The Estates At Greeley Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Stillwater, Minnesota.
- Location
- 313 South Greeley Street, Stillwater, Minnesota 55082
- CMS Provider Number
- 245342
- Inspections on file
- 21
- Latest survey
- June 12, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at The Estates At Greeley Llc during CMS and state inspections, most recent first.
Two residents at high risk for falls did not receive care planned interventions to prevent accidents. One resident, dependent on a full body lift for transfers, was instead transferred with a standing lift, resulting in a fall. Another resident, with severe cognitive impairment and a history of falls, was observed without non-slip footwear and was not offered toileting as care planned. Staff interviews and documentation confirmed that required fall prevention measures were not consistently implemented.
A facility failed to report allegations of sexual abuse within the required two-hour timeframe to the State Agency for a resident with cognitive impairments. The incident involved a sexual interaction between two residents, initially reported as consensual but later escalated to nonconsensual. Facility staff, including the administrator and social worker, did not report the incident promptly, citing reasons such as the resident's initial claim of consent and the belief that the hospital social worker was handling the report. The facility's policy mandates reporting all allegations of abuse within two hours, which was not followed.
A facility failed to thoroughly investigate a sexual abuse allegation involving a resident with cognitive impairments and another cognitively intact resident. The initial investigation was not revisited after receiving additional information from a hospital social worker, which detailed further abuse. This inaction was against the facility's policy to investigate all abuse allegations.
A facility failed to update a resident's care plan to include interventions for monitoring behaviors and interactions with female residents. The resident, who was cognitively intact and had a history of a fractured rib and weakness, was identified as a vulnerable adult. Despite discussions among staff about the resident's behaviors, the care plan lacked documentation of these interventions. Interviews with the social worker, nurse practitioner, and DON confirmed the oversight, and the facility could not provide a care planning policy.
A facility failed to implement proper infection control measures for two residents requiring precautions. One resident with C. diff was not managed with appropriate contact precautions, as staff did not wear PPE or perform hand hygiene. Another resident requiring enhanced barrier precautions was not properly managed, with staff failing to wear gowns and perform hand hygiene during care. Interviews revealed misunderstandings and policy gaps regarding infection control procedures.
A resident with severe cognitive impairment was found to have her wheelchair locked by a housekeeper, which was considered a restraint as the resident could not unlock it herself. The facility lacked a policy on restraints, and the care plan did not include specific interventions for wheelchair locking, leading to a deficiency in ensuring the resident's freedom from restraints.
Two residents at risk for pressure injuries did not receive proper skin assessments and interventions. One resident's cam boot was not removed for skin checks, leading to significant skin issues, while another resident did not have documented interventions for pressure injury prevention. The facility failed to follow its policy on skin assessment and wound management, resulting in deficiencies.
A resident with a history of ankle fracture and other conditions required podiatry services for overgrown and thick toenails, as noted in weekly skin inspections. Despite the need, the resident was not placed on the list for in-house podiatry services, and no urgent referral was made. Observations showed the resident's foot was extremely dry with peeling skin and thick, curled toenails. Interviews revealed a lack of clarity in the process for obtaining podiatry services, leading to the deficiency.
A resident with severe cognitive impairment and a history of falls experienced repeated falls due to inadequate supervision and inconsistent implementation of fall prevention measures. Despite having a care plan, staff failed to follow it consistently, leading to the use of restraints and improper use of fall mats. The facility lacked a policy on restraints, and staff were unclear about fall prevention interventions.
The facility failed to attempt or justify gradual dose reductions (GDR) for psychotropic medications for two residents. One resident with moderate cognitive impairment and insomnia was on trazodone without a GDR attempt or clinical contraindication documentation. Another resident with major depressive disorder was on escitalopram, and the nurse practitioner noted 'patient POA refused' without providing a clinical rationale. Interviews revealed inadequate documentation and communication regarding GDRs, leading to the deficiency.
The facility failed to provide menus and alternate food choices to two residents, leading to their unawareness of meal options. Despite having care plans that included offering substitutes, the residents reported not receiving menus or being asked about meal preferences. Staff interviews revealed inconsistencies in menu distribution and communication, with some staff unaware of the facility's policy requiring menus to be developed and posted for resident choice.
The facility did not post complete and timely nurse staffing information, affecting all 48 residents, staff, and visitors. A form titled 'Estates at [NAME]' lacked the census number, complete staff titles, and total hours worked by RNs, LPNs, and NAs. The administrator confirmed the omissions, and the DON verified that forms from late July to early August lacked tallied hours.
A resident with epilepsy was admitted to a facility with a prescription for 1250 mg of Depakote twice daily. Due to a transcription error, the medication was administered only once daily, leading to subtherapeutic levels and subsequent seizures. The error was not caught by the health information manager or the LPN responsible for confirming the order, resulting in the resident being hospitalized.
Failure to Implement Care Planned Fall Interventions
Penalty
Summary
The facility failed to implement care planned interventions to reduce fall risk for two residents identified as being at risk for falls. One resident, with a history of vascular dementia, stroke, and right-sided weakness, was care planned to require two staff and a full body lift (MAXI lift) for all transfers. Despite this, a nursing assistant attempted to transfer the resident using a standing lift at the resident's request, resulting in the resident's right leg buckling and a fall to the floor. Multiple staff interviews confirmed that the transfer was not performed according to the care plan, and the resident's medical condition necessitated the use of the full body lift for safety. Another resident, with severely impaired cognition, heart failure, repeated falls, and on hospice care, was care planned to always have non-slip footwear and to be offered toileting at specific times, including before and after meals. Observations revealed the resident was found wearing slippery socks without grips and was not offered toileting as specified in the care plan. Staff interviews confirmed awareness of the care plan requirements, but these interventions were not consistently implemented during the survey period. Facility policies required that care plans be updated to reflect fall interventions and that staff use the care plan to guide daily care routines. Documentation and staff statements indicated that the care planned interventions for both residents were not followed, resulting in increased risk for falls and actual incidents of falls.
Failure to Timely Report Allegations of Sexual Abuse
Penalty
Summary
The facility failed to report allegations of sexual abuse within the required two-hour timeframe to the State Agency (SA) for a resident who was moderately cognitively impaired with diagnoses including dementia, anxiety, depression, psychotic disorder, and post-traumatic stress disorder. The incident involved a sexual interaction between this resident and another resident, which was initially reported as consensual but later escalated to nonconsensual. The facility staff, including the administrator, social worker, and nurse practitioner, did not report the incident promptly, citing various reasons such as the resident's initial claim of consent and the belief that the hospital social worker was handling the report. Interviews with facility staff revealed a lack of immediate action in reporting the incident. The administrator acknowledged receiving a report from the hospital social worker indicating nonconsensual penetration but did not report it to the SA immediately. The social worker at the facility assumed the hospital social worker's report sufficed, while the nurse practitioner did not report the incident, believing it was not her responsibility since the resident was not in the facility at the time. The facility's policy mandates reporting all allegations of abuse within two hours, which was not adhered to in this case.
Failure to Reinvestigate Sexual Abuse Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation into allegations of sexual abuse involving a resident, identified as R1, who was moderately cognitively impaired with diagnoses including dementia, anxiety, depression, psychotic disorder, and post-traumatic stress disorder. The incident involved another resident, R2, who was cognitively intact. R1 reported a sexual interaction with R2 that began consensually but escalated to nonconsensual, with R2 allegedly pinning or grabbing R1's hands. The initial investigation included interviews with R1 by a social worker, staff, and other residents, as well as a review of R1's care plan and directives. However, the investigation lacked follow-up after additional information was provided by a hospital social worker. The facility's social worker and administrator acknowledged that the additional information from the hospital, which included details of R1 being held down and penetrated by R2, was not further investigated. The director of nursing confirmed that the facility did not reinvestigate the incident after receiving this new information. This inaction was contrary to the facility's policy, which mandates the investigation of all alleged or suspected abuse incidents. The failure to reinvestigate after receiving new information represents a deficiency in the facility's handling of the abuse allegation.
Failure to Update Care Plan for Resident's Behavioral Monitoring
Penalty
Summary
The facility failed to update the comprehensive care plan for a resident, identified as R2, to include necessary interventions for monitoring relationships and behaviors. R2 was cognitively intact and had diagnoses including a fractured rib and weakness. Despite being identified as a vulnerable adult, R2's care plan did not address the relationship with another resident, R1, nor did it provide instructions for staff to monitor R2's behavior and interactions with female residents. Interviews with the social worker, nurse practitioner, and director of nursing revealed that although R2's behaviors were discussed and staff were informed to monitor interactions, these interventions were not documented in the care plan. The facility was unable to provide a policy for care planning upon request.
Failure to Implement Proper Infection Control Measures
Penalty
Summary
The facility failed to implement proper transmission-based precautions for a resident diagnosed with Clostridium difficile (C. diff), a highly contagious infection. The resident's admission records and care plan did not indicate the need for contact precautions, despite the presence of a sign on the resident's door. During an observation, a certified occupational therapy assistant (COTA) was seen assisting the resident without wearing the required personal protective equipment (PPE) such as gloves and a gown, and did not perform hand hygiene upon entering or exiting the room. Interviews with staff revealed a misunderstanding of the requirements for PPE usage, with some staff believing that gowns and gloves were only necessary when performing direct care. Another deficiency was noted with a second resident who required enhanced barrier precautions (EBP) due to their medical conditions, including Parkinson's disease and diabetes. The resident's care plan and orders did not indicate the need for EBP, although signage was present on the resident's door. During an observation, a nursing assistant (NA) failed to wear a gown and did not perform hand hygiene after glove removal while assisting the resident with personal care tasks. The NA admitted to not following proper procedures, citing the lack of hand sanitizer in their pocket as a reason for not performing hand hygiene. Interviews with the Director of Nursing (DON) and the infection preventionist (IP) confirmed that staff were expected to follow posted precautions, including wearing gowns and gloves and performing hand hygiene when moving from unclean to clean tasks. The facility's policies on transmission-based precautions and handwashing were found to lack specific guidance on enteric precautions and the necessity of handwashing with soap and water for infections like C. diff. This oversight contributed to the improper implementation of infection control measures for the residents involved.
Failure to Ensure Resident Freedom from Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident, identified as R37, was free from physical restraints. R37, who had severe cognitive impairment and was on hospice care, was observed to have her wheelchair locked by a housekeeper while she was at the dining room table. The housekeeper stated that she locked the wheelchair brakes to prevent R37 from trying to get up. However, this action was not in line with the facility's practices, as locking the wheelchair was considered a restraint, especially since R37 was unable to unlock it herself. Interviews with various staff members, including a licensed practical nurse and a registered nurse, confirmed that locking the wheelchair was considered a restraint and could pose a safety issue. R37's care plan and physician's orders did not include the use of restraints, and the facility did not have a policy on restraints because they did not use them. The care plan indicated that R37 was at risk for falls and had a history of impulsive behavior and forgetfulness. Despite this, the care plan lacked specific interventions regarding the locking of the wheelchair. The director of nursing acknowledged that housekeeping staff needed education on this matter, as they did not have access to the care plan. The nursing assistant also confirmed that R37 could not think to unlock the wheelchair, indicating a lack of understanding and communication among staff regarding the resident's care needs.
Failure to Conduct Proper Skin Assessments and Implement Interventions
Penalty
Summary
The facility failed to ensure proper skin assessments and interventions for two residents at risk for pressure injuries. Resident 16, who had a cam boot for a left ankle fracture, did not have the boot removed for skin assessments as required. Despite being cognitively intact and aware of the boot's removal instructions, the resident reported that the boot was never removed for skin checks. Nursing staff were unaware of the need to remove the boot, and conflicting orders were not clarified until after the survey entrance. Upon removal of the boot, significant skin issues were observed, including dry, cracked skin and a strong odor, indicating a lack of proper skin care. Resident 20, who was at risk for pressure injuries due to conditions such as Parkinson's disease and diabetes, did not receive appropriate interventions to prevent skin breakdown. The care plan required daily monitoring of skin integrity and the use of pressure-reducing devices, but these interventions were not documented or communicated effectively to the staff. The nursing assistant was unaware of the resident's risk for pressure injuries and did not encourage leg elevation in the recliner, as required. Additionally, there was no evidence of a skin and wound evaluation for the resident's deep tissue injury, and hospice care was managing the condition without proper documentation or follow-up by the facility's nursing staff. The facility's policy on skin assessment and wound management was not followed, as weekly skin assessments and appropriate interventions were not consistently implemented. The lack of communication and documentation regarding residents' care needs and the failure to update care plans and orders contributed to the deficiencies observed. The Director of Nursing acknowledged the expectation for staff to follow up on skin concerns and ensure that orders were updated upon residents' return from appointments, but these practices were not adhered to in the cases of Residents 16 and 20.
Failure to Obtain Podiatry Services for Resident
Penalty
Summary
The facility failed to ensure podiatry services were obtained for a resident who required assistance with foot care. The resident, who was cognitively intact, had a history of a left ankle fracture, lung disease, and schizoaffective disorder, and was dependent on staff for personal care, including bathing and dressing the lower body and feet. Weekly skin inspections from mid-June to mid-July indicated the resident had overgrown and thick toenails that required podiatry services. However, the resident's medical record did not show any indication that they had been seen or referred for podiatry services. On August 7th, a registered nurse observed the resident's foot to be extremely dry with peeling skin and yellowed, thick toenails that were slightly curled over the toes. Interviews with nursing staff and the admission coordinator revealed a lack of clarity and communication regarding the process for obtaining podiatry services. The resident was not placed on the list for in-house podiatry services, which were offered every 2-3 months, and no urgent referral was made despite the evident need. The Director of Nursing expected residents requiring podiatry services to be on the list and seen when podiatry was in-house, but this did not occur for the resident in question.
Failure to Prevent Falls and Use of Restraints
Penalty
Summary
The facility failed to ensure that a resident, identified as R37, was free from accident hazards and provided with adequate supervision to prevent falls. R37, who had severe cognitive impairment and a history of falls, was observed to have multiple falls over several months. Despite having a care plan in place with various interventions, such as ensuring the TV remote was within reach, encouraging the resident to be in common areas, and implementing a toileting schedule, these measures were insufficient in preventing repeated falls. The care plan also lacked specific interventions, such as ensuring the resident's wheelchair was locked when at the dining room table. Observations and interviews revealed that staff did not consistently follow the care plan. For instance, a housekeeper locked R37's wheelchair, which was considered a restraint, and left the resident unattended. Additionally, the floor mat intended to prevent falls was not always used correctly, as it was found on the floor even when R37 was not in bed. Staff interviews indicated a lack of clarity and consistency in implementing fall prevention measures, with some staff believing that locking the wheelchair was a restraint and others stating that the mat should always be on the floor. The facility's documentation, including incident reviews and analysis forms, highlighted multiple instances where R37 fell, often due to self-transferring or tripping over the floor mat. Despite these incidents, the facility did not have a policy on restraints, and there was a lack of specific fall prevention interventions documented in the CNA report sheet. The director of nursing acknowledged the need for staff education and the importance of following the care plan, but the report indicates that these measures were not effectively implemented, leading to the deficiency.
Failure to Attempt or Justify Gradual Dose Reductions for Psychotropic Medications
Penalty
Summary
The facility failed to ensure gradual dose reductions (GDR) were attempted or adequately justified for the use of psychotropic medications for two residents. Resident 19, who had moderate cognitive impairment and a history of Parkinson's disease, dementia, and insomnia, was on trazodone for insomnia. Despite the requirement for a GDR within the first year of medication use, no attempt was made, nor was there documentation of clinical contraindication. The consultant pharmacist recommended a dose reduction assessment, but the response from the provider was merely 'patient refuses,' lacking any clinical rationale. Similarly, Resident 14, diagnosed with major depressive disorder, was on escitalopram. The resident's care plan indicated a potential for adverse reactions, and the consultant pharmacist recommended a GDR assessment. However, the nurse practitioner noted 'patient POA refused' without providing a clinical rationale or noting any contraindications. The facility's policy required documentation of clinical rationale if a GDR was not attempted, which was not adhered to in these cases. Interviews with the Director of Nursing and the consultant pharmacist revealed a lack of proper documentation and communication regarding the necessity of GDRs. The DON acknowledged that 'patient refused' was not an adequate rationale, and the consultant pharmacist admitted to accepting refusals without verifying the resident's decision-making capacity. This lack of adherence to policy and proper documentation led to the deficiency in managing psychotropic medication use.
Failure to Provide Menus and Meal Choices
Penalty
Summary
The facility failed to provide menus and alternate food choices to two residents, R14 and R98, as required. R14, who has intact cognition and medical conditions including congestive heart disease, type II diabetes, and hypertension, reported not receiving a menu or being asked about meal preferences. Despite having a care plan that included offering substitutes for dislikes, R14 stated that he was unaware of the available menu options and had to eat whatever was provided. Similarly, R98, who also has intact cognition and medical conditions such as enterocolitis due to C-diff and hypertension, expressed that she did not know what meals she would receive and was not informed about alternative menu items. Interviews with staff revealed inconsistencies in the distribution and communication of menu options. The cook mentioned that menus were posted in dining halls and that residents received a menu upon admission, but acknowledged that staff did not ask residents about their meal preferences. The dietary manager stated that the facility had a fixed menu with limited options and a Bistro menu with alternatives, but the Bistro menu was not distributed to residents or prominently displayed. Nursing assistants and other staff members provided conflicting accounts regarding the distribution of menus, with some stating that residents received weekly menus and others indicating that it was the residents' responsibility to request them. The facility's policy on menus, dated October 2017, required that menus be developed to meet resident choices and posted in accessible areas. However, the survey revealed that this policy was not consistently followed, leading to residents being unaware of their meal options and not receiving the necessary information to make informed dietary choices. This deficiency highlights a lack of communication and adherence to established procedures regarding menu distribution and resident choice in meal planning.
Incomplete Nurse Staffing Information Posting
Penalty
Summary
The facility failed to ensure that complete and timely nurse staffing information was posted daily, which had the potential to affect all 48 residents, staff, and visitors who might wish to review this information. On August 6, 2024, a form titled 'Estates at [NAME]' was found next to the administrator's office. This form was missing the census number and did not include all staff and their titles, nor did it provide information on the total number and actual hours worked by registered nurses (RNs), licensed practical nurses (LPNs), and nursing assistants (NAs). During an interview, the administrator confirmed that the form was intended for staff posting and acknowledged the missing census number, which was then added. The administrator also mentioned that the total hours worked were usually recorded after the shift was completed. The director of nursing (DON) confirmed that staff posting forms from July 26, 2024, through August 6, 2024, lacked tallied hours, and a policy was requested but not received.
Medication Transcription Error Leads to Resident Seizures
Penalty
Summary
The facility failed to accurately transcribe a physician's order for an anti-convulsant medication, Depakote, for a resident upon admission. The resident, who had a history of epilepsy, was supposed to receive 1250 mg of Depakote twice daily. However, due to a transcription error, the medication was ordered to be administered only once daily at bedtime. This error went unnoticed by both the health information manager and the licensed practical nurse responsible for confirming the order. As a result of the transcription error, the resident did not receive the correct dosage of the anti-seizure medication, leading to subtherapeutic levels of valproic acid in their system. Consequently, the resident experienced a petit mal seizure followed by a grand mal seizure and required hospitalization. The hospital records indicated that the resident's valproic acid levels were significantly lower than the normal range, which was attributed to the incorrect administration frequency of the medication. Interviews with facility staff revealed that the error was a result of human oversight during the transcription process. The licensed practical nurse and the health information manager both failed to catch the discrepancy between the hospital discharge orders and the electronic health record. The facility's director of nursing later discovered the error while reviewing the resident's orders after the incident, confirming that the resident did not receive the medication as prescribed from the time of admission until the seizures occurred.
Removal Plan
- House audits were performed to ensure all orders entered on admission in EHRs corresponded with original hospital admission orders for all residents on the TCU, all new admissions, and all residents taking medications for seizures.
- Audits were performed of other resident charts to ensure current orders were all correct.
- Hospital admission orders had a new third check by nursing management to ensure orders were entered correctly.
- Nursing management was performing ongoing audits of orders to ensure they were accurate.
- Staff responsible for error received education and corrective action.
- House-wide audit for new admissions.
- Therapeutic dosing medications will pull labs to get baseline levels and put orders to repeat those labs every three months.
- Nursing leadership will conduct audits to ensure resident's orders are being inputted accurately.
- Education on Medication Transcription Errors must be reviewed and understood prior to next shift.
- Audits done by Nurse Leadership team to ensure orders are accurate.
- Education provided: education on Medication Transcription Errors.
- Policy titled Admission Order Transcription was reviewed with staff in this education.
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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