The Estates At Chateau Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Minneapolis, Minnesota.
- Location
- 2106 Second Avenue South, Minneapolis, Minnesota 55404
- CMS Provider Number
- 245222
- Inspections on file
- 31
- Latest survey
- February 3, 2026
- Citations (last 12 mo.)
- 15 (1 serious)
Citation history
Health deficiencies cited at The Estates At Chateau Llc during CMS and state inspections, most recent first.
A resident with COPD, pulmonary fibrosis, dementia, and continuous O2 use was assessed as safe to smoke independently and initially allowed to store her own cigarettes and lighter, despite MDS findings of moderate cognitive impairment and a diagnosis of dementia. After she was found smoking in her room, the plan was changed so that smoking materials were to be kept at the nurse station, but the care plan was not promptly revised, and there was no documented monitoring of the intervention’s effectiveness. The resident later caused a fire when smoking in her room with O2 equipment present, and subsequent records and staff interviews showed she frequently refused to surrender smoking materials, hid cigarettes and a lighter, and continued to possess them while on O2, while staff lacked a tracking system, did not consistently check her after smoking, and did not document her refusals or non-compliance.
The facility did not procure food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
A resident with intact cognition who wished to move closer to family did not receive adequate discharge planning, as the facility failed to document or follow up on referrals and updates related to the discharge process. Staff interviews confirmed a lack of ongoing communication and follow-up, despite the facility's policy requiring continuous evaluation of discharge goals.
Two residents who were dependent on staff for ADLs did not receive routine personal hygiene, including showers, hair care, and shaving. One resident was left with a long beard despite requesting to be shaved, and another was observed with matted hair and lacked documentation of recent bathing or grooming. Staff interviews and records confirmed that personal hygiene care was not consistently provided or documented according to facility policy.
The facility did not provide care and treatment in accordance with physician orders and the resident’s stated preferences and goals, as identified through surveyor observation and record review.
A resident with a history of smoking violations was allowed to keep smoking materials in her room and continued to smoke there despite facility policy requiring smoking only in designated areas. Staff observed evidence of smoking in the resident's bathroom, and interviews confirmed ongoing non-compliance. The resident refused to have smoking materials stored at the nursing station, and staff found it difficult to supervise her due to her insistence on privacy.
A resident with a history of urethral stricture and obstructive uropathy had an indwelling urinary catheter in place for an extended period without documented clinical justification, periodic reassessment, or attempts at removal, despite experiencing multiple catheter-associated UTIs, including one resulting in hospitalization. Staff confirmed the absence of trial removal or timely urology referral, and the care plan lacked detail regarding catheter management.
Several residents with specific dietary needs, including those requiring large portions for malnutrition and wound healing, and one requiring yogurt or cottage cheese for weight gain, did not consistently receive the prescribed food portions or supplements. Additionally, a resident with a fluid restriction order was able to access fluids freely without monitoring or education from staff. Staff interviews and observations confirmed that dietary and fluid orders were not consistently followed.
A resident who required dialysis did not receive safe and appropriate dialysis care and services as needed. The facility did not ensure that dialysis care was provided according to the resident's requirements.
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 deficiency was cited when a resident’s drug regimen included unnecessary medications, either lacking clinical indication, being excessive in duration, or duplicative, without proper documentation to justify their use.
A resident with central spinal cord syndrome did not receive a physical therapy evaluation as ordered after a care conference where the need for additional PT was discussed. Although a provider order for PT was entered, staff interviews confirmed that the evaluation was not completed due to a lapse in follow-through, and the facility could not provide a relevant therapy policy when requested.
A resident with no cognitive impairment and multiple psychiatric diagnoses was involved in a loud verbal altercation with a dietary aide over a meal request, during which both parties exchanged derogatory language. The incident was partially observed on facility camera footage, and another staff member intervened to de-escalate the situation. Facility leadership was not aware of the event until notified by surveyors, and the facility's abuse policy was not followed.
A resident with no cognitive impairment and multiple psychiatric diagnoses was involved in a verbal altercation with a dietary aide, during which both parties exchanged inappropriate language. Another staff member intervened, but neither staff nor the resident reported the incident to management as required by facility policy. The administrator was unaware of the event until the survey, resulting in a failure to report the suspected abuse to the State Agency and facility leadership.
A former resident with a history of behavioral issues repeatedly gained unauthorized access to the facility through an unsecured door, resulting in non-consensual contact with a resident and theft from another. Staff were often unaware of the trespass order or the former resident's presence, and the front door was frequently left propped open. Additionally, two residents were not protected from abuse during a series of altercations with another resident, with staff failing to implement effective interventions.
A resident reported $80 missing from her purse, but facility staff did not report the suspected theft to the State Agency or law enforcement within the required timeframe. The resident, who was cognitively intact and had a history of fractures and depression, was told by the social worker to file her own police report, and staff interviews revealed confusion about reporting requirements. The facility's policy required timely reporting of suspected misappropriation, but this was not followed.
A resident with diabetes and heart disease missed multiple doses of Rybelsus due to the facility's lack of a clear process for obtaining timely prior authorization (PA) for medications. Staff interviews revealed confusion about the PA process, with delays in returning required forms to the pharmacy and inconsistent communication among nurses, medication aides, and providers. The facility's medication policy did not address PA procedures, leading to repeated missed doses over several months.
A facility failed to remove alcohol from a resident's room and did not analyze the causes of increased aggression in a resident with substance abuse issues. Despite the resident's history of alcohol dependence and aggressive behavior, staff did not confiscate alcohol without the resident's permission, contrary to facility policy. The resident declined treatment and harm reduction approaches, leading to multiple incidents of aggression. Staff interviews revealed inconsistencies in addressing the resident's behavior, and the facility's administrator admitted the policy was not followed.
A resident's care plan contained conflicting instructions regarding the number of staff required for personal care, leading to inconsistent care. Despite the care plan indicating the need for two caregivers, staff often provided care with only one person. The resident had multiple diagnoses, including cerebral infarction and hemiplegia, and the care plan was not updated to reflect current needs, as noted by facility staff.
The facility failed to maintain aseptic technique during perineal care, with staff observed wiping from back to front and reusing washcloths improperly. Additionally, timely incontinent care was not provided, as evidenced by saturated briefs and linens for two residents. One resident did not receive weekly showers as preferred, highlighting deficiencies in personal hygiene care.
A facility failed to ensure licensed staff were trained on wound VAC procedures, affecting a resident with a wound VAC due to an open fracture. The resident reported staff's inability to manage wound VAC alerts, and interviews revealed frequent alarm issues. The DON admitted uncertainty about staff education on wound VACs, and the facility lacked a formal policy or procedure for wound VAC management.
The facility failed to monitor and remove expired food, improperly stored food items, and did not maintain safe refrigerator temperatures, affecting all residents consuming food from the facility kitchen. Observations revealed undated and expired food in the kitchen, improper storage practices in the dry storage room, and uncovered food trays during service. Staff were unsure of safe refrigerator temperatures, leading to spoiled food, and the facility's policies on food safety were not followed.
The facility's QAA program failed to address ongoing food storage and handling deficiencies in the main kitchen and unit refrigerators, despite repeated non-compliance over multiple years. The dietary manager acknowledged the issues, citing staff turnover and lack of formal audits. The administrator confirmed awareness of the concerns but noted no PIP or documented audits were in place.
The facility failed to serve meals at a warm and palatable temperature, affecting residents' quality of life and nutritional intake. Observations showed that food trays were transported on non-enclosed carts without insulated bases, leading to meals being served at room temperature. The dietary manager confirmed the food was not hot, and the facility's policy lacked specific guidelines for timely tray passing.
A resident with multiple health conditions and intact cognition was not provided with personal clothing, despite expressing a preference for wearing shorts and a shirt instead of a hospital gown. The facility's care plan lacked documentation of the resident's clothing preferences, and staff interviews confirmed the absence of personal clothing. The facility's policy emphasized supporting resident preferences, yet the resident's needs were not adequately addressed, resulting in a deficiency in maintaining personal dignity.
A resident with intact cognition reported that her overhead light had been broken for weeks, despite multiple requests for repair. The maintenance director was unaware of the issue until the survey and admitted to accidentally closing the request. The room was dimly lit, and the facility's maintenance policy lacked a timeline for completing requests.
The facility failed to implement and document care-planned interventions for substance use for two residents, leading to a lack of continuity in their care. One resident was found intoxicated multiple times without vital signs being monitored as directed. Another resident displayed signs of intoxication, but medications were not held, and vital signs were not checked. Additionally, the care plan for a third resident on psychotropic medications lacked target behaviors and specific interventions, contrary to facility policy.
A resident with paraplegia and diabetes was inaccurately assessed as a non-smoker upon admission, despite smoking regularly. The facility failed to conduct a comprehensive smoking assessment, leaving questions about the resident's need for supervision or adaptive equipment unanswered. Staff interviews and observations confirmed the resident's smoking status, highlighting inconsistencies in the assessment process and a deficiency in ensuring a safe environment.
A resident with moderate cognitive impairment and frequent pain was not adequately assessed or managed for newly developed back pain. Despite expressing significant discomfort and dissatisfaction with current pain management, the facility failed to update the care plan or conduct a comprehensive assessment. Nursing staff acknowledged the resident's increased pain complaints, but the facility's Pain Management Protocol was not followed, resulting in inadequate pain management.
A resident with asthma did not receive a scheduled dose of Dulera inhaler due to a delay in reordering the medication. An LPN noted the medication was out of stock and would not arrive until later, causing the resident to miss the morning dose. The interim DON confirmed that medications should be reordered in advance to prevent such issues.
A resident with diabetes did not have their blood sugar levels consistently monitored after an increase in insulin dosage. The facility's staff acknowledged that the order for blood sugar checks was accidentally discontinued, leading to a lack of documentation and monitoring, contrary to the facility's procedures.
A facility failed to have a qualifying diagnosis for the routine use of an antipsychotic medication and did not complete an AIMS assessment for a resident. The resident was prescribed olanzapine for anxiety, which is not an appropriate indication. The care plan lacked documentation of interventions and potential side effects. The facility's policy required an AIMS assessment, but it was only completed after the survey visit. A pharmacy recommendation for a gradual dose reduction was not followed, contributing to the deficiency.
The facility failed to post accurate nurse staffing information, affecting all 65 residents and visitors. From August 5 to August 14, 2024, the posted staffing levels were higher than the actual staffing levels, with discrepancies noted in the number of nursing assistants (NAs) present during shifts. The staffing coordinator identified a computer program error that pulled unfilled NA slots as filled, leading to inaccurate postings. The facility's policy requires accurate posting of NAs responsible for resident care, which was not followed.
The facility failed to ensure residents' right to be free from abuse and provide adequate supervision for two residents with a history of alcohol abuse and altercations. Both residents were involved in a physical altercation while intoxicated, resulting in injuries. Staff interviews revealed inadequate monitoring of intoxicated residents and a lack of reeducation for staff on managing such situations.
Failure to Control Smoking Materials and Prevent Oxygen-Related Fire
Penalty
Summary
The deficiency involves the facility’s failure to prevent an unintentional fire and to control smoking materials for a resident who used continuous oxygen and had documented dementia with moderate cognitive impairment. The resident’s diagnoses included pulmonary fibrosis, COPD, depression, nicotine dependence, and dementia. A smoking evaluation dated 12/19/25 identified the resident as safe to smoke independently, with no cognitive loss, no visual or dexterity problems, and allowed her to store and handle her own cigarettes and lighter. This evaluation did not address whether the resident understood safety measures related to removing or positioning oxygen equipment prior to smoking. The initial smoking care plan, initiated 12/23/25, set a goal for the resident to smoke safely and independently, noted education on the dangers of oxygen and smoking, and stated she was independent with smoking per evaluation, but did not include specific interventions regarding oxygen placement or removal before or during smoking. On 12/24/25, the resident was found smoking in her room, contrary to facility expectations. The incident analysis identified that she was a new admission and independent with smoking per her admission form. She was re-educated, and the plan was to remove smoking materials and keep them at the nursing station. A smoking evaluation dated 12/24/25 again documented no cognitive loss despite the MDS showing moderate cognitive impairment and a dementia diagnosis, and it specified that the resident could light her own cigarette but could not store her own smoking materials, which were to be kept at the nursing station. However, the smoking care plan was not revised until 12/29/25 to add the intervention to store smoking materials at the nurse station. A Risk vs Benefits form dated 12/30/25 identified the concern of the resident smoking in her room while on oxygen and described the dangers of oxygen-related fires, but it did not list any benefits, was not signed by the resident or representative, and there was no documentation of monitoring or evaluation of the effectiveness of the intervention to store smoking materials at the nurse’s station. On 1/29/26 at 8:39 a.m., progress notes documented that the resident was smoking in her room and caused a fire, indicating that the 12/29/25 intervention to keep smoking materials at the nurse’s station was not followed. The resident denied smoking and refused a respiratory assessment and skin check. An incident analysis for 1/29/26 stated that staff heard the roommate yelling for help and found a fire on the resident’s oxygen tank in her room while the resident was smoking, though she denied it. The fire was extinguished, and both residents were assessed with no injuries found. A search of the room revealed a pack of cigarettes, which was taken to the nurse’s station. The smoking evaluation dated 1/29/26 again documented no cognitive loss despite the MDS and dementia diagnosis, noted that the resident smoked 5–10 times per day, could light her own cigarette, could not store her own smoking materials, and that smoking materials were supposed to be kept at the nurse’s station. It also stated that daily room checks were to be done, that the resident used oxygen, had been educated to remove and store oxygen prior to smoking, and had a wanderguard on her portable oxygen tank. Following the fire, the care plan was updated on 1/29/26 with interventions such as daily room searches with the resident’s permission, safety checks, posting signs in Spanish about no smoking and oxygen being flammable, visualizing the room every shift to remove visible smoking materials, and using a wanderguard on the portable oxygen tank. However, between 1/29/26 and 2/2/26, the record did not include a comprehensive assessment or analysis supporting that 15-minute checks were appropriate or sufficient to prevent the resident from smoking, nor did the care plan provide instructions for staff if the resident was non-compliant with surrendering smoking materials. There was no documented assessment of the resident’s task-specific decisional capacity to safely engage in smoking while using oxygen, despite her dementia, moderate cognitive impairment on the MDS, and prior non-compliance on 12/24/25 and 1/29/26. On 2/2/26, the resident told an interviewer she did not trust staff with her smoking materials and admitted refusing to give them up when asked. She produced a box of cigarettes and a lighter from her coat pocket while wearing a nasal cannula connected to oxygen at 2 LPM. A nursing assistant reported that the resident often refused to give up her smoking materials after returning from smoking outside and that staff did not always have time to check residents after smoking to ensure materials were turned in. Another nursing assistant and an RN stated the resident was non-compliant with smoking rules, hid smoking materials, and that residents sometimes shared supplies, but these refusals and hiding behaviors were not documented in the record between 12/23/25 and 2/2/26. An LPN showed that the drawer designated for smoking materials at the nurse’s station contained only office supplies and confirmed there was no log to track smoking supplies. The DON acknowledged that family brought in smoking materials without first bringing them to the nursing station and that it was difficult to take items from the resident. These observations and interviews demonstrated that the resident remained in possession of cigarettes and a lighter after the fire, that staff were aware of ongoing non-compliance and family involvement in supplying materials, and that there was no effective system or documentation to ensure smoking materials were secured as care planned, resulting in continued risk of fire.
Removal Plan
- Reviewed smoking policies with the medical director and ombudsman input.
- Developed and implemented a comprehensive system to prevent accidents, hazards, and fires related to smoking inside the facility, including a plan for residents who fail to comply with safe smoking practices.
- Reassessed R1's capacity to make safe decisions regarding smoking.
- Revised R1's care plan with individualized interventions.
- Identified residents with similar smoking risks and their level of compliance with facility smoking policy.
- Implemented individualized interventions for residents with similar smoking risks to prevent unsafe smoking.
- Re-educated residents on safe smoking policies and administered a knowledge check quiz.
- Educated all staff on smoking policies and administered a knowledge check quiz to demonstrate understanding.
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 Ensure Adequate Discharge Planning and Follow-Up
Penalty
Summary
The facility failed to maintain an adequate discharge planning process to ensure a resident's preference for discharge was met. The resident, who had intact cognition and no behavioral or psychiatric issues, expressed a desire to move closer to family in a neighboring state. Although the care plan indicated that the resident and family were seeking a skilled nursing facility (SNF) in the desired area and that referrals had been initiated, there was a lack of documentation regarding where referrals were sent, updates on the status of those referrals, or outcomes from the MNchoice assessment. Progress notes showed some referrals and assessments were made, but did not include follow-up information or communication with the resident or family about the discharge process after certain dates. Interviews with staff revealed that there was no evidence of follow-up on discharge plans or referrals in the electronic medical record since the last care conference, despite the resident's ongoing wish to discharge. The social services director acknowledged the absence of follow-up, and the director of nursing stated that the expectation was for social services to remain involved and for resources to be set up for a safe discharge in a timely manner. The facility's own discharge planning policy required continuous evaluation and implementation of interventions to address discharge goals, which was not reflected in the documentation or actions taken for this resident.
Failure to Provide Routine Personal Hygiene for Dependent Residents
Penalty
Summary
The facility failed to ensure that routine personal hygiene, including showers, hair care, and shaving, was completed for two residents who were dependent on staff for activities of daily living (ADLs). One resident, who was cognitively intact but had significant physical impairments and was dependent on staff for all personal hygiene, was observed with a two-inch long beard despite expressing a preference to be clean-shaven. Documentation and care plans lacked specific instructions or preferences regarding shaving, and staff interviews confirmed that the resident had been requesting to be shaved for several weeks without the request being fulfilled due to staff being too busy. Another resident, also cognitively intact but with multiple medical diagnoses and a self-care deficit, required staff assistance for bathing, dressing, grooming, and oral hygiene. The care plan did not include the resident's preferences or evidence of refusals for bathing or assistance. Weekly skin assessments and progress notes showed repeated refusals of baths, but there was no documentation of staff offering additional opportunities for bathing or partial baths, nor was there evidence of staff reapproaching the resident or documenting interventions. Observations revealed the resident appeared disheveled with a large, matted clump of hair, and staff interviews confirmed the lack of recent bathing and grooming. The facility's policy required that care and services be provided based on comprehensive assessment and resident needs and choices, to ensure that abilities in ADLs do not diminish unless unavoidable. However, the lack of documentation, failure to follow up on resident requests and preferences, and insufficient attempts to provide or document personal hygiene care led to the deficiency identified during the survey.
Failure to Follow Physician Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. This deficiency was identified through surveyor observation and record review, which indicated that care provided did not align with the documented orders or the expressed wishes and objectives of the resident. Specific details regarding the resident’s medical history or condition at the time of the deficiency were not provided in the report.
Failure to Prevent Smoking Hazards for Resident with Repeated Violations
Penalty
Summary
A resident with a history of smoking violations was not adequately protected from potential smoking-related accidents. The resident was assessed as having adequate memory and cognitive function and was care planned to smoke independently, with interventions including smoking in her room, no smoking signs, and not allowing removal of cigarettes. Despite these interventions, documentation and staff interviews confirmed that the resident repeatedly smoked in her room, in violation of facility policy, and kept all smoking materials in her possession. Observations revealed evidence of smoking in the resident's bathroom, including a plastic cup with tar-colored liquid, coffee grounds, a strong odor of smoke, loose tobacco on the floor, and a bag of loose tobacco on the resident's wheelchair. Staff interviews indicated that the resident would not allow staff into her room without knocking and waiting for a response, making supervision difficult. The resident refused to have her smoking materials stored at the nursing station, despite being assessed as unsafe with her own smoking materials. The facility's policy required residents to smoke only in designated areas and allowed for revocation of smoking privileges for non-compliance, but the resident continued to smoke in her room. The administrator and DON confirmed the facility's policy and the ongoing non-compliance.
Failure to Document and Reassess Indwelling Catheter Use
Penalty
Summary
The facility failed to ensure appropriate clinical decision-making and documentation regarding the use of an indwelling urinary catheter for one resident. The resident, who was cognitively intact and independent with activities of daily living, had a history of urethral stricture and obstructive and reflux uropathy. Despite these diagnoses, the medical record did not contain documentation of the reason for the catheter's insertion, justification for its continued use, or evidence of periodic reassessment. There was also no documentation of any attempt to remove the catheter or a referral to urology for further management until recently, even though the resident had experienced multiple urinary tract infections (UTIs) associated with the catheter, including one that resulted in hospitalization for sepsis. Interviews with staff confirmed that no trial removal of the catheter had been attempted since the resident's admission, and the care plan only referenced long-term catheter use without further detail. The resident reported a history of frequent UTIs and expressed that the catheter was intended to remain until he could stand and care for himself, based on previous medical advice. The facility's electronic medical record lacked evidence of ongoing assessment or a clear plan for catheter management, and no relevant policy was provided upon request.
Failure to Follow Dietary and Fluid Restriction Orders
Penalty
Summary
The facility failed to follow established nutritional interventions and dietary orders for several residents, resulting in deficiencies in the provision of adequate food and fluids. Three residents with specific dietary needs, including large portions for wound healing and malnutrition, and the addition of yogurt or cottage cheese for weight gain, did not consistently receive the prescribed food portions or supplements. Observations and interviews revealed that residents who were supposed to receive double or large portions were served meals of the same size as other residents, and one resident did not receive the ordered yogurt or cottage cheese with meals. Staff interviews confirmed that the intended larger portions were not being provided, and the dietary staff did not consistently follow meal tickets or care plans specifying these interventions. Additionally, the facility failed to ensure that a fluid restriction order was followed for a resident with hyponatremia. The resident was observed drinking fluids freely from large containers, and staff reported that they were unable to monitor her intake because she was independent in obtaining fluids. There was no documentation of education or risk versus benefit discussions with the resident regarding the importance of adhering to the fluid restriction. The resident herself stated that she had not received any education from facility staff about her fluid restriction or its significance. Facility policies were reviewed and indicated that food and nutritional needs should be met according to physician orders, and that therapeutic diets should be prepared and served as prescribed. However, the observed practices did not align with these policies, as residents did not receive the prescribed diets or fluid restrictions. The lack of adherence to dietary and fluid orders was confirmed through staff interviews, resident statements, and direct observation of meal service and resident behavior.
Failure to Provide Safe and Appropriate Dialysis Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate dialysis care and services for a resident who required such treatment. The report notes that the facility failed to ensure that the necessary dialysis care was provided in accordance with the resident's needs. Specific details about the actions or omissions that led to this deficiency, as well as the resident's medical history or condition at the time, are not provided in the report.
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.
Unnecessary Drugs in Resident Drug Regimens
Penalty
Summary
A deficiency was identified regarding the management of residents' drug regimens. The facility failed to ensure that each resident’s drug regimen was free from unnecessary drugs, as required by regulations. This indicates that at least one resident was prescribed or administered medications that were not clinically indicated, excessive in duration, or duplicative, without adequate justification documented in the medical record.
Failure to Provide Ordered Rehabilitative Services
Penalty
Summary
A resident with central spinal cord syndrome and a history of receiving physical, occupational, and speech therapy did not receive specialized rehabilitative services as ordered. The resident's care plan was updated to include passive range of motion (PROM) and instructions to follow physical therapy (PT) orders. During a care conference, the resident and family requested additional PT due to observed movement in the resident's lower extremities. A provider subsequently ordered a PT evaluation, but the evaluation was not completed after the order was written. Interviews with staff revealed that the PT order was not acted upon, with the LPN confirming that the order "fell through the cracks." The director of nursing stated that the expectation was for therapy to evaluate residents within 72 hours of a new order and to communicate the therapy plan to nursing staff within one week. Despite these expectations, the resident was not evaluated by PT after the new order, and the facility was unable to provide a policy for therapy services when requested.
Failure to Protect Resident from Staff Verbal Abuse
Penalty
Summary
A resident with a BIMS score of 15/15 and diagnoses including weakness, schizophrenia, anxiety disorder, depression, and chronic pain syndrome was involved in a verbal altercation with a dietary aide at the kitchen door. The incident occurred when the resident requested two chicken sandwiches and was told only one was available. Both the resident and the dietary aide admitted to yelling and calling each other derogatory names, specifically 'bitch.' Another dietary aide intervened and asked the resident to leave, which he did. There was no physical interaction, but the exchange was loud and disrespectful. Facility camera footage partially captured the incident but lacked audio and did not cover the entire altercation. The facility's leadership was unaware of the event until informed by surveyors. The facility's policy emphasizes protecting residents from all forms of abuse, including verbal abuse by staff. The incident demonstrated a failure to protect the resident from staff-to-resident verbal abuse as required by facility policy.
Failure to Report Staff-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of staff-to-resident abuse to the State Agency and the facility administrator after a verbal altercation occurred between a resident and a dietary aide. The resident, who was cognitively intact with a BIMS score of 15/15 and had diagnoses including schizophrenia, anxiety disorder, depression, and chronic pain syndrome, reported that he and a staff member engaged in a heated exchange involving yelling and name-calling over a request for two sandwiches. Another staff member intervened to de-escalate the situation, but neither staff member nor the resident reported the incident to facility management. Interviews revealed that both staff involved in the incident acknowledged the altercation and the use of inappropriate language, but did not notify management as required by facility policy. The administrator confirmed that leadership was unaware of the incident until it was brought to their attention during the survey. Facility policy mandates immediate reporting of any situation considered abuse or neglect, but this procedure was not followed in this case.
Failure to Prevent Unauthorized Entry and Resident Abuse
Penalty
Summary
The facility failed to ensure resident safety by allowing a former resident, who had been discharged and issued a no-trespass order, to repeatedly gain unauthorized entry into the building through an unsecured door without staff awareness. This resulted in non-consensual contact when the former resident entered a female resident's room at night and kissed her on the forehead, causing her mental anguish and difficulty sleeping. The former resident also misappropriated property from another resident and was observed in multiple areas of the facility after discharge, including attempting to sleep in his old room and interacting with residents on various floors. Staff interviews revealed that the former resident was able to enter the building undetected on several occasions, often due to the front door being propped open by residents, and that staff were not always aware of his presence or the trespass order in place. The report documents that the former resident had a history of behavioral issues, including increased aggression towards staff and residents, frequent intoxication, and providing alcohol to other residents. Despite being discharged against medical advice and given a trespass order, the former resident continued to return to the facility, sometimes entering the building and resident rooms, and at other times remaining just outside the property. Police were called multiple times, but the former resident often left before their arrival. Staff and residents reported feeling unsafe, and some residents expressed a desire to file restraining orders due to the former resident's threats and inappropriate behavior. The facility's front door was identified as a key vulnerability, as it was often left propped open, allowing unauthorized access. Additionally, the facility failed to protect two residents from abuse when another resident engaged in a verbal and physical altercation with one resident, which escalated to a physical incident with a second resident later the same day. Documentation and interviews confirmed that staff were aware of the altercations but did not implement effective interventions to prevent further incidents. The affected residents had various medical and behavioral diagnoses, including alcohol dependence, depression, and physical disabilities, but were generally independent in their self-care. The facility's lack of effective monitoring and response to both the unauthorized entries and resident-to-resident altercations resulted in a finding of Immediate Jeopardy, placing all residents at risk.
Failure to Timely Report Alleged Theft of Resident Property
Penalty
Summary
The facility failed to immediately report an allegation of stolen money to the State Agency (SA) and law enforcement, as required by policy and regulation. A cognitively intact resident with a history of multiple fractures and depression reported that $80 was taken from her purse overnight while she was asleep. The resident discovered the theft the following morning and filed a grievance with the facility. The grievance form indicated that the resident herself made a police report, but facility staff did not assist her in this process. Interviews revealed that the social worker informed the resident she would need to file her own police report and did not offer assistance. The incident was not reported to the SA within the required 24-hour timeframe, nor was it reported to law enforcement by the facility. Staff interviews indicated a misunderstanding of reporting requirements, with some staff believing that confirmation of the theft or proof that the resident had the money was necessary before reporting to the SA. The director of nursing acknowledged that taking a resident's money could be considered financial abuse and should have been reported. The facility's policy required reporting any suspicion of misappropriation of resident property to the SA within 24 hours, regardless of whether the incident resulted in serious bodily injury. Despite this, the facility did not follow its own policy or state law, resulting in a failure to report the suspected theft in a timely manner.
Failure to Ensure Timely Prior Authorization Resulted in Missed Diabetes Medication Doses
Penalty
Summary
The facility failed to ensure a process was in place for timely prior authorization (PA) of medications, resulting in a resident missing multiple doses of a prescribed diabetes medication, Rybelsus. The resident, who was cognitively intact and had diagnoses including diabetes and heart disease, had a care plan directing staff to administer medications as ordered. However, medication administration records showed repeated missed doses of Rybelsus over several months, with gaps in March, April, and May. The missed doses were due to delays in completing and returning the required PA forms to the pharmacy, which prevented the pharmacy from dispensing the medication. Interviews with staff revealed a lack of clarity and knowledge regarding the PA process. The pharmacist confirmed that the facility did not return PA forms in a timely manner, and staff, including medication aides and nurses, were unsure of their roles in ordering and authorizing medications requiring PA. The medication aide reported notifying nurses about the need for refills but did not escalate the issue promptly when the medication did not arrive. Nurses and nurse managers were also unaware of the extent of missed doses, and documentation in progress notes did not consistently reflect the missing medication. The resident reported missing Rybelsus doses for about a month in March and April, as well as some in May, and stated that nurses attributed the delay to the need for administrative approval. The facility's medication orders policy did not include guidance on the PA process, contributing to the confusion and failure to ensure timely medication administration as ordered by the provider.
Failure to Remove Alcohol and Address Aggression in Resident
Penalty
Summary
The facility failed to adhere to its policy of removing alcohol from a resident's room and did not adequately analyze the underlying causes of increased aggression in a resident with a history of substance abuse. The resident, who had diagnoses of alcohol dependence, cocaine dependence, and major depressive disorder, exhibited physical and verbal aggression towards others, particularly after consuming alcohol. Despite the facility's policy allowing for the confiscation of substances posing risks to residents' health and safety, staff did not remove alcohol from the resident's room without explicit permission from the resident. The resident's care plan included interventions such as monitoring for intoxication, offering community resources, and notifying providers of substance use. However, the resident repeatedly declined treatment and harm reduction approaches. The facility documented several incidents where the resident became aggressive after consuming alcohol, including altercations with other residents and staff. Despite these incidents, alcohol was not removed from the resident's room, as staff believed they needed the resident's consent to do so. Interviews with facility staff revealed a lack of consistent action in addressing the resident's alcohol use and aggression. Staff were aware of the resident's behavior changes and the presence of alcohol in the resident's room but did not take steps to remove it, citing the resident's right to refuse. The facility's administrator acknowledged that the facility's policy was not followed, and the resident's aggression was a new behavior that had not been assessed for root causes.
Inconsistent Care Plan for Resident
Penalty
Summary
The facility failed to maintain a consistent care plan for a resident, identified as R4, who was reviewed for care plans. R4's care plan contained conflicting information regarding the number of staff required to assist with personal care tasks. While one part of the care plan indicated that two staff members were needed, another section stated that only one staff member was required for bathing, dressing, and personal hygiene. This inconsistency was observed during a visit when a nursing assistant changed R4's incontinent brief alone, despite the care plan's indication of needing two caregivers. R4 was admitted with a primary diagnosis of cerebral infarction and additional conditions such as hemiplegia, repeated falls, and anxiety disorders. The resident's care plan was not updated to reflect current needs, as noted by various staff members during interviews. The nurse manager and director of nursing both expressed expectations that care plans should be regularly updated and consistent. However, the intervention requiring two caregivers was not removed from the care plan, despite it no longer being applicable. This oversight was acknowledged by the social services staff who initially added the intervention following reports of abuse.
Deficiencies in Perineal Care and Incontinence Management
Penalty
Summary
The facility failed to maintain aseptic technique during perineal care for residents, as observed in multiple instances. Nursing assistants were seen wiping residents' perineal areas from back to front, which is contrary to the expected front-to-back method. This improper technique was noted during the care of residents R1, R2, and R4, with the same washcloth being reused without changing sides or using a new cloth for each stroke, as required by aseptic standards. Additionally, the facility did not provide timely incontinent care for residents R1 and R4. R4's brief was found saturated with urine, and the linens were soaked, indicating a lack of regular checks and changes. The care plan for R4 specified that incontinent briefs should be checked every two to three hours, but this was not adhered to, as evidenced by the delay in changing R4's brief until several hours later. R1 also reported that staff did not regularly check or change her incontinent brief, and she often had to use her call light to request assistance. The facility also failed to provide weekly showers for R1, who expressed a preference for showers. Despite this preference being documented, R1 did not receive a shower as expected, and her family member reported having to bathe her during visits. The facility's policy on activities of daily living was not followed, as residents did not receive the necessary care to maintain their abilities in these areas, leading to deficiencies in personal hygiene and comfort.
Inadequate Training on Wound VAC Procedures
Penalty
Summary
The facility failed to ensure that licensed staff were adequately trained on wound vacuum-assisted closure (VAC) procedures, which affected five out of sixteen licensed staff. A resident was admitted with a wound VAC due to an open fracture and required regular dressing changes as per the care plan. However, the facility's records showed inconsistencies in the treatment administration record, with multiple registered nurses and licensed practical nurses checking off completed treatments without proper training. The resident reported that staff were unable to manage the wound VAC alerts, indicating a lack of competency in handling the device. Interviews with staff and family members revealed that the wound VAC alarm frequently went off, and staff were unsure how to address the issues. The Director of Nursing admitted uncertainty about whether staff had been educated on wound VACs and acknowledged the absence of a formal policy or procedure for wound VAC management. The facility could only provide wound VAC education competencies for a limited number of staff, and the administrator confirmed the lack of comprehensive training documentation for all licensed nurses.
Deficiencies in Food Safety and Storage Practices
Penalty
Summary
The facility failed to ensure proper monitoring and timely removal of food stored in refrigerators and freezers, which could potentially affect all 65 residents consuming food from the facility kitchen. During an observation, several undated and improperly stored food items were found in the kitchen's refrigerator and freezer, including undated corn, peas, carrots, turkey lunch meat, and caramel sauce, as well as expired items like carrots and apple sauce. The dietary manager acknowledged that these items should have been dated and discarded, indicating a lapse in the facility's food safety practices. Additionally, the facility did not adhere to proper food storage practices, as observed in the dry storage room where a Styrofoam cup was used to scoop flour, and food items like sweet potatoes and onions were stored on the floor. The dietary manager admitted that storing food on the floor was unacceptable and that the cup should not have been left in the flour container. Furthermore, the third-floor unit refrigerator temperatures were not properly monitored, with recorded temperatures exceeding safe levels, leading to spoiled food. Staff members, including a registered nurse and a licensed practical nurse, were unsure of the appropriate refrigerator temperatures, highlighting a lack of knowledge and oversight in maintaining food safety. The facility also failed to cover food items properly when serving residents, as observed with uncovered food trays in the third-floor hallway. A fly was seen around the serving area, and the dietary manager confirmed that all food should be covered during tray pass to prevent contamination. The facility's policies on refrigerator temperatures and food storage were not followed, contributing to these deficiencies in food safety and handling practices.
Ongoing Food Storage and Handling Deficiencies
Penalty
Summary
The facility failed to ensure proper food storage and handling practices in its main production kitchen and unit-based refrigerators, as identified during a recertification survey. The Quality Assurance and Assessment (QAA) program did not effectively identify or implement actions to address these ongoing issues, despite repeated non-compliance with federal regulations over multiple years. The deficiencies included undated food items in the kitchen refrigerators and freezers, and over-packed unit refrigerators that were not maintaining appropriate temperatures. The dietary manager (DM), who had been in the role for nearly a year, acknowledged the issues with kitchen safety and food storage. The DM noted that there had been significant staff turnover, making it challenging to maintain consistent practices. Although the DM attended routine QA meetings, no formal audits or ongoing monitoring were conducted outside of their manual checks. A recent corporate mock survey had identified similar concerns, but only partial education had been provided to staff, and no Performance Improvement Project (PIP) was in place to address the kitchen issues. The facility administrator confirmed that the QA team met monthly and was aware of the kitchen concerns, which had been discussed previously. However, despite recognizing the need for staff coaching and accountability, no PIP or documented audits were in place for the kitchen issues. The administrator mentioned that a new plating system had been introduced to address food temperature concerns, but the lack of labeling, dating, and proper storage in refrigerators remained unaddressed. The most recent QAPI meeting minutes were requested but not provided.
Failure to Serve Meals at Appropriate Temperature
Penalty
Summary
The facility failed to ensure meals were served in a warm and palatable manner, affecting the quality of life and nutritional intake for three residents. These residents, who had intact cognition and no delusional thinking, reported that their meals were consistently served cold. Observations confirmed that food trays were transported on non-enclosed carts without insulated plate bases, leading to meals being served at room temperature. The dietary manager acknowledged that the food was not hot and expressed that trays should have been passed within approximately 15 minutes to maintain appropriate temperatures. The facility's Meal Tray Service policy did not specify a time frame for meal tray passes or methods to ensure meals remained at a palatable temperature. The administrator expected staff to use a heated plate system with both an insulated lid and bottom, and anticipated that management and additional staff would assist in timely tray passing. However, the observed delay in tray distribution contributed to the deficiency, as the last tray was passed significantly later than expected, resulting in cold meals for residents.
Failure to Maintain Resident Dignity in Personal Care
Penalty
Summary
The facility failed to maintain personal dignity for a resident, identified as R16, who was reviewed for dignity with personal care. R16, who had intact cognition, required maximal staff assistance for various activities of daily living due to multiple diagnoses, including osteoarthritis, heart failure, diabetes, and chronic pain. Despite these needs, R16's care plan lacked evidence of his preference to wear a hospital gown versus personal clothing, and there was no documentation of the facility's efforts to obtain personal clothing for him. Observations and interviews revealed that R16 was often seen wearing a hospital gown, although he expressed a preference for wearing shorts and a shirt. R16 stated that he had requested clothing from his family, but due to his wife's health and living situation, she was unable to provide them. Staff interviews confirmed that R16 did not have personal clothing at the facility and that he seemed more comfortable in shorts and a shirt, which was his preference. However, there was no follow-up to ensure R16 received clothing, and the facility's staff had not discussed his clothing preferences with him. The facility's policy on Activities of Daily Living (ADLs) emphasized honoring and supporting each resident's preferences, choices, values, and beliefs. Despite this policy, the facility did not adequately address R16's clothing needs or preferences, as evidenced by the lack of documentation and follow-up actions. The assistant director of nursing and social worker acknowledged the facility's responsibility to assist residents in obtaining clothing, yet R16's situation remained unresolved, highlighting a deficiency in maintaining his personal dignity.
Failure to Maintain Homelike Environment Due to Unresolved Maintenance Request
Penalty
Summary
The facility failed to ensure necessary maintenance services were performed to provide a homelike environment for a resident with a broken overhead light. The resident, who had intact cognition and required supervision for oral and personal hygiene, reported that the overhead light in her room had not worked since she moved in several weeks ago. Despite requests to the maintenance staff, the issue remained unresolved. The facility's Closed Work Order report indicated a request for a correctly fitting mattress and noted the non-functional light, but the maintenance director was unaware of the broken light until it was brought to his attention during the survey. During observations, the resident's room was found to be dimly lit, with the bed positioned against the far wall and a privacy curtain drawn, further reducing light from the working entrance light. The maintenance director acknowledged that the facility was transitioning to LED lights and had recently received a shipment that could be used to fix the light. However, he admitted to accidentally closing the maintenance request for the light, as it was combined with the mattress request. The facility's maintenance policy did not specify a timeline for completing requests, contributing to the oversight.
Failure to Implement and Document Care Plans for Substance Use and Psychotropic Medication
Penalty
Summary
The facility failed to implement and document care-planned interventions for substance use for two residents, R44 and R1, leading to a lack of continuity in their care. R44, who had a history of substance abuse and was a current smoker, was found intoxicated on multiple occasions. Despite the care plan's directive to monitor vital signs when intoxicated, there was no evidence of such monitoring in R44's medical records. Interviews with staff, including a registered nurse and the assistant director of nursing, confirmed the absence of recorded vital signs and highlighted inconsistencies in documentation practices. Similarly, R1, who had a history of cocaine and alcohol abuse, displayed signs of intoxication on several occasions as documented in the Medication Administration Records (MAR). However, there was no indication that medications were held or that vital signs were checked as per the care plan's instructions. Interviews with a licensed practical nurse and a nurse practitioner revealed that vital signs were not consistently monitored, and the nurse practitioner was unaware of the frequency of R1's substance use. Additionally, the facility failed to individualize the care plan for R48, who was on psychotropic medications, by not including target behaviors for the use of these medications. The care plan lacked specific documentation of pharmacological and non-pharmacological interventions, as well as potential side effects of the medication olanzapine. The interim director of nursing and the administrator acknowledged the absence of specific behavior charting and target symptoms in the care plan, which was contrary to the facility's care planning policy.
Inadequate Smoking Assessment for Resident
Penalty
Summary
The facility failed to accurately and comprehensively assess a resident's smoking practices, leading to a deficiency in ensuring a safe environment free from accident hazards. The resident, who has intact cognition and medical conditions including paraplegia and diabetes, was admitted with a care plan indicating they could smoke safely and independently. However, the initial smoking evaluation inaccurately stated that the resident was not a smoker, leaving several assessment questions unanswered. This oversight meant that the resident's ability to smoke safely, including their need for supervision or adaptive equipment, was not properly evaluated. Interviews with staff revealed inconsistencies in the smoking assessment process. A licensed practical nurse (LPN) familiar with the resident confirmed that the resident was a smoker and had been smoking since their arrival at the facility. Despite this, the smoking evaluation in the electronic medical record incorrectly indicated the resident was a non-smoker. Another LPN was unsure of the resident's smoking status, further highlighting the lack of a comprehensive assessment. The assistant director of nursing (ADON) acknowledged the discrepancy and noted that smoking assessments are intended to ensure resident safety. Observations of the resident smoking independently outside the facility confirmed their smoking status. The resident was seen using a lighter and cigarettes stored in a pouch around their neck, demonstrating their ability to smoke without assistance. Despite the resident's safe smoking practices, the facility's failure to conduct a thorough initial assessment and update the care plan accordingly constituted a deficiency in providing adequate supervision and ensuring a safe environment for the resident.
Inadequate Pain Management for Resident with New Back Pain
Penalty
Summary
The facility failed to comprehensively assess and manage pain for a resident, identified as R11, who developed new back pain. R11's quarterly Minimum Data Set (MDS) indicated moderate cognitive impairment and frequent pain that interfered with daily activities, yet no scheduled or as-needed pain medication was recorded. The MHM Pain Evaluations noted non-pharmacological interventions like warm towels were used, but lacked detailed information on the pain's location or characteristics. R11's care plan mentioned non-medicinal pain relief and monitoring for medication side effects but did not specify current pain issues or management goals. Observations and interviews revealed that R11 experienced significant pain, particularly in the arms and lower back, and expressed dissatisfaction with the current pain management, stating a need for different interventions. The Medication Administration Record (MAR) showed limited use of PRN Bio Freeze, with recorded pain levels reaching up to 4, but lacked detailed documentation of pain characteristics. Nursing staff, including a nursing assistant and a registered nurse, acknowledged R11's recent increase in back pain complaints, yet there was no comprehensive assessment or update to the care plan. The assistant director of nursing confirmed that the newly reported back pain was not evaluated or recorded in the medical record, as it was not communicated to them. The facility's Pain Management Protocol mandates assessment of new or worsening pain, but this was not followed for R11. The lack of communication and documentation resulted in inadequate pain management for the resident, contrary to the facility's policy aimed at ensuring effective pain management for residents.
Failure to Timely Reorder Asthma Medication
Penalty
Summary
The facility failed to ensure timely reordering of physician-ordered medications, resulting in a delay in administration for a resident diagnosed with asthma. The resident, who had intact cognition and required maximal assistance with eating and oral hygiene, had an order for two puffs of Dulera inhaler twice a day. However, on one occasion, the medication was not administered in the morning because it was out of stock, and the nurse had to order a new inhaler. The medication was not expected to arrive until later in the day, causing the resident to miss the scheduled dose. The issue was identified during an observation and interview with an LPN, who acknowledged the delay and noted that the medication should have been reordered when about 15 doses were left. The LPN mentioned that while she routinely reorders medications when they are low, there have been problems with other nurses not reordering in a timely manner. The interim DON confirmed that nursing staff should reorder medications when they are running low to prevent missed doses. The facility's policy indicated that medications should be reordered three to five days in advance to maintain an adequate supply.
Failure to Monitor Blood Sugar Levels for Diabetic Resident
Penalty
Summary
The facility failed to ensure adequate blood sugar monitoring for a resident diagnosed with diabetes, depression, and schizophrenia, leading to potential unnecessary administration of insulin. The resident's Medication Administration Record (MAR) showed orders for insulin glargine and insulin aspart, but there were no corresponding blood sugar level tests documented. The resident's blood sugar was only recorded twice over a period of several weeks, despite an increase in insulin dosage due to previously high blood sugar levels. Interviews with facility staff, including a nurse practitioner, registered nurse, assistant director of nursing, and regional nurse consultant, revealed that the order for blood sugar checks was inadvertently discontinued when the insulin orders were updated. This oversight resulted in inconsistent monitoring of the resident's blood sugar levels, which was not aligned with the facility's Blood Glucose Monitoring Procedure that required documentation after each test.
Failure to Conduct AIMS Assessment and Inappropriate Antipsychotic Use
Penalty
Summary
The facility failed to have a qualifying diagnosis for the routine use of an antipsychotic medication and did not complete an Abnormal Involuntary Movement Scale (AIMS) assessment for a resident reviewed for unnecessary medications. The resident, who was cognitively intact and had no behaviors, was prescribed olanzapine, an antipsychotic medication, for anxiety, which is not an appropriate indication for its use. The resident's medical record lacked a baseline AIMS assessment before the initiation of olanzapine, and the care plan did not include individualized documentation of pharmacological and non-pharmacological interventions or potential side effects of the medication. The facility's policy required an AIMS assessment to screen for tardive dyskinesia at baseline, semi-annually, and after discontinuation every month for three months. However, the interim Director of Nursing admitted that the initial AIMS assessment was only completed after the survey visit. Additionally, a pharmacy recommendation indicated that a gradual dose reduction was necessary, but there was no evidence of a timeline for this reduction or a referral to the Associated Clinic of Psychology. The facility's failure to adhere to its policy and the lack of appropriate documentation and assessments contributed to the deficiency.
Inaccurate Nurse Staffing Information Posted
Penalty
Summary
The facility failed to ensure the accuracy of the posted nurse staffing information, which had the potential to affect all 65 residents and visitors who may wish to view the information. The staff postings for the period from August 5 to August 14, 2024, indicated that the facility had six nursing assistants (NAs) on the day and evening shifts and three NAs on the night shifts. However, the actual staffing reports for the same period showed discrepancies, with fewer NAs present than what was posted. For instance, on August 5, 2024, the day shift had three NAs, the evening shift had four NAs, and the night shift had two NAs, contrary to the posted information. During an interview on August 15, 2024, the staffing coordinator revealed that the facility used a computer program to generate the staffing information for the postings. The coordinator noted that the computer program was erroneously pulling unfilled NA slots as if they were filled, leading to inaccurate staff postings. The facility's Nursing Hours Posting policy, dated October 2022, mandates that the total number of NAs directly responsible for resident care during each shift must be posted, which was not adhered to in this instance.
Failure to Monitor Intoxicated Residents Leading to Physical Altercation
Penalty
Summary
The facility failed to ensure residents' right to be free from abuse, provide adequate supervision, and develop a comprehensive care plan for two residents with a history of alcohol abuse and altercations. Both residents, R1 and R2, were involved in a physical altercation while intoxicated, resulting in injuries. R1's care plan indicated a need for monitoring while intoxicated, but this was not effectively implemented, leading to the incident where R2 struck R1 on the face, causing a scratch, and R1 retaliated by hitting R2 on the cheek, causing redness and warmth. Interviews with staff and other residents revealed that intoxicated residents frequently return to the facility and are not adequately monitored, leading to safety concerns. Staff members, including trained medication aides and registered nurses, confirmed that both R1 and R2 were intoxicated during the altercation and that there was no history of resident-to-resident altercations noted in their care plans. Despite the altercation, no reeducation was provided to staff regarding the monitoring of intoxicated residents, and there was a lack of awareness about the residents' history of assaulting others. The director of nursing and the facility administrator acknowledged the incident and the failure to provide adequate supervision and monitoring. The administrator confirmed that R2 is alcohol-dependent and resistant to treatment, and both residents were placed on 15-minute checks for 24 hours following the assault. However, no root cause analysis was completed, and no reeducation was provided to staff, highlighting a significant gap in the facility's approach to managing residents with a history of alcohol abuse and altercations.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
