The Estates At Excelsior Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Excelsior, Minnesota.
- Location
- 515 Division Street, Excelsior, Minnesota 55331
- CMS Provider Number
- 245332
- Inspections on file
- 27
- Latest survey
- November 26, 2025
- Citations (last 12 mo.)
- 1 (1 serious)
Citation history
Health deficiencies cited at The Estates At Excelsior Llc during CMS and state inspections, most recent first.
The facility did not consistently provide snacks to residents when meals were more than 14 hours apart. A resident with multiple health conditions reported never being offered a snack and was unaware of the option. Staff interviews revealed that snacks were not routinely distributed, and the dietary manager and registered dietitian confirmed the lack of a clear process. The facility's policy did not specify when or how often snacks should be offered, leading to a gap in care.
A staff member was observed eating a sandwich at a food preparation counter in the kitchen, placing the wrapper on the hot holding steam table counter. The dietary manager and registered dietician confirmed that eating in the kitchen is not permitted and constitutes an infection control concern. No relevant policy was provided during the survey.
The facility did not analyze or document data submitted to the QAPI committee, resulting in a lack of oversight for issues such as pressure injuries, falls, psychoactive medication use, increased ADL assistance, infection control, and unplanned hospitalizations. QAPI meeting minutes lacked goals, action plans, and data analysis, contrary to facility policy.
The facility did not document goals, action plans, or data analysis for multiple PIPs, including call light response times, change in condition notifications, enhanced barrier precautions, and air mattress monitoring. QAPI minutes showed repeated lack of detail and no evidence of committee review or project closure decisions, with no additional supporting materials or policies provided.
The facility did not consistently track or document employee illnesses and their clearance to return to work, resulting in incomplete records for staff who reported symptoms such as fever, sore throat, and diarrhea. Logs lacked key information on symptom resolution and test results, and the process for reviewing and clearing staff to return was not reliably followed or documented.
The facility did not consistently post or provide dietary menus to residents, despite repeated concerns raised during resident council meetings and acknowledgment by staff. Residents reported not receiving menus or information about upcoming meals, and observations confirmed menus were not posted as required by facility policy. Staff interviews indicated awareness of the issue but a lack of follow-through to resolve it.
The facility did not notify the Ombudsman of multiple resident transfers to acute care hospitals and failed to provide required bed hold notices or written transfer notifications to residents or their representatives. These deficiencies were identified through record reviews and staff interviews, affecting residents with complex medical needs and resulting in missing documentation and notifications.
Multiple dependent residents did not receive necessary assistance with ADLs, including toileting, repositioning, queuing for meals and fluids, and personal hygiene. One resident with severe cognitive impairment and on hospice was left in bed for long periods without being offered food or fluids, and was frequently found in soiled clothing and bedding with matted hair. Another resident experienced long delays in call light response, leading to incontinence and inadequate hygiene. A third resident was transferred with poor hygiene and reported not having a shower for months. Staff interviews confirmed inconsistent care and lack of oversight.
A resident with documented dementia and cognitive impairment was required to sign a Notice of Medicare Non-Coverage without the involvement of their power of attorney, despite clear evidence of incapacity and a family member acting as decision-maker. The facility did not notify the representative, resulting in the resident being unaware of the coverage change and an outstanding bill, contrary to facility policy and regulatory requirements.
Multiple residents were served meals that did not align with their documented food preferences and dietary restrictions, including a resident with end stage renal disease who received restricted items and disliked foods, and others who were not offered alternatives when served items they disliked. Staff interviews revealed a lack of training and awareness regarding the process for addressing food preferences, resulting in residents not receiving appropriate meal options.
The facility did not ensure that psychotropic medications were prescribed with clearly identified target behaviors or symptoms, nor did staff monitor for these behaviors to assess medication effectiveness. For example, a resident with depression and anxiety received antipsychotic medications without individualized target behaviors documented in the care plan or medical record. Staff, including CNAs, LPNs, and RNs, were unable to identify specific behaviors to monitor, and the facility's policy requiring such documentation was not followed for several residents.
A resident with multiple medical conditions was admitted and required assistance with several activities of daily living. The facility's baseline care plan did not specify the level of assistance or staffing needed, and the resident was not added to care sheets used by nursing assistants. Both an RN and the DON confirmed that the care plan lacked essential information needed to guide care within the required 48-hour timeframe.
A resident with a history of TIA and cerebral infarction, who was moderately cognitively impaired and prescribed clopidogrel for myocardial infarction, did not have a care plan that included interventions or safety precautions for anti-platelet therapy. Nursing staff confirmed the absence of necessary monitoring and interventions in the care plan, despite facility policy requiring individualized and comprehensive care planning.
The facility did not update care plans for two residents to reflect their current care needs. One resident's care plan incorrectly indicated the presence of a Foley catheter, which staff confirmed was not present, while another resident's care plan listed an outdated dialysis transportation schedule. Staff interviews and observations confirmed these discrepancies, and the consulting nurse acknowledged the care plans were not current.
A resident with a pressure ulcer and significant cognitive impairment did not have an individualized turning and repositioning schedule established or documented according to professional standards. Staff reported repositioning every 2 hours, but this was not consistently recorded, and the care plan lacked specific interventions to promote wound healing. The facility's documentation and care planning practices did not ensure appropriate pressure ulcer prevention and care.
A resident with end stage renal disease and a fluid restriction was not consistently provided with the prescribed renal diet, receiving inappropriate foods and insufficient portions despite clear dietary orders and documented preferences. Dietary staff and the RD were unaware of the ongoing issues, and the facility could not provide a relevant policy during the survey.
A resident who was dependent on staff for mobility missed a scheduled dialysis appointment because staff did not ensure timely readiness for transportation, resulting in the ride leaving. When an alternative dialysis appointment was offered, the facility did not pay for the required private transportation, despite a contract stating the facility was responsible for all transportation costs. This led to the resident missing necessary dialysis care.
A resident with severe cognitive impairment and multiple medical conditions, including C-diff, did not receive several prescribed doses of vancomycin due to the facility's failure to ensure medication supply and notify the provider or pharmacy of the shortage. Communication lapses among nursing staff, the provider, and the pharmacy contributed to the missed doses, and required procedures for medication ordering and notification were not followed.
A resident who did not eat toast was not offered an alternative meal item after voicing her preference to a NA, who did not notify the kitchen or return to address the issue. The NA was unaware of an alternate menu and had not received training on handling such situations, and the facility's policy did not specify procedures for offering alternatives when a resident cannot or will not eat a served item.
The facility did not complete comprehensive assessments for continued antibiotic use for two residents, as required by CDC guidelines. Although infection logs tracked basic information, there was no documentation that criteria for ongoing antibiotic therapy were met. The DON acknowledged the lack of an accessible form for staff to document assessment criteria, and the facility's policy requiring use of Mcgreer's criteria was not fully implemented.
A resident with a history of lymphoma, anemia, and dementia was not offered or provided an updated pneumococcal vaccine as required by CDC guidelines, and there was no documentation of vaccine offer or declination in the medical record, despite facility policy and standing orders mandating such actions.
A resident with a history of stroke and peripheral vascular disease, receiving hospice services, was admitted with a non-healing Stage 3 pressure ulcer. Despite physician orders for an air pressure redistribution mattress to aid in pain management and ulcer relief, the facility delayed its implementation for over two weeks. This delay, despite multiple reminders to hospice, contributed to the worsening of the resident's pressure ulcer, contrary to the facility's policy for immediate implementation of medical orders.
A facility failed to implement appropriate PPE for a resident under enhanced barrier precautions (EBP) to prevent infection spread. The resident had multiple medical conditions requiring wound care and antibiotic treatment via a PICC line. Despite signage indicating EBP, nursing assistants were observed performing peri care without gowns, citing time constraints. The facility's policy mandates gown and glove use during high-contact care activities, but staff did not adhere to these guidelines, resulting in a deficiency.
A facility failed to notify a physician about a resident's deteriorating diabetic foot ulcer, despite a nurse practitioner's orders for an X-ray and lab work to rule out osteomyelitis. The resident's care plan required immediate notification for wound complications, but a new RN did not report the concerns to the physician, only informing the DON without mentioning specific orders.
The facility's QAPI committee failed to maintain effective action plans for infection control practices related to Foley catheters, resulting in deficiencies such as improper hand hygiene, PPE use, and catheter care. Despite having a QAPI plan, the facility's audits were insufficient and poorly documented, contributing to the recurrence of these issues.
The facility failed to label insulin pens and eye drops with open dates, as required by policy, for two residents and a previously discharged resident. This oversight was confirmed by interviews with the RN and DON, who acknowledged the importance of labeling to prevent administering expired medications.
The facility failed to adhere to infection control protocols, including the use of PPE and hand hygiene. Staff did not follow enhanced barrier precautions for residents requiring high-contact care, and a nurse neglected hand hygiene during wound care. Additionally, a Foley catheter was improperly managed, with the drainage port not cleaned after emptying.
The facility failed to provide written notification of the bed hold policy to two residents during their hospitalizations. Despite having a policy requiring such notifications, the facility did not provide them to residents with multiple health conditions, as confirmed by staff interviews and record reviews.
A facility failed to ensure a resident received the pneumococcal vaccination as per CDC guidelines. The resident, with a history of chronic health conditions, had previously received PCV-13 and PPSV23 but was not offered or administered the PCV20 vaccination. Facility records lacked evidence of the vaccination, and interviews revealed a deficiency in obtaining shared clinical decision-making and providing the vaccination.
A facility failed to report an allegation of staff-to-resident abuse within the required two-hour timeframe. A resident, who was mildly cognitively impaired, reported being roughly handled by a nursing assistant. The incident was not reported to the State Agency until the following day, violating the facility's abuse reporting policy.
Failure to Routinely Offer Snacks Between Meals
Penalty
Summary
The facility failed to routinely offer snacks to residents when the interval between meals exceeded 14 hours, affecting all 35 residents. One resident, who was cognitively intact and had diagnoses including heart failure, diabetes, and COPD, reported never being offered a snack during her stay and was unaware she could request one. Staff interviews revealed inconsistent practices regarding snack distribution, with some staff noting that snacks were only available if specifically requested from the kitchen and that there was no regular snack cart or routine offering. The dietary manager confirmed that snacks were not consistently provided and was unsure of the established process, while the registered dietitian acknowledged that residents would benefit from snacks and fluids at least once daily but was unfamiliar with the facility's procedures. The administrator agreed that there was a significant gap in the process, noting that there were 15 hours between supper and breakfast without a substantial snack being offered. Review of the facility's snack policy showed that while it described how to assist residents with snacks, it did not specify the timing or frequency for offering them. This lack of routine snack provision and unclear policy contributed to the deficiency identified during the survey.
Staff Consumed Food in Kitchen Food Preparation Area
Penalty
Summary
A deficiency occurred when a staff member, identified as Cook-A, was observed eating a sub sandwich at a food preparation counter in the kitchen, near the microwave, with a plate of food also present on the counter. After finishing her meal, Cook-A placed the sandwich wrapper on the hot holding steam table counter. The dietary manager confirmed that staff are not permitted to eat in the kitchen and noted that Cook-A has physical challenges, with the staff break room located down a flight of stairs in the basement. Cook-A acknowledged she should not have been eating in the kitchen and typically eats in the designated break room. The registered dietician also agreed that eating in the kitchen at the food prep counter is an infection control concern and that all staff should eat only in the designated break room. No relevant policy was provided during the survey period.
Failure to Analyze and Document QAPI Data and Action Plans
Penalty
Summary
The facility failed to ensure that data submitted to the Quality Assurance and Performance Improvement (QAPI) committee was properly analyzed and documented, resulting in a lack of oversight for identified areas needing improvement. Review of QAPI meeting minutes from March 2025 through May 2025 showed that department heads presented data on several key quality indicators, including pressure injuries above the national average, trends in falls, psychoactive medication use, increased assistance with activities of daily living (ADLs), rising antibiotic use for infection control, and six unplanned hospitalizations. However, there were no documented goals, action plans, or analysis of the data presented for these areas. An interview with the interim administrator confirmed that the QAPI meeting minutes lacked identification of goals, action plans, and data analysis for the issues brought forward. The administrator acknowledged the need for improvement and recognized the deficiencies in the QAPI process. Additionally, the facility's QAPI policy required the committee to oversee improvement areas, develop action plans, and analyze results, but documentation did not reflect these activities. No information was provided regarding the involvement of the medical director, as messages left were not returned.
Lack of Documentation and Data Analysis in QAPI Performance Improvement Projects
Penalty
Summary
The facility failed to provide evidence of a goal, action plan, or analysis of data for its identified Performance Improvement Projects (PIPs) as required by regulatory standards. Review of QAPI minutes from March through May 2025 showed that for several PIPs—including call light response times, notification of change in condition, enhanced barrier precautions, and air mattress monitoring—there was either no goal identified, no documentation of the action plan, or no analysis of data presented to the committee. In multiple instances, the documentation remained unchanged from month to month, and there was no indication that the committee had reviewed or analyzed any data related to these projects. Additionally, the QAPI minutes lacked documentation regarding the decision to end certain PIPs or the analysis of data that would support such decisions. Interviews and email communications confirmed that the facility had no additional material or details about the PIP projects beyond what was recorded in the QAPI minutes. Requests for relevant policies were not fulfilled by the end of the survey, and attempts to contact the medical director for further information were unsuccessful. This deficiency had the potential to affect all 35 residents residing at the facility.
Failure to Accurately Track and Document Employee Illnesses for Return to Work
Penalty
Summary
The facility failed to ensure that employee illnesses were properly tracked and documented to determine when staff could safely return to work, as required by their infection prevention and control program. Review of employee absence and illness logs from February through June 2025 revealed incomplete documentation for three sampled staff members, including missing information on symptom resolution, test results, and clearance for return to work. For example, a housekeeping aide returned to work after reporting a fever, but there was no documentation of symptom resolution. Similarly, a speech therapist returned after a sore throat and COVID testing, but the log lacked evidence of test results. A certified nursing assistant returned to work after experiencing diarrhea, but there was no documentation of symptom resolution or whether the illness was potentially norovirus. Interviews with the administrator confirmed that employees were expected to report symptoms to the DON, who would then review their health status for clearance to return to work. However, the administrator was not aware of the specific illness or treatment for the certified nursing assistant, and the illness logs did not consistently reflect accurate tracking or clearance procedures. Policy review indicated that staff were required to report certain infections to the infection preventionist and to seek evaluation if symptoms persisted or worsened, but these procedures were not consistently followed or documented.
Failure to Post and Provide Dietary Menus to Residents
Penalty
Summary
The facility failed to honor residents' rights to organize and participate in resident/family groups by not acting promptly or providing resolution for concerns related to the posting of dietary menus. Resident council meeting minutes from several months documented repeated complaints from residents that menus were not posted or provided, and that kitchen staff were unable to inform them of upcoming meals. Despite these concerns being raised multiple times and documented in both resident council and QAPI committee minutes, there was no evidence of consistent improvement or effective action taken to resolve the issue. Observations on-site confirmed that menus were not posted in resident areas as required by facility policy. Interviews with facility staff, including the activity director, dietary manager, and administrator, confirmed awareness of the ongoing issue but revealed a lack of follow-through and monitoring to ensure the deficiency was corrected. The dietary manager acknowledged not posting or distributing menus despite having them available, and the administrator was unable to provide documentation of audits or follow-up to verify resolution. The facility's own policy required menus to be written in advance and posted in at least two resident areas, but this was not being followed at the time of the survey.
Failure to Notify Ombudsman and Provide Bed Hold Notices During Resident Hospitalizations
Penalty
Summary
The facility failed to provide required notifications and documentation related to resident transfers and discharges, specifically omitting notification to the Ombudsman for several residents who were hospitalized. For example, one resident with diagnoses including ataxia, COPD, chronic back pain, and paranoid schizophrenia was transferred to an acute care hospital after calling 911 due to back pain. The medical record and staff interview confirmed that the Ombudsman was not notified of this transfer. Similar failures to notify the Ombudsman were identified for three other residents who experienced hospitalizations, as evidenced by the absence of these residents on monthly discharge notices and lack of documentation in their records. Additionally, the facility did not ensure that residents or their legal representatives were informed of bed hold rights or provided with written notices of transfer in at least one case. For a resident dependent on staff for transfers and with multiple complex medical conditions, there was no documentation that a bed hold notice was given during a hospital transfer, and the facility confirmed that no bed hold was provided. These deficiencies were identified through review of medical records, facility documentation, and staff interviews, which consistently showed a lack of required notifications and documentation for residents transferred to hospitals.
Failure to Provide Adequate Assistance with Activities of Daily Living
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for several dependent residents, including assistance with toileting, turning and repositioning, queuing for food and hydration, and personal hygiene. One resident with severe cognitive impairment, hemiplegia, and on hospice care was repeatedly observed lying in bed for extended periods without being offered food, fluids, or assistance. Meal trays were left untouched and removed without staff attempting to queue or assist the resident, and her water pitcher was not refreshed. The resident was frequently found in soiled clothing and bedding, with matted hair that eventually required cutting due to lack of care. Multiple interviews with hospice staff, family members, and facility staff confirmed ongoing issues with personal care, hydration, and communication between facility and hospice staff. Another resident, who was cognitively intact but physically dependent, reported frequent delays in staff response to call lights, resulting in episodes of incontinence and feelings of neglect. He stated that staff rarely offered to take him to the toilet and only changed his brief upon request, sometimes after significant delays. Family members corroborated these accounts, describing long waits for assistance and inadequate hygiene care, such as only having his face washed in the morning and infrequent bathing. A third resident, who was transferred to another facility, was found with dried feces on her back, dirty feet, matted hair, and body odor, and reported not having had a shower in three months. Her personal care assistant and family members noted repeated issues with lack of hygiene and long waits for staff assistance. Another dependent resident was observed with visible facial hair that was not addressed by staff, despite family requests and care plan instructions. Staff interviews revealed a lack of clarity and consistency in providing grooming and personal care, with some staff unaware of or not performing required tasks. The facility lacked documented audits or oversight to ensure that ADL care was being provided as required.
Failure to Notify Resident Representative of Medicare Non-Coverage Due to Cognitive Impairment
Penalty
Summary
The facility failed to ensure that a Notice of Medicare Non-Coverage (NOMNC) and Advanced Beneficiary Notice (ABN) were provided to the appropriate representative for a resident with known cognitive impairment. The resident in question had documented moderate to severe cognitive deficits, as evidenced by a Brief Interview for Mental Status (BIMS) score of 9 and multiple St. Louis University Mental Status Examination (SLUMS) scores indicating dementia. The resident's care plan and provider notes consistently identified cognitive impairment, confusion, and the involvement of a family member as the resident's decision-maker and power of attorney (POA). Despite this, the facility had the resident personally sign the NOMNC form when skilled services were ending, without involving the family member or POA. The business office manager stated that the facility was unaware of the POA status, as there was no documentation of a POA or guardian on file, and the resident was listed as the guarantor on hospital forms. The family member, who had previously handled all paperwork for the resident, was not notified of the coverage termination and only became aware after the resident's status changed to private pay, resulting in an outstanding bill. The facility's policy required that the NOMNC be issued to the resident or legal responsible party, but did not specify procedures for residents with cognitive deficits. The policy also indicated that staff should confirm receipt of the notice and adequately explain it, but in this case, the notice was not communicated to the family or POA, and the resident, due to cognitive impairment, was unable to understand or contest the decision. The deficiency was identified through interviews, document review, and communication with the ombudsman.
Failure to Honor Resident Food Preferences and Dietary Restrictions
Penalty
Summary
The facility failed to honor food preferences and dietary restrictions for multiple residents, as evidenced by direct observations, interviews, and review of dietary documentation. One resident with end stage renal disease and a fluid restriction was served items specifically listed as dislikes and not permitted on his diet slip, including milk and apple juice at dinner, as well as potatoes and broccoli. The resident expressed that he was not supposed to receive milk and did not like several items on his tray, which were clearly documented as dislikes. As a result, the resident did not eat his meal. The resident's care plan and dietary slip outlined specific dietary needs and preferences, which were not followed by staff. Additional observations included a resident being served toast despite a documented dislike, with the nursing assistant failing to offer an alternative or notify the kitchen due to time constraints and lack of training. Another resident reported frustration after being served mushrooms, which were also listed as a dislike, and only received a replacement meal after specifically requesting it from the cook. Staff interviews confirmed a lack of awareness and training regarding alternative food options and the process for addressing resident dislikes. The facility's policy required staff to document and honor food preferences, but this was not consistently implemented for the residents involved.
Failure to Identify and Monitor Target Behaviors for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that psychotropic medications prescribed to residents had clearly identified target behaviors or symptoms, and did not monitor for these behaviors or symptoms to assess medication effectiveness. For example, one resident with diagnoses of seizures, anxiety, and depression was receiving antipsychotic medications for major depressive disorder, but neither the care plan nor the medical record specified individualized target behaviors to monitor. The care plan only included general interventions such as assessments, redirection, and emotional support, without detailing specific behaviors to track. The director of nursing confirmed that while weekly meetings reviewed nursing progress notes, individualized target behaviors were not documented in the medical record for residents on psychotropic medications. Similarly, another resident with dementia and anxiety was prescribed both antidepressant and antipsychotic medications, but the orders and care plan lacked evidence of specific target behaviors the medications were intended to address. Staff interviews revealed that nursing assistants and nurses were unable to identify or were unaware of any target behaviors for these medications, and this information was not reflected in the medication administration record or care plan. The facility's policy required ongoing documentation of behavioral indicators, symptoms, and monitoring for effectiveness, but this was not followed for multiple residents reviewed.
Failure to Complete 48-Hour Baseline Care Plan Upon Admission
Penalty
Summary
The facility failed to complete a 48-hour baseline care plan upon admission for one resident. The resident's admission Minimum Data Set (MDS) assessment indicated she was cognitively intact, experienced depression several days a week, and required assistance with hygiene while being independent with transfers. She had multiple diagnoses, including heart failure, diabetes, COPD, respiratory failure, and atrial fibrillation, and was at risk for pressure ulcers. She was prescribed insulin, an anticoagulant, and a diuretic. The baseline care plan documented that she required assistance with bathing, dressing, hygiene, mobility, and transfers, but did not specify the level of assistance or the number of staff required for these tasks. During interviews, a registered nurse stated that the care plan lacked sufficient detail to determine the resident's care requirements or staffing needs. The director of nursing confirmed that the baseline care plan was missing essential information and acknowledged that the resident had not yet been added to the care sheets used by nursing assistants for guidance on activities of daily living, transfers, diet, and precautions. The facility's policy requires a baseline plan of care to be developed within 48 hours of admission to address immediate needs, but this was not completed for the resident in question.
Failure to Address Anti-Platelet Therapy in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for one resident that addressed the use of anti-platelet therapy and associated safety precautions. The resident had a history of transient ischemic attack and cerebral infarction, was moderately cognitively impaired, and required assistance with daily activities. Despite being prescribed clopidogrel bisulfate (Plavix) for myocardial infarction, the resident's care plan did not include interventions or monitoring parameters related to anti-platelet therapy, such as monitoring for signs and symptoms of bleeding or bruising. Interviews with nursing staff confirmed that the care plan lacked necessary identification of interventions and monitoring for the anti-platelet medication, and review of facility policy indicated that care plans should be individualized and comprehensive.
Failure to Update Care Plans to Reflect Current Resident Needs
Penalty
Summary
The facility failed to revise and update care plans to reflect the current care needs of two residents. For one resident with severe cognitive deficits and multiple diagnoses, the care plan continued to indicate the presence of a Foley catheter and related enhanced barrier precautions, despite staff observations and interviews confirming that the resident did not have a Foley catheter. Nursing assistants providing care were unaware of any history of a Foley catheter for this resident, and no catheter was observed during care. For another resident with intact cognition and multiple complex medical conditions, including end stage renal disease and a history of lung transplant, the care plan listed an outdated dialysis transportation schedule. The resident reported, and staff confirmed, that the actual pick-up time for dialysis had changed months prior, but the care plan was not updated to reflect this. The consulting nurse acknowledged that both care plans did not accurately represent the residents' current care needs, and the facility's policy requires individualized and current care plans prepared by the interdisciplinary team.
Failure to Individualize and Document Pressure Ulcer Repositioning Interventions
Penalty
Summary
The facility failed to identify and implement an appropriate turning and repositioning schedule for a resident with a pressure ulcer, as well as to document when staff performed repositioning. The resident had a diagnosis of pressure ulcers, diabetes, and neurocognitive disorder with Lewy body dementia, and was identified as severely cognitively impaired and at risk for pressure ulcer development. The care plan indicated the need for turning and repositioning every 2 to 3 hours and as needed, but there was no evidence that a specific, individualized schedule was established or documented in accordance with professional standards of practice. Observations and interviews revealed that staff repositioned the resident, but did not consistently document when repositioning occurred. Nursing staff reported that repositioning was done every 2 hours, but this was not always recorded, and the care plan lacked personalized interventions to promote wound healing. The CNA report sheet did not reflect the required interventions, and staff were not required to use a checklist to document hourly rounding or repositioning. The wound care nurse noted that repositioning every 2 hours was not sufficient to promote wound healing for this resident. The facility's care planning policy required individualized care plans, but the resident's plan did not include specific, personalized interventions for pressure ulcer prevention and care. The lack of documentation and individualized planning contributed to the failure to minimize the risk of further pressure ulcer development and ensure that appropriate interventions were implemented.
Failure to Provide Prescribed Renal Diet and Fluid Restriction
Penalty
Summary
The facility failed to provide a prescribed therapeutic renal diet to a resident with complex medical needs, including end stage renal disease, severe protein-calorie malnutrition, and a fluid restriction. Despite clear dietary orders and documented food preferences, the resident was repeatedly served meals that did not comply with his renal diet or fluid restrictions. On multiple occasions, the resident received items such as milk and apple juice, which were not permitted, and was not provided with double portions as required. The resident also reported receiving foods he disliked and was not supposed to have, such as potatoes and broccoli, and was not offered adequate calorie intake, especially after being away from the facility for medical appointments. Interviews with dietary staff and the registered dietician revealed a lack of awareness and adherence to the resident's prescribed diet. The dietary manager acknowledged that the correct diet was not served on at least two occasions and noted confusion among staff regarding the provision of second helpings. The registered dietician was unaware of the ongoing issues and relied on dietary staff to follow the prescribed orders. The facility was unable to provide a policy related to prescribed diets during the survey, and the resident's care plan clearly outlined the need for increased protein, fluid restriction, and communication with the renal dietician, which was not consistently implemented.
Failure to Arrange and Cover Transportation for Dialysis as Required by Contract
Penalty
Summary
The facility failed to implement its dialysis contract and arrange for appropriate transportation for a resident who required regular dialysis treatments. The resident, who was cognitively intact but physically dependent on staff for transfers and mobility, missed a scheduled dialysis appointment because staff did not ensure he was ready and at the pick-up location on time. The resident had a long-standing schedule for dialysis transportation, but on the day in question, staff reported he refused to get up until the ride arrived, resulting in the transportation service leaving after waiting the required five minutes. Documentation and interviews revealed conflicting accounts, with staff stating the resident was not ready and the resident and his roommate asserting that staff did not get him up in time. Following the missed ride, the facility contacted the dialysis center and was offered an alternative appointment later that day, which required the resident to pay privately for transportation. The resident declined this option, stating he did not have the funds and was unwilling to pay. The facility did not offer to cover the cost, citing that the resident was a member of Metro Mobility and that the facility was not obligated to pay for private transportation. The resident was also offered a dialysis appointment the following morning but refused to reschedule another personal appointment he had at that time. As a result, the resident missed his regular dialysis session and was rescheduled for an additional day later in the week. A review of the facility's contract with the dialysis provider revealed that the facility was responsible for arranging suitable transportation for the resident to and from the dialysis center, including covering all associated costs. Despite this contractual obligation, the facility did not pay for the alternative transportation when the resident missed his scheduled ride, leading to the resident missing his dialysis treatment. Interviews with staff, transportation providers, and the resident confirmed that the facility did not fulfill its responsibility to ensure the resident received timely and appropriate dialysis care as required by the contract.
Failure to Administer and Supply Ordered Antibiotic for C-diff
Penalty
Summary
The facility failed to ensure the timely supply and administration of a prescribed antibiotic medication for a resident with a diagnosis of diabetes mellitus type 2, neuromuscular dysfunction of the bladder, neurogenic bowel, and a terminal diagnosis of CVA. The resident was admitted with septic shock and diarrhea, and had a positive test for clostridium difficile (C-diff), for which vancomycin was ordered. According to the Medication Administration Record, five doses of vancomycin were missed on specific dates, and a Medication Error Incident summary later identified a total of seven missed doses. There was no documentation that the provider or pharmacy was notified about the missed doses or the lack of medication supply. Interviews revealed that the nurse practitioner was unaware of the missed doses and noted ongoing communication challenges with the facility. The DON confirmed that nurses had not notified the physician or pharmacy about the medication shortage, which was expected per facility policy. The pharmacist stated that the pharmacy had not received any request for a refill and that the facility had multiple ways to request additional medication. Facility policy required staff to accurately transcribe medication orders and communicate with the pharmacy as directed, but this was not followed in this case.
Failure to Offer Alternative Meal for Resident Food Preference
Penalty
Summary
A nursing assistant (NA) delivered a breakfast tray to a resident that included toast, which the resident stated she did not eat. The NA did not respond to the resident's comment, did not offer an alternative food item, and did not notify the kitchen of the resident's preference. Instead, the NA continued passing trays to other residents and did not return to address the issue. The NA later confirmed he was unaware of an alternate menu and had not received training on how to handle such situations, typically offering a snack like Jello when a resident disliked a food item. The director of nursing stated that staff are expected to offer an alternative food item with equal nutritional value when a resident voices a dislike for a food item. Review of the facility's Resident Food Preference policy showed that while it required documenting preferences and offering a variety of foods, it did not specify procedures for when a resident receives food they cannot or will not eat. This resulted in the resident not being provided with an appropriate alternative meal option.
Failure to Complete Comprehensive Antibiotic Assessments
Penalty
Summary
The facility failed to complete comprehensive assessments for the continued use of antibiotics for two of three sampled residents reviewed for antibiotic stewardship. According to CDC guidelines, residents started on antibiotics should be comprehensively reviewed within 48-72 hours to ensure the medication is effective, which involves evaluating current symptoms and laboratory results. However, review of the facility's infection control logs and medical records for two residents revealed that there was no documentation of an initial comprehensive assessment after antibiotics were prescribed. One resident, admitted with septic shock and diarrhea, was prescribed vancomycin for a C-diff infection, but the medical record lacked evidence of an initial assessment. Another resident, admitted with a duodenal ulcer and hemorrhage, was prescribed metronidazole and tetracycline for H. pylori, but similarly, no initial comprehensive assessment was documented. The facility's infection summary reports and logs included information such as resident names, infection dates, body systems affected, and medications, but did not provide evidence that criteria for continuation of antibiotic use were met. The DON confirmed that while symptoms were assessed and communicated to the physician, and Mcgreer's criteria were referenced, there was no accessible form for staff to document that criteria had been met. Additionally, the facility's policy required the use of Mcgreer's criteria and review of antibiotic therapy for appropriateness, but a copy of the criteria was not provided upon request.
Failure to Offer and Document Updated Pneumococcal Vaccination
Penalty
Summary
The facility failed to ensure that one of five sampled residents was offered or provided an updated pneumococcal vaccination in accordance with CDC recommendations. The resident in question was an older adult with a history of non-Hodgkin lymphoma, anemia, and dementia, who had previously received PPSV-23 and PCV-13 vaccines. Despite facility policies requiring assessment of immunization status within five days of admission and offering the vaccine within thirty days if indicated, the medical record did not contain evidence that the resident was offered the updated pneumococcal vaccine or had signed a declination form. Document review showed that standing orders and facility policy aligned with CDC guidelines, mandating documentation of vaccination status, administration details, and periodic audits by the Infection Preventionist. However, the resident's medical record lacked documentation of being offered the vaccine or declining it, and the Minimum Data Set incorrectly indicated that vaccines were up to date. The DON confirmed the expectation that vaccines should be current, highlighting the gap between policy and practice.
Failure to Implement Air Pressure Redistribution Mattress
Penalty
Summary
The facility failed to implement the use of an air pressure redistribution mattress for a resident who was reviewed for pain management and had a history of cerebral infarction, peripheral vascular disease, and was receiving hospice services. The resident was admitted with a non-healing Stage 3 pressure ulcer and required ongoing pain management. Despite physician orders for an air pressure redistribution mattress dated 12/3/24, the mattress was not implemented until after 12/21/24. This delay occurred despite multiple reminders and calls to hospice by the facility staff. The resident's care plan and wound care notes indicated the necessity of the mattress for pressure ulcer relief and pain management. The facility's director of nursing and nurse manager were unaware of the delay in implementation, which was contrary to the facility's policy on immediate implementation of medical provider orders. The delay in providing the air pressure redistribution mattress contributed to the worsening of the resident's pressure ulcer, as noted in progress notes that documented an increase in the size and drainage of the ulcer.
Failure to Implement Proper PPE for Resident Under Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement appropriate personal protective equipment (PPE) for a resident under enhanced barrier precautions (EBP) to prevent the spread of infection. The resident, identified as R2, had multiple medical conditions including Clostridioides difficile infection, a nephrostomy tube, and a positive sputum culture for methicillin-susceptible Staphylococcus aureus. R2 required wound care, nephrostomy flushes, and antibiotic treatment via a peripherally inserted central catheter (PICC) line. Despite the presence of signage indicating the need for EBP, nursing assistants were observed performing peri care without wearing gowns, which are required along with gloves and face masks during high-contact resident care activities. The nursing assistant acknowledged the requirement to wear a gown but cited time constraints as a reason for not donning all the necessary PPE. The registered nurse and director of nursing confirmed the need for EBP due to the resident's current infection, PICC line, and open wounds. The facility's policy on enhanced barrier precautions, revised in April 2024, mandates the use of gowns and gloves during specific care activities and requires clear signage to be posted. However, the staff did not adhere to these guidelines, leading to a deficiency in infection control practices.
Failure to Notify Physician of Resident's Wound Deterioration
Penalty
Summary
The facility failed to provide timely notification to the physician regarding a change in condition for a resident with diabetic foot ulcers. The resident's care plan required immediate notification to the provider for any complications such as increased drainage, odor, or changes in the wound. On a specific date, a nurse practitioner observed the resident's right toe wound deteriorating with odorous drainage and ordered an X-ray and lab work to rule out osteomyelitis. Despite these observations and orders, the nurse practitioner expressed concerns to the nurse manager about the resident's discharge to home, but the physician was not notified. A registered nurse, who was new and unsure of the procedure, did not report the nurse practitioner's concerns or the orders for X-ray and lab work to the resident's physician. The nurse did inform the director of nursing but did not receive any feedback and failed to mention the specific orders. The facility's policy required staff to notify the physician immediately of any changes in a resident's condition that might require intervention, which was not followed in this case.
Inadequate Infection Control Practices for Foley Catheters
Penalty
Summary
The facility failed to ensure the effectiveness of its Quality Assurance Process Improvement (QAPI) committee in maintaining appropriate action plans to correct a previously identified quality deficiency related to infection control practices for indwelling Foley catheters. During the survey, deficiencies were identified, including improper hand hygiene during wound care for one resident, improper use of personal protective equipment (PPE) for two residents, and improper placement and cleaning of a Foley catheter bag for another resident. These issues were observed despite the facility's QAPI plan, which included goals to decrease urinary tract infections and ensure proper infection control practices. The facility's QAPI meeting minutes from June 2023 to April 2024 lacked information regarding audits completed for infection control related to catheter care. Although an audit plan was mentioned in the QAPI meeting minutes dated November 28, 2023, the audits conducted were insufficient and lacked detailed documentation. For instance, only a few audits were completed in July 2023, and subsequent months showed a significant decrease in the number of audits, with some months having only one or two audits that did not specify what was audited. Interviews with the facility administrator revealed that the QAPI committee met monthly to discuss problem areas, but there was no evidence of comprehensive audits on catheter care. The administrator acknowledged the lack of documentation in the QAPI minutes for catheter care and confirmed that no additional audits were completed. This lack of effective monitoring and documentation contributed to the recurrence of deficiencies related to infection control practices for Foley catheters.
Failure to Label Insulin Pens and Eye Drops
Penalty
Summary
The facility failed to ensure that insulin pens and eye drops were appropriately labeled with an opened date according to the manufacturer's guidelines and facility policy. During an observation of the north medication cart, it was found that insulin pens for two residents had been opened and used without any labels indicating when they were first removed from the refrigerator and opened. Additionally, three bottles of eye drops, intended for use by two residents and one previously discharged resident, were also found without labels indicating their open dates. Interviews with the registered nurse and the director of nursing confirmed that the facility's practice requires staff to label medications with the date they are opened to prevent the administration of expired medications. The facility's policies, reviewed in May 2022, also mandate that staff check expiration dates and label multi-dose containers with the date opened. The lack of adherence to these procedures led to the potential risk of administering expired medications to residents.
Infection Control Deficiencies in PPE Use and Hand Hygiene
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices, as evidenced by multiple observations and interviews. For one resident, staff did not adhere to enhanced barrier precautions, which required the use of gowns, masks, and gloves during high-contact activities. Despite signage indicating these precautions, staff were observed entering the resident's room without the necessary protective equipment. This lapse in protocol was confirmed by interviews with nursing staff, who acknowledged the importance of PPE in preventing the spread of infections. Another deficiency was noted in the handling of a resident with an indwelling Foley catheter. The catheter bag was observed on the floor without a barrier, and the drainage port was not cleaned with alcohol after being emptied. This was contrary to the facility's policy, which requires cleaning the port to prevent cross-contamination. The nursing assistant involved admitted to not having the necessary supplies to perform the task correctly, highlighting a gap in resource availability or adherence to protocol. Additionally, a registered nurse failed to perform hand hygiene during wound care for a resident with a stage 3 pressure ulcer. The nurse did not wash hands after removing gloves at various stages of the wound care process, which is a critical step in preventing infection. This oversight was acknowledged by the nurse, who recognized the potential risk of spreading infections within the facility. The facility's wound care procedure explicitly requires hand hygiene after glove removal, indicating a failure to follow established protocols.
Failure to Provide Bed Hold Notification
Penalty
Summary
The facility failed to provide written notification of the bed hold policy to two residents, R1 and R20, during their hospitalizations. R1, who had multiple diagnoses including dysphagia, obesity, and COPD, was hospitalized twice, but there was no evidence in the medical record that a written notification of the bed hold policy was provided to R1 or their representative. Similarly, R20, who had conditions such as immunodeficiency, malnutrition, and end-stage renal disease, was hospitalized, and their medical record also lacked evidence of a written notification of the bed hold policy. Interviews with the facility staff revealed that the responsibility for completing bed holds was unclear, with the director of social services indicating it depended on staff availability, and the DON stating it was the nursing staff's responsibility. The facility's policy, updated in February 2023, required that written information about bed holds be given to residents and their representatives prior to a transfer, but this was not adhered to in the cases of R1 and R20.
Failure to Administer Pneumococcal Vaccination
Penalty
Summary
The facility failed to ensure that a resident was offered or received the pneumococcal vaccination in accordance with CDC recommendations. The resident, who had intact cognition and was admitted to the facility in January 2024, had a medical history that included acute on chronic diastolic congestive heart failure, chronic kidney disease, and type two diabetes mellitus. Despite having received PCV-13 in 2015 and PPSV23 in 2017, there was no evidence that the resident was offered or administered the PCV20 vaccination, nor was there documentation of shared clinical decision-making regarding this vaccination. The facility's records, including the resident's medication administration record and treatment administration record for January and February 2024, lacked evidence of the PCV20 vaccination being administered. Interviews with the director of nursing and the regional nurse consultant revealed that the facility had a vaccination schedule and procedures in place, but they acknowledged a deficiency in obtaining shared clinical decision-making and providing the PCV20 vaccination to the resident. The facility's policy required assessment of immunization status and offering of the pneumococcal vaccine within 30 days of admission, but this was not adhered to in the case of the resident.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to ensure an allegation of staff-to-resident abuse was reported immediately to the State Agency (SA) for a resident who was mildly cognitively impaired. The incident involved a nursing assistant who allegedly grabbed the resident by the rib cage, picked her up, and threw her onto a wheelchair to assist with a transfer to the bathroom. The resident reported the incident to a registered nurse the following morning, but the nurse did not report it to any other staff, thinking the resident was having a difficult time adjusting to the transitional care unit. The resident's son also reported the incident to another registered nurse, who then attempted to contact the administrator but did not receive a response that evening. The administrator became aware of the incident the following morning and subsequently reported it to the SA. The facility's policy requires suspected abuse to be reported to the SA no later than two hours after forming the suspicion of abuse. The delay in reporting the incident violated this policy, as the initial report was not made until the day after the incident was first reported by the resident.
Latest citations in Minnesota
A resident with dry eye syndrome and degenerative eye disease had orders for cyclosporine ophthalmic emulsion and Refresh Tears, both scheduled at the same time. Medication records and direct observation showed a TMA instilled cyclosporine drops in both eyes and immediately followed with Refresh Tears in both eyes without waiting between medications. This practice conflicted with referenced professional guidance recommending several minutes between multiple eye drops and with the medical provider’s recommendation to wait fifteen minutes between the two ophthalmic medications. No facility policy on ophthalmic medication administration was provided when requested.
A resident with severe cognitive impairment, impaired mobility, and high fall risk was care planned to have wheelchair footrests in place at all times, with staff ensuring proper positioning and monitoring for leaning during transport. A NA transported the resident in a manual wheelchair from the shower without the footrests, and while going through the doorway the wheelchair struck the door frame, causing the resident, who was leaning forward, to fall out. The resident sustained a T12 fracture, head injury with concussion, abrasions and contusions, and multiple right-hand lacerations requiring sutures, and the DON confirmed the care plan had not been followed.
A high‑risk, immobile resident with MS and prior heel DTI developed an avoidable unstageable coccygeal pressure ulcer after staff failed to consistently assess and document skin status, did not transfer or timely provide ordered pressure‑relieving mattresses, and did not reliably perform q2h repositioning. The resident was repeatedly left on a bedpan for prolonged periods despite early reports of this issue, and the toileting care plan was not revised to a bedside commode until after the coccygeal wound had significantly worsened. Wound assessments lacked complete measurements and staging, changes in wound size and color were not promptly recognized as deterioration or reported to providers, and recommended interventions from a wound NP (including an air mattress and offloading) were not promptly implemented. As a result, the coccygeal ulcer rapidly progressed to a large, necrotic, malodorous wound requiring hospital transfer and surgical debridement.
A resident with spastic hemiplegia, muscle weakness, and moderate cognitive impairment was observed using bilateral bed grab bars for bed mobility and transfers, but the care plan did not address grab bar or side rail use. Review of the EMR showed no completed bed mobility device or side rail assessment to determine the necessity or safety of the grab bars, and no documentation that risks and benefits were discussed or that informed consent was obtained. An LPN and the ADON stated that a bed mobility device assessment is required before grab bars are installed and confirmed that no such assessment existed for this resident.
A resident with bilateral heel pressure ulcers and multiple comorbidities received wound care during which an RN removed dressings from both heels, cleansed both wounds, and wiped each heel without changing gloves or performing hand hygiene between wounds or after disposing of soiled dressings. This practice conflicted with the facility’s written wound care procedure, which requires glove removal and hand hygiene after dressing removal and after wound cleansing. In interviews, the RN, NP, and DON/IP acknowledged that hand hygiene and glove changes are expected between dirty and clean tasks and between separate wounds to prevent infection.
A resident with MS, neurogenic bladder, mobility limitations, and existing pressure injuries was identified as dependent for toileting hygiene and at risk for pressure ulcers, yet the care plan lacked an individualized toileting/incontinence plan and a defined repositioning schedule. Despite a new coccyx pressure ulcer and documentation that interventions such as increased repositioning and incontinent care were needed, the care plan was not revised for a period of time to reflect these changes. During this time, the resident sometimes fell asleep on a bedpan and remained on it until staff removed it, and staff were not initially informed that the bedpan should no longer be used. The DON later acknowledged that the care plan revisions for turning, repositioning, and toileting were delayed until after the resident’s coccyx ulcer had significantly worsened.
A resident with diabetes, Crohn’s disease, bowel incontinence, and a history of MASD on the right gluteus developed an open, painful lesion on the right gluteal area that was documented over time without complete wound characteristics, clear etiology, or timely provider notification. Wound care orders were written for a stage 3 pressure ulcer on the left buttocks, while staff reported the wound was only on the right side and applied the left‑sided orders to the right gluteal wound in the absence of specific right‑side treatment orders. The DON acknowledged discomfort with staging the wound, lack of early physician notification, and confusion over wound classification, despite a facility policy requiring comprehensive wound assessment, consistent measurement, and provider notification when treatment orders are absent.
A resident with diabetes, chronic leg ulcer, kidney transplant, and a documented gluteal wound was care-planned for Enhanced Barrier Precautions (EBP), with posted instructions requiring gown and gloves for high-contact care such as transfers and wound care. During a telehealth wound assessment, the DON donned a gown and initially performed hand hygiene but then applied gloves without hand hygiene, removed a soiled dressing from the resident’s gluteal area, discarded it, removed gloves, and applied new gloves again without performing hand hygiene between glove changes. On another occasion, during use of a sit-to-stand lift, an NA wore gown and gloves, but the DON handled the lift harness, the resident’s clothing, and assisted with the transfer and repositioning while wearing a gown but no gloves, despite EBP requirements for transfers. The DON stated EBP was only needed for catheter or wound care and not for transfers, contradicting the posted EBP instructions and facility policy.
A resident with severe dementia, psychiatric disorders, and high dependence for ADLs was verbally abused during evening care when a NA, frustrated with the resident’s crying and resistance, loudly ridiculed her as acting like a two-year-old, threatened to hit her back if struck, told her she would be sent to a locked unit, and questioned who would want to care for her when she cried like a baby. Multiple staff witnessed the loud, stern, and intimidating tone and reported it to an LPN, who recognized it as verbal abuse but did not immediately remove the NA from duty or promptly report the allegation per policy, allowing the NA to continue working on the unit. Following this incident, the resident demonstrated increased crying, combativeness, resistance to care, wandering, self-isolation, and refusal of food, fluids, and medications above baseline, with documentation of significant emotional distress and subsequent ED evaluation for aggressive behaviors and poor intake.
A resident with dementia, bilateral above‑knee amputations, vascular disease, and severe protein‑calorie malnutrition developed a wound on an amputation stump that had a dressing dated several days before any documentation or treatment orders appeared in the record. Although bath audits and nursing notes initially reported no skin issues, a later assessment described a full‑thickness stage 4 ulcer/diabetic ulcer on the stump with exposed bone, erythema/edema, slough, and moderate serosanguineous drainage. Nursing staff interviews showed no one could identify who first discovered the wound or applied the initial dressing, and there was no evidence that the wound was assessed, the provider notified, or standing orders implemented when it was first present, despite facility expectations that new wounds be promptly evaluated and reported.
Failure to Follow Professional Standards for Ophthalmic Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice for administering ophthalmic medications to a resident with dry eye syndrome and degenerative eye disease. The resident was cognitively intact, required assistance with ADLs, and had physician orders for cyclosporine ophthalmic emulsion 0.05% one drop in both eyes twice daily and Refresh Tears ophthalmic solution one drop in both eyes four times daily for dry eyes. The administration summary showed that both eye medications were scheduled for the same time and were documented as being given at the same time on multiple dates. During a medication pass observation, a trained medication aide administered the ordered oral medications, then applied gloves and instilled one drop of cyclosporine in each eye, immediately followed by one drop of Refresh Tears in each eye, without any waiting period between the two medications. The surveyors referenced guidance from the American Academy of Allergy, Asthma, and Immunology stating that when more than one eye drop is ordered, three to four minutes should be allowed between drops in the same eye, and five to fifteen minutes should be allowed between different eye medications to prevent dilution. Interviews with the DON, pharmacy consultant, and medical provider confirmed that best practice and the provider’s recommendation were to wait between administration of cyclosporine and Refresh Tears, with the medical provider specifying a fifteen-minute interval. The facility did not provide a policy on ophthalmic medications when requested. The observed practice and documented administration times demonstrated that staff did not follow these professional standards or the medical provider’s recommended interval between the two eye medications.
Failure to Follow Wheelchair Transport Care Plan Leads to Fall With Injuries
Penalty
Summary
The deficiency involves the facility’s failure to implement care-planned fall prevention interventions for a resident at high risk for falls, resulting in a fall with injury. The resident had diagnoses including aphasia, dysphagia, muscle weakness, traumatic brain injury, and impaired mobility, with severe cognitive impairment documented on the MDS and dependence on staff for transfers and wheelchair transport. A care plan addressing wheelchair transport safety and positioning directed staff to ensure the resident was fully positioned and supported in the wheelchair prior to transport, verify footrests were in place prior to transport, and monitor for leaning, sliding, or unsafe positioning. An additional care-planned approach required wheelchair pedals to be on at all times. On the date of the incident, a nursing assistant transported the resident in a manual wheelchair from the shower room to the resident’s room without the foot pedals in place, contrary to the care plan. While being wheeled through the doorway, the wheelchair struck the door frame, causing the chair to stop and the resident, who had begun leaning forward, to fall out of the wheelchair onto the floor. Progress notes and ED documentation identified that the resident sustained a T12 vertebral fracture, a head injury with concussion, an abrasion and contusion to the head, a bruise to the left knee, and multiple lacerations to the right hand requiring sutures. The nursing assistant later acknowledged awareness that the foot pedals should have been on but did not apply them because the transport was only from the shower to the room. The DON confirmed that the resident’s care plan had not been followed when the fall occurred.
Failure to Implement and Update Pressure Ulcer Prevention and Treatment Led to Avoidable Unstageable Coccygeal Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, monitor, and implement individualized pressure ulcer prevention and treatment interventions for multiple high‑risk residents, resulting in an avoidable, unstageable coccygeal pressure ulcer for one resident that required surgical debridement and hospitalization. The resident had primary progressive multiple sclerosis, hereditary spastic paraplegia, obesity, and pre‑existing pressure‑related deep tissue injury to the left heel, and was identified as high risk for pressure ulcers on the Braden Scale due to constant moisture, chairfast status, very limited mobility, inadequate nutrition, and friction/shear risk. Hospital records on readmission documented irritant contact dermatitis of the bilateral gluteal cleft with specific cleansing and barrier cream orders, and facility documentation showed the resident could not reposition in bed or chair and required assist of two and a full‑body mechanical lift for transfers. Despite this, the admission/readmission skin assessment and weekly skin checks lacked measurements and detailed wound characteristics for the heel ulcer and gluteal dermatitis, and the care plan did not include comprehensive, individualized interventions beyond generic repositioning and wound care orders. After a new coccyx pressure ulcer was identified and documented as a stage 2 lesion, the facility failed to promptly and accurately update the care plan and implement recommended pressure‑relieving interventions. The wound nurse practitioner on 3/5 ordered coccyx wound care, an air mattress, pressure offloading, and a dietician consult, but the care plan was not revised and there was no evidence that an air mattress was placed on the bed for nearly two weeks. The environmental services director later confirmed that when the resident was moved to a new room, the gel mattress was not transferred, and the air mattress requested on 3/17 was not actually placed until the following day, despite being marked as completed. During this period, TAR documentation showed gaps in the every‑2‑hour repositioning order, and staff interviews revealed that CNAs were unaware of which residents were on repositioning programs, were not consistently repositioning residents, and had not received recent education on pressure ulcer prevention. The DON and RN case manager acknowledged that the coccyx wound increased in size and changed color between assessments, that the bed lacked the ordered gel mattress, and that the physician was not notified of the wound’s deterioration at that time. The facility also failed to timely modify toileting and incontinence care practices despite knowledge that the resident was being left on a bedpan for extended periods. The DON reported hearing before an IDT meeting that the resident had fallen asleep on a bedpan for an undetermined amount of time, but the care plan was not revised to discontinue bedpan use and implement a bedside commode until after the coccyx wound had significantly worsened. CNAs confirmed that the resident sometimes fell asleep on the bedpan and that they were not informed she should no longer use it until after the sore had worsened. Subsequent wound assessments documented rapid progression of the coccyx wound from a small stage 2 ulcer to a large, malodorous, necrotic wound with eschar, slough, erythema, and purulent drainage, ultimately classified as an unstageable pressure ulcer. The DON, NP, PA, and medical director all indicated that the lack of a pressure‑relieving mattress, failure to adjust pressure‑reducing interventions, and prolonged time on a bedpan likely contributed to the development and deterioration of the resident’s pressure ulcer, which was determined to be avoidable and resulted in hospitalization and surgical debridement. Additional documentation and interviews showed systemic assessment and communication failures related to pressure ulcer management. Weekly skin checks and wound assessments often omitted complete measurements, staging, and wound characteristics, and changes in wound size and appearance were not consistently recognized as deterioration or communicated to providers. The DON acknowledged that a 3/12 assessment showing increased wound size and purple discoloration should have been identified as a deep tissue injury and reported to the physician, but this did not occur. When nursing later documented foul odor, increased pain, and expanding necrotic tissue, telemedicine and PA responses deferred in‑person evaluation and ED transfer despite earlier recommendations that the resident be sent to the ED if an in‑person provider could not assess the wound. The NP ultimately found a large, malodorous, purulent wound with expanding eschar and ordered transfer to the hospital, where imaging and surgical findings confirmed a large necrotic sacral wound requiring extensive debridement. Throughout this sequence, the facility did not consistently follow its own pressure ulcer protocols, did not ensure ordered pressure‑relieving equipment was in place, and did not promptly revise care plans or interventions in response to known risk factors and documented wound changes. The report also notes that other residents reviewed for pressure ulcers were affected by similar failures in monitoring and individualized intervention, though detailed narratives focus primarily on this resident. Staff interviews revealed that CNAs relied on paper care guides that did not clearly identify residents on repositioning programs or at risk for skin breakdown, and that they were unaware of some residents’ special mattress orders or toileting restrictions. The DON and medical director stated that residents at risk for pressure ulcers should have immediate pressure‑relieving interventions and that existing ulcers require ongoing evaluation to prevent deterioration, but the documented practices for this resident did not align with those expectations. These combined actions and inactions—insufficient assessment detail, delayed or missing care plan revisions, failure to implement ordered support surfaces and repositioning, and delayed response to wound deterioration—constituted the deficiency in providing appropriate pressure ulcer care and preventing new ulcers from developing.
Failure to Assess, Care Plan, and Obtain Consent for Bed Grab Bar Use
Penalty
Summary
The deficiency involves the facility’s failure to follow required procedures before installing and using bed grab bars for a resident. The resident had diagnoses including spastic hemiplegia affecting the left side and muscle weakness, and an admission MDS indicating moderate cognitive impairment. During observation, the resident was seen in a power chair with bilateral grab bars on the bed and reported using them to roll in bed and for transfers. The resident’s care plan, dated 1/23/26, documented a need for assistance with bed mobility and independence with transfers but did not mention or address the use of grab bars or side rails. Review of the electronic medical record showed no completed grab bar/side rail or bed mobility device assessment to determine the necessity of the grab bars or whether the resident could safely use them. There was also no evidence that the resident or the resident’s representative had been educated on the risks of having a grab bar on the bed or that informed consent had been obtained. In interviews, an LPN and the ADON both stated that a bed mobility device assessment was required to determine need and safety prior to installing grab bars, and both confirmed that no such assessment was present in the resident’s record.
Failure to Perform Hand Hygiene and Change Gloves During Wound Care
Penalty
Summary
Surveyors observed that a registered nurse (RN) and a nurse practitioner (NP) did not follow the facility’s established infection control practices during wound care for one resident. During a wound treatment, the RN wore gloves while removing the dressing from the resident’s left heel, then removed the dressing from the right heel, sprayed both wounds with wound cleanser, wiped the left heel with gauze, and then used a clean gauze pad to wipe the right heel. The RN did not remove her gloves or perform hand hygiene after disposing of the soiled dressings or between cleaning the left and right heel wounds, contrary to the facility’s written wound care procedure, which requires glove removal and hand hygiene after removing the previous dressing and again after cleaning the wound. The resident’s admission MDS documented diagnoses including multiple rib fractures, heart failure, dementia, anxiety, and the presence of a pressure ulcer, and indicated the resident was cognitively intact and required staff assistance with care and transfers. The resident’s care plan identified pressure ulcers on both heels requiring wound care. In interviews, the RN, NP, and the DON/infection prevention nurse each stated that gloves should be changed when moving from dirty to clean areas and that hand hygiene is expected after glove removal and between wounds to prevent infection, confirming that the observed practice did not align with facility policy or expected infection control standards.
Failure to Timely Revise Care Plan for Toileting and Skin Integrity
Penalty
Summary
The deficiency involves the facility’s failure to timely revise and individualize a resident’s care plan to address toileting and incontinence needs in relation to impaired skin integrity. The resident had diagnoses including primary progressive multiple sclerosis, hereditary spastic paraplegia, obesity, and a pressure-induced deep tissue injury to the left heel. A Significant Change MDS identified the resident as dependent for toileting hygiene, with lower extremity range-of-motion limitations, wheelchair use, dependence for transfers, occasional urinary incontinence, intact cognition, and at risk for pressure ulcers with existing unhealed pressure injuries and MASD. The resident’s skin-focused care plan, revised on various dates, included skin inspections, wound care orders, weekly skin checks, pressure ulcer care to the left heel, nutritional supplements, and a gel mattress, but did not include an individualized toileting or incontinence plan. On a weekly skin check dated 3/3/26, nursing staff identified a new Stage 2 pressure ulcer on the coccyx and contact dermatitis on both gluteal folds. An IDT Final Post Review Follow Up dated 3/10/26 (signed 3/23/26) documented that a new skin issue had occurred and that interventions after the incident included wound care treatment orders, increased repositioning, and increased incontinent care. However, the resident’s care plan from 3/3/26 through 3/16/26 did not show revisions reflecting increased incontinence care or a repositioning schedule, and the care plan was not updated to include these elements until 3/17/26. During this period, the care plan still lacked an individualized toileting plan despite the resident’s identified incontinence and new coccyx pressure ulcer. Progress notes on 3/17/26 documented that the resident’s coccyx wound had declined, with an evaluation describing a deteriorating wound characterized as a Kennedy terminal ulcer/End of Life, staged as a Stage 4 pressure ulcer, in-house acquired, with increased size, exudate, odor, pain, and surrounding erythema. On that same date, the skin focus care plan was revised to include prompt incontinence care and keeping the skin clean and dry, and the elimination focus care plan was revised to address incontinence due to neurogenic bladder with use of a bedside commode offered every 2–3 hours. A nursing assistant reported that when working with the resident, the resident would sometimes fall asleep on the bedpan and forget to ask staff to remove it, and that she was not aware the resident was not supposed to use the bedpan until after the sore had worsened. The DON stated that the resident’s care plan had not been revised earlier to include a turning and repositioning schedule or toileting changes, and that it should have been revised as soon as staff learned the resident was falling asleep on the bedpan, rather than waiting until after the pressure ulcer worsened.
Failure to Assess and Notify Provider for Right Gluteal Wound
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess and appropriately manage a non‑pressure skin issue on a resident’s right gluteal area, and to notify the physician in a timely manner. The resident had diagnoses including diabetes, Crohn’s disease, and a kidney transplant, and the MDS indicated occasional bowel incontinence, no pressure ulcers, and no moisture‑associated skin damage at that time. Earlier documentation identified a resolved MASD to the right gluteus, and a progress note later described a sacral wound with creams applied, noting that sores were still open and painful during application, but without any measurements, wound characteristics, or evidence of physician notification. Subsequent wound assessments documented an open lesion on the right gluteus with specific measurements on multiple dates, but did not identify the wound type or other characteristics, and the record did not show physician notification or treatment orders for the right gluteal lesion. Provider orders in place initially addressed cleansing the buttocks and applying barrier cream, and later included a detailed wound care order for a stage 3 pressure ulcer documented on the left buttocks. However, the resident’s record did not contain a specific treatment order for the right gluteal wound, despite the ongoing documentation of an open lesion in that area. Interviews revealed confusion and inconsistency in wound identification and classification. The DON stated that the right gluteal wound was documented as an open lesion because she did not feel comfortable determining the wound type, and acknowledged that the physician should have been notified when the wound was first identified. The DON was unaware that the NP had documented the wound as being on the left buttocks and as a stage 3 pressure ulcer, while the RN reported that the wound had never been on the left buttocks and that she had been applying the left‑sided wound orders to the right gluteal area because there was no open area on the left. The resident reported a recurring painful area on the right buttocks and chronic stool leakage since prior anal fistula surgery. The facility’s own wound treatment policy required comprehensive assessment of wound etiology and characteristics, consistent measurement and documentation, and provider notification in the absence of treatment orders, which were not followed for this resident’s right gluteal wound. The deficiency centers on the lack of a comprehensive wound assessment for the right gluteal lesion, incomplete documentation of wound characteristics, failure to clearly determine and document the wound etiology, and failure to notify the physician and obtain appropriate treatment orders when the wound was identified and remained open. These actions and inactions resulted in a discrepancy between the documented wound location and type and the actual clinical presentation, as well as a period during which the right gluteal wound had no specific, clearly ordered treatment despite being open and painful.
Failure to Perform Hand Hygiene and Implement Enhanced Barrier Precautions During Wound Care and Transfers
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper hand hygiene during wound care and to consistently implement Enhanced Barrier Precautions (EBP) for a resident requiring such measures. The resident had diagnoses including diabetes, a non-pressure chronic ulcer of the right lower leg, and a kidney transplant, and a wound assessment documented an open lesion on the right gluteal area. The resident’s care plan and a sign posted outside the room specified that EBP, including gown and gloves, were required for high-contact care activities such as dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, catheter care, and wound care. During one observation, the DON performed hand hygiene and donned a gown before entering the resident’s room for a telehealth wound assessment. Inside the room, the DON went into the bathroom, applied gloves without performing hand hygiene, removed the resident’s brief, and removed a foam dressing from the right gluteal area that had stool on one corner. After discarding the soiled dressing, the DON removed gloves and then applied new gloves without performing hand hygiene between glove changes. When questioned, the DON stated that hand hygiene should be done when hands or gloves are visibly soiled and before and after removing or applying gloves, and acknowledged that hand hygiene had not been performed each time gloves were removed and reapplied. In a separate observation, the resident was transferred using a sit-to-stand mechanical lift while EBP requirements were not fully followed. An NA entered the room wearing a gown and gloves with the lift, and the DON applied the lift harness under the resident’s arms and cinched the waist strap, encountering the resident’s clothing, while not wearing gloves. After the transfer to bed, the DON pulled down the resident’s pants and removed the harness while touching the resident’s clothes. Following wound care by a CNP-WOC, the DON again assisted the resident by sitting the resident on the edge of the bed, applying the lift harness, and adjusting the resident’s pants and shirt while wearing a gown but no gloves. The DON stated that EBP was only needed for catheter or wound care and not for transfers, and only upon reading the posted EBP sign acknowledged that EBP was required for all high-contact resident care activities, including transfers.
Failure to Protect Resident From Verbal Abuse and Delay in Removing Alleged Perpetrator
Penalty
Summary
The deficiency involves the facility’s failure to protect a vulnerable resident from mental abuse and to respond appropriately to an allegation of abuse. The resident had severe cognitive impairment, Alzheimer’s disease, dementia, anxiety, depression, psychotic disorder, and significant functional dependence, including frequent incontinence and the need for extensive assistance with ADLs and transfers. Her care plan identified behavioral and mood issues such as wandering, yelling, combative behavior, and calling staff names, with interventions including calm approaches, emotional support, redirection, and monitoring for emotional distress and mood/behavior changes. She was identified as a vulnerable adult, with instructions to monitor for signs of emotional distress and to follow the facility’s abuse reporting policy. On the evening in question, while the resident was crying on the phone with her son and expressing a desire to leave, NA-A and NA-B entered to provide evening care using an EZ stand lift. After the resident ended the phone call, multiple staff reported that NA-A spoke to the resident in a loud, stern, and frustrated tone, telling her to stop crying and that she was acting like a two-year-old. When the resident swatted at NA-A, NA-A stated, “If you hit me, I’m going to hit you back,” and later told the resident she was “in trouble now.” Staff reported that NA-A told the resident she would be sent to a locked unit so she could not get out, and questioned who would want to care for her when she cried like a baby, and that nobody would want to keep working with her. NA-C described NA-A yelling commands such as “HOLD ON!” and “Stop crying! Where would you be if you were not here? Probably lying on the floor,” and felt NA-A was obviously upset and overwhelmed. These statements were made in the presence of the resident while she was already distressed and crying. Following this interaction, the resident exhibited crying, yelling, combativeness, resistance to care, wandering into other residents’ rooms, self-isolation, and refusal of food, fluids, and medications above her prior baseline, as documented in behavior charts, target behavior monitoring, and nursing progress notes. Staff documented that she cried most of the morning, was very restless, difficult to redirect, hit and pinched staff, called staff names, and refused care and meals. She required repeated redirection, 1:1 attention, and non-pharmacological interventions, and was ultimately sent to the ED for evaluation of combativeness and emotional distress, where she was treated for dementia with aggressive behavior and hypoglycemia related to poor intake. The report identifies that the resident’s actual response and the reasonable person concept showed serious psychosocial harm, including increased crying and combative behavior above baseline, fear/anxiety manifested as combativeness, resistance to care and social interaction, and self-isolation. The facility also failed to immediately remove the alleged perpetrator from resident care and to promptly report and investigate the allegation in accordance with its abuse policy. After NA-B and NA-C reported to LPN-A that NA-A had yelled at and threatened the resident, LPN-A acknowledged it as verbal abuse but did not initiate immediate protective measures or timely reporting. LPN-A stated she believed she had 24 hours to report because there was no injury, despite facility policy requiring reporting within two hours. NA-A remained on the unit and continued working until the end of her shift, including after staff had clearly communicated their concerns to LPN-A. TMA and NA staff described uncertainty about their authority to remove NA-A and reliance on the nurse to act, while the DON later informed LPN-A that NA-A should have been removed from the floor to prevent further danger to residents. The Immediate Jeopardy was determined to have begun when NA-A’s derogatory, intimidating, and threatening statements were made and continued while she remained on duty with access to the resident and other vulnerable residents.
Failure to Timely Assess and Treat Newly Discovered Stump Wound
Penalty
Summary
The deficiency involves the facility’s failure to provide timely treatment and care for a newly discovered wound on a resident’s above‑knee amputation stump. The resident was admitted with diagnoses including unspecified dementia with behavioral disturbances, vascular dementia, bilateral above‑knee amputations, vascular disease, reduced mobility, and severe protein‑calorie malnutrition, and had no documented ulcers or skin problems on admission or on the most recent MDS. A weekly bath audit on 3/17/26 documented only non‑tender lymph nodes on the right upper hip and did not identify any open areas. However, when the wound was later assessed, the dressing on the stump was dated 3/16/26, indicating that a wound and dressing existed at that time, even though no corresponding assessment, provider notification, or treatment orders were documented. On 3/23/26, nursing staff documented a new skin issue above the resident’s knee at the amputation site, describing a stage 4 pressure ulcer/injury with full‑thickness skin and tissue loss, exposed bone, erythema/edema, and moderate serosanguineous exudate. The wound measured 1.56 cm by 1.64 cm, with 20–29% granulation tissue and 80% slough. A progress note and skin issues assessment on that date confirmed the wound characteristics and staging, and the NP, after reviewing a picture, determined the wound to be a diabetic ulcer with peripheral vascular disease and severe protein‑calorie malnutrition as contributing factors. On that same date, the NP was notified, antibiotic therapy (doxycycline) was ordered for possible cellulitis, and specific wound care orders were initiated, with documentation on the MAR that these treatments were carried out beginning 3/23/26. Multiple interviews with nursing staff revealed that no one could identify who discovered the wound or who applied the initial dressing dated 3/16/26, and there was no documentation of a wound assessment, provider notification, or interim treatment between 3/16/26 and 3/22/26. Several RNs and LPNs who worked shifts from 3/16/26 through 3/20/26 stated they did not notice a wound on the stump and that, per their usual practice, they would have contacted the provider and initiated treatment if they had found one. One LPN recalled seeing a band‑aid with a date on the stump but could not recall the date, and another LPN stated she did not see the wound because she was not looking for one. The facility’s standing orders required staff to assess all wounds daily, change dressings every three days and as needed, treat with normal saline or non‑cytotoxic cleanser and appropriate dressings, and notify the provider the next business day when a new wound or injury was found. Despite these expectations, the wound identified by the dated dressing on 3/16/26 was not assessed, reported, or treated according to orders and facility policy until 3/23/26.
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