The Emeralds At St Paul Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Paul, Minnesota.
- Location
- 420 Marshall Avenue, Saint Paul, Minnesota 55102
- CMS Provider Number
- 245295
- Inspections on file
- 36
- Latest survey
- July 30, 2025
- Citations (last 12 mo.)
- 21 (1 serious)
Citation history
Health deficiencies cited at The Emeralds At St Paul Llc during CMS and state inspections, most recent first.
The facility did not obtain food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
A resident with severe cognitive impairment and chronic respiratory failure required mechanical ventilation, but the POLST form on file indicated DNR with selective treatment, including no mechanical ventilation, which conflicted with the resident's actual care. Nursing staff were unclear about the review process for POLST forms, and the form was not updated after significant changes in the resident's condition, despite facility policy requiring routine audits.
A resident with ALS, major depressive disorder, and ventilator dependence was prescribed clonazepam for anxiety, but staff did not identify or monitor target behaviors related to the medication. Nursing staff and the DON confirmed that there was no ongoing documentation of anxiety behaviors, despite facility policy requiring such monitoring for psychotropic medication use.
A resident with cognitive impairment and hemiplegia, dependent on staff for ADLs, was observed with excessively long fingernails and repeatedly requested nail care, which was not provided. Staff interviews revealed inconsistent understanding of nail care responsibilities, and documentation failed to show that nail care was performed or refused, despite facility policy requiring such care.
A resident with hemiplegia and severe contractures did not receive consistent application of a prescribed hand splint to maintain upper extremity range of motion. Staff were unaware of the splint order, documentation systems lacked prompts for splint use, and the splint had been missing for months without follow-up or replacement. No evidence was found of physician notification regarding pain or therapy involvement during the relevant period.
Staff did not deliver care or services in a manner that was trauma informed or culturally competent, failing to meet required standards for addressing residents' trauma histories or cultural needs.
A resident with a diagnosed mental disorder or history of trauma did not receive the necessary treatment and services to address their mental health or psychosocial needs, resulting in a deficiency related to individualized care requirements.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
A resident with quadriplegia and respiratory failure, who was fully dependent on staff, was observed multiple times without access to a call light within reach, despite facility policy and care plan requirements. The resident confirmed inability to activate the call light, and staff interviews verified the deficiency.
A resident did not receive appropriate care for existing pressure ulcers, and the facility did not take adequate steps to prevent new ulcers from developing, as observed and documented by surveyors.
A resident with severe cognitive and sensory impairments, who was fully dependent on staff and used eyeglasses and a pocket talker device continuously, did not have a care plan that addressed the risk of pressure ulcers from these devices. Despite assessments identifying the risk and staff confirming the resident's refusal to remove the devices, the care plan lacked interventions to prevent skin breakdown on the nose and ears.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in increased risk of accidents for residents.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident with multiple pressure ulcers returned from a hospital stay and did not receive comprehensive skin assessments or necessary wound care for several weeks. Despite clear hospital documentation and orders, staff failed to assess, monitor, or treat the wounds, and did not update care plans or communicate effectively with hospice. The resident experienced severe pain, untreated wounds, and lack of repositioning, with the deficiency only identified after surveyor intervention.
A resident receiving hospice care for a terminal condition experienced frequent, severe pain that was not effectively managed despite multiple pain medications and interventions. Staff failed to consistently assess, document, and communicate about the resident's pain, and the care plan did not address pain management needs. The resident often reported high pain levels, sometimes calling EMS and family for help, and was observed in significant distress during care. The facility lacked a coordinated system for pain management and did not provide a pain management policy when requested.
A resident with multiple pressure ulcers and severe pain did not receive necessary wound care or effective pain management due to a lack of communication and coordination between facility staff and hospice. Staff were unclear about their responsibilities, did not consistently assess or document wounds, and failed to report uncontrolled pain, resulting in untreated wounds and ongoing pain for the resident.
A resident with multiple pressure ulcers and wounds was not accurately assessed or documented in the facility's significant change MDS, despite clear evidence from hospital discharge records and direct observation. The MDS nurse did not perform a direct skin assessment or interview the resident, relying only on existing nursing documentation, which led to missed identification of wounds. Facility staff believed hospice was responsible for wound care, and the care planning policy lacked guidance for significant change assessments, resulting in incomplete documentation of the resident's condition.
The facility did not attempt alternative devices or conduct proper risk assessments before installing bed rails for two residents, failed to document the use of bed rails and specialty mattresses in care plans and MDS, and staff lacked awareness and training regarding bed rail safety and entrapment risks. Manufacturer guidelines for assessment and inspection were not followed, and the facility's policy did not address these requirements.
The facility did not perform regular, documented inspections of bed frames, mattresses, and bed rails for two residents using bed rails, resulting in a lack of assessment for entrapment risks and equipment compatibility. Staff interviews revealed inconsistent practices and unclear responsibilities regarding bed safety checks, and manufacturer guidelines for regular inspection and compatibility were not followed or documented.
A resident with severe cognitive impairment and a history of trauma expressed concerns about being harmed and was later observed ingesting wound cleanser, but staff failed to report or investigate the abuse allegation or the chemical ingestion, and did not notify the provider or poison control as required by facility policy.
A resident with severe cognitive impairment and a history of trauma made an abuse allegation and was later observed ingesting wound cleanser, but staff failed to document, investigate, or notify medical providers or poison control as required by facility policy. Interviews confirmed staff were unaware of the incidents and did not follow procedures for reporting or investigation.
A resident with severe cognitive impairment and ventilator dependence was not properly assessed or monitored after developing a bruise, ingesting wound cleanser spray, and experiencing repeated pulse oximeter alarms. Staff failed to document or investigate the bruise, did not notify a provider or poison control after the ingestion, and did not respond to multiple oximeter alarms, with no relevant policies provided.
The facility failed to ensure licensed nurses were adequately trained on vest and cough assist therapies, affecting residents with chronic respiratory conditions. Interviews revealed inconsistencies in staff training, and treatment records showed missed or improperly administered therapies. The facility lacked specific competencies and documentation for these treatments.
A facility failed to protect two residents from potential abuse by not adequately assessing their vulnerabilities for sexual abuse. One resident had mental health issues impairing judgment, while the other had a history of alcohol abuse and inappropriate sexual behavior. Despite these factors, the facility did not effectively monitor their interactions or assess their ability to consent to a sexual relationship. Staff were unsure of procedures to determine consent, and the facility's policy on abuse prevention was not effectively implemented.
The facility failed to implement care plans for two residents involved in inappropriate sexual behavior and alcohol use. Despite care plans requiring close monitoring, staff did not effectively intervene when the residents were found engaging in sexual activity. The care plans did not adequately address the residents' behavioral health needs, leading to a deficiency in supervision and safety.
The facility failed to administer medications according to physician orders and did not report medication errors for three residents. One resident received excess doses of oxycodone, while another had missing documentation for scheduled medications. The facility's medication administration record system did not prevent these errors, and staff interviews revealed a lack of adherence to established protocols.
A resident with intact cognition reported grievances regarding her roommate's care and an NA's behavior, but the facility failed to follow up with her. Despite the facility's grievance policy requiring documentation and resolution, the resident stated no one followed up on her concerns, and the administrator and social services were unaware of any documented follow-up.
Two residents were reported to have used crack cocaine on the facility's smoking patio, but the facility failed to assess or monitor them for potential life-threatening side effects and drug interactions. Staff were aware of the drug use but did not report it to administration or take appropriate actions, such as confiscating illegal substances or notifying the police. The facility's substance use policy was not effectively implemented, and the pharmacist and nurse practitioner were not informed of the residents' drug use, leading to a deficiency in ensuring a safe environment.
A resident with moderate cognitive impairment experienced verbal and emotional abuse by a family member, who engaged in inappropriate behavior and physical aggression. The facility failed to report the incident to the State Agency within the required timeframe, as the administrator did not initially consider the actions as reportable abuse.
A resident with complex medical needs, including diabetes and recent amputations, was discharged from a facility to a homeless shelter that could not meet his care requirements. The discharge plan was incomplete, lacking necessary assessments and instructions for medication and wound care management. The resident was left without adequate support, posing a risk to his health and safety.
A resident's ventilator alarmed 237 times over several hours without staff response, indicating high pressure or obstruction. Staff were occupied with other residents, and the facility lacked a policy for alarm response. The deficiency highlighted a gap in monitoring and responding to critical alarms.
The facility did not include ventilator-dependent residents in its facility-wide assessment, impacting resource allocation for their care. The FA tool assessed resident acuity based on ADLs and mobility but omitted specific needs of these residents. The DON acknowledged this omission and noted staffing requirements for the second floor. The RNC was unaware of the omission and the lack of an annual FA review.
A resident was allowed to self-administer inhalation medications without a proper self-administration assessment or provider order. The resident, who was cognitively intact and had multiple diagnoses, was found with a bottle of lotion at the bedside, which was not approved for self-administration. Staff interviews confirmed the lack of necessary documentation and orders, contrary to facility policy.
A resident with diabetes experienced multiple instances of elevated blood glucose levels, yet the facility failed to notify the physician as required by specific orders. The nurse manager cited frequent use of agency staff as a contributing factor to this oversight, and the director of nursing confirmed that all staff were expected to follow physician orders. The facility's policy on physician notification was not provided.
A resident with significant cognitive and physical impairments, including depression, did not have a comprehensive care plan with specific target symptom monitoring and interventions. The facility's documentation lacked behavior monitoring and non-pharmacological interventions, contrary to its policy on psychotropic medication use. Interviews with staff revealed inconsistencies in documenting behaviors and interventions, leading to inadequate care planning for the resident.
A resident was diagnosed with schizophrenia without proper documentation of symptoms as per DSM-5 criteria. Despite being on antipsychotic medication, the resident's records and staff observations did not show persistent symptoms of schizophrenia. The facility's policy on psychotropic medication use was not followed, and the diagnosis was questioned by medical staff.
A resident with a traumatic brain injury and respiratory failure was not provided with preferred activities, such as listening to Native American music, as noted in their care plan. Observations showed the resident's TV was often on a news channel, and staff were unaware of how to access the preferred content. The director of therapeutic recreation confirmed the TV's limitations and the absence of a policy for therapeutic recreation.
A facility failed to hold a blood thinner medication for a resident before a scheduled procedure, leading to its cancellation due to bleeding risks. Additionally, another resident on Amiodarone did not receive required thyroid and liver function tests, highlighting deficiencies in medication administration and monitoring processes.
A resident with a feeding tube was not consistently positioned with the head of the bed elevated as required, leading to deficiencies in care. The facility also failed to label and replace tube feeding equipment according to policy. Staff interviews confirmed these lapses, highlighting challenges in maintaining proper positioning due to the resident's involuntary movements.
A resident with a history of above-the-knee amputation due to diabetes did not receive timely referral and treatment for a well-fitting prosthetic leg. Despite being motivated to increase independence, the resident was not wearing the prosthetic due to discomfort and lack of adjustments. Facility staff were unaware of the resident's prosthetic needs, and there was no evidence of follow-up or communication to ensure the prosthetic was usable.
A facility failed to attempt gradual dose reductions (GDR) or provide adequate justification for a resident's psychotropic medication use. Despite the resident showing no cognitive impairment or significant behavioral issues, they were on routine antipsychotic medication without GDR attempts. The Care Area Assessment lacked documentation of target symptoms and interventions. A consultant pharmacist recommended a GDR due to inappropriate antipsychotic use, but no follow-up occurred. Staff interviews revealed documentation gaps, and the facility's policy on psychotropic medication use was not effectively implemented.
A resident with complex medical needs, including an indwelling catheter, had her catheter drainage bag placed on the floor, contrary to CDC guidelines. This practice was observed in a facility where staff interviews revealed inconsistent adherence to infection control protocols. The resident, who has a history of UTIs and was recently hospitalized for sepsis, is at high risk for infections, underscoring the importance of proper catheter management.
The facility failed to ensure two residents received the pneumococcal vaccine according to CDC guidelines. One resident, with chronic kidney disease, consented to the vaccine but did not receive it, while another resident, with chronic respiratory failure and diabetes, was due for a vaccine but lacked documented consent. The DON acknowledged the issue and mentioned a new system for better tracking immunization records.
A resident with severe cognitive impairment and a feeding tube experienced a lack of cleanliness in their room, with tube feeding liquid spilled on the floor and pump pole. Staff interviews revealed inconsistencies in cleaning responsibilities, and the facility lacked a policy on maintaining a homelike environment.
Failure to Follow Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Update POLST to Reflect Resident's Current Wishes and Treatment
Penalty
Summary
The facility failed to ensure that a Provider Order for Life Sustaining Treatment (POLST) was updated to accurately reflect the current wishes of a resident with severely impaired cognition, quadriplegia, and chronic respiratory failure. The resident had a tracheostomy and required mechanical ventilation, yet the POLST form indicated Do Not Resuscitate (DNR) with selective treatment, specifying no intubation, advanced airway, or mechanical ventilation. This conflicted with the resident's actual care needs, as the resident was dependent on mechanical ventilation following a recent hospitalization. The provider order and POLST were not aligned with the resident's current treatment, and the POLST had not been updated after significant changes in the resident's condition. Interviews with nursing staff revealed uncertainty about the frequency of POLST reviews after admission, and it was confirmed that while care conferences discussed the POLST, the actual form was not reviewed for accuracy. The Director of Nursing stated that POLST forms should be reviewed upon admission and after hospitalizations, but this was not consistently done. Facility policy required routine audits of POLST documentation, but this was not followed, resulting in a discrepancy between the resident's documented wishes and the care provided.
Failure to Monitor Target Behaviors for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that target behaviors were identified and monitored for a resident who was prescribed psychotropic medications for anxiety related to major depressive disorder. The resident, who was cognitively intact and had diagnoses including acute respiratory failure, Amyotrophic Lateral Sclerosis, and major depressive disorder, was ventilator dependent and received clonazepam via gastrostomy tube. Provider orders indicated the use of clonazepam for anxiety, but there was no documentation or monitoring of specific target behaviors associated with the medication. The care plan noted the potential for adverse drug reactions and included general interventions such as administering medications as ordered and monitoring for adverse reactions, but did not specify or track target behaviors for anxiety. Interviews with nursing staff confirmed that while the resident had a history of anxiety, especially during suctioning and repositioning, there was no ongoing documentation of anxiety-related behaviors or the effectiveness of the psychotropic medication. Staff only documented changes in condition, not daily observations of anxiety or related behaviors. The DON stated that monitoring target behaviors was expected for residents on psychotropic medications to assess medication effectiveness, but acknowledged that this was not being done. Facility policy required identification and monitoring of target behaviors for residents prescribed psychotropic medications, but this was not followed in the resident's case.
Failure to Provide Required Nail Care for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with moderately impaired cognition, hemiplegia, hemiparesis, and vascular dementia was not provided with necessary nail care assistance. The resident required staff help with most activities of daily living (ADLs) due to impairment on one side of the upper extremities. Despite care plan documentation indicating the need for assistance and multiple staff interviews confirming that nail care should be performed weekly on bath day, observations revealed that the resident's fingernails were approximately an inch long and had not been trimmed for several weeks. The resident expressed a desire to have his nails cut, but this was not addressed. Staff interviews indicated confusion regarding responsibility for nail care, with varying responses about whether nursing assistants, nurses, or activities staff were responsible, particularly for diabetic residents. Documentation and skin assessments for the month did not indicate that nail trimming was necessary, and there was no record of refusals or completed nail care. Facility policy required that residents unable to perform ADLs receive necessary services to maintain grooming and hygiene, but this was not followed in the resident's case.
Failure to Provide Prescribed Splint for Resident with Limited ROM
Penalty
Summary
A deficiency occurred when a resident with a history of hemiplegia and severe contractures following a stroke did not consistently receive care as ordered to maintain range of motion (ROM) in the left upper extremity. The resident's care plan and provider orders specified the use of a hand splint on the left arm each morning, to be worn for up to six hours and removed in the afternoon, with hand hygiene performed before application. However, multiple observations over several days revealed that the resident was not wearing the splint at any observed time. Interviews with staff indicated a lack of awareness regarding the splint order, with some staff only aware of the use of blue boots for the resident's legs and feet. Documentation systems did not include a prompt for splint application, and the splint itself had reportedly been missing for months without follow-up or replacement. Further, there was no evidence in the medical record of physician notification regarding the resident's reported pain with splint use, nor were there any therapy orders in place during the relevant period. Therapy staff confirmed the resident had not been on their caseload for splint management since a previous year, and the DON acknowledged that missing or painful splints should prompt provider notification and therapy involvement. The facility was unable to provide a splint usage policy when requested. These actions and inactions resulted in the resident not receiving the prescribed intervention to maintain or improve ROM, as required by their care plan and provider orders.
Failure to Provide Trauma-Informed and Culturally Competent Care
Penalty
Summary
The facility failed to provide care or services that were trauma informed and/or culturally competent. This deficiency indicates that staff did not consider or incorporate trauma-informed approaches or cultural competence in the delivery of care or services to residents, as required. The report does not specify the number of residents affected or provide details about their medical history or condition at the time of the deficiency.
Failure to Provide Appropriate Mental Health and Psychosocial Services
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident who displayed or was diagnosed with a mental disorder, psychosocial adjustment difficulty, or had a history of trauma and/or post-traumatic stress disorder. The deficiency was identified when it was observed that the resident did not receive the necessary care and interventions to address their mental health or psychosocial needs, as required by their condition and diagnosis. This lack of appropriate services and treatment was directly related to the resident's documented mental health history and current presentation, indicating a failure to meet regulatory requirements for individualized care.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence or inadequacy of a comprehensive infection prevention and control program, but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with quadriplegia and respiratory failure, who was cognitively intact and fully dependent on staff for care, did not have access to their call light. The resident's care plan specified that the call light should be within reach due to their risk of falls and total dependence. During multiple observations, the call light was found placed on the right side of the resident's pillow, out of their reach, and the resident confirmed they could not activate it when needed. The resident communicated that they sometimes had difficulty breathing and had to wait for staff assistance, further indicating the importance of accessible call light placement. Interviews with nursing staff and the DON confirmed that the expectation and facility policy required call lights to be within reach of all residents. Despite this, staff initially believed the resident could use the call light by nudging it with their head, but later verified that the resident was unable to do so. The facility's policy, revised in the previous year, directed staff to ensure call lights or other communication devices were accessible to each resident, which was not followed in this instance.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that the necessary interventions to manage existing pressure ulcers and prevent additional ones were not consistently carried out for affected residents.
Failure to Address Pressure Ulcer Risk from Assistive Devices in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan addressing all of a resident's needs, specifically for a resident with severe cognitive impairment, no speech, highly impaired hearing, and impaired vision. The resident was completely dependent on staff for all activities of daily living and had multiple diagnoses, including acute and chronic respiratory failure with hypoxia, tracheostomy, and anxiety disorder. Assessments identified the resident as being at risk for pressure ulcers, and the care plan noted the resident's consistent use of eyeglasses and headphones for a pocket talker device, which she often refused to remove, even during sleep. Despite these findings, the care plan did not include interventions to prevent skin breakdown or pressure ulcers related to the continuous use of eyeglasses and headphones. Interviews with nursing staff and the DON confirmed that the care plan lacked specific prevention interventions for pressure ulcers on the nose or ears, areas at risk due to the resident's refusal to remove her devices. The facility's care planning policy requires the interdisciplinary team to develop individualized care plans based on comprehensive assessments, but in this case, the care plan was not updated to address the identified risks associated with the resident's use of assistive devices. This omission resulted in a failure to meet the resident's needs for pressure ulcer prevention as required by facility policy.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential resident information or proper record-keeping were not followed as expected. No additional details about specific residents, their medical history, or the exact circumstances of the deficiency are provided in the report.
Failure to Maintain a Safe Environment and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Assess and Treat Pressure Ulcers Results in Serious Harm
Penalty
Summary
A facility failed to complete a comprehensive skin assessment and provide necessary treatment for a resident who returned from a hospital admission with multiple pressure ulcers. Upon readmission, the hospital discharge summary documented pressure ulcers on the coccyx, left heel, right heel, and lateral right foot, with instructions for wound cleansing and dressing changes. Despite these documented wounds and clear orders for wound care, the facility did not assess, monitor, or treat these pressure ulcers for approximately six weeks. Nursing documentation and care plans failed to reflect the presence or treatment of these wounds, and the Treatment Administration Record (TAR) did not include the required wound care interventions. The resident, who was dependent on staff for all activities of daily living and had significant comorbidities including chronic heart failure, opioid dependence, and chronic pain, experienced severe pain that made repositioning and skin assessments difficult. Staff interviews revealed confusion and lack of communication regarding responsibility for wound care, with some believing hospice was responsible, while hospice staff indicated the facility was to provide wound care per the plan of care. During this period, the resident was observed with untreated wounds, dirty dressings, and ongoing severe pain, with no evidence of regular repositioning or adequate pain management to facilitate wound care or assessment. Documentation and interviews further showed that weekly skin inspections and wound assessments were either not performed or not documented, and that staff did not notify providers or update care plans to reflect the resident's condition. The lack of assessment, monitoring, and treatment resulted in the resident's wounds going untreated for an extended period, with staff only identifying and addressing the wounds after surveyor intervention. The facility's failure to follow its own policies and professional standards of practice led to serious harm for the resident.
Failure to Provide Effective Pain Management for Hospice Resident
Penalty
Summary
A resident with a terminal diagnosis and a history of opioid addiction was admitted to hospice care and required comprehensive pain management. Despite having multiple pain medications ordered, including hydromorphone, buprenorphine/naloxone, gabapentin, acetaminophen, and non-pharmacological interventions, the resident's pain was frequently severe and inadequately controlled. Documentation revealed persistent high pain scores, frequent reports of pain, and repeated instances where pain medications were either not administered when indicated or were ineffective. The facility's care plan did not initially address pain management, and there was a lack of consistent pain assessment and follow-up on the effectiveness of interventions. The resident often experienced pain levels of 8 to 10 out of 10, sometimes resulting in the resident calling emergency services and his daughter for help due to unrelieved pain. Nursing progress notes and electronic medication administration records (eMAR) showed inconsistent documentation of pain assessments, medication effectiveness, and communication with hospice regarding the resident's pain. Staff interviews indicated confusion about responsibility for pain management, with some staff believing hospice was solely responsible and failing to report uncontrolled pain to nursing management or hospice. The resident's pain was so severe at times that basic care, such as repositioning and wound assessment, could not be performed without causing significant distress. Observations confirmed the resident was in visible pain, screamed during care, and was not consistently offered additional pain management when needed. The facility also failed to provide a policy regarding pain management when requested. The lack of a coordinated system to monitor, assess, and manage the resident's pain in accordance with professional standards and the hospice plan of care resulted in unnecessary physical and psychological harm. The facility did not ensure that pain was managed effectively, did not update the care plan to reflect the resident's pain needs, and did not communicate effectively with hospice or among staff. The resident's own notes reflected ongoing suffering and a lack of adequate support from facility management.
Failure to Coordinate Hospice Services Resulting in Untreated Pressure Ulcers and Uncontrolled Pain
Penalty
Summary
The facility failed to establish and implement an effective communication process with the hospice provider to ensure that a resident's needs were addressed and met. Upon admission to hospice services, the resident had multiple pressure ulcers and was experiencing uncontrollable pain, but there was no clear process or designated staff member responsible for coordinating care with hospice. The facility's care plan did not include hospice-related interventions at the time of hospice admission, and staff were unclear about their responsibilities regarding wound care and pain management, leading to confusion and lack of appropriate care. Observations and interviews revealed that the resident's pressure ulcers went untreated for approximately six weeks, and pain was not adequately managed, which limited staff's ability to perform activities of daily living. Nursing staff did not consistently assess or document the resident's wounds, and some believed that hospice or the wound care team was responsible for wound care, while others thought the facility was not responsible. Communication between facility staff and hospice was minimal, with neither party reaching out to the other regarding the resident's worsening condition or pain control issues. The hospice plan of care indicated that facility staff were responsible for wound care, but this was not communicated or understood by the facility staff. Interviews with facility leadership and hospice staff confirmed a lack of coordination and communication. The DON and nurse manager were unaware of the specific responsibilities outlined in the hospice care plan, and the medical director had not been informed of any concerns. The resident's family reported that the resident was in significant pain and not being repositioned, and that communication from the facility was lacking. The facility's own policy required a designated interdisciplinary team member to coordinate with hospice, but this was not in place at the time of the deficiency.
Failure to Accurately Assess and Document Resident Pressure Ulcers
Penalty
Summary
The facility failed to ensure that a resident's assessment accurately reflected the resident's health status, specifically regarding the presence of pressure ulcers. A resident was admitted with multiple wounds, including pressure ulcers on the coccyx, both heels, feet, and knee, as documented in the hospital discharge summary and hospice plan of care. Despite this, the significant change Minimum Data Set (MDS) completed by the facility did not indicate the presence of any pressure ulcers or other skin conditions. The MDS nurse relied solely on nursing documentation and did not personally observe the resident's skin or interview the resident about their skin condition, missing the wounds because there were no explicit hospital orders for wound care. Upon observation, the resident was found to have visible pressure ulcers and abrasions on multiple areas, including the sacrum, heels, feet, and toes, with some wounds covered by dressings. The resident experienced significant pain during attempts at repositioning, and staff were unable to complete a thorough skin assessment due to the resident's pain. Subsequent wound evaluations documented several pressure ulcers and abrasions, some of which were in-house acquired. The facility's weekly skin inspection summary confirmed the presence of these wounds, and the in-house wound nurse completed assessments and treatments after the deficiency was identified. Interviews with facility staff revealed that the MDS nurse did not conduct direct skin assessments or pain evaluations, instead relying on existing nursing notes. The DON acknowledged that the nurse missed documenting the wounds, attributing this to the belief that hospice was responsible for wound care. The facility's policy on care planning did not specify the development of a significant change care plan, contributing to the lack of accurate and comprehensive documentation of the resident's wounds.
Failure to Assess and Document Alternatives Prior to Bed Rail Use
Penalty
Summary
The facility failed to attempt alternative devices before implementing bed rails for two residents, and did not conduct adequate assessments for risk of entrapment or ensure that bed dimensions were appropriate. Both residents had bed rails or grab bars installed based on their preference, but there was no documentation of alternative methods being tried prior to installation. The assessments did not specify the type of bed rails used, did not include measurements, and did not address the risks of entrapment, particularly in the context of specialty mattresses such as air mattresses. For one resident, the bed mobility device evaluation indicated the use of grab bars, but did not detail the type of rails, measurements, or entrapment risks, nor did it mention the use of an air mattress or any related precautions. The care plan and Minimum Data Set (MDS) did not reflect the use of bed rails or an air mattress, despite the resident having both in use. The resident reported using the rails for repositioning and fall prevention, but was unable to remove them independently. The equipment was provided by hospice, and facility staff were unaware of the specific setup or the associated risks. Staff interviews revealed a lack of awareness and training regarding the safety concerns of bed rails, especially when used with air mattresses. Maintenance staff did not perform zone measurements or physical checks upon implementation, relying instead on verbal assessments and periodic physical checks. Facility leadership believed that the use of grab bars did not require adherence to bed rail regulations or the documentation of alternatives. Manufacturer instructions for the bed, mattress, and rails all emphasized the need for proper assessment, compatibility, and regular inspection to prevent entrapment, but these procedures were not followed. The facility's policy did not address the assessment for restraints, alternative methods, or entrapment risk.
Failure to Conduct Regular and Documented Bed Rail Safety Inspections
Penalty
Summary
The facility failed to conduct regular and thorough inspections of bed frames, mattresses, and bed rails as part of its maintenance program, specifically for two residents who were using bed rails. Both residents were cognitively intact and required varying levels of assistance with activities of daily living. Observations revealed that one resident was using an air mattress and bilateral halo bed rails, while another was using bilateral quarter rails at the head of the bed. In both cases, the use of bed rails was not documented in the Minimum Data Set (MDS), and there was no evidence that compatibility or entrapment risks were assessed upon implementation. Interviews with facility staff, including the director of maintenance, LPN, ADON, DON, and the administrator, revealed a lack of clarity and consistency regarding the inspection process for beds and bed rails. The director of maintenance admitted to not being aware of specific bed rail installations, such as the halo rail with an air mattress, and had not performed physical checks on beds with electric features or bed rails. The maintenance checks were inconsistently documented, often relying on verbal confirmation from nursing staff or a general check mark in the TELS system, rather than detailed, resident-specific documentation. There was also uncertainty about who was responsible for verifying the compatibility of beds, mattresses, and rails, especially for equipment provided by hospice. Manufacturer instructions for the air mattress, halo rails, and quarter bed rails all emphasized the importance of regular inspections, ensuring compatibility, and minimizing gaps to prevent entrapment. However, the facility's maintenance documentation did not specify the frequency of inspections, criteria for identifying entrapment zones, or procedures for verifying equipment compatibility. The facility's policy on safe medical devices did not address inspection or maintenance requirements for these devices, contributing to the deficiency in ensuring resident safety related to bed systems.
Failure to Report and Investigate Abuse Allegation and Chemical Ingestion
Penalty
Summary
The facility failed to report and investigate an allegation of abuse and an incident of chemical ingestion involving a resident with severe cognitive impairment and a history of trauma. Video footage showed the resident expressing concern about being harmed at night, referencing a bruise and stating that a man was bothering her. The registered nurse present did not further question the resident or initiate an investigation into the possible abuse allegation, nor was there documentation of the incident or any follow-up in the resident's progress notes. Additionally, the same resident was observed on video ingesting wound cleanser, a product labeled to seek medical attention or contact poison control if swallowed. The psychologist present did not recall reporting the ingestion, and there was no documentation that the physician or poison control was notified. Interviews with facility staff, including the nurse practitioner, ADON, and DON, confirmed a lack of awareness and follow-up regarding the ingestion event. The facility's policy requires immediate reporting and investigation of abuse allegations and incidents, but these procedures were not followed in either case.
Failure to Investigate Abuse Allegation and Chemical Ingestion
Penalty
Summary
The facility failed to investigate and respond appropriately to allegations of abuse and chemical ingestion involving a resident with severe cognitive impairment and a history of trauma. The resident, who was dependent on a ventilator and had diagnoses including chronic respiratory failure and paranoid schizophrenia, was observed on video footage making a statement about being harmed by a male at night and later ingesting wound cleanser. Despite these incidents, there was no documentation in the resident's progress notes regarding the abuse allegation or the ingestion event, nor evidence that the physician or poison control were notified. Staff interviews revealed a lack of awareness and follow-up regarding both the abuse allegation and the ingestion of wound cleanser. The psychologist present during the ingestion could not recall reporting the incident, and nursing staff were unaware of both the ingestion and the resident's claim of abuse. The facility's own policy requires immediate reporting and investigation of abuse allegations and injuries of unknown origin, as well as appropriate medical response to chemical ingestion, but these procedures were not followed in this case.
Failure to Assess, Monitor, and Respond to Resident Incidents
Penalty
Summary
A resident with severe cognitive impairment, chronic respiratory failure, tracheostomy, and ventilator dependence was not properly assessed or monitored for several significant events. The facility failed to document or investigate a bruise observed on the resident's right upper arm, despite the bruise being pointed out by a family member and the resident making a statement suggesting possible abuse. There was no documentation in the progress notes or weekly skin assessments regarding the bruise, nor evidence of staff-to-resident abuse allegations being investigated, as required by facility policy. Additionally, the resident ingested a wound cleanser spray, an event witnessed by a psychologist and later reported by a family member. There was no documentation that the physician or poison control was notified, nor any evidence of monitoring or follow-up after the ingestion, despite the product label instructing to seek medical attention if swallowed. Interviews with facility staff, including the nurse practitioner, psychologist, and ADON, confirmed a lack of awareness or documentation regarding the ingestion incident. The facility also failed to respond to repeated pulse oximeter alarms while the resident was on a ventilator. Video footage showed the alarm sounding multiple times over several minutes without staff response, and the ADON confirmed that staff should have checked on the resident. The facility was unable to provide policies or procedures related to chemical ingestion or pulse oximeter alarm response, and the DON acknowledged that documentation and follow-up were lacking in these incidents.
Lack of Training on Respiratory Therapies
Penalty
Summary
The facility failed to ensure that a sufficient number of licensed nurses had the necessary training on vest therapy treatments and cough assist therapy treatments for residents who had orders for these therapies. This deficiency affected multiple residents, including those with chronic respiratory conditions and tracheostomy dependencies. The report highlights that the facility did not have specific competencies or policies in place for these treatments, and there was a lack of documentation regarding staff training. Interviews with various staff members, including RNs, LPNs, and the respiratory therapist, revealed inconsistencies in training and knowledge about the use of cough assist and vest therapy machines. Some staff members reported not being trained at all, while others could not recall when they were trained. The facility's administrator and DON were also unsure about the existence of specific training or documentation for these therapies, indicating a systemic issue in staff education and competency verification. The deficiency was further evidenced by the treatment administration records, which showed that treatments were not consistently administered as ordered. In some cases, treatments were missed without documented reasons, and there were instances where the equipment was not properly fitted or used, leading to ineffective therapy. The lack of proper training and documentation posed a risk to the residents' well-being, as these therapies are critical for managing their respiratory conditions.
Failure to Protect Residents from Potential Abuse Due to Inadequate Assessment
Penalty
Summary
The facility failed to protect two residents from potential abuse by not comprehensively assessing their vulnerabilities for sexual abuse. One resident had an extensive mental health history, including schizophrenia, bipolar disorder, and a dependent personality disorder, which impaired her judgment and decision-making abilities. The other resident had a history of alcohol abuse and inappropriate sexual behaviors. Despite these factors, the facility did not adequately assess their ability to consent to a sexual relationship or monitor their interactions effectively. The facility's documentation and interviews revealed that the residents were involved in a sexual relationship, with incidents occurring where one resident was found lying on top of the other. Staff interventions were insufficient, as they did not adequately address the residents' ability to consent, especially considering one resident's alcohol consumption and the other's mental health impairments. The facility's staff, including the RN, NA, and administrator, were unsure of the procedures to determine consent for sexual relationships, and there was no clear policy in place to guide them. The facility's policy on abuse prevention and investigation was not effectively implemented, as the incidents were not thoroughly investigated, and the residents' vulnerabilities were not adequately addressed. The lack of a comprehensive assessment and appropriate interventions led to a failure in protecting the residents from potential abuse, as the facility did not ensure their safety and well-being in light of their mental health and behavioral issues.
Failure to Implement Care Plans for Behavioral Health and Supervision
Penalty
Summary
The facility failed to adhere to the care plan interventions for two residents, R1 and R2, who were involved in inappropriate sexual behavior and alcohol use. R1's care plan required every 15-minute checks or 1:1 observation when engaging in sexual activity and vital signs monitoring when alcohol use was suspected. However, the care plan did not address R1's schizophrenia, bipolar disorder, dependent personality disorder, and associated impaired insight, judgment, and impulsivity. R2's care plan included interventions for his inappropriate sexual behavior and alcohol use, but these were not effectively implemented. On January 7, 2025, staff found R1 and R2 in R1's room engaging in sexual activity. Despite R1's care plan requiring close monitoring, staff did not intervene effectively. R2 was found intoxicated and had a history of inappropriate sexual behavior, yet staff only redirected him without enforcing stricter supervision. Interviews revealed that staff were aware of the situation but did not take appropriate action to prevent the incident or ensure the residents' safety. The facility's failure to develop and implement comprehensive care plans for R1 and R2, addressing their behavioral health needs and ensuring adequate supervision, led to the deficiency. The lack of a care plan policy and insufficient staff intervention contributed to the incident, highlighting the need for better assessment and management of residents with behavioral health issues and substance abuse problems.
Medication Administration and Reporting Deficiencies
Penalty
Summary
The facility failed to ensure medications were administered in accordance with physician orders and did not identify and report medication errors according to facility policy for three residents. One resident received oxycodone in excess of the prescribed maximum daily dose on multiple occasions. Despite the presence of a medication administration record (MAR) system, the staff did not adhere to the prescribed limits, leading to medication errors that were not reported or addressed. Interviews with nursing staff and management revealed a lack of awareness and failure to follow the established protocol for medication administration and error reporting. Another resident's medication administration record lacked documentation for scheduled doses of furosemide and gabapentin, indicating that these medications were either not administered or not properly recorded. The absence of documentation was confirmed during an interview with the Director of Nursing (DON), who acknowledged that missed administrations constitute medication errors that should be reported and addressed. The facility's policy requires documentation of medication administration and reporting of errors, but these procedures were not followed. A third resident's MAR also showed missing documentation for several scheduled medications, including aspirin, Claritin, and gabapentin, among others. The DON confirmed that blank documentation likely indicated missed administrations, which were not reported as errors. The facility's failure to adhere to its medication administration and error reporting policies resulted in unaddressed medication errors, posing potential risks to resident safety.
Failure to Follow Up on Resident Grievances
Penalty
Summary
The facility failed to inform a resident, R3, of the outcome of a grievance she filed regarding concerns for her roommate, R4, who was moaning in pain. R4 was identified as having severe cognitive impairment and was rarely/never understood, while R3 had intact cognition. R3 reported that she placed a call light for assistance because she believed R4 was in pain, but the nursing assistant (NA) dismissed her concerns, stating that R4 could not talk and was not in pain. The grievance summary indicated that the nurse manager was to obtain a statement from the NA, and it was noted that a nurse had helped R4. However, R3 stated that no one followed up with her about the grievance. Additionally, R3 reported another incident where she recorded a conversation with an NA who was mocking R4. R3 reported this to the social services designee (SSD), who then informed the administrator. The SSD confirmed hearing the recording, which included an argument between R3 and the NA, and believed R3's account. Despite these reports, R3 stated that no follow-up occurred. The facility's grievance policy requires that grievances be documented, investigated, and resolved with follow-up to the complainant, but the administrator and director of social services were unaware of any documented follow-up for R3's grievances.
Failure to Monitor and Address Illicit Drug Use
Penalty
Summary
The facility failed to ensure the safety of two residents who were reported to have used crack cocaine on the facility's smoking patio. The residents were not assessed or monitored for potential life-threatening side effects and drug interactions. The facility's staff, including the director of nursing and the administrator, were aware of the drug use but did not take appropriate actions to address the situation. The facility's substance use policy was not effectively implemented, as staff did not confiscate illegal substances or notify the police as required. One resident, who had severe cognitive impairment and was her own decision-maker, was seen smoking crack cocaine and had a history of smoking marijuana. Despite being educated about the facility's substance use policy, the resident continued to use illicit drugs on the premises. The resident's care plan did not reflect her history of substance use, and her provider orders lacked directions about monitoring or use of illegal substances. Another resident, who was an independent decision-maker, also used crack cocaine and had a history of substance use. This resident's care plan indicated a history of smoking marijuana, but there were no specific interventions in place to address the use of illicit drugs. Staff interviews revealed that many were aware of the drug use but did not report it to administration, believing that everyone already knew. The facility's policy directed staff to confiscate illegal substances and notify the police, but this was not done. The pharmacist and nurse practitioner were not informed of the residents' drug use, which could have led to dangerous drug interactions. The facility failed to implement interventions to prevent drug use and did not adequately monitor residents for adverse effects, resulting in a deficiency in ensuring a safe environment for all residents.
Failure to Timely Report Abuse Incident
Penalty
Summary
The facility failed to report an allegation of verbal and emotional abuse immediately to the State Agency as required. The incident involved a resident with moderate cognitive impairment, whose family member was reported to have engaged in inappropriate behavior within the facility. This included staying overnight, threatening other residents, and soliciting money for hair services. On one occasion, the family member became irate, shouted, pointed fingers, and physically shoved the resident into a table, causing the resident to fall backward into a chair. The family member then grabbed the resident by the wrists and took them outside the facility, prompting staff to call the police. Despite the severity of the incident, the facility administrator did not report the abuse to the Minnesota Department of Health within the required two-hour timeframe. The administrator believed that the incident was not reportable because the police were involved immediately and did not consider the family member's actions as abuse. The facility's policy clearly directed that any suspicion of abuse should be reported within two hours, which was not adhered to in this case.
Inadequate Discharge Planning for Resident with Complex Medical Needs
Penalty
Summary
The facility failed to adequately evaluate and plan for a resident's discharge, resulting in the resident being sent to a homeless shelter that could not meet his complex medical needs. The resident, who had a history of diabetes, amputation, and wound care needs, was discharged without ensuring that the receiving location could provide necessary medical care, such as blood sugar monitoring, insulin administration, and wound care. The discharge plan lacked critical information and assessments, including the resident's ability to self-administer medications and manage his medical conditions independently. The resident's medical history included significant health issues such as diabetes mellitus, osteomyelitis, and recent amputations, which required ongoing medical management. Despite these needs, the facility discharged the resident to a homeless shelter without confirming the shelter's capacity to provide the required care. The discharge instructions were incomplete, lacking details on medication administration, wound care, and follow-up care, and there was no evidence that the resident was educated on managing his medical needs post-discharge. The facility's actions were further complicated by the resident's behavioral issues and substance use, which were documented in the facility's records. Despite these challenges, the facility proceeded with the discharge without ensuring a safe and appropriate transition of care. The resident was left without adequate support, leading to a situation where he was unable to receive necessary medical care, posing a risk to his health and safety.
Failure to Respond to Ventilator Alarms
Penalty
Summary
The facility failed to respond timely to ventilator alarms for a resident who was dependent on a ventilator while sleeping due to chronic respiratory failure. On a specific date, the resident's ventilator alarmed intermittently from 3:19 a.m. to 5:47 a.m., totaling 237 alarms, indicating high pressure or an obstruction in the ventilation system. Despite the alarms, staff did not respond, resulting in an immediate jeopardy situation for the resident. Interviews with staff revealed that the alarms were not heard or attended to due to various reasons, including being occupied with other residents and insufficient staffing. The LPN assigned to the resident did not check the alarms, and other staff members were engaged with a new admission and other critical residents. The facility lacked a policy for responding to ventilator alarms, and there was no system in place to audit response times or ensure alarms were addressed promptly. The facility's assessment did not consider the acuity of ventilator-dependent residents, and the respiratory therapy policy did not address the management of ventilator alarms. The DON and other staff acknowledged the oversight, and it was noted that the facility had not reviewed ventilator alarm response times prior to the incident. The deficiency highlighted a significant gap in the facility's ability to monitor and respond to critical alarms, putting the resident at risk.
Failure to Include Ventilator-Dependent Residents in Facility Assessment
Penalty
Summary
The facility failed to adequately conduct and document a facility-wide assessment (FA) to determine the necessary resources for caring for residents, particularly those who are ventilator-dependent, during both day-to-day operations and emergencies. The FA tool, dated 11/22/23, assessed resident acuity based on activities of daily living (ADLs) and mobility but did not account for the specific needs of fifteen ventilator-dependent residents. During an interview, the Director of Nursing (DON) acknowledged the omission of ventilator-dependent residents in the acuity section of the FA. The DON also noted that staffing on the second floor, where these residents lived, required two nurses during the night shift, with an increase to three nurses if the number of ventilator-dependent residents reached sixteen. Additionally, the facility failed to review the FA annually, as confirmed by the Regional Nurse Consultant (RNC), who was unaware of the omission of ventilator-dependent residents in the FA and the lack of an annual review.
Failure to Conduct Self-Administration Assessment and Obtain Provider Order
Penalty
Summary
The facility failed to perform a self-administration of medication assessment and obtain a provider order for a resident who was self-administering medication. The resident, who was cognitively intact and had diagnoses including renal insufficiency, diabetes, and asthma, was approved to self-administer inhalation medications. However, the facility did not have a self-administration of medication assessment or a provider order for the resident to self-administer or keep a bottle of lotion at the bedside. Observations revealed that the resident had a bottle of lotion on the window seal next to the bed, which was not documented in the medication administration record (MAR) as being approved for self-administration. Interviews with staff, including an LPN, RN, and the director of nursing, confirmed that there was no assessment or order for the lotion to be self-administered or kept at the bedside. The facility's policy indicated that a resident could self-administer medication if a self-administration of medication assessment determined it was clinically appropriate, which was not followed in this case.
Failure to Notify Physician of Elevated Blood Glucose Levels
Penalty
Summary
The facility failed to notify a physician of elevated blood glucose levels for a resident with diabetes mellitus and peripheral vascular disease, despite having specific physician orders for such notifications. The resident, who was cognitively intact and had a history of refusing blood sugar checks and medications, had multiple instances of elevated blood glucose readings significantly above the threshold set by the physician's orders. These elevated readings occurred over several days, yet there was no documentation indicating that the physician was informed, except for one instance where a nurse practitioner was notified. The nurse manager acknowledged that the facility often used agency staff on the evening shift, which contributed to the failure in notifying the physician as required. The director of nursing confirmed that both regular and agency staff were expected to follow physician orders, including notifying the provider of elevated blood glucose results. Despite requests, the facility's policy on physician notification was not provided, indicating a possible lack of clear guidelines or adherence to existing protocols.
Failure to Develop Comprehensive Care Plan for Resident on Psychotropic Medication
Penalty
Summary
The facility failed to develop a comprehensive, resident-centered care plan for a resident identified as R72, who was reviewed for unnecessary medications. R72's Minimum Data Set (MDS) indicated significant cognitive and physical impairments, including non-traumatic brain dysfunction, respiratory failure with a tracheostomy, and depression. Despite these conditions, the care plan lacked specific target symptom monitoring and resident-specific interventions, particularly non-pharmacological interventions, which are crucial for managing the resident's depression and potential adverse drug reactions. The Care Area Assessments (CAAs) for R72 highlighted moderate cognitive impairment and depression, with noted difficulties in sleep and fatigue. However, the CAAs did not document specific target symptoms for monitoring or effective non-pharmacological interventions. Additionally, the facility's documentation, including the treatment administration record (TAR) and behavior monitoring logs, showed a lack of recorded behavior monitoring and interventions for a significant period. Interviews with nursing staff revealed inconsistencies in documenting behaviors and interventions, with no clear identification of target behaviors for R72. The facility's policy on psychotropic medication use required the interdisciplinary team to document specific symptoms and non-pharmacological interventions, which was not adhered to in R72's case. The Director of Nursing acknowledged the expectation for resident-specific interventions and symptom monitoring, which were not implemented. This deficiency in care planning and documentation led to a failure in adequately addressing R72's needs related to her psychotropic medication use and associated conditions.
Failure to Follow Diagnostic Standards for Schizophrenia
Penalty
Summary
The facility failed to ensure diagnostic standards of practice were followed for a resident newly diagnosed with schizophrenia. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), a diagnosis of schizophrenia requires the presence of two or more specific symptoms over a period of at least six months. However, the resident's medical records and observations did not document the required symptoms persistently, nor did they show reduced functioning as per the DSM-5 criteria. The resident, who was 77 years old, had a history of bipolar disorder in full remission, non-Alzheimer's dementia, and was taking antipsychotic medication. Despite the recent addition of a schizophrenia diagnosis, the resident's records, including the Minimum Data Set (MDS) and Care Area Assessments (CAA), did not reflect behaviors or symptoms consistent with schizophrenia. Interviews with staff and observations of the resident indicated stable mood and behavior, with no persistent symptoms of schizophrenia documented. The facility's policy on psychotropic medication use required a comprehensive assessment and documentation of specific conditions for which such medications were necessary. However, the facility did not provide adequate documentation or assessment to support the schizophrenia diagnosis. The diagnosis was questioned by the facility's medical director and other staff, who noted the absence of persistent delusions or hallucinations typically associated with schizophrenia. The facility's policy did not align with the recommendations from the Consultant Pharmacy based on CMS regulations.
Failure to Provide Preferred Activities for Resident
Penalty
Summary
The facility failed to ensure a resident's preferred activities for individual entertainment were available, specifically for a resident with a traumatic brain injury and respiratory failure. The resident, who was rarely understood and unable to communicate verbally or through gestures, was identified by family as enjoying listening to healing traditional Native American music. Despite this preference being noted in the care plan, observations revealed that the resident's television was often tuned to a news channel rather than the preferred music or shows. Staff, including registered nurses and nursing assistants, were observed not engaging with the resident to determine his preferences or change the television channel to the preferred content. Interviews with staff indicated a lack of awareness or understanding of how to access the resident's preferred music or shows on the television. A sign placed by the family member in the resident's room indicated the preference for Native American music, yet staff were unsure how to implement this. The director of therapeutic recreation confirmed that the care planned activities should be implemented to promote enrichment and preferred activities, but acknowledged that the resident's television lacked the capability to play the preferred music. A policy for therapeutic recreation was requested but not provided, indicating a possible gap in the facility's procedures for ensuring resident preferences are met.
Failure to Follow Medication Orders and Monitoring Protocols
Penalty
Summary
The facility failed to adhere to a provider's order to hold blood thinner medication for a resident scheduled for a baclofen trial procedure. The resident, who was severely cognitively impaired and dependent on staff for all activities of daily living, was on anticoagulant medication to prevent blood clots. Despite instructions to withhold the medication two days prior to the procedure, the resident received doses on the days leading up to the scheduled trial. This oversight resulted in the cancellation of the procedure due to the risk of bleeding, causing distress to the resident and their representative who had been planning for discharge post-procedure. Additionally, the facility did not implement a physician's order for another resident who was on Amiodarone, a medication requiring regular monitoring due to potential side effects on the heart, liver, lungs, and thyroid. The resident's medical record lacked documentation of the necessary thyroid and liver function tests, which were supposed to be conducted at specified intervals. The nursing staff acknowledged the absence of these tests, despite the orders being in place, indicating a lapse in monitoring the resident's condition as required. Interviews with the nursing staff and the Director of Nursing revealed that there was an expectation for orders to be accurately entered and followed to prevent complications. However, the failure to hold the anticoagulant medication and the lack of lab tests for the second resident highlighted deficiencies in the facility's medication administration and monitoring processes. The facility's policy on following provider orders was requested but not provided, further underscoring the issues in compliance with prescribed care protocols.
Deficiencies in Feeding Tube Care and Positioning
Penalty
Summary
The facility failed to ensure proper positioning and care for a resident with a feeding tube, leading to multiple deficiencies. The resident, who was severely cognitively impaired and dependent on staff for all activities of daily living, had a history of aspiration pneumonia and was at risk for aspiration due to the presence of a feeding tube. Despite care plan instructions to keep the head of the bed (HOB) elevated to 45 degrees at all times, observations revealed that the resident was often positioned incorrectly, with the HOB at approximately 30 degrees or lower during medication administration and tube feeding. Additionally, the facility did not adhere to proper labeling and replacement protocols for tube feeding equipment. During observations, the resident's tube feeding bottle was found unlabeled, and the tubing had not been changed since the previous day, contrary to the facility's policy of changing the administration set every 24 hours. Interviews with nursing staff confirmed these lapses, as they acknowledged the importance of labeling and timely replacement to prevent infection and ensure proper care. The facility's staff also struggled with maintaining the resident's position due to the resident's involuntary movements, which often caused them to slide down the bed. Despite this challenge, staff did not consistently reposition the resident before administering medications or tube feedings, as required by the care plan. Interviews with nursing staff and the director of nursing highlighted the expectation to limit the time the resident was positioned lower than 30 degrees to prevent aspiration, yet this was not consistently achieved.
Failure to Coordinate Prosthetic Care for Resident
Penalty
Summary
The facility failed to provide adequate assistance and coordination of services for a resident, identified as R37, who required a prosthesis. R37, who was cognitively intact and had a history of a nontraumatic above-the-knee amputation due to diabetes, was motivated to increase independence through ambulation. Despite this, the facility did not ensure timely referral and treatment for a well-fitting prosthetic leg. R37's care plan indicated the need for a prosthetic during transfers, yet observations and interviews revealed that R37 was not wearing the prosthetic and had not received necessary adjustments or evaluations for its fit. The prosthetic was described as extremely uncomfortable, and no arrangements had been made by the facility for re-evaluation by the vendor. Interviews with staff, including LPN-B, NA-G, RN-C, and the physical therapist, indicated a lack of awareness and communication regarding R37's prosthetic needs. R37 had been discharged from physical therapy before receiving a new prosthetic, and there was no evidence of follow-up to ensure the prosthetic was usable. The certified occupational therapy assistant was unaware of R37's receipt of a new prosthetic and had not received any communication from nursing staff about R37's needs. The director of nursing was also unsure about the current status of R37's prosthetic and indicated that staff would assist with its use if it did not fit. The facility did not provide a policy on coordination of prosthetic care, and the administrator mentioned that staff worked with therapy on prosthetic care coordination, but no specific actions were documented.
Failure to Attempt Gradual Dose Reduction for Psychotropic Medication
Penalty
Summary
The facility failed to ensure gradual dose reductions (GDR) were attempted or adequately justified for the use of psychotropic medications for a resident, identified as R42. The resident's Minimum Data Set (MDS) indicated no cognitive impairment or significant behavioral issues, yet he was on a routine antipsychotic medication without any GDR attempts. The Care Area Assessment (CAA) noted potential adverse effects from medication use but lacked documentation of resident-specific target symptoms and interventions for symptom management. Despite a consultant pharmacist's recommendation for a GDR due to the inappropriate use of antipsychotic medication for major depressive disorder, there was no follow-up or documentation from the provider or facility. Interviews with facility staff, including a registered nurse (RN) and the director of nursing (DON), revealed gaps in documentation and monitoring of the resident's behavior and the effectiveness of interventions. The RN was unable to identify resident-specific target symptoms or behavior monitoring documentation, and the DON acknowledged the importance of GDRs to avoid unnecessary medication use. The consultant pharmacist confirmed that a recommendation for a GDR was made in February 2024, but no response was received from the provider or facility. The facility's policy on psychotropic medication use emphasized prescribing at the lowest possible dosage and subjecting medications to GDR and re-review. However, the policy's implementation was lacking, as evidenced by the absence of documented clinical contraindications for GDR and the failure to follow up on the consultant pharmacist's recommendations. The facility did not provide documentation to support the claim that a GDR was clinically contraindicated for R42.
Infection Control Deficiency: Catheter Bag Placement
Penalty
Summary
The facility failed to adhere to infection control evidence-based practices concerning the management of a urinary catheter bag for a resident, identified as R72. During an observation, it was noted that R72's catheter drainage bag was placed on the floor next to her bed. This practice is contrary to the guidelines set by the Centers for Disease Control (CDC), which state that catheter collection bags should not rest on the floor to prevent the introduction of bacteria and potential infections. R72 is a resident with significant medical complexities, including non-traumatic brain dysfunction, chronic respiratory failure with a tracheostomy, and Extended-Spectrum Beta Lactamase (ESBL) resistance. She is dependent on staff for all activities of daily living and has an indwelling catheter due to an unstageable pressure ulcer on her sacrum. R72 has a history of urinary tract infections (UTIs) and was recently hospitalized for sepsis related to a UTI, highlighting her vulnerability to infections. Interviews with facility staff revealed a lack of consistent understanding and adherence to infection prevention protocols. A registered nurse initially did not perceive the catheter bag on the floor as problematic due to the use of a closed-system drainage bag. However, subsequent interviews with other staff, including a nursing assistant and the director of nursing, confirmed that placing the catheter bag on the floor is against infection control practices. The facility's policy on infection prevention and control emphasizes the importance of following established guidelines to prevent complications and the spread of infections.
Failure to Administer Pneumococcal Vaccines as per CDC Guidelines
Penalty
Summary
The facility failed to ensure that two residents, R24 and R52, were offered or received the pneumococcal vaccine in accordance with CDC recommendations. R24, who was cognitively intact and had chronic kidney disease, had a signed Resident Vaccine Administration (RAC) form indicating consent for the pneumococcal vaccine, but the vaccine was not administered. The form also showed that R24 received the influenza and COVID-19 vaccines, but the pneumococcal vaccine section was unchecked, and there was no indication that R24 declined the vaccine. During the survey, a signed RAC form dated 5/21/24 confirmed R24's consent for the pneumococcal vaccine, yet it was still not administered. R52, also cognitively intact, had a history of chronic respiratory failure with hypercapnia and hypoxia, as well as type 2 diabetes mellitus. R52's immunization record showed receipt of PCV13 in 2015 and PPSV23 in 2007. According to CDC guidelines, R52 was due for a dose of Prevnar 20 (PCV20) or another dose of PPSV23. However, there was no record of consent for the pneumococcal vaccine being obtained. The Director of Nursing (DON) acknowledged the facility's tracking of immunizations and audits but noted the implementation of a new system to improve tracking and documentation of immunization consents and administration.
Failure to Maintain a Homelike Environment for Resident with Feeding Tube
Penalty
Summary
The facility failed to provide a homelike environment for a resident who was dependent on staff for all activities of daily living and received more than 50% of their nutrition through a feeding tube. Observations revealed that the base of the tube feeding pump pole and the floor beneath it were soiled with more than 50 drips of tube feeding liquid. The resident's representative expressed frustration with the lack of cleanliness, indicating that the mess was bothersome. Interviews with staff revealed inconsistencies in cleaning responsibilities. A licensed practical nurse stated that nurses were responsible for cleaning spills, while a housekeeper mentioned that housekeeping cleaned floors but not the poles. A registered nurse confirmed that both the floor and pole needed cleaning and acknowledged that they would not leave such a mess in their own home. The director of nursing stated that staff should ensure cleanliness when changing feeding equipment and notify housekeeping if unable to clean spills. The facility lacked a policy regarding a homelike environment or cleaning of resident equipment.
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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