The Estates At Fridley Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Fridley, Minnesota.
- Location
- 5700 East River Road, Fridley, Minnesota 55432
- CMS Provider Number
- 245201
- Inspections on file
- 30
- Latest survey
- March 27, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at The Estates At Fridley Llc during CMS and state inspections, most recent first.
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.
The facility failed to implement effective pest control, resulting in an ongoing mouse infestation reported by multiple residents and observed by staff. A resident with pressure ulcers reported repeated mouse sightings in her room, while others described seeing mice frequently, finding dead mice among personal belongings, and hearing mice in the walls. Food was stored in resident rooms and in cluttered conditions, including bags and totes stacked on beds and in corners, and one resident used his own rat/mouse poison trays in his room. Staff, including an RN, the maintenance director, the dietary manager, and therapy staff, acknowledged a mouse problem in resident areas, the breakroom, and a therapy storage area where food had been hidden and droppings seen. Although an external pest control company was under contract, a scheduled visit was missed due to lack of supplies, and the facility’s own pest control policy requiring an ongoing program to keep the building free of rodents was not effectively carried out.
A resident with a history of substance abuse and recent methamphetamine use exhibited escalating aggressive behaviors, including vandalism and physical assault on another resident who was cognitively impaired and required supervision. Despite multiple incidents of erratic and violent behavior, the facility did not adequately reassess or update interventions for the resident's mental health needs, nor did it consistently document safety checks or targeted interventions, resulting in a failure to protect a resident from abuse.
A resident with a history of alcohol abuse, trauma, and mental health disorders did not receive adequate mental health and psychosocial services. The care plan lacked person-centered interventions, measurable goals, and support for autonomy or community connections. The resident's mental health declined, resulting in aggressive behaviors, substance use, and multiple hospitalizations, while staff failed to provide or document appropriate therapeutic or chemical dependency interventions.
A deficiency was found when an LPN failed to perform hand hygiene between glove changes while providing wound care to a resident with cognitive impairment and skin wounds. The LPN changed gloves multiple times without sanitizing hands, contrary to the care plan and facility policy. The DON confirmed that hand hygiene was not performed as required during the procedure.
A nursing assistant did not receive a required annual performance review, as confirmed by both the staff member and the DON. The facility also lacked a policy on performance reviews, and this lapse had the potential to impact all residents under the care of this staff member.
A resident's allegation of rough care by a nursing assistant, resulting in pain, was not reported by facility staff to the State Agency within the required two-hour timeframe. Although the incident was reported to authorities by an outside party, facility staff did not submit a separate report as mandated by policy, and interviews revealed confusion among staff regarding proper reporting procedures.
The facility failed to ensure an RN was scheduled for a minimum of 8 consecutive hours a day, affecting all 35 residents. The ADON and DON, who are RNs, were not included in the regular schedule and were only on call during weekends. The facility had difficulty hiring RNs and did not have a staffing policy, leading to situations where LPNs had to call the on-call physician or the ADON/DON for assistance.
A resident with multiple medical conditions did not receive ordered podiatry care, resulting in long, thickened, and dirty toenails. Staff were unsure about the last nail care provided, and there was confusion about the eligibility of transitional care unit residents for podiatry services.
A facility failed to ensure a resident received prescribed medication for skin picking, resulting in 15 missed doses. Staff interviews revealed lapses in ordering and follow-up procedures, with the BOM unsure if the medication was ordered and the RN acknowledging the delay. The DON stated that medications should be obtained promptly, but the facility did not follow through.
The facility failed to ensure timely implementation of pharmacist recommendations for a resident on antiplatelet medication and with hyperlipidemia. The pharmacist's repeated recommendations for a lipid panel were not addressed for several months, and the resident's care plan lacked documentation for coronary artery disease and hyperlipidemia goals or interventions. The DON confirmed the missed orders and the facility's policy on pharmacy MRRs was not provided.
The facility failed to ensure proper use and documentation of antipsychotic medications for two residents. One resident was prescribed Seroquel for insomnia without adequate medical justification or a discussion of risks and benefits. Another resident's medical record lacked behavior tracking and non-pharmacological interventions before administering PRN antipsychotic medication. Staff interviews revealed a lack of awareness regarding regulations related to antipsychotic administration.
The facility failed to ensure that a resident with a history of chronic lung disease and other conditions was offered or received the pneumococcal vaccine according to CDC recommendations. The assistant director of nursing assumed the resident was up to date based on existing documentation, but no clinical decision-making discussion occurred as required.
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 Implement Effective Pest Control for Mouse Infestation
Penalty
Summary
Failure to implement effective and timely pest control measures resulted in an ongoing mouse infestation affecting resident rooms and common areas. Multiple residents reported frequently seeing mice in their rooms, including one resident who stated she sees mice "all of the time" and recently observed a mouse running from her room into the hallway. Another resident reported seeing mice in her room on approximately ten different occasions and overheard a nurse say a mouse was seen coming out of a power outlet. This resident also had pressure ulcers on her coccyx and expressed concern about the mouse infestation. Observations showed food stored in resident rooms, including food in containers and bags on a nightstand, and clutter such as stacked plastic totes, bags of clothing, and miscellaneous items on beds and in rooms. Residents described taking their own measures to address the mice, including one resident who kept Rat/Mice X products in his walker seat and placed them in the corners of his room, and another who found a dead mouse between stacked plastic totes and removed it herself. That same resident reported a mouse caught in a sticky trap that she moved to a hallway garbage can, and described watching two baby mice playing on her floor by her bed and hearing mice in the walls at night. Staff interviews corroborated the infestation, with an RN reporting seeing mice in the breakroom and hearing resident complaints of mice in rooms. A physical therapy assistant reported a broken bed in a back hallway piled with old wheelchair parts and bags of unknown items, and stated she had observed a resident who liked to store food in that bed and had seen mouse droppings there. The maintenance director acknowledged awareness of a mouse problem in the building for almost a year and stated it worsened during cold weather. He reported that an outside pest control company visits monthly and as needed, and that nurses are instructed to document mouse sightings in a book for targeted treatment. However, he and the administrator both stated that a recent pest control visit did not occur as planned because the company reported being out of bait and products. The dietary manager confirmed there was a mouse problem and stated more proactive treatment was needed, noting that mice had been trapped in a live trap under the three-compartment sink in the kitchen, although she had not personally seen mice or droppings in the kitchen and food there was contained. The facility’s pest control policy required an ongoing program to keep the building free of insects and rodents and prohibited accumulation of garbage and trash, but the observed mouse activity, resident reports, cluttered rooms and storage areas, and reliance on residents’ own pest control efforts demonstrated that effective pest control measures were not implemented.
Failure to Protect Resident from Abuse Due to Inadequate Mental Health Intervention
Penalty
Summary
The facility failed to protect a resident from abuse when it did not adequately evaluate or address the effectiveness of interventions for another resident's mental health and substance use needs. One resident, with a history of substance abuse and recent methamphetamine use, exhibited escalating behavioral disturbances, including vandalism, aggression toward staff, and ultimately a physical assault on another resident. Despite multiple incidents indicating a change in mental status and behavior, including reports of auditory hallucinations, aggression, and erratic actions, the facility's documentation lacked evidence of reassessment or adjustment of care plan interventions to address these acute mental health concerns. The resident who committed the assault had a documented history of substance abuse and mental health diagnoses, including adjustment disorder and alcohol abuse. In the days leading up to the incident, this resident was observed engaging in disruptive and violent behaviors, such as letting air out of vehicle tires, scratching cars, and attempting to physically harm staff. The resident was also noted to have refused medications and was found to be under the influence of methamphetamines, as confirmed by hospital records. Despite these warning signs and hospital visits for psychiatric evaluation, the facility did not implement or document enhanced monitoring or effective interventions to mitigate the risk posed by this resident. The victim of the assault was a cognitively impaired resident with a history of traumatic brain injury and required supervision for daily activities. This resident was physically pushed over in his wheelchair by the other resident, who then attempted to further harm him before staff intervened. The victim expressed ongoing fear and emotional distress following the incident. The facility's records did not show consistent documentation of safety checks or targeted interventions for either resident in response to the escalating behaviors and the eventual assault.
Failure to Provide Appropriate Mental Health and Psychosocial Services
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident with a history of alcohol abuse, extreme trauma, and mental health disorders. The resident was assessed as cognitively intact with minimal depression and had a goal to return home. Although the resident declined in-house psychiatry services, the care plan did not address opportunities for autonomy, community connections, or support for cultural and religious practices. The care plan also lacked a thorough, person-centered description of the resident's distress and did not include measurable interventions or programs to assist the resident in achieving optimal mental and psychosocial functioning. The resident experienced a decline in mental health, which manifested in aggressive and abusive behaviors toward staff and another resident, as well as multiple incidents involving law enforcement and hospitalizations. Documentation showed that the resident was prescribed medications for mood and sleep, but non-pharmacological interventions such as redirection and one-to-one visits were not clearly defined in purpose or intent. The care plan did not specify the rationale for these interventions, and there was no evidence of reassessment or updates to the care plan following significant behavioral incidents, substance use, or psychiatric hospitalizations. Interviews with facility staff revealed a lack of awareness and action regarding the provision of chemical dependency treatment, trauma-informed care, or psychosocial therapies tailored to the resident's needs, especially considering language barriers and the resident's history of trauma and substance abuse. The social services director confirmed that no chemical dependency or therapeutic interventions were offered, and the director of nursing was unaware of any such services being provided. The facility was unable to provide a policy for treatment and/or services for mental and psychosocial concerns, and the medical record did not reflect that appropriate support, treatment, or services were provided to help the resident attain the highest practicable mental and psychosocial well-being.
Failure to Perform Hand Hygiene During Wound Care
Penalty
Summary
A deficiency was identified when a licensed practical nurse (LPN) failed to perform proper hand hygiene during wound care for a resident with moderate cognitive impairment and moisture-associated skin wounds. The resident's care plan required enhanced barrier precautions and specified that staff should don and doff personal protective equipment (PPE) according to protocol when providing high-contact care. During the observed wound care procedure, the LPN repeatedly changed gloves without sanitizing her hands between glove changes, despite handling both clean and dirty tasks. The LPN acknowledged not knowing that hand hygiene was required between glove changes. The director of nursing (DON) observed the procedure and confirmed that the LPN did not follow the facility's wound care treatment procedure, which directed staff to complete hand hygiene after removing gloves and before donning another pair. The DON stated that the expectation was to sanitize hands between glove changes and to change gloves between clean and dirty care. The facility's policy, as well as the resident's care plan, required these infection prevention measures, but they were not followed during the observed wound care event.
Failure to Complete Annual Performance Review for Nursing Assistant
Penalty
Summary
The facility failed to complete an annual performance review for a nursing assistant who was hired in October 2023. Review of the personnel file showed no evidence that a performance evaluation had been conducted. During interviews, the nursing assistant confirmed that no evaluation had taken place since hire, and the DON acknowledged that the review was due but had not been completed. Additionally, the facility did not have a policy regarding performance reviews. This deficiency had the potential to affect all residents receiving care from this staff member.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to ensure that an allegation of potential abuse involving a resident who complained of rough care by a nursing assistant was reported to the State Agency (SA) immediately, but no later than two hours after the suspicion was formed. The incident was initially brought to the facility's attention by local police, who informed the Social Services Director (SSD) that a report had already been filed with the Minnesota Abuse Reporting Center (MAARC) regarding the alleged rough handling of the resident, which resulted in pain to the resident's leg and abdomen. Despite being made aware of the allegation, the facility did not file a separate report with the SA as required by their Abuse Prohibition/Vulnerable Adult policy, which mandates reporting within two hours of suspicion. Interviews with facility staff, including the DON, registered nurse, nursing assistants, and social services designee, revealed inconsistent understanding of the reporting requirements, with some staff believing the timeframe was 24 hours and others unsure of the exact process. The DON confirmed that no report was filed by the facility, relying instead on the fact that another entity had already reported the incident. The facility's policy, however, clearly states that suspected abuse must be reported to the Office of Health Facility Complaints (OHFC) within two hours, a step that was not taken in this case.
Failure to Schedule Registered Nurse for Minimum Required Hours
Penalty
Summary
The facility failed to ensure a registered nurse (RN) was scheduled for a minimum of 8 consecutive hours a day, affecting all 35 residents. Review of the facility's daily staffing hours and staff schedules from February 1, 2024, to April 30, 2024, revealed that there was no RN scheduled on multiple dates. Interviews with the staffing coordinator, Licensed Practical Nurses (LPNs), the Assistant Director of Nursing (ADON), the Director of Nursing (DON), and the administrator confirmed the absence of RNs on these dates. The ADON and DON, who are RNs, were not included in the regular schedule and were only on call during weekends. The facility also had a Manager on Duty (MOD) on weekends, but not all MODs were RNs, and they were only required to work 4 hours a day. The staffing coordinator admitted that the facility did not have any RNs on staff except for the ADON, DON, and occasional agency/pool nurses. The administrator acknowledged the difficulty in hiring RNs due to better pay in hospitals and mentioned that they had recently hired two RNs who were still in training. The facility did not have a policy on staffing, and the lack of RNs on the floor led to situations where LPNs had to call the on-call physician or the ADON/DON for assistance. This deficiency had the potential to affect the quality of care provided to all residents in the facility.
Failure to Provide Ordered Podiatry Care
Penalty
Summary
The facility failed to provide ordered podiatry care for a resident (R23) who required assistance with personal hygiene and had multiple medical conditions, including heart failure, respiratory failure, hypertension, morbid obesity, and a fungal infection of the nail. Despite a nurse practitioner's order for a podiatry consult due to overgrown toenails, there was no documentation of a podiatry visit from the time of the order until the survey. Observations revealed that R23's toenails were long, torn, yellow, thickened, and dirty, indicating a lack of proper foot care. Interviews with staff confirmed that nail care was not consistently provided, and there was confusion about whether transitional care unit residents could receive podiatry services. The nursing assistant and health unit coordinator (HUC) were unsure when R23's nail care was last performed, and the HUC admitted that R23 had not been seen by a podiatrist historically. The licensed practical nurse (LPN) confirmed that R23's toenails were too thick to be cut with regular clippers and required podiatry intervention. The director of nursing (DON) explained that ancillary services like podiatry were discussed during care conferences, but there was a misunderstanding about the eligibility of transitional care unit residents for podiatry services. This misunderstanding led to the failure to initiate the podiatry order for R23, resulting in inadequate foot care for the resident.
Failure to Ensure Availability of Prescribed Medication
Penalty
Summary
The facility failed to ensure prescribed medications were available for a resident (R23) who was awaiting a new medication. R23, who had intact cognition and required extensive assistance with personal hygiene and bathing, had a history of heart failure, respiratory failure, hypertension, and morbid obesity. The resident's care plan identified an alteration in skin integrity due to self-inflicted skin tears, and a provider order dated 4/25/24 prescribed N-acetyl-cysteine to address skin picking. However, the medication was not administered from 4/26/24 through 5/2/24, resulting in 15 missed doses. Interviews with staff revealed that the medication was considered a house stock item, and the business office manager (BOM) was responsible for ordering it. The pharmacy technician confirmed that the facility had not completed the required house stock medication form, leading to the medication not being sent out. Further interviews indicated that the BOM was unsure if the medication had been ordered, and the registered nurse (RN) acknowledged that the missing medication should have been addressed sooner. The director of nursing (DON) stated that if the pharmacy could not provide a house stock medication, the facility staff should have purchased it themselves, ideally on the same day or within two days. The facility's assessment identified that they offered medication administration services and had vendors in place to provide necessary supplies and services, yet the medication for R23 was not obtained in a timely manner.
Failure to Implement Pharmacist Recommendations Timely
Penalty
Summary
The facility failed to ensure the timely implementation of pharmacist recommendations for a resident reviewed for unnecessary medications. The resident's annual Minimum Data Set (MDS) indicated diagnoses including coronary artery disease, hypertension, and hyperlipidemia, and the resident was on antiplatelet medication. The care plan initiated lacked documentation for coronary artery disease and hyperlipidemia goals or interventions. The pharmacist's medication regimen review (MRR) repeatedly recommended a lipid panel to evaluate the ongoing use of Fenofibrate, but these recommendations were not addressed until several months later. The Director of Nursing (DON) confirmed that the lipid panel order was missed for two consecutive months and was only ordered in the third month, with the results showing elevated triglyceride levels. During an interview, the DON stated that the facility's process involved completing pharmacy MRRs at the beginning of the month and providing copies to the provider and the facility. The facility would also fax the MRRs to the provider and track the provider's response. However, the DON was unable to locate follow-up documentation for the pharmacy MRR for the initial months and confirmed that the lipid panel order was missed. The facility policy on pharmacy MRRs was requested but not received, indicating a lapse in the facility's adherence to its own procedures and policies regarding medication regimen reviews and follow-up actions.
Failure to Ensure Proper Use and Documentation of Antipsychotic Medications
Penalty
Summary
The facility failed to ensure an antipsychotic medication was not started without adequate medical justification and that a discussion of risks, benefits, and potential side effects was understood by the resident, representative, or family for one resident. Specifically, a resident with severe cognitive impairment was prescribed Seroquel for insomnia without proper documentation of medical justification or a discussion of the medication's risks and benefits. The resident's care plan lacked focus areas, goals, or interventions related to insomnia or antipsychotic medications, and there was no tracking of insomnia behaviors or non-pharmacological interventions to manage insomnia behaviors in the medical record. Additionally, the facility failed to include individualized approaches for care, including behavior tracking and non-pharmacological interventions for two residents. One resident's medical record lacked documentation of behaviors occurring before the administration of PRN antipsychotic medication and non-pharmacological interventions attempted prior to administration. The resident received Seroquel PRN for agitation related to paranoid personality disorder, but the medical record did not document the necessary behavior tracking or non-pharmacological interventions. Interviews with staff revealed a lack of awareness regarding regulations related to antipsychotic administration and the importance of behavior tracking and non-pharmacological interventions. The facility's policy on psychotropic medication use was not followed, as it required informed consent, behavior tracking, and non-pharmacological interventions to be documented. The consultant pharmacist confirmed that the medical records were lacking appropriate justification for the use of antipsychotic medications, non-pharmacological interventions, behavior tracking, and evaluation by the provider after 14 days of using a PRN antipsychotic.
Failure to Offer Pneumococcal Vaccine as per CDC Guidelines
Penalty
Summary
The facility failed to ensure that one of five residents was offered or received the pneumococcal vaccine in accordance with CDC recommendations. The resident, who had a history of non-Alzheimer's dementia, asthma, chronic obstructive pulmonary disease, and chronic lung disease, had documentation indicating that their pneumococcal vaccinations were up to date. However, upon review, it was found that the resident had received Prevnar 23 in 2010 and Prevnar 13 in 2015, but there was no evidence of a shared clinical decision-making discussion regarding additional pneumococcal vaccinations as per CDC guidelines. During an interview, the assistant director of nursing (ADON) stated that they had assumed the resident did not need additional pneumococcal vaccinations based on the current documentation. The ADON clarified that the facility and provider had not conducted a clinical decision-making discussion with the resident. The facility's policy indicated that all residents should be assessed for immunization status within five days of admission and offered the vaccine within 30 days if indicated. However, this process was not followed for the resident in question.
Latest citations in Minnesota
A resident with dry eye syndrome and degenerative eye disease had orders for cyclosporine ophthalmic emulsion and Refresh Tears, both scheduled at the same time. Medication records and direct observation showed a TMA instilled cyclosporine drops in both eyes and immediately followed with Refresh Tears in both eyes without waiting between medications. This practice conflicted with referenced professional guidance recommending several minutes between multiple eye drops and with the medical provider’s recommendation to wait fifteen minutes between the two ophthalmic medications. No facility policy on ophthalmic medication administration was provided when requested.
A resident with severe cognitive impairment, impaired mobility, and high fall risk was care planned to have wheelchair footrests in place at all times, with staff ensuring proper positioning and monitoring for leaning during transport. A NA transported the resident in a manual wheelchair from the shower without the footrests, and while going through the doorway the wheelchair struck the door frame, causing the resident, who was leaning forward, to fall out. The resident sustained a T12 fracture, head injury with concussion, abrasions and contusions, and multiple right-hand lacerations requiring sutures, and the DON confirmed the care plan had not been followed.
A high‑risk, immobile resident with MS and prior heel DTI developed an avoidable unstageable coccygeal pressure ulcer after staff failed to consistently assess and document skin status, did not transfer or timely provide ordered pressure‑relieving mattresses, and did not reliably perform q2h repositioning. The resident was repeatedly left on a bedpan for prolonged periods despite early reports of this issue, and the toileting care plan was not revised to a bedside commode until after the coccygeal wound had significantly worsened. Wound assessments lacked complete measurements and staging, changes in wound size and color were not promptly recognized as deterioration or reported to providers, and recommended interventions from a wound NP (including an air mattress and offloading) were not promptly implemented. As a result, the coccygeal ulcer rapidly progressed to a large, necrotic, malodorous wound requiring hospital transfer and surgical debridement.
A resident with spastic hemiplegia, muscle weakness, and moderate cognitive impairment was observed using bilateral bed grab bars for bed mobility and transfers, but the care plan did not address grab bar or side rail use. Review of the EMR showed no completed bed mobility device or side rail assessment to determine the necessity or safety of the grab bars, and no documentation that risks and benefits were discussed or that informed consent was obtained. An LPN and the ADON stated that a bed mobility device assessment is required before grab bars are installed and confirmed that no such assessment existed for this resident.
A resident with bilateral heel pressure ulcers and multiple comorbidities received wound care during which an RN removed dressings from both heels, cleansed both wounds, and wiped each heel without changing gloves or performing hand hygiene between wounds or after disposing of soiled dressings. This practice conflicted with the facility’s written wound care procedure, which requires glove removal and hand hygiene after dressing removal and after wound cleansing. In interviews, the RN, NP, and DON/IP acknowledged that hand hygiene and glove changes are expected between dirty and clean tasks and between separate wounds to prevent infection.
A resident with MS, neurogenic bladder, mobility limitations, and existing pressure injuries was identified as dependent for toileting hygiene and at risk for pressure ulcers, yet the care plan lacked an individualized toileting/incontinence plan and a defined repositioning schedule. Despite a new coccyx pressure ulcer and documentation that interventions such as increased repositioning and incontinent care were needed, the care plan was not revised for a period of time to reflect these changes. During this time, the resident sometimes fell asleep on a bedpan and remained on it until staff removed it, and staff were not initially informed that the bedpan should no longer be used. The DON later acknowledged that the care plan revisions for turning, repositioning, and toileting were delayed until after the resident’s coccyx ulcer had significantly worsened.
A resident with diabetes, Crohn’s disease, bowel incontinence, and a history of MASD on the right gluteus developed an open, painful lesion on the right gluteal area that was documented over time without complete wound characteristics, clear etiology, or timely provider notification. Wound care orders were written for a stage 3 pressure ulcer on the left buttocks, while staff reported the wound was only on the right side and applied the left‑sided orders to the right gluteal wound in the absence of specific right‑side treatment orders. The DON acknowledged discomfort with staging the wound, lack of early physician notification, and confusion over wound classification, despite a facility policy requiring comprehensive wound assessment, consistent measurement, and provider notification when treatment orders are absent.
A resident with diabetes, chronic leg ulcer, kidney transplant, and a documented gluteal wound was care-planned for Enhanced Barrier Precautions (EBP), with posted instructions requiring gown and gloves for high-contact care such as transfers and wound care. During a telehealth wound assessment, the DON donned a gown and initially performed hand hygiene but then applied gloves without hand hygiene, removed a soiled dressing from the resident’s gluteal area, discarded it, removed gloves, and applied new gloves again without performing hand hygiene between glove changes. On another occasion, during use of a sit-to-stand lift, an NA wore gown and gloves, but the DON handled the lift harness, the resident’s clothing, and assisted with the transfer and repositioning while wearing a gown but no gloves, despite EBP requirements for transfers. The DON stated EBP was only needed for catheter or wound care and not for transfers, contradicting the posted EBP instructions and facility policy.
A resident with severe dementia, psychiatric disorders, and high dependence for ADLs was verbally abused during evening care when a NA, frustrated with the resident’s crying and resistance, loudly ridiculed her as acting like a two-year-old, threatened to hit her back if struck, told her she would be sent to a locked unit, and questioned who would want to care for her when she cried like a baby. Multiple staff witnessed the loud, stern, and intimidating tone and reported it to an LPN, who recognized it as verbal abuse but did not immediately remove the NA from duty or promptly report the allegation per policy, allowing the NA to continue working on the unit. Following this incident, the resident demonstrated increased crying, combativeness, resistance to care, wandering, self-isolation, and refusal of food, fluids, and medications above baseline, with documentation of significant emotional distress and subsequent ED evaluation for aggressive behaviors and poor intake.
A resident with dementia, bilateral above‑knee amputations, vascular disease, and severe protein‑calorie malnutrition developed a wound on an amputation stump that had a dressing dated several days before any documentation or treatment orders appeared in the record. Although bath audits and nursing notes initially reported no skin issues, a later assessment described a full‑thickness stage 4 ulcer/diabetic ulcer on the stump with exposed bone, erythema/edema, slough, and moderate serosanguineous drainage. Nursing staff interviews showed no one could identify who first discovered the wound or applied the initial dressing, and there was no evidence that the wound was assessed, the provider notified, or standing orders implemented when it was first present, despite facility expectations that new wounds be promptly evaluated and reported.
Failure to Follow Professional Standards for Ophthalmic Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice for administering ophthalmic medications to a resident with dry eye syndrome and degenerative eye disease. The resident was cognitively intact, required assistance with ADLs, and had physician orders for cyclosporine ophthalmic emulsion 0.05% one drop in both eyes twice daily and Refresh Tears ophthalmic solution one drop in both eyes four times daily for dry eyes. The administration summary showed that both eye medications were scheduled for the same time and were documented as being given at the same time on multiple dates. During a medication pass observation, a trained medication aide administered the ordered oral medications, then applied gloves and instilled one drop of cyclosporine in each eye, immediately followed by one drop of Refresh Tears in each eye, without any waiting period between the two medications. The surveyors referenced guidance from the American Academy of Allergy, Asthma, and Immunology stating that when more than one eye drop is ordered, three to four minutes should be allowed between drops in the same eye, and five to fifteen minutes should be allowed between different eye medications to prevent dilution. Interviews with the DON, pharmacy consultant, and medical provider confirmed that best practice and the provider’s recommendation were to wait between administration of cyclosporine and Refresh Tears, with the medical provider specifying a fifteen-minute interval. The facility did not provide a policy on ophthalmic medications when requested. The observed practice and documented administration times demonstrated that staff did not follow these professional standards or the medical provider’s recommended interval between the two eye medications.
Failure to Follow Wheelchair Transport Care Plan Leads to Fall With Injuries
Penalty
Summary
The deficiency involves the facility’s failure to implement care-planned fall prevention interventions for a resident at high risk for falls, resulting in a fall with injury. The resident had diagnoses including aphasia, dysphagia, muscle weakness, traumatic brain injury, and impaired mobility, with severe cognitive impairment documented on the MDS and dependence on staff for transfers and wheelchair transport. A care plan addressing wheelchair transport safety and positioning directed staff to ensure the resident was fully positioned and supported in the wheelchair prior to transport, verify footrests were in place prior to transport, and monitor for leaning, sliding, or unsafe positioning. An additional care-planned approach required wheelchair pedals to be on at all times. On the date of the incident, a nursing assistant transported the resident in a manual wheelchair from the shower room to the resident’s room without the foot pedals in place, contrary to the care plan. While being wheeled through the doorway, the wheelchair struck the door frame, causing the chair to stop and the resident, who had begun leaning forward, to fall out of the wheelchair onto the floor. Progress notes and ED documentation identified that the resident sustained a T12 vertebral fracture, a head injury with concussion, an abrasion and contusion to the head, a bruise to the left knee, and multiple lacerations to the right hand requiring sutures. The nursing assistant later acknowledged awareness that the foot pedals should have been on but did not apply them because the transport was only from the shower to the room. The DON confirmed that the resident’s care plan had not been followed when the fall occurred.
Failure to Implement and Update Pressure Ulcer Prevention and Treatment Led to Avoidable Unstageable Coccygeal Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, monitor, and implement individualized pressure ulcer prevention and treatment interventions for multiple high‑risk residents, resulting in an avoidable, unstageable coccygeal pressure ulcer for one resident that required surgical debridement and hospitalization. The resident had primary progressive multiple sclerosis, hereditary spastic paraplegia, obesity, and pre‑existing pressure‑related deep tissue injury to the left heel, and was identified as high risk for pressure ulcers on the Braden Scale due to constant moisture, chairfast status, very limited mobility, inadequate nutrition, and friction/shear risk. Hospital records on readmission documented irritant contact dermatitis of the bilateral gluteal cleft with specific cleansing and barrier cream orders, and facility documentation showed the resident could not reposition in bed or chair and required assist of two and a full‑body mechanical lift for transfers. Despite this, the admission/readmission skin assessment and weekly skin checks lacked measurements and detailed wound characteristics for the heel ulcer and gluteal dermatitis, and the care plan did not include comprehensive, individualized interventions beyond generic repositioning and wound care orders. After a new coccyx pressure ulcer was identified and documented as a stage 2 lesion, the facility failed to promptly and accurately update the care plan and implement recommended pressure‑relieving interventions. The wound nurse practitioner on 3/5 ordered coccyx wound care, an air mattress, pressure offloading, and a dietician consult, but the care plan was not revised and there was no evidence that an air mattress was placed on the bed for nearly two weeks. The environmental services director later confirmed that when the resident was moved to a new room, the gel mattress was not transferred, and the air mattress requested on 3/17 was not actually placed until the following day, despite being marked as completed. During this period, TAR documentation showed gaps in the every‑2‑hour repositioning order, and staff interviews revealed that CNAs were unaware of which residents were on repositioning programs, were not consistently repositioning residents, and had not received recent education on pressure ulcer prevention. The DON and RN case manager acknowledged that the coccyx wound increased in size and changed color between assessments, that the bed lacked the ordered gel mattress, and that the physician was not notified of the wound’s deterioration at that time. The facility also failed to timely modify toileting and incontinence care practices despite knowledge that the resident was being left on a bedpan for extended periods. The DON reported hearing before an IDT meeting that the resident had fallen asleep on a bedpan for an undetermined amount of time, but the care plan was not revised to discontinue bedpan use and implement a bedside commode until after the coccyx wound had significantly worsened. CNAs confirmed that the resident sometimes fell asleep on the bedpan and that they were not informed she should no longer use it until after the sore had worsened. Subsequent wound assessments documented rapid progression of the coccyx wound from a small stage 2 ulcer to a large, malodorous, necrotic wound with eschar, slough, erythema, and purulent drainage, ultimately classified as an unstageable pressure ulcer. The DON, NP, PA, and medical director all indicated that the lack of a pressure‑relieving mattress, failure to adjust pressure‑reducing interventions, and prolonged time on a bedpan likely contributed to the development and deterioration of the resident’s pressure ulcer, which was determined to be avoidable and resulted in hospitalization and surgical debridement. Additional documentation and interviews showed systemic assessment and communication failures related to pressure ulcer management. Weekly skin checks and wound assessments often omitted complete measurements, staging, and wound characteristics, and changes in wound size and appearance were not consistently recognized as deterioration or communicated to providers. The DON acknowledged that a 3/12 assessment showing increased wound size and purple discoloration should have been identified as a deep tissue injury and reported to the physician, but this did not occur. When nursing later documented foul odor, increased pain, and expanding necrotic tissue, telemedicine and PA responses deferred in‑person evaluation and ED transfer despite earlier recommendations that the resident be sent to the ED if an in‑person provider could not assess the wound. The NP ultimately found a large, malodorous, purulent wound with expanding eschar and ordered transfer to the hospital, where imaging and surgical findings confirmed a large necrotic sacral wound requiring extensive debridement. Throughout this sequence, the facility did not consistently follow its own pressure ulcer protocols, did not ensure ordered pressure‑relieving equipment was in place, and did not promptly revise care plans or interventions in response to known risk factors and documented wound changes. The report also notes that other residents reviewed for pressure ulcers were affected by similar failures in monitoring and individualized intervention, though detailed narratives focus primarily on this resident. Staff interviews revealed that CNAs relied on paper care guides that did not clearly identify residents on repositioning programs or at risk for skin breakdown, and that they were unaware of some residents’ special mattress orders or toileting restrictions. The DON and medical director stated that residents at risk for pressure ulcers should have immediate pressure‑relieving interventions and that existing ulcers require ongoing evaluation to prevent deterioration, but the documented practices for this resident did not align with those expectations. These combined actions and inactions—insufficient assessment detail, delayed or missing care plan revisions, failure to implement ordered support surfaces and repositioning, and delayed response to wound deterioration—constituted the deficiency in providing appropriate pressure ulcer care and preventing new ulcers from developing.
Failure to Assess, Care Plan, and Obtain Consent for Bed Grab Bar Use
Penalty
Summary
The deficiency involves the facility’s failure to follow required procedures before installing and using bed grab bars for a resident. The resident had diagnoses including spastic hemiplegia affecting the left side and muscle weakness, and an admission MDS indicating moderate cognitive impairment. During observation, the resident was seen in a power chair with bilateral grab bars on the bed and reported using them to roll in bed and for transfers. The resident’s care plan, dated 1/23/26, documented a need for assistance with bed mobility and independence with transfers but did not mention or address the use of grab bars or side rails. Review of the electronic medical record showed no completed grab bar/side rail or bed mobility device assessment to determine the necessity of the grab bars or whether the resident could safely use them. There was also no evidence that the resident or the resident’s representative had been educated on the risks of having a grab bar on the bed or that informed consent had been obtained. In interviews, an LPN and the ADON both stated that a bed mobility device assessment was required to determine need and safety prior to installing grab bars, and both confirmed that no such assessment was present in the resident’s record.
Failure to Perform Hand Hygiene and Change Gloves During Wound Care
Penalty
Summary
Surveyors observed that a registered nurse (RN) and a nurse practitioner (NP) did not follow the facility’s established infection control practices during wound care for one resident. During a wound treatment, the RN wore gloves while removing the dressing from the resident’s left heel, then removed the dressing from the right heel, sprayed both wounds with wound cleanser, wiped the left heel with gauze, and then used a clean gauze pad to wipe the right heel. The RN did not remove her gloves or perform hand hygiene after disposing of the soiled dressings or between cleaning the left and right heel wounds, contrary to the facility’s written wound care procedure, which requires glove removal and hand hygiene after removing the previous dressing and again after cleaning the wound. The resident’s admission MDS documented diagnoses including multiple rib fractures, heart failure, dementia, anxiety, and the presence of a pressure ulcer, and indicated the resident was cognitively intact and required staff assistance with care and transfers. The resident’s care plan identified pressure ulcers on both heels requiring wound care. In interviews, the RN, NP, and the DON/infection prevention nurse each stated that gloves should be changed when moving from dirty to clean areas and that hand hygiene is expected after glove removal and between wounds to prevent infection, confirming that the observed practice did not align with facility policy or expected infection control standards.
Failure to Timely Revise Care Plan for Toileting and Skin Integrity
Penalty
Summary
The deficiency involves the facility’s failure to timely revise and individualize a resident’s care plan to address toileting and incontinence needs in relation to impaired skin integrity. The resident had diagnoses including primary progressive multiple sclerosis, hereditary spastic paraplegia, obesity, and a pressure-induced deep tissue injury to the left heel. A Significant Change MDS identified the resident as dependent for toileting hygiene, with lower extremity range-of-motion limitations, wheelchair use, dependence for transfers, occasional urinary incontinence, intact cognition, and at risk for pressure ulcers with existing unhealed pressure injuries and MASD. The resident’s skin-focused care plan, revised on various dates, included skin inspections, wound care orders, weekly skin checks, pressure ulcer care to the left heel, nutritional supplements, and a gel mattress, but did not include an individualized toileting or incontinence plan. On a weekly skin check dated 3/3/26, nursing staff identified a new Stage 2 pressure ulcer on the coccyx and contact dermatitis on both gluteal folds. An IDT Final Post Review Follow Up dated 3/10/26 (signed 3/23/26) documented that a new skin issue had occurred and that interventions after the incident included wound care treatment orders, increased repositioning, and increased incontinent care. However, the resident’s care plan from 3/3/26 through 3/16/26 did not show revisions reflecting increased incontinence care or a repositioning schedule, and the care plan was not updated to include these elements until 3/17/26. During this period, the care plan still lacked an individualized toileting plan despite the resident’s identified incontinence and new coccyx pressure ulcer. Progress notes on 3/17/26 documented that the resident’s coccyx wound had declined, with an evaluation describing a deteriorating wound characterized as a Kennedy terminal ulcer/End of Life, staged as a Stage 4 pressure ulcer, in-house acquired, with increased size, exudate, odor, pain, and surrounding erythema. On that same date, the skin focus care plan was revised to include prompt incontinence care and keeping the skin clean and dry, and the elimination focus care plan was revised to address incontinence due to neurogenic bladder with use of a bedside commode offered every 2–3 hours. A nursing assistant reported that when working with the resident, the resident would sometimes fall asleep on the bedpan and forget to ask staff to remove it, and that she was not aware the resident was not supposed to use the bedpan until after the sore had worsened. The DON stated that the resident’s care plan had not been revised earlier to include a turning and repositioning schedule or toileting changes, and that it should have been revised as soon as staff learned the resident was falling asleep on the bedpan, rather than waiting until after the pressure ulcer worsened.
Failure to Assess and Notify Provider for Right Gluteal Wound
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess and appropriately manage a non‑pressure skin issue on a resident’s right gluteal area, and to notify the physician in a timely manner. The resident had diagnoses including diabetes, Crohn’s disease, and a kidney transplant, and the MDS indicated occasional bowel incontinence, no pressure ulcers, and no moisture‑associated skin damage at that time. Earlier documentation identified a resolved MASD to the right gluteus, and a progress note later described a sacral wound with creams applied, noting that sores were still open and painful during application, but without any measurements, wound characteristics, or evidence of physician notification. Subsequent wound assessments documented an open lesion on the right gluteus with specific measurements on multiple dates, but did not identify the wound type or other characteristics, and the record did not show physician notification or treatment orders for the right gluteal lesion. Provider orders in place initially addressed cleansing the buttocks and applying barrier cream, and later included a detailed wound care order for a stage 3 pressure ulcer documented on the left buttocks. However, the resident’s record did not contain a specific treatment order for the right gluteal wound, despite the ongoing documentation of an open lesion in that area. Interviews revealed confusion and inconsistency in wound identification and classification. The DON stated that the right gluteal wound was documented as an open lesion because she did not feel comfortable determining the wound type, and acknowledged that the physician should have been notified when the wound was first identified. The DON was unaware that the NP had documented the wound as being on the left buttocks and as a stage 3 pressure ulcer, while the RN reported that the wound had never been on the left buttocks and that she had been applying the left‑sided wound orders to the right gluteal area because there was no open area on the left. The resident reported a recurring painful area on the right buttocks and chronic stool leakage since prior anal fistula surgery. The facility’s own wound treatment policy required comprehensive assessment of wound etiology and characteristics, consistent measurement and documentation, and provider notification in the absence of treatment orders, which were not followed for this resident’s right gluteal wound. The deficiency centers on the lack of a comprehensive wound assessment for the right gluteal lesion, incomplete documentation of wound characteristics, failure to clearly determine and document the wound etiology, and failure to notify the physician and obtain appropriate treatment orders when the wound was identified and remained open. These actions and inactions resulted in a discrepancy between the documented wound location and type and the actual clinical presentation, as well as a period during which the right gluteal wound had no specific, clearly ordered treatment despite being open and painful.
Failure to Perform Hand Hygiene and Implement Enhanced Barrier Precautions During Wound Care and Transfers
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper hand hygiene during wound care and to consistently implement Enhanced Barrier Precautions (EBP) for a resident requiring such measures. The resident had diagnoses including diabetes, a non-pressure chronic ulcer of the right lower leg, and a kidney transplant, and a wound assessment documented an open lesion on the right gluteal area. The resident’s care plan and a sign posted outside the room specified that EBP, including gown and gloves, were required for high-contact care activities such as dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, catheter care, and wound care. During one observation, the DON performed hand hygiene and donned a gown before entering the resident’s room for a telehealth wound assessment. Inside the room, the DON went into the bathroom, applied gloves without performing hand hygiene, removed the resident’s brief, and removed a foam dressing from the right gluteal area that had stool on one corner. After discarding the soiled dressing, the DON removed gloves and then applied new gloves without performing hand hygiene between glove changes. When questioned, the DON stated that hand hygiene should be done when hands or gloves are visibly soiled and before and after removing or applying gloves, and acknowledged that hand hygiene had not been performed each time gloves were removed and reapplied. In a separate observation, the resident was transferred using a sit-to-stand mechanical lift while EBP requirements were not fully followed. An NA entered the room wearing a gown and gloves with the lift, and the DON applied the lift harness under the resident’s arms and cinched the waist strap, encountering the resident’s clothing, while not wearing gloves. After the transfer to bed, the DON pulled down the resident’s pants and removed the harness while touching the resident’s clothes. Following wound care by a CNP-WOC, the DON again assisted the resident by sitting the resident on the edge of the bed, applying the lift harness, and adjusting the resident’s pants and shirt while wearing a gown but no gloves. The DON stated that EBP was only needed for catheter or wound care and not for transfers, and only upon reading the posted EBP sign acknowledged that EBP was required for all high-contact resident care activities, including transfers.
Failure to Protect Resident From Verbal Abuse and Delay in Removing Alleged Perpetrator
Penalty
Summary
The deficiency involves the facility’s failure to protect a vulnerable resident from mental abuse and to respond appropriately to an allegation of abuse. The resident had severe cognitive impairment, Alzheimer’s disease, dementia, anxiety, depression, psychotic disorder, and significant functional dependence, including frequent incontinence and the need for extensive assistance with ADLs and transfers. Her care plan identified behavioral and mood issues such as wandering, yelling, combative behavior, and calling staff names, with interventions including calm approaches, emotional support, redirection, and monitoring for emotional distress and mood/behavior changes. She was identified as a vulnerable adult, with instructions to monitor for signs of emotional distress and to follow the facility’s abuse reporting policy. On the evening in question, while the resident was crying on the phone with her son and expressing a desire to leave, NA-A and NA-B entered to provide evening care using an EZ stand lift. After the resident ended the phone call, multiple staff reported that NA-A spoke to the resident in a loud, stern, and frustrated tone, telling her to stop crying and that she was acting like a two-year-old. When the resident swatted at NA-A, NA-A stated, “If you hit me, I’m going to hit you back,” and later told the resident she was “in trouble now.” Staff reported that NA-A told the resident she would be sent to a locked unit so she could not get out, and questioned who would want to care for her when she cried like a baby, and that nobody would want to keep working with her. NA-C described NA-A yelling commands such as “HOLD ON!” and “Stop crying! Where would you be if you were not here? Probably lying on the floor,” and felt NA-A was obviously upset and overwhelmed. These statements were made in the presence of the resident while she was already distressed and crying. Following this interaction, the resident exhibited crying, yelling, combativeness, resistance to care, wandering into other residents’ rooms, self-isolation, and refusal of food, fluids, and medications above her prior baseline, as documented in behavior charts, target behavior monitoring, and nursing progress notes. Staff documented that she cried most of the morning, was very restless, difficult to redirect, hit and pinched staff, called staff names, and refused care and meals. She required repeated redirection, 1:1 attention, and non-pharmacological interventions, and was ultimately sent to the ED for evaluation of combativeness and emotional distress, where she was treated for dementia with aggressive behavior and hypoglycemia related to poor intake. The report identifies that the resident’s actual response and the reasonable person concept showed serious psychosocial harm, including increased crying and combative behavior above baseline, fear/anxiety manifested as combativeness, resistance to care and social interaction, and self-isolation. The facility also failed to immediately remove the alleged perpetrator from resident care and to promptly report and investigate the allegation in accordance with its abuse policy. After NA-B and NA-C reported to LPN-A that NA-A had yelled at and threatened the resident, LPN-A acknowledged it as verbal abuse but did not initiate immediate protective measures or timely reporting. LPN-A stated she believed she had 24 hours to report because there was no injury, despite facility policy requiring reporting within two hours. NA-A remained on the unit and continued working until the end of her shift, including after staff had clearly communicated their concerns to LPN-A. TMA and NA staff described uncertainty about their authority to remove NA-A and reliance on the nurse to act, while the DON later informed LPN-A that NA-A should have been removed from the floor to prevent further danger to residents. The Immediate Jeopardy was determined to have begun when NA-A’s derogatory, intimidating, and threatening statements were made and continued while she remained on duty with access to the resident and other vulnerable residents.
Failure to Timely Assess and Treat Newly Discovered Stump Wound
Penalty
Summary
The deficiency involves the facility’s failure to provide timely treatment and care for a newly discovered wound on a resident’s above‑knee amputation stump. The resident was admitted with diagnoses including unspecified dementia with behavioral disturbances, vascular dementia, bilateral above‑knee amputations, vascular disease, reduced mobility, and severe protein‑calorie malnutrition, and had no documented ulcers or skin problems on admission or on the most recent MDS. A weekly bath audit on 3/17/26 documented only non‑tender lymph nodes on the right upper hip and did not identify any open areas. However, when the wound was later assessed, the dressing on the stump was dated 3/16/26, indicating that a wound and dressing existed at that time, even though no corresponding assessment, provider notification, or treatment orders were documented. On 3/23/26, nursing staff documented a new skin issue above the resident’s knee at the amputation site, describing a stage 4 pressure ulcer/injury with full‑thickness skin and tissue loss, exposed bone, erythema/edema, and moderate serosanguineous exudate. The wound measured 1.56 cm by 1.64 cm, with 20–29% granulation tissue and 80% slough. A progress note and skin issues assessment on that date confirmed the wound characteristics and staging, and the NP, after reviewing a picture, determined the wound to be a diabetic ulcer with peripheral vascular disease and severe protein‑calorie malnutrition as contributing factors. On that same date, the NP was notified, antibiotic therapy (doxycycline) was ordered for possible cellulitis, and specific wound care orders were initiated, with documentation on the MAR that these treatments were carried out beginning 3/23/26. Multiple interviews with nursing staff revealed that no one could identify who discovered the wound or who applied the initial dressing dated 3/16/26, and there was no documentation of a wound assessment, provider notification, or interim treatment between 3/16/26 and 3/22/26. Several RNs and LPNs who worked shifts from 3/16/26 through 3/20/26 stated they did not notice a wound on the stump and that, per their usual practice, they would have contacted the provider and initiated treatment if they had found one. One LPN recalled seeing a band‑aid with a date on the stump but could not recall the date, and another LPN stated she did not see the wound because she was not looking for one. The facility’s standing orders required staff to assess all wounds daily, change dressings every three days and as needed, treat with normal saline or non‑cytotoxic cleanser and appropriate dressings, and notify the provider the next business day when a new wound or injury was found. Despite these expectations, the wound identified by the dated dressing on 3/16/26 was not assessed, reported, or treated according to orders and facility policy until 3/23/26.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
