to determine the necessity or safety of the grab bars, and no documentation that risks and benefits were discussed or that informed consent was obtained. An LPN and the ADON stated that a bed mobility device assessment is required before grab bars are installed and confirmed that no such assessment existed for this resident.
A resident with bilateral heel pressure ulcers and multiple comorbidities received wound care during which an RN removed dressings from both heels, cleansed both wounds, and wiped each heel without changing gloves or performing hand hygiene between wounds or after disposing of soiled dressings. This practice conflicted with the facility’s written wound care procedure, which requires glove removal and hand hygiene after dressing removal and after wound cleansing. In interviews, the RN, NP, and DON/IP acknowledged that hand hygiene and glove changes are expected between dirty and clean tasks and between separate wounds to prevent infection.
A resident with MS, neurogenic bladder, mobility limitations, and existing pressure injuries was identified as dependent for toileting hygiene and at risk for pressure ulcers, yet the care plan lacked an individualized toileting/incontinence plan and a defined repositioning schedule. Despite a new coccyx pressure ulcer and documentation that interventions such as increased repositioning and incontinent care were needed, the care plan was not revised for a period of time to reflect these changes. During this time, the resident sometimes fell asleep on a bedpan and remained on it until staff removed it, and staff were not initially informed that the bedpan should no longer be used. The DON later acknowledged that the care plan revisions for turning, repositioning, and toileting were delayed until after the resident’s coccyx ulcer had significantly worsened.
A resident with diabetes, Crohn’s disease, bowel incontinence, and a history of MASD on the right gluteus developed an open, painful lesion on the right gluteal area that was documented over time without complete wound characteristics, clear etiology, or timely provider notification. Wound care orders were written for a stage 3 pressure ulcer on the left buttocks, while staff reported the wound was only on the right side and applied the left‑sided orders to the right gluteal wound in the absence of specific right‑side treatment orders. The DON acknowledged discomfort with staging the wound, lack of early physician notification, and confusion over wound classification, despite a facility policy requiring comprehensive wound assessment, consistent measurement, and provider notification when treatment orders are absent.
A resident with diabetes, chronic leg ulcer, kidney transplant, and a documented gluteal wound was care-planned for Enhanced Barrier Precautions (EBP), with posted instructions requiring gown and gloves for high-contact care such as transfers and wound care. During a telehealth wound assessment, the DON donned a gown and initially performed hand hygiene but then applied gloves without hand hygiene, removed a soiled dressing from the resident’s gluteal area, discarded it, removed gloves, and applied new gloves again without performing hand hygiene between glove changes. On another occasion, during use of a sit-to-stand lift, an NA wore gown and gloves, but the DON handled the lift harness, the resident’s clothing, and assisted with the transfer and repositioning while wearing a gown but no gloves, despite EBP requirements for transfers. The DON stated EBP was only needed for catheter or wound care and not for transfers, contradicting the posted EBP instructions and facility policy.
A resident with severe dementia, psychiatric disorders, and high dependence for ADLs was verbally abused during evening care when a NA, frustrated with the resident’s crying and resistance, loudly ridiculed her as acting like a two-year-old, threatened to hit her back if struck, told her she would be sent to a locked unit, and questioned who would want to care for her when she cried like a baby. Multiple staff witnessed the loud, stern, and intimidating tone and reported it to an LPN, who recognized it as verbal abuse but did not immediately remove the NA from duty or promptly report the allegation per policy, allowing the NA to continue working on the unit. Following this incident, the resident demonstrated increased crying, combativeness, resistance to care, wandering, self-isolation, and refusal of food, fluids, and medications above baseline, with documentation of significant emotional distress and subsequent ED evaluation for aggressive behaviors and poor intake.
A resident with dementia, bilateral above‑knee amputations, vascular disease, and severe protein‑calorie malnutrition developed a wound on an amputation stump that had a dressing dated several days before any documentation or treatment orders appeared in the record. Although bath audits and nursing notes initially reported no skin issues, a later assessment described a full‑thickness stage 4 ulcer/diabetic ulcer on the stump with exposed bone, erythema/edema, slough, and moderate serosanguineous drainage. Nursing staff interviews showed no one could identify who first discovered the wound or applied the initial dressing, and there was no evidence that the wound was assessed, the provider notified, or standing orders implemented when it was first present, despite facility expectations that new wounds be promptly evaluated and reported.
Failure to Follow Professional Standards for Ophthalmic Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice for administering ophthalmic medications to a resident with dry eye syndrome and degenerative eye disease. The resident was cognitively intact, required assistance with ADLs, and had physician orders for cyclosporine ophthalmic emulsion 0.05% one drop in both eyes twice daily and Refresh Tears ophthalmic solution one drop in both eyes four times daily for dry eyes. The administration summary showed that both eye medications were scheduled for the same time and were documented as being given at the same time on multiple dates. During a medication pass observation, a trained medication aide administered the ordered oral medications, then applied gloves and instilled one drop of cyclosporine in each eye, immediately followed by one drop of Refresh Tears in each eye, without any waiting period between the two medications. The surveyors referenced guidance from the American Academy of Allergy, Asthma, and Immunology stating that when more than one eye drop is ordered, three to four minutes should be allowed between drops in the same eye, and five to fifteen minutes should be allowed between different eye medications to prevent dilution. Interviews with the DON, pharmacy consultant, and medical provider confirmed that best practice and the provider’s recommendation were to wait between administration of cyclosporine and Refresh Tears, with the medical provider specifying a fifteen-minute interval. The facility did not provide a policy on ophthalmic medications when requested. The observed practice and documented administration times demonstrated that staff did not follow these professional standards or the medical provider’s recommended interval between the two eye medications.
Failure to Follow Wheelchair Transport Care Plan Leads to Fall With Injuries
Penalty
Summary
The deficiency involves the facility’s failure to implement care-planned fall prevention interventions for a resident at high risk for falls, resulting in a fall with injury. The resident had diagnoses including aphasia, dysphagia, muscle weakness, traumatic brain injury, and impaired mobility, with severe cognitive impairment documented on the MDS and dependence on staff for transfers and wheelchair transport. A care plan addressing wheelchair transport safety and positioning directed staff to ensure the resident was fully positioned and supported in the wheelchair prior to transport, verify footrests were in place prior to transport, and monitor for leaning, sliding, or unsafe positioning. An additional care-planned approach required wheelchair pedals to be on at all times. On the date of the incident, a nursing assistant transported the resident in a manual wheelchair from the shower room to the resident’s room without the foot pedals in place, contrary to the care plan. While being wheeled through the doorway, the wheelchair struck the door frame, causing the chair to stop and the resident, who had begun leaning forward, to fall out of the wheelchair onto the floor. Progress notes and ED documentation identified that the resident sustained a T12 vertebral fracture, a head injury with concussion, an abrasion and contusion to the head, a bruise to the left knee, and multiple lacerations to the right hand requiring sutures. The nursing assistant later acknowledged awareness that the foot pedals should have been on but did not apply them because the transport was only from the shower to the room. The DON confirmed that the resident’s care plan had not been followed when the fall occurred.
Failure to Implement and Update Pressure Ulcer Prevention and Treatment Led to Avoidable Unstageable Coccygeal Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, monitor, and implement individualized pressure ulcer prevention and treatment interventions for multiple high‑risk residents, resulting in an avoidable, unstageable coccygeal pressure ulcer for one resident that required surgical debridement and hospitalization. The resident had primary progressive multiple sclerosis, hereditary spastic paraplegia, obesity, and pre‑existing pressure‑related deep tissue injury to the left heel, and was identified as high risk for pressure ulcers on the Braden Scale due to constant moisture, chairfast status, very limited mobility, inadequate nutrition, and friction/shear risk. Hospital records on readmission documented irritant contact dermatitis of the bilateral gluteal cleft with specific cleansing and barrier cream orders, and facility documentation showed the resident could not reposition in bed or chair and required assist of two and a full‑body mechanical lift for transfers. Despite this, the admission/readmission skin assessment and weekly skin checks lacked measurements and detailed wound characteristics for the heel ulcer and gluteal dermatitis, and the care plan did not include comprehensive, individualized interventions beyond generic repositioning and wound care orders. After a new coccyx pressure ulcer was identified and documented as a stage 2 lesion, the facility failed to promptly and accurately update the care plan and implement recommended pressure‑relieving interventions. The wound nurse practitioner on 3/5 ordered coccyx wound care, an air mattress, pressure offloading, and a dietician consult, but the care plan was not revised and there was no evidence that an air mattress was placed on the bed for nearly two weeks. The environmental services director later confirmed that when the resident was moved to a new room, the gel mattress was not transferred, and the air mattress requested on 3/17 was not actually placed until the following day, despite being marked as completed. During this period, TAR documentation showed gaps in the every‑2‑hour repositioning order, and staff interviews revealed that CNAs were unaware of which residents were on repositioning programs, were not consistently repositioning residents, and had not received recent education on pressure ulcer prevention. The DON and RN case manager acknowledged that the coccyx wound increased in size and changed color between assessments, that the bed lacked the ordered gel mattress, and that the physician was not notified of the wound’s deterioration at that time. The facility also failed to timely modify toileting and incontinence care practices despite knowledge that the resident was being left on a bedpan for extended periods. The DON reported hearing before an IDT meeting that the resident had fallen asleep on a bedpan for an undetermined amount of time, but the care plan was not revised to discontinue bedpan use and implement a bedside commode until after the coccyx wound had significantly worsened. CNAs confirmed that the resident sometimes fell asleep on the bedpan and that they were not informed she should no longer use it until after the sore had worsened. Subsequent wound assessments documented rapid progression of the coccyx wound from a small stage 2 ulcer to a large, malodorous, necrotic wound with eschar, slough, erythema, and purulent drainage, ultimately classified as an unstageable pressure ulcer. The DON, NP, PA, and medical director all indicated that the lack of a pressure‑relieving mattress, failure to adjust pressure‑reducing interventions, and prolonged time on a bedpan likely contributed to the development and deterioration of the resident’s pressure ulcer, which was determined to be avoidable and resulted in hospitalization and surgical debridement. Additional documentation and interviews showed systemic assessment and communication failures related to pressure ulcer management. Weekly skin checks and wound assessments often omitted complete measurements, staging, and wound characteristics, and changes in wound size and appearance were not consistently recognized as deterioration or communicated to providers. The DON acknowledged that a 3/12 assessment showing increased wound size and purple discoloration should have been identified as a deep tissue injury and reported to the physician, but this did not occur. When nursing later documented foul odor, increased pain, and expanding necrotic tissue, telemedicine and PA responses deferred in‑person evaluation and ED transfer despite earlier recommendations that the resident be sent to the ED if an in‑person provider could not assess the wound. The NP ultimately found a large, malodorous, purulent wound with expanding eschar and ordered transfer to the hospital, where imaging and surgical findings confirmed a large necrotic sacral wound requiring extensive debridement. Throughout this sequence, the facility did not consistently follow its own pressure ulcer protocols, did not ensure ordered pressure‑relieving equipment was in place, and did not promptly revise care plans or interventions in response to known risk factors and documented wound changes. The report also notes that other residents reviewed for pressure ulcers were affected by similar failures in monitoring and individualized intervention, though detailed narratives focus primarily on this resident. Staff interviews revealed that CNAs relied on paper care guides that did not clearly identify residents on repositioning programs or at risk for skin breakdown, and that they were unaware of some residents’ special mattress orders or toileting restrictions. The DON and medical director stated that residents at risk for pressure ulcers should have immediate pressure‑relieving interventions and that existing ulcers require ongoing evaluation to prevent deterioration, but the documented practices for this resident did not align with those expectations. These combined actions and inactions—insufficient assessment detail, delayed or missing care plan revisions, failure to implement ordered support surfaces and repositioning, and delayed response to wound deterioration—constituted the deficiency in providing appropriate pressure ulcer care and preventing new ulcers from developing.
Failure to Assess, Care Plan, and Obtain Consent for Bed Grab Bar Use
Penalty
Summary
The deficiency involves the facility’s failure to follow required procedures before installing and using bed grab bars for a resident. The resident had diagnoses including spastic hemiplegia affecting the left side and muscle weakness, and an admission MDS indicating moderate cognitive impairment. During observation, the resident was seen in a power chair with bilateral grab bars on the bed and reported using them to roll in bed and for transfers. The resident’s care plan, dated 1/23/26, documented a need for assistance with bed mobility and independence with transfers but did not mention or address the use of grab bars or side rails. Review of the electronic medical record showed no completed grab bar/side rail or bed mobility device assessment to determine the necessity of the grab bars or whether the resident could safely use them. There was also no evidence that the resident or the resident’s representative had been educated on the risks of having a grab bar on the bed or that informed consent had been obtained. In interviews, an LPN and the ADON both stated that a bed mobility device assessment was required to determine need and safety prior to installing grab bars, and both confirmed that no such assessment was present in the resident’s record.
Failure to Perform Hand Hygiene and Change Gloves During Wound Care
Penalty
Summary
Surveyors observed that a registered nurse (RN) and a nurse practitioner (NP) did not follow the facility’s established infection control practices during wound care for one resident. During a wound treatment, the RN wore gloves while removing the dressing from the resident’s left heel, then removed the dressing from the right heel, sprayed both wounds with wound cleanser, wiped the left heel with gauze, and then used a clean gauze pad to wipe the right heel. The RN did not remove her gloves or perform hand hygiene after disposing of the soiled dressings or between cleaning the left and right heel wounds, contrary to the facility’s written wound care procedure, which requires glove removal and hand hygiene after removing the previous dressing and again after cleaning the wound. The resident’s admission MDS documented diagnoses including multiple rib fractures, heart failure, dementia, anxiety, and the presence of a pressure ulcer, and indicated the resident was cognitively intact and required staff assistance with care and transfers. The resident’s care plan identified pressure ulcers on both heels requiring wound care. In interviews, the RN, NP, and the DON/infection prevention nurse each stated that gloves should be changed when moving from dirty to clean areas and that hand hygiene is expected after glove removal and between wounds to prevent infection, confirming that the observed practice did not align with facility policy or expected infection control standards.
Failure to Timely Revise Care Plan for Toileting and Skin Integrity
Penalty
Summary
The deficiency involves the facility’s failure to timely revise and individualize a resident’s care plan to address toileting and incontinence needs in relation to impaired skin integrity. The resident had diagnoses including primary progressive multiple sclerosis, hereditary spastic paraplegia, obesity, and a pressure-induced deep tissue injury to the left heel. A Significant Change MDS identified the resident as dependent for toileting hygiene, with lower extremity range-of-motion limitations, wheelchair use, dependence for transfers, occasional urinary incontinence, intact cognition, and at risk for pressure ulcers with existing unhealed pressure injuries and MASD. The resident’s skin-focused care plan, revised on various dates, included skin inspections, wound care orders, weekly skin checks, pressure ulcer care to the left heel, nutritional supplements, and a gel mattress, but did not include an individualized toileting or incontinence plan. On a weekly skin check dated 3/3/26, nursing staff identified a new Stage 2 pressure ulcer on the coccyx and contact dermatitis on both gluteal folds. An IDT Final Post Review Follow Up dated 3/10/26 (signed 3/23/26) documented that a new skin issue had occurred and that interventions after the incident included wound care treatment orders, increased repositioning, and increased incontinent care. However, the resident’s care plan from 3/3/26 through 3/16/26 did not show revisions reflecting increased incontinence care or a repositioning schedule, and the care plan was not updated to include these elements until 3/17/26. During this period, the care plan still lacked an individualized toileting plan despite the resident’s identified incontinence and new coccyx pressure ulcer. Progress notes on 3/17/26 documented that the resident’s coccyx wound had declined, with an evaluation describing a deteriorating wound characterized as a Kennedy terminal ulcer/End of Life, staged as a Stage 4 pressure ulcer, in-house acquired, with increased size, exudate, odor, pain, and surrounding erythema. On that same date, the skin focus care plan was revised to include prompt incontinence care and keeping the skin clean and dry, and the elimination focus care plan was revised to address incontinence due to neurogenic bladder with use of a bedside commode offered every 2–3 hours. A nursing assistant reported that when working with the resident, the resident would sometimes fall asleep on the bedpan and forget to ask staff to remove it, and that she was not aware the resident was not supposed to use the bedpan until after the sore had worsened. The DON stated that the resident’s care plan had not been revised earlier to include a turning and repositioning schedule or toileting changes, and that it should have been revised as soon as staff learned the resident was falling asleep on the bedpan, rather than waiting until after the pressure ulcer worsened.
Failure to Assess and Notify Provider for Right Gluteal Wound
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess and appropriately manage a non‑pressure skin issue on a resident’s right gluteal area, and to notify the physician in a timely manner. The resident had diagnoses including diabetes, Crohn’s disease, and a kidney transplant, and the MDS indicated occasional bowel incontinence, no pressure ulcers, and no moisture‑associated skin damage at that time. Earlier documentation identified a resolved MASD to the right gluteus, and a progress note later described a sacral wound with creams applied, noting that sores were still open and painful during application, but without any measurements, wound characteristics, or evidence of physician notification. Subsequent wound assessments documented an open lesion on the right gluteus with specific measurements on multiple dates, but did not identify the wound type or other characteristics, and the record did not show physician notification or treatment orders for the right gluteal lesion. Provider orders in place initially addressed cleansing the buttocks and applying barrier cream, and later included a detailed wound care order for a stage 3 pressure ulcer documented on the left buttocks. However, the resident’s record did not contain a specific treatment order for the right gluteal wound, despite the ongoing documentation of an open lesion in that area. Interviews revealed confusion and inconsistency in wound identification and classification. The DON stated that the right gluteal wound was documented as an open lesion because she did not feel comfortable determining the wound type, and acknowledged that the physician should have been notified when the wound was first identified. The DON was unaware that the NP had documented the wound as being on the left buttocks and as a stage 3 pressure ulcer, while the RN reported that the wound had never been on the left buttocks and that she had been applying the left‑sided wound orders to the right gluteal area because there was no open area on the left. The resident reported a recurring painful area on the right buttocks and chronic stool leakage since prior anal fistula surgery. The facility’s own wound treatment policy required comprehensive assessment of wound etiology and characteristics, consistent measurement and documentation, and provider notification in the absence of treatment orders, which were not followed for this resident’s right gluteal wound. The deficiency centers on the lack of a comprehensive wound assessment for the right gluteal lesion, incomplete documentation of wound characteristics, failure to clearly determine and document the wound etiology, and failure to notify the physician and obtain appropriate treatment orders when the wound was identified and remained open. These actions and inactions resulted in a discrepancy between the documented wound location and type and the actual clinical presentation, as well as a period during which the right gluteal wound had no specific, clearly ordered treatment despite being open and painful.
Failure to Perform Hand Hygiene and Implement Enhanced Barrier Precautions During Wound Care and Transfers
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper hand hygiene during wound care and to consistently implement Enhanced Barrier Precautions (EBP) for a resident requiring such measures. The resident had diagnoses including diabetes, a non-pressure chronic ulcer of the right lower leg, and a kidney transplant, and a wound assessment documented an open lesion on the right gluteal area. The resident’s care plan and a sign posted outside the room specified that EBP, including gown and gloves, were required for high-contact care activities such as dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, catheter care, and wound care. During one observation, the DON performed hand hygiene and donned a gown before entering the resident’s room for a telehealth wound assessment. Inside the room, the DON went into the bathroom, applied gloves without performing hand hygiene, removed the resident’s brief, and removed a foam dressing from the right gluteal area that had stool on one corner. After discarding the soiled dressing, the DON removed gloves and then applied new gloves without performing hand hygiene between glove changes. When questioned, the DON stated that hand hygiene should be done when hands or gloves are visibly soiled and before and after removing or applying gloves, and acknowledged that hand hygiene had not been performed each time gloves were removed and reapplied. In a separate observation, the resident was transferred using a sit-to-stand mechanical lift while EBP requirements were not fully followed. An NA entered the room wearing a gown and gloves with the lift, and the DON applied the lift harness under the resident’s arms and cinched the waist strap, encountering the resident’s clothing, while not wearing gloves. After the transfer to bed, the DON pulled down the resident’s pants and removed the harness while touching the resident’s clothes. Following wound care by a CNP-WOC, the DON again assisted the resident by sitting the resident on the edge of the bed, applying the lift harness, and adjusting the resident’s pants and shirt while wearing a gown but no gloves. The DON stated that EBP was only needed for catheter or wound care and not for transfers, and only upon reading the posted EBP sign acknowledged that EBP was required for all high-contact resident care activities, including transfers.
Failure to Protect Resident From Verbal Abuse and Delay in Removing Alleged Perpetrator
Penalty
Summary
The deficiency involves the facility’s failure to protect a vulnerable resident from mental abuse and to respond appropriately to an allegation of abuse. The resident had severe cognitive impairment, Alzheimer’s disease, dementia, anxiety, depression, psychotic disorder, and significant functional dependence, including frequent incontinence and the need for extensive assistance with ADLs and transfers. Her care plan identified behavioral and mood issues such as wandering, yelling, combative behavior, and calling staff names, with interventions including calm approaches, emotional support, redirection, and monitoring for emotional distress and mood/behavior changes. She was identified as a vulnerable adult, with instructions to monitor for signs of emotional distress and to follow the facility’s abuse reporting policy. On the evening in question, while the resident was crying on the phone with her son and expressing a desire to leave, NA-A and NA-B entered to provide evening care using an EZ stand lift. After the resident ended the phone call, multiple staff reported that NA-A spoke to the resident in a loud, stern, and frustrated tone, telling her to stop crying and that she was acting like a two-year-old. When the resident swatted at NA-A, NA-A stated, “If you hit me, I’m going to hit you back,” and later told the resident she was “in trouble now.” Staff reported that NA-A told the resident she would be sent to a locked unit so she could not get out, and questioned who would want to care for her when she cried like a baby, and that nobody would want to keep working with her. NA-C described NA-A yelling commands such as “HOLD ON!” and “Stop crying! Where would you be if you were not here? Probably lying on the floor,” and felt NA-A was obviously upset and overwhelmed. These statements were made in the presence of the resident while she was already distressed and crying. Following this interaction, the resident exhibited crying, yelling, combativeness, resistance to care, wandering into other residents’ rooms, self-isolation, and refusal of food, fluids, and medications above her prior baseline, as documented in behavior charts, target behavior monitoring, and nursing progress notes. Staff documented that she cried most of the morning, was very restless, difficult to redirect, hit and pinched staff, called staff names, and refused care and meals. She required repeated redirection, 1:1 attention, and non-pharmacological interventions, and was ultimately sent to the ED for evaluation of combativeness and emotional distress, where she was treated for dementia with aggressive behavior and hypoglycemia related to poor intake. The report identifies that the resident’s actual response and the reasonable person concept showed serious psychosocial harm, including increased crying and combative behavior above baseline, fear/anxiety manifested as combativeness, resistance to care and social interaction, and self-isolation. The facility also failed to immediately remove the alleged perpetrator from resident care and to promptly report and investigate the allegation in accordance with its abuse policy. After NA-B and NA-C reported to LPN-A that NA-A had yelled at and threatened the resident, LPN-A acknowledged it as verbal abuse but did not initiate immediate protective measures or timely reporting. LPN-A stated she believed she had 24 hours to report because there was no injury, despite facility policy requiring reporting within two hours. NA-A remained on the unit and continued working until the end of her shift, including after staff had clearly communicated their concerns to LPN-A. TMA and NA staff described uncertainty about their authority to remove NA-A and reliance on the nurse to act, while the DON later informed LPN-A that NA-A should have been removed from the floor to prevent further danger to residents. The Immediate Jeopardy was determined to have begun when NA-A’s derogatory, intimidating, and threatening statements were made and continued while she remained on duty with access to the resident and other vulnerable residents.
Failure to Timely Assess and Treat Newly Discovered Stump Wound
Penalty
Summary
The deficiency involves the facility’s failure to provide timely treatment and care for a newly discovered wound on a resident’s above‑knee amputation stump. The resident was admitted with diagnoses including unspecified dementia with behavioral disturbances, vascular dementia, bilateral above‑knee amputations, vascular disease, reduced mobility, and severe protein‑calorie malnutrition, and had no documented ulcers or skin problems on admission or on the most recent MDS. A weekly bath audit on 3/17/26 documented only non‑tender lymph nodes on the right upper hip and did not identify any open areas. However, when the wound was later assessed, the dressing on the stump was dated 3/16/26, indicating that a wound and dressing existed at that time, even though no corresponding assessment, provider notification, or treatment orders were documented. On 3/23/26, nursing staff documented a new skin issue above the resident’s knee at the amputation site, describing a stage 4 pressure ulcer/injury with full‑thickness skin and tissue loss, exposed bone, erythema/edema, and moderate serosanguineous exudate. The wound measured 1.56 cm by 1.64 cm, with 20–29% granulation tissue and 80% slough. A progress note and skin issues assessment on that date confirmed the wound characteristics and staging, and the NP, after reviewing a picture, determined the wound to be a diabetic ulcer with peripheral vascular disease and severe protein‑calorie malnutrition as contributing factors. On that same date, the NP was notified, antibiotic therapy (doxycycline) was ordered for possible cellulitis, and specific wound care orders were initiated, with documentation on the MAR that these treatments were carried out beginning 3/23/26. Multiple interviews with nursing staff revealed that no one could identify who discovered the wound or who applied the initial dressing dated 3/16/26, and there was no documentation of a wound assessment, provider notification, or interim treatment between 3/16/26 and 3/22/26. Several RNs and LPNs who worked shifts from 3/16/26 through 3/20/26 stated they did not notice a wound on the stump and that, per their usual practice, they would have contacted the provider and initiated treatment if they had found one. One LPN recalled seeing a band‑aid with a date on the stump but could not recall the date, and another LPN stated she did not see the wound because she was not looking for one. The facility’s standing orders required staff to assess all wounds daily, change dressings every three days and as needed, treat with normal saline or non‑cytotoxic cleanser and appropriate dressings, and notify the provider the next business day when a new wound or injury was found. Despite these expectations, the wound identified by the dated dressing on 3/16/26 was not assessed, reported, or treated according to orders and facility policy until 3/23/26.
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