The Estates At Roseville Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Roseville, Minnesota.
- Location
- 2727 North Victoria, Roseville, Minnesota 55113
- CMS Provider Number
- 245105
- Inspections on file
- 22
- Latest survey
- November 20, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at The Estates At Roseville Llc during CMS and state inspections, most recent first.
The facility did not employ a full-time registered dietician or a qualified culinary director to oversee food and nutrition services, as required. Documentation and interviews revealed that the dietician split her time between multiple buildings and her hours at the facility were unclear, while the culinary director and assistant culinary director lacked necessary certifications and proof of qualifications. Personnel files and documentation of staff credentials were incomplete or missing.
The facility did not attempt alternative devices or adequately assess medical need and entrapment risks before installing bed rails for four residents with cognitive and mobility impairments. Documentation was incomplete, care plans lacked necessary interventions, and staff did not consistently inform residents or representatives about risks and benefits. Maintenance installed bed rails without full assessment of compatibility or entrapment zones, and facility policy did not address these requirements.
Surveyors observed multiple deficiencies in food storage and kitchen sanitation, including unlabeled and undated food items in the freezer, expired milk in the cooler, improper storage of cups in bread crumb bins, dented cans on shelves, and a persistent brown stain on the dry storage floor. Kitchen equipment, such as ovens, showed significant grease buildup and lacked regular cleaning, with no cleaning logs maintained. Staff confirmed inconsistent cleaning practices and failure to follow facility policy for food storage and sanitation.
Two residents with cognitive impairment were found with their wheelchair brakes locked, restricting their movement during activities. Neither had assessments or physician orders for this restraint, and staff were unsure if the use of locked brakes was care planned. Facility policy required assessment and documentation for restraints, which was not completed in these cases.
A resident with a suprapubic catheter and multiple medical conditions did not have documentation of monthly catheter changes as ordered by the physician. Nursing staff and the DON confirmed that the required catheter changes were not performed or recorded, and the facility's catheter care policy lacked guidance on change frequency.
A resident with severe cognitive impairment and chronic respiratory failure was not weaned from supplemental oxygen as ordered by the provider. Despite instructions to reduce oxygen as tolerated and maintain saturations above 90%, staff did not attempt or document weaning, and records lacked details on oxygen flow rates. Nursing staff and the DON confirmed the absence of weaning attempts and documentation, and the facility could not provide a policy for oxygen use.
A resident with a history of kidney stones and multiple sclerosis continued to receive Ciprofloxacin without an end date after returning from a urology visit. Despite pharmacy recommendations and staff awareness of the missing stop date, the PA and nursing staff did not obtain clarification from the urology clinic or document follow-up, resulting in prolonged, unjustified antibiotic use.
A resident with a history of multiple sclerosis, neuromuscular bladder dysfunction, and a kidney stone continued to receive Ciprofloxacin without an end date or documented justification, despite pharmacy recommendations and facility policy requiring clarification. Staff interviews confirmed awareness of the issue, but there was no evidence of adequate follow-up with the prescribing provider or documentation of the need for ongoing antibiotic therapy.
A resident with a history of stroke and recent dental extraction continued to receive a minced and moist (IDDSI Level 5) diet after the temporary order for this texture had ended, instead of returning to the prescribed soft, bite-sized (IDDSI Level 6) diet. The resident was not reassessed for mouth comfort or diet preferences, and staff interviews revealed a breakdown in communication and documentation, resulting in the resident receiving the incorrect diet despite an active order for the appropriate texture.
Two residents with cognitive and mobility impairments did not have their call lights within reach on multiple occasions, despite care plans and facility policy requiring accessibility. Staff and family observations confirmed repeated instances where call lights were on the floor, tangled, or out of reach, and staff interviews acknowledged the expectation for call lights to be accessible at all times.
Staff did not consistently follow required enhanced barrier and respiratory precautions for two residents—one with wounds requiring EBP and another with COVID-19 on enhanced respiratory precautions. During wound care, a nurse failed to don a gown as required, and multiple staff entered the COVID-19 positive resident's room without full PPE, such as N95 masks and eye protection, despite clear signage and facility policy. Staff interviews revealed confusion about PPE requirements for different precaution types.
Failure to Employ Qualified Food and Nutrition Services Staff
Penalty
Summary
The facility failed to employ a full-time registered dietician (RD) or a qualified culinary director (CD) to oversee the food and nutrition services, which had the potential to affect all 135 residents. Documentation showed that while the dietician held a valid license, her timecards did not specify the exact hours or days spent at the facility, and she split her time between multiple buildings. The administrator stated that 30 hours per week was considered full-time for the dietician, but the records did not clearly confirm her presence at the facility for those hours. Additionally, the dietician herself confirmed she was not a Certified Dietary Manager (CDM) and that her hours varied week to week. The culinary director (CD) and assistant culinary director (ACD) also lacked the required qualifications. The CD had a certificate from Le Cordon Bleu but was not a CDM, had not completed coursework in food management, and did not have an associate's degree or higher. The CD was reportedly being enrolled in a CDM program at the time of the survey. The ACD had a bachelor's degree in culinary arts and was a Certified Food Protection Manager (CFPM), but proof of credentials and certifications was not available in the personnel file. The ACD had only recently started working at the facility and had not yet provided documentation of his qualifications. Interviews with staff and administrators revealed confusion and inconsistencies regarding the credentials and roles of the dietician, CD, and ACD. The facility was unable to provide complete personnel files or clear documentation of staff qualifications and hours worked. Job descriptions for the CD and ACD outlined requirements for education and experience, but the individuals in these roles did not meet all the stated qualifications, and supporting documentation was incomplete or missing.
Failure to Assess Alternatives and Risks Prior to Bed Rail Installation
Penalty
Summary
The facility failed to attempt alternative devices before installing bed rails on the beds of four residents, did not identify the specific medical needs to be met with bed rail use, and did not assess potential entrapment zones. For each of the four residents reviewed, documentation was lacking regarding the evaluation of alternatives to bed rails, and care plans did not consistently include interventions related to bed rail use prior to their installation. In several cases, sections of the interdisciplinary team (IDT) care conference forms related to positioning devices were left blank, and bed mobility device evaluations were either missing or incomplete. Residents involved had varying degrees of cognitive and physical impairment, including diagnoses such as stroke, dementia, and depression. Some residents required substantial or maximal assistance with bed mobility and transfers, while others had no functional impairment to upper or lower body. Despite these differences, the process for assessing the need for bed rails and documenting alternatives was not followed. In some cases, residents or their representatives were not informed about the use of bed rails or the associated risks and benefits prior to installation. Observations revealed that bed rails were in use for all four residents, and maintenance staff were responsible for installation and ensuring compatibility. However, bed rails were found to be loose in some instances, and maintenance staff were not always notified of issues. Manufacturer guidelines for the bed rails were not readily available, and there was a lack of clear process or policy for assessing entrapment risks. The facility's policy did not address the need to attempt alternatives before bed rail installation or provide resources for entrapment risk assessment.
Deficient Food Storage, Labeling, and Kitchen Sanitation
Penalty
Summary
The facility failed to adhere to professional standards for food storage, preparation, and cleanliness as evidenced by multiple observations during a kitchen tour and staff interviews. Surveyors found several food items in the freezer, including fish, chicken, tator tots, and breadsticks, that were not labeled or dated. An opened box of hamburgers was left exposed to air, and a gallon of milk was found in the cooler past its best by date. In dry storage, cups were improperly stored in a bin of bread crumbs, and dented cans of peaches and applesauce were found on the shelf with other cans. Additionally, a large, thick brown stain was observed on the floor under shelving in dry storage, which staff acknowledged had been present for an extended period and had not been effectively cleaned. Further observations revealed that kitchen equipment, such as ovens, had significant grease buildup and had not been cleaned regularly, with one oven missing a knob and brownish residue present on the doors and handles. Staff interviews confirmed that cleaning logs were not maintained for kitchen floors or equipment, and cleaning tasks were inconsistently performed due to staffing issues. The facility's policy required food storage areas to be kept clean at all times and for all foods to be properly labeled, dated, and covered, but these standards were not met as documented by surveyors.
Failure to Assess and Document Use of Wheelchair Brakes as Restraints
Penalty
Summary
The facility failed to ensure that two residents were free from the use of physical restraints, specifically the use of locked wheelchair brakes, without proper assessment or physician orders. Both residents had significant cognitive impairments, including dementia, and required varying levels of assistance with mobility and transfers. Despite this, their care plans and medical records did not indicate any assessment to determine if they could independently unlock their wheelchair brakes, nor were there orders for the use of locked brakes as a restraint. During observations, both residents were found in the common area with their wheelchair brakes locked, restricting their ability to move. One resident attempted to stand and propel the wheelchair but was unable to do so due to the locked brakes, resulting in repeated unsuccessful attempts to move or stand. The other resident, who was dependent on others to lock or unlock the brakes but could self-propel, was also unable to move the wheelchair or reach for support due to the brakes being locked. Staff interviews revealed uncertainty about whether these residents could unlock their brakes and whether the use of locked brakes was part of their care plan. Further interviews with nursing staff and the DON confirmed that wheelchair brakes should not be locked unless the resident can unlock them, as this would otherwise constitute a restraint. The facility's own policy required a comprehensive assessment, education on risks and benefits, and a physician's order for the use of physical restraints, none of which were documented for these residents. The lack of assessment and documentation led to the inappropriate restriction of movement for both residents.
Failure to Provide Monthly Suprapubic Catheter Changes as Ordered
Penalty
Summary
A resident with moderately impaired cognition and diagnoses including multiple sclerosis, neuromuscular dysfunction of the bladder, and kidney calculus was identified as having a suprapubic catheter. The resident's care plan specified interventions such as regular toileting assistance, pericare, monitoring for urinary tract infection (UTI) symptoms, and changing the suprapubic catheter according to policy. Physician orders directed that the catheter be changed monthly and as needed. However, review of the resident's Medical Administration Record (MAR), Treatment Administration Record (TAR), and progress notes from November 2024 through April 2025 showed no documentation that the catheter had been changed since admission. Interviews with nursing staff, including a registered nurse, a nurse manager, and the director of nursing, confirmed that the physician's orders for monthly catheter changes were not followed, and there was no evidence of catheter changes in the records. Additionally, a nurse from the urology provider confirmed the necessity of monthly catheter changes to prevent complications. The facility's catheter care policy did not specify the required frequency for catheter changes, contributing to the lack of compliance with physician orders.
Failure to Follow Oxygen Weaning Orders and Document Care
Penalty
Summary
The facility failed to follow provider orders to wean supplemental oxygen for a resident with severe cognitive impairment, chronic respiratory failure, and dementia. The resident had been hospitalized for sepsis, pneumonia, and urinary tract infection, and was discharged with instructions to be weaned off supplemental oxygen as able, maintaining oxygen saturation at or above 90%. Provider orders and the care plan directed staff to wean oxygen as tolerated, but documentation in the treatment administration record, oxygen saturation summary, and nursing progress notes lacked evidence of any attempts to wean the resident from oxygen or to record oxygen flow rates during such attempts. Observations confirmed the resident was continuously on oxygen via nasal cannula, and interviews with nursing staff and the DON revealed that no recent weaning attempts had been made or documented. The DON verified that the order to wean oxygen was still active and acknowledged the lack of documentation regarding weaning efforts. The facility was unable to provide a policy for resident oxygen use when requested.
Failure to Clarify and Discontinue Prolonged Antibiotic Therapy Due to Lack of Provider Coordination
Penalty
Summary
The facility failed to ensure proper coordination of care between the provider and an outside urology clinic, resulting in a resident receiving prolonged antibiotic therapy without appropriate justification or an established end date. The resident, who had multiple sclerosis, neuromuscular bladder dysfunction, and a history of kidney stones, was dependent on staff for toileting and had a catheter. After a urology visit, the resident was prescribed Ciprofloxacin for nephrolithiasis, but the order lacked a specified duration. The physician assistant (PA) continued to sign monthly orders for the antibiotic without an end date, and the pharmacy flagged the issue, requesting clarification, which was not adequately addressed. Multiple staff interviews revealed that when a resident returns from the hospital with new orders, it is standard practice for nurses to verify and clarify any discrepancies, such as missing end dates for antibiotics, by contacting the provider. In this case, although staff were aware of the missing end date and the ongoing use of Ciprofloxacin, there was no documented follow-up or resolution. The PA stated he attempted to contact the urology clinic but did not receive a response and continued the order regardless. The medical director confirmed there was no clinical justification for prophylactic antibiotic use in this situation and expected the provider to follow through with the specialist for clarification. Documentation in the resident's medical record was incomplete, lacking evidence of follow-up with the urology clinic or justification for continued antibiotic use. Progress notes indicated attempts to contact the urologist, but there was no record of any response or further action. The deficiency was further compounded by the lack of communication and documentation among nursing staff, the PA, and the urology clinic, resulting in the resident receiving unnecessary antibiotic therapy beyond the intended period.
Failure to Ensure Antibiotic Orders Had End Date or Justification
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs by not providing an end date or documented justification for the continued use of a prophylactic antibiotic. The resident in question had multiple diagnoses, including multiple sclerosis, neuromuscular bladder dysfunction, and a kidney stone, and was dependent on staff for toileting and had a suprapubic catheter. Despite the original order for Ciprofloxacin being intended for a limited duration following a surgical procedure, the antibiotic was continued without an end date or clear clinical justification. Documentation showed that the pharmacy flagged the ongoing use of Ciprofloxacin and requested clarification on the duration of therapy, but the provider only handwrote 'prophylactic-urology' without specifying an end date. Interviews with nursing staff, the PA, and the DON revealed that staff were aware of the missing end date and the lack of justification for continued antibiotic use, but failed to follow up adequately with the prescribing urologist or to document any resolution. The medical record lacked evidence of appropriate follow-up or communication with the urology clinic regarding the necessity and duration of the antibiotic. Facility policy required that all antibiotic orders include a duration and that any discrepancies be clarified with the provider. Despite this, the resident continued to receive Ciprofloxacin without a documented indication or stop date, and there was no evidence that the facility’s antibiotic stewardship protocols were followed. The deficiency was further supported by the absence of documentation of follow-up actions or provider responses in the resident’s medical record.
Failure to Provide Ordered Therapeutic Diet After Temporary Downgrade
Penalty
Summary
A deficiency occurred when a resident with a history of cerebral infarction, aphasia, and type 2 diabetes did not receive the ordered therapeutic diet. The resident was initially placed on a regular diet with soft, bite-sized textures (IDDSI Level 6) due to their medical condition. Following a dental extraction, a temporary order was placed for a softer, minced and moist diet (IDDSI Level 5) for two days, after which the resident was to resume their normal diet as comfortable. However, after the temporary order ended, the resident continued to receive the Level 5 diet instead of returning to the Level 6 diet as ordered. There was no documented reassessment of the resident's mouth or dental comfort, nor any conversation about diet preferences during this period. Multiple interviews with staff revealed that the process for updating diet orders involved communication between nursing and dietary departments, with orders entered into the electronic health record system and meal tickets printed accordingly. Despite the active order for a Level 6 diet, the resident continued to receive Level 5 meals, and staff could not explain the discrepancy. The resident expressed dissatisfaction with the minced and moist diet, stating it was unappetizing and that they had not been reassessed or consulted about advancing their diet. Facility policy required regular review and documentation of residents' responses to therapeutic diets, but this was not followed in this case.
Failure to Ensure Call Lights Within Reach for Residents with Cognitive and Mobility Impairments
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents who required extensive assistance and had cognitive impairments. One resident with severe cognitive impairment, dementia, and anxiety was observed on two separate occasions lying in bed with the call light on the floor, tangled and pushed against the wall, making it inaccessible. Staff interviews confirmed that the call light was not within reach and that it should have been accessible to the resident at all times, as directed by the care plan. Another resident with moderate cognitive impairment, a history of falls, and significant mobility limitations was repeatedly found without access to their call light, both in bed and in a wheelchair. Family members reported multiple instances where the call light was out of reach or under the bed, and documentation confirmed these occurrences. Staff interviews acknowledged the expectation that call lights should be within arm's reach of residents, and facility policy required call lights to be accessible to all residents.
Failure to Follow Enhanced Precautions for Wound Care and COVID-19
Penalty
Summary
Staff failed to follow appropriate transmission-based precautions for two residents requiring enhanced infection control measures. One resident with moderate cognitive impairment, dementia, and frostbite with surgical amputations had provider orders and a care plan directing staff to use enhanced barrier precautions (EBP), including donning gown and gloves during high-contact care. During a dressing change, a registered nurse performed hand hygiene and wore gloves but did not don a gown, despite signage and policy requiring both. The nurse later acknowledged the omission. The Director of Nursing confirmed that EBP required gown and gloves for wound care, as outlined in facility policy. Another resident with a recent COVID-19 diagnosis was on enhanced respiratory precautions, with care plan interventions for isolation and monitoring but lacking specific PPE instructions. Observations showed that staff entered the resident's room wearing only surgical masks or omitting required PPE such as N95 respirators and eye protection, despite signage indicating enhanced respiratory precautions. Interviews with staff revealed inconsistent understanding and implementation of required PPE protocols for both EBP and enhanced respiratory precautions, as well as a need for further education on the differences between these precautions.
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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