The Estates At Bloomington Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Bloomington, Minnesota.
- Location
- 9200 Nicollet Avenue South, Bloomington, Minnesota 55420
- CMS Provider Number
- 245324
- Inspections on file
- 27
- Latest survey
- January 30, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at The Estates At Bloomington Llc during CMS and state inspections, most recent first.
The facility failed to properly clean and disinfect community-use glucometers between uses, affecting nine diabetic residents. Staff did not follow the manufacturer's instructions, using hand sanitizer instead of EPA-registered wipes and not adhering to required contact times. Additionally, residents' fingers were not washed with soap and water before testing. Interviews revealed inconsistencies in staff knowledge and implementation of proper procedures, and the facility's policy on cleaning medical equipment was not provided.
Two residents shared a room with an unfinished wall, which had been left unsanded and unpainted since October 2024. Despite the residents' complaints about the unhomelike environment, staff failed to notice or report the issue for maintenance. The maintenance director cited logistical challenges in completing the repair, and the facility's maintenance policy was not provided.
A resident with severe cognitive impairment was not provided with dentures, which were necessary for safe and independent eating. Despite having a care plan indicating the use of dentures, staff were unaware of their presence and did not offer them during morning care. The interim DON confirmed that refusals were not documented, leading to a failure in providing appropriate care.
A resident in a LTC facility did not receive routine nail care despite needing assistance with ADLs. The resident had long, yellow fingernails and a cracked toenail, and expressed dissatisfaction with the lack of assistance. Staff were responsible for trimming nails on bath days, but assessments inaccurately indicated no need for trimming. The facility's policy emphasized necessary services for grooming, which was not followed.
The facility failed to assess and address poor wheelchair posture for a resident with severe cognitive impairment and functional limitations, as well as to provide necessary interventions for another resident with limited ROM. Observations showed inadequate wheelchair positioning and lack of protective devices, with staff unaware of required interventions. The facility's policies lacked guidance on therapy referrals, leading to deficiencies in resident care.
A resident with worsening hearing loss did not receive a timely audiology consult despite a provider's order. The Health Information Manager confirmed the appointment was not scheduled, leading to the resident's social withdrawal. A policy on audiology services was requested but not provided.
A resident with intact cognition and mobility independence was found with an unsecured mattress hanging over the bed frame, lacking a footboard or retainer bar. Despite staff awareness, no documentation or alternatives were provided to address the safety risk. The facility's bed safety policy was not available.
A facility failed to monitor and document the oxygen use for a resident with COPD and respiratory failure, leading to a deficiency in care. The resident's oxygen saturation levels were recorded without noting the liters per minute (LPM) of oxygen administered, despite an order to maintain saturation above 92 percent. The resident experienced worsening shortness of breath and was hospitalized, while the facility's system did not allow for proper documentation of oxygen dosage.
A facility failed to ensure the safety of a resident's bed rails, leading to a deficiency. The resident, who required assistance for bed mobility, had a loose side rail that increased the risk of injury. Despite the resident's concerns, staff did not take corrective action, and the facility's documentation lacked comprehensive assessment and maintenance of the side rails. Interviews revealed a lack of communication and follow-up regarding the issue, and the facility did not have a policy on side rail evaluation and maintenance.
A facility failed to address consulting pharmacist recommendations for a resident on multiple psychotropic medications. The pharmacist recommended reviewing the lowest effective doses, but no response was documented. Interviews revealed a lack of evidence of provider response, and the interim DON was unsure if recommendations were sent to the correct psychiatrist due to recent changes.
A facility failed to document symptoms and non-pharmacological interventions before administering PRN psychotropic medication to a resident with severe cognitive impairment and on hospice care. The resident's records showed multiple administrations of lorazepam without supporting documentation, and staff interviews revealed inconsistent documentation practices. The facility's policy required such documentation to ensure the medication's necessity and efficacy, but this was not adhered to, highlighting a gap in care.
A resident with cellulitis and other conditions did not receive prescribed wound care due to the facility's failure to verify and implement orders from a nurse practitioner. The orders for daily cleaning and Betadine application were not reflected in the treatment records, and staff did not clarify the orders with the provider. The facility lacked a treatment order policy, indicating a procedural gap.
Improper Cleaning of Glucometers in LTC Facility
Penalty
Summary
The facility failed to ensure proper cleaning and disinfection of community-use glucometers between patient uses, as well as failed to ensure that staff were knowledgeable about the correct procedures for cleaning and disinfecting these devices according to the manufacturer's instructions. This deficiency had the potential to affect nine residents who were diabetic and required blood glucose monitoring using a community glucometer. The manufacturer's instructions for the Arkray Assure Platinum Blood Glucose Monitoring System specify that the device should be cleaned and disinfected with an EPA-registered wipe, such as the Super Sani-Cloth Germicidal Disposable Wipes, which require a contact time of two minutes to be effective. During observations, it was noted that registered nurses and other staff members did not follow the manufacturer's instructions for cleaning and disinfecting the glucometers. For instance, RN-A used hand sanitizer on a facial tissue to clean the glucometer instead of the recommended Saniwipe, and did not allow the device to remain wet for the required contact time. Similarly, RN-C used a Saniwipe but did not adhere to the recommended contact time, and LPN-B incorrectly stated that alcohol wipes could be used for cleaning the glucometer. Additionally, staff did not wash residents' fingers with soap and water before obtaining blood samples, as required by the manufacturer's guidelines. Interviews with various staff members, including the assistant director of nursing and the facility's infection control preventionist, revealed inconsistencies in the understanding and implementation of the correct cleaning procedures. The facility's policy on cleaning and disinfecting medical equipment was requested but not provided, indicating a possible lack of formalized procedures or training. This lack of adherence to proper infection control practices could potentially lead to the transmission of blood-borne pathogens among residents using shared glucometers.
Unfinished Wall Repair in Resident Room
Penalty
Summary
The facility failed to ensure a comfortable and homelike environment for two residents sharing a room with an unfinished wall. The wall had a large area of white joint compound that was unsanded and unpainted, which had been in this state since one of the residents moved into the room in October 2024. Both residents expressed dissatisfaction with the appearance of the wall, stating it made the room feel unclean and uncared for. Despite the residents' intact cognition, the issue was not addressed by the staff, who were expected to notify maintenance for repairs. Interviews with various staff members, including registered nurses, nursing assistants, and the maintenance director, revealed that none had noticed the unfinished wall or submitted a maintenance request to complete the repair. The maintenance director acknowledged the patching work but cited a lack of available rooms to relocate the residents temporarily and the absence of matching paint as reasons for the delay in completing the repair. The facility's policy on building maintenance and repair was requested but not provided, indicating a possible lapse in procedural adherence.
Failure to Provide Dentures for Resident with Cognitive Impairment
Penalty
Summary
The facility failed to ensure that a resident, identified as R60, was provided with necessary dental appliances to promote safety and independence in eating. R60, who had severe cognitive impairment and was dependent on staff for oral hygiene, was observed without dentures on multiple occasions. Despite having a care plan that indicated the use of dentures, there was no evidence that R60 was offered or refused his dentures during the observed days. Nursing staff, including a nursing assistant and a registered nurse, were unaware of the presence of R60's dentures, which were found in his room, and did not offer them to him during morning care. The interim director of nursing confirmed that R60 had dentures and acknowledged that refusals to wear them were not documented. The facility's policy on maintaining abilities in activities of daily living emphasized the importance of providing necessary care to prevent a decline in residents' abilities unless unavoidable. However, the lack of documentation and awareness among staff regarding R60's dentures led to a failure in providing appropriate care, as dentures were not offered or placed before meals, which is essential for the resident's ability to eat properly.
Failure to Provide Routine Nail Care for Resident
Penalty
Summary
The facility failed to provide routine nail care for a resident who required assistance with activities of daily living (ADLs). The resident, who was cognitively intact and did not refuse care, had long, yellow fingernails with dark orange matter underneath and a cracked toenail with a sharp edge. Despite the resident's need for assistance with personal care, as indicated in their care plan and clinical diagnosis report, the facility did not provide the necessary nail care. The resident expressed dissatisfaction with the lack of assistance, stating that it had been at least a month since staff helped with nail care. Observations and interviews revealed that the facility's staff, including nursing assistants and a nurse manager, were responsible for trimming residents' nails on bath days. However, the resident's weekly skin assessments inaccurately indicated that nail trimming was not needed. The assistant director of nursing acknowledged the importance of nail care for infection control and preventing skin problems, but the facility's failure to provide this care resulted in the deficiency. The facility's policy on activities of daily living emphasized the need for necessary services to maintain grooming and personal hygiene, which was not adhered to in this case.
Failure to Address Wheelchair Posture and ROM Interventions
Penalty
Summary
The facility failed to adequately assess and address the wheelchair posture of a resident with severe cognitive impairment and functional limitations in range of motion. The resident was observed multiple times seated in a standard wheelchair with poor posture, as his arms could not rest on the armrests without hunching his shoulders. The wheelchair was in disrepair, with worn-down wheels exposing the underlying material. Despite these observations, the resident's care plan did not include specific interventions for wheelchair positioning, and there was no evidence of recent evaluation by occupational therapy to address these issues. Another resident with severely impaired cognition and limited range of motion was not provided with the necessary interventions to prevent skin injury and contracture worsening. The resident's care plan included the use of palm protectors and positioning of elbows with towels or pillows, but these interventions were not consistently implemented. Observations revealed the resident lying in bed with hands balled into fists and no protective devices in place. Nursing staff were unaware of the need for these interventions and did not document any refusals or alternative measures. The facility's failure to communicate and implement assessed interventions for both residents highlights a lack of coordination between nursing and therapy services. Staff interviews revealed a lack of awareness and follow-through on necessary interventions, leading to inadequate care for residents with mobility and positioning needs. The facility's policies did not provide clear guidance on when to refer residents to therapy services for ongoing concerns, contributing to the deficiencies observed.
Failure to Schedule Audiology Consult for Resident
Penalty
Summary
The facility failed to act promptly on an order for an audiology referral for a resident who expressed difficulty with hearing. The resident, who had intact cognition and no delusional thinking, was noted in a quarterly Minimum Data Set (MDS) to have adequate hearing and did not use hearing aids. However, a referral form dated February 22, 2024, indicated an order for an audiology consult due to a diagnosis of hearing loss. By July 1, 2024, the resident reported worsening hearing loss, leading to social withdrawal, and the provider's note reiterated the need for an audiology consult. Interviews revealed that the interim Director of Nursing (DON) directed questions about resident appointments to the Health Information Manager (HIM), who confirmed that the audiology appointment had not been scheduled or refused by the resident. The HIM acknowledged the oversight and stated that scheduling the appointment would now take about four months. A policy regarding audiology services was requested but not provided, indicating a lack of documented procedures for ensuring timely access to necessary medical consultations.
Failure to Secure Bed Mattress for Resident
Penalty
Summary
The facility failed to ensure the safety of a resident, identified as R59, by not assessing and securing the bed mattress properly. R59, who had intact cognition and was independent in most mobility-related activities, was observed with a mattress that hung over the foot of the bed frame by about 12 inches, lacking a footboard or retainer bar to prevent it from sliding. The resident expressed difficulty in getting on and off the bed and mentioned that the footboard was removed and placed in the closet by staff. Despite being aware of the issue, the maintenance director and nursing staff did not document or offer alternatives to address the overhanging mattress. Interviews with various staff members, including a nursing assistant, RN, LPN, and the assistant director of nursing, revealed a lack of communication and documentation regarding the resident's bed safety. The maintenance director acknowledged the availability of bed extensions and longer mattresses but did not document any efforts to provide these alternatives. The facility's failure to assess and document the appropriateness of the mattress and bed frame for R59, who was at risk for pressure ulcers, was evident. The facility's policy on bed safety was requested but not provided, indicating a potential gap in procedural adherence.
Failure to Monitor and Document Oxygen Use
Penalty
Summary
The facility failed to ensure ongoing monitoring of a resident's oxygen use, which led to a deficiency in respiratory care. The resident, who had intact cognition and was diagnosed with heart failure, kidney failure, COPD, and respiratory failure, was on oxygen therapy and had a care plan indicating the need for monitoring and documentation of her respiratory status. However, the facility's medication and treatment records did not document the liters per minute (LPM) of oxygen being administered, despite an order to maintain oxygen saturation above 92 percent. This lack of documentation made it difficult to correlate the oxygen saturation levels with the oxygen dosage being administered. The resident experienced shortness of breath and was observed receiving oxygen at a rate of four LPM, which was not documented in the medical record. The registered nurse confirmed that the computer system did not allow for documentation of the LPM of oxygen administered, and the interim director of nursing acknowledged that the order for recording the oxygen flow rate had been missed. The resident's condition worsened, leading to hospitalization, and the facility was unable to provide a policy regarding oxygen use when requested.
Failure to Maintain Safe Bed Rails for Resident
Penalty
Summary
The facility failed to accurately assess and maintain the safety of side rails for a resident, identified as R33, who used bilateral quarter-sized side rails on their bed. R33's admission Minimum Data Set (MDS) indicated that the resident had intact cognition and required substantial assistance for bed mobility. During an observation, it was noted that the side rail on the open side of R33's bed was loose, allowing significant movement and increasing the risk of entrapment or injury. Despite R33 expressing concerns about the loose rail to staff, no corrective action was taken, and the resident was not informed of alternative options to assist with bed mobility. The facility's documentation, including the Monarch Healthcare Management (MHM) Bed Mobility Device Evaluation, lacked comprehensive information on the assessment of alternative devices for R33. The evaluation incorrectly identified the use of grab bars instead of side rails and did not specify which devices had been attempted or discussed with the resident. Additionally, R33's care plan did not include any information or direction regarding the use of side rails, despite the resident being at risk of falls and injury due to mobility issues. Interviews with staff revealed a lack of communication and follow-up regarding the maintenance of the side rails. Nursing Assistant (NA)-A acknowledged the loose rail but had not reported it for maintenance. The Director of Maintenance (DOR) confirmed that no maintenance requests had been submitted prior to the surveyor's inquiry. The interim Director of Nursing (DON) admitted that the evaluation was completed in error and that the rented bed limited alternative options. The facility did not have a policy on side rail evaluation and maintenance, contributing to the oversight in ensuring the safety of the resident's bed rails.
Failure to Address Pharmacist Recommendations for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that consulting pharmacist recommendations were fully addressed or acted upon for a resident reviewed for unnecessary medications. The resident, who had intact cognition, was diagnosed with major depressive disorder, bipolar disorder, and an anxiety disorder. The resident was prescribed multiple psychotropic medications, including quetiapine, bupropion XL, duloxetine, lamotrigine, aripiprazole, melatonin, and buspirone. The consulting pharmacist made recommendations on two occasions, in December and January, for the prescriber to review whether the resident was on the lowest effective doses of these medications. However, the recommendations were left unaddressed, with no signature, date, or prescriber response documented. Interviews with the consulting pharmacist and the interim director of nursing revealed that there was no evidence of a provider response to the pharmacist's recommendations. The consulting pharmacist noted the importance of attempting to reduce psychotropic medication use when possible, and the interim director of nursing confirmed that the recommendations should have been sent to the resident's psychiatrist. However, due to a recent change in psychiatrists and oversight by the previous director of nursing, it was unclear who the recommendations were sent to. The facility's Medication Regimen Review policy required that pharmacist recommendations be acted upon and documented, but this was not followed in this case.
Failure to Document Symptoms and Interventions for PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that acute, potentially distressing psychoactive symptoms were recorded and non-pharmacological interventions were attempted or documented for a resident (R2) before administering as-needed (PRN) psychotropic medication. R2, who had severe cognitive impairment and was on hospice care, was observed to have been administered PRN lorazepam multiple times without documentation of symptoms or behaviors justifying its use, nor any attempts at non-pharmacological interventions. The resident's care plan indicated a history of refusing care and medications, and a risk for adverse reactions to psychotropic medications, yet the facility did not adhere to the outlined protocols. The Medication Administration Record (MAR) and Treatment Administration Record (TAR) for January 2025 showed five administrations of PRN lorazepam, each lacking documentation of symptoms or non-pharmacological interventions. Interviews with staff, including a trained medication aide and a registered nurse, revealed that while non-pharmacological interventions were sometimes attempted, they were not consistently documented. The registered nurse acknowledged the absence of recorded symptoms or interventions and suggested that staff might have been administering the medication without proper documentation. Further interviews with the regional nurse consultant and the consulting pharmacist confirmed that the facility's policy required non-pharmacological interventions to be attempted and documented before administering PRN psychotropic medications. However, the resident's medical record lacked the necessary behavior monitoring order set, which should have been used to document interventions and support medication use. The facility's failure to document symptoms and interventions contravened its own policy and highlighted a gap in ensuring the efficacy and necessity of PRN psychotropic medication for the resident.
Failure to Verify and Implement Wound Care Orders
Penalty
Summary
The facility failed to verify and implement wound care orders for a resident with a primary diagnosis of cellulitis of the right lower limb, along with other conditions such as venous insufficiency, muscle weakness, chronic kidney disease stage three, and anemia. The resident's medical records showed that a nurse practitioner had ordered daily cleaning and Betadine application for a vascular ulcer on the resident's right side. However, these orders were not reflected in the treatment administration record for July 2024, indicating a lapse in following the prescribed treatment plan. Interviews with facility staff revealed a breakdown in communication and verification processes. The registered nurse and clinical manager described a procedure where the wound care nurse and clinical manager would update treatment plans based on the wound care provider's notes. However, the clinical manager assumed the orders were a mistake and did not verify them with the nurse practitioner. The nurse practitioner confirmed that the facility staff did not clarify the orders with her, and the administrator stated that her expectation was for staff to follow and clarify orders as needed. The facility did not provide a treatment order policy when requested, highlighting a potential gap in their procedural documentation.
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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