The Estates At St Louis Park Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Louis Park, Minnesota.
- Location
- 3201 Virginia Avenue South, Saint Louis Park, Minnesota 55426
- CMS Provider Number
- 245148
- Inspections on file
- 38
- Latest survey
- August 7, 2025
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at The Estates At St Louis Park Llc during CMS and state inspections, most recent first.
Kitchen staff did not consistently use required hair restraints while serving food, as a cook was observed serving meals without a hair net or beard guard. The cook admitted forgetting the hair net and was unaware of beard guard requirements. Leadership confirmed expectations for hair restraints, but the facility lacked a specific policy, referencing only a general handbook statement. This affected all residents receiving meals on the affected unit.
A resident with a history of skin issues developed new red spots on her chin that were not promptly assessed or monitored by staff, despite care plan interventions and policy requirements. In a separate incident, a resident with anemia and end-stage renal disease had a critically low hemoglobin lab result that was not immediately reported to the provider as required, with staff failing to follow established protocols for critical lab notification.
Two residents with limited ROM did not consistently receive required ROM exercises or use of a palm protector as ordered. One resident with severe cognitive impairment and contractures was often without the prescribed hand guard, and staff failed to perform or document ROM during care. Another resident with a history of stroke and contractures lacked a documented ROM program despite care plan interventions, and staff were unaware of any ROM instructions. In both cases, care plans and orders were incomplete or not followed, and staff interviews confirmed gaps in care delivery.
A resident in need of pain management did not receive safe and appropriate pain management services, resulting in a deficiency related to the facility's failure to meet the resident's needs.
A resident who required dialysis did not receive safe and appropriate dialysis care and services as needed.
Three newly admitted residents with cognitive concerns and recent medical events were not provided with the 1:1 staff care and 15-minute safety checks specified in their baseline care plans. Staff interviews and observations showed that these interventions were not performed, and staff were either unaware of the care plan requirements or unable to implement them due to staffing limitations. Facility leadership was unclear about how these interventions were included in the care plans, resulting in a failure to meet the residents' immediate safety needs.
A resident with a history of brain cancer and recent surgery experienced a fall, and the facility failed to document or complete required neurological checks and post-fall monitoring as outlined in the care plan and facility policy. Staff could not provide evidence of timely neuro checks, and family members reported concerns about the resident's condition and lack of monitoring. The facility was unable to produce documentation or a specific neuro check policy during the survey.
A resident with a VP shunt and related diagnoses did not have the shunt or its management addressed in their care plan, despite physician orders for wound care at the shunt site. Nursing staff and leadership were unaware or unsure of the shunt's inclusion in the care plan, and the facility's policy requiring comprehensive assessment-based interventions was not followed.
The facility failed to uphold resident dignity for two residents. One resident was found with stool on his hands and legs in the dining room, and his bed lacked sheets, causing embarrassment. Another resident expressed dissatisfaction with sleeping on a bed without sheets. Staff confirmed that residents should have sheets for comfort and hygiene, but the facility lacked a specific dignity policy.
A resident with Parkinson's and severe cognitive impairment was supposed to be NPO and receive tube feeding per hospital discharge orders. However, the facility failed to adhere to these orders, allowing the resident to consume food orally on multiple occasions. Staff, including an LPN, RN, and SLP, were unaware of the NPO status, and the DON acknowledged an ineffective process for checking diet orders. This oversight potentially compromised the resident's health.
The facility failed to implement physician-ordered weight monitoring for two residents, leading to deficiencies in their nutritional care. One resident, undergoing dialysis, did not have daily weights recorded as ordered, with significant discrepancies in recorded weights. Another resident, with malnutrition, had inconsistencies in weekly weight recordings, with some weights missing entirely. Staff interviews revealed confusion and lack of adherence to care plans and provider orders.
A resident in a secure memory unit with a history of aggressive behavior struck another resident, causing injury. The facility failed to document daily behaviors and interventions for the aggressive resident and did not update care plans following previous altercations. Additionally, preventive measures, such as a stop sign on the victim's door, were not consistently maintained, contributing to the incident.
The facility failed to provide a dignified environment for residents, as observed with a resident left waiting for breakfast for over an hour without engagement, and another resident with cognitive impairment left alone without activities. Visible clothing labels on residents' attire further compromised dignity. Staff acknowledged the issues, noting changes in breakfast timing and lack of engagement for residents.
A resident with severe cognitive impairment was observed with an uncovered catheter bag, visible to other residents and staff, which was against the facility's dignity policy. Despite the care plan noting the resident's refusal to cover the bag, no interventions or alternatives were documented. Staff and other residents expressed discomfort with the situation, and the Director of Nursing acknowledged the lack of guidance in the care plan.
An unlocked medication cart was found unattended in a dining room with 12 residents and numerous staff present. An RN locked the cart upon noticing it, and the LPN responsible admitted it was a violation. The DON confirmed that carts should always be locked when unattended. The facility's medication storage policy was not provided.
The facility failed to follow infection control practices during medication administration through a gastrostomy tube, did not maintain enhanced barrier precautions for residents requiring them, and neglected proper hand hygiene during meal service. An LPN did not stop enteral feeding before administering medication, and staff did not use PPE correctly or perform hand hygiene between assisting residents, increasing the risk of contamination.
A privacy breach occurred when a medication cart was left unattended with a laptop displaying a resident's medication list in a dining room with multiple residents and staff present. An RN closed the laptop, and the LPN responsible acknowledged the violation, citing HIPAA regulations. The DON confirmed that carts should be locked and laptops turned off when unattended, aligning with the facility's policy on resident privacy.
A facility failed to conduct timely person-centered care conferences for a resident with severe cognitive impairment and multiple diagnoses. Despite regular MDS assessments, care conferences were missing for several periods. Interviews with the DON and SS-D confirmed the expectation for quarterly conferences, which were not met for a year. The facility's policy on care conference timing was not provided.
The facility failed to provide routine personal hygiene assistance to two residents, resulting in unmet needs for nail care and shaving. Additionally, the facility did not implement an effective communication system for a resident with severe cognitive impairment and a primary language of Vietnamese, as staff did not utilize available interpreter resources. These deficiencies highlight a lack of adherence to facility policies on Activities of Daily Living and Interpreter Services.
The facility failed to provide individualized activities for two residents, one with severe cognitive impairment and multiple diagnoses, and another in the transitional care unit. Both residents' preferences for activities like watching TV and listening to music were not accommodated, and assessments for activities of interest were not completed. Staff interviews and observations confirmed the lack of adherence to care plans and recommendations, leading to unmet activity needs.
A facility failed to provide adequate care for two residents, one with severe cognitive impairment and contractures, and another with mobility needs. The first resident did not receive necessary PROM exercises, and staff were unaware of the care plan details. The second resident, who required walking assistance, was instead wheeled to meals, contrary to care plan directives. Staff interviews confirmed a lack of adherence to care plans and physician orders.
A resident experienced inadequate pain management for mobility-related pain in an LTC facility. Despite being on a scheduled pain medication regimen, the resident reported moderate pain during repositioning and transfers, which was not effectively managed. Facility staff failed to comprehensively reassess or address these complaints, and the resident's pain levels were inaccurately recorded as zero. The facility's pain management protocol was not followed, leading to a deficiency in providing adequate pain relief.
A facility failed to consistently monitor and document a resident's dialysis site, risking complications like infection and bleeding. Despite orders for regular checks, assessments were not documented, and staff were unclear about monitoring responsibilities. Interviews revealed a lack of communication and clarity, with some staff unaware of the dialysis site's location.
A facility failed to assess and document PTSD triggers for a resident, leading to a lack of specific interventions in the care plan. Staff interviews revealed that the care sheets did not list the resident's PTSD or triggers, which were expected to be included. The DON and social worker director acknowledged the care plan's deficiencies, despite facility policy requiring trauma-informed care details.
The facility did not respond to the consulting pharmacist's medication regimen review for two residents on psychotropic medications. One resident experienced multiple falls, and the pharmacist recommended reducing Hydroxyzine, but no follow-up was documented. Another resident was prescribed Seroquel without an appropriate diagnosis, and there was no evidence of provider response. The facility's process for handling MRRs was ineffective, leading to missed follow-ups.
A resident with severe cognitive impairment was prescribed Seroquel without an appropriate diagnosis, and their electronic medical record lacked evidence of target behavior monitoring. The facility's process for handling medication regimen reviews was ineffective, leading to missed follow-ups and inadequate documentation, as acknowledged by the DON.
A facility failed to adhere to pneumococcal vaccination standards for a resident over 65. The resident's immunization record showed receipt of PPSV23 and PCV13 vaccines, but lacked evidence of further pneumococcal vaccinations. The Care Conference Form was incomplete regarding immunizations. The DON confirmed oversight of immunizations and acknowledged a lapse in offering the PCV20 vaccine due to a lost list, despite eventual guardian approval.
A resident's closet door was in disrepair with exposed nails, posing a safety risk. Despite the resident's request for repair, no work order was submitted, and maintenance was unaware of the issue until a survey. The door eventually fell off when a nursing assistant attempted to move it, highlighting the facility's failure to maintain a safe environment.
The facility failed to ensure a resident call light was within reach for one resident and failed to ensure call light cords were adequately cleaned for two residents. Observations revealed soiled call light cords and residents unable to reach their call lights. Staff interviews indicated confusion over cleaning responsibilities, and the facility lacked a specific policy for cleaning call light cords.
The facility failed to provide adequate toileting and repositioning assistance for a resident dependent on staff, and did not follow another resident's preference for getting out of bed due to a lack of Hoyer lift and sling availability. This led to residents sitting in soiled briefs for extended periods and increased the risk of infections and pressure sores. Staff reported a shortage of slings and Hoyer lifts, which impacted the care provided to residents.
Failure to Ensure Kitchen Staff Use Hair Restraints While Serving Food
Penalty
Summary
Kitchen staff failed to use appropriate hair restraints while serving food, as observed when a cook with a full head of hair and facial hair served food from a steam table without wearing a hair net or beard guard. The cook acknowledged forgetting to wear a hair net and was unfamiliar with the requirement for a beard guard. The culinary director confirmed that the expectation was for servers to wear both hair nets and beard guards when serving food, while the DON stated an expectation for hair nets but was not familiar with beard guard regulations. The facility was unable to provide a specific policy on hair restraints, only referencing a handbook statement that hairnets must be worn in kitchen areas. This deficiency had the potential to affect all residents receiving meals on the 2 South wing.
Failure to Monitor Skin Condition and Follow Up on Critical Lab Result
Penalty
Summary
The facility failed to comprehensively assess and monitor a skin condition for a resident who was at risk for skin breakdown due to multiple diagnoses, including diabetes and dementia. The resident had a history of rashes and was noted to have developed red spots on her chin, which were observed by staff but not promptly recognized or documented as a new skin concern. Nursing staff were unaware of the red areas until they were pointed out, and there was a lack of consistent monitoring and communication regarding the skin changes. The care plan included interventions for skin care and monitoring, but staff interviews revealed gaps in awareness and follow-through on these interventions. Additionally, the facility failed to ensure timely follow-up on a critical laboratory result for another resident with complex medical needs, including end-stage renal disease, anemia, and a bleeding disorder. The resident's lab results showed a critically low hemoglobin level, which was flagged as such on the report. Despite established protocols requiring immediate provider notification for critical labs, the nurse who reviewed the result did not contact the provider. Multiple staff interviews confirmed that the critical value was not communicated as required, and there was no documentation of provider notification in the progress notes. The facility's policies directed staff to notify providers of new skin concerns and critical lab results, but these procedures were not followed in the cases reviewed. Staff interviews indicated confusion or lack of awareness regarding the significance of the findings and the required actions. The director of nursing confirmed that the expected process was not followed in both cases, and documentation and communication lapses contributed to the deficiencies identified.
Failure to Provide Consistent Range of Motion Care and Use of Palm Protector
Penalty
Summary
The facility failed to ensure that range of motion (ROM) exercises and the use of a palm protector were consistently provided for two residents with limited ROM. One resident with severe cognitive impairment, hemiplegia, Parkinson’s disease, and contractures was dependent on staff for all activities of daily living and had clear care plan and physician orders for daily passive ROM and continuous use of a palmar hand guard. Despite these orders, observations revealed that the resident was often without the palm protector, and staff interviews confirmed that the device had not been seen or used for extended periods. Staff also failed to perform or document ROM during multiple care opportunities, and the resident’s care records indicated no restorative nursing minutes for ROM or splint/brace assistance. Staff were aware of the need for the palm protector and ROM but did not consistently implement these interventions, and the palm protector was found unused in a drawer during care observations. Another resident with a history of stroke, contractures, and impaired mobility was also not provided with a ROM program despite documented impairments and care plan interventions indicating the need for ROM to prevent further contracture. The resident’s care sheets and physician orders lacked any mention of a ROM program, and therapy evaluations over several years did not recommend or initiate a ROM program, nor did they document refusals until a recent assessment. Interviews with staff revealed a lack of awareness and documentation regarding the resident’s need for ROM, and the care plan lacked specific interventions or instructions for ROM. The resident expressed a desire for help with hand movement and did not have a splint or brace in place during observations. Throughout the review, staff interviews indicated reliance on care plans and task sheets to guide care, but these documents were incomplete or missing necessary instructions for ROM. There was also a lack of clear policy or standardized approach for ROM programs, with the facility stating that each program was individualized and based on therapy recommendations. The absence of consistent documentation, implementation, and monitoring of ROM interventions for residents with limited mobility led to the identified deficiencies.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
A resident who required pain management services did not receive safe and appropriate pain management. The report identifies a deficiency in the facility's provision of necessary pain management for a resident in need, but does not provide further details regarding the specific actions or omissions that led to this deficiency, nor does it include information about the resident's medical history or condition at the time.
Failure to Provide Safe and Appropriate Dialysis Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate dialysis care and services for a resident who required such services. The facility failed to ensure that the necessary dialysis care was provided in accordance with the resident's needs. Specific details about the actions or omissions that led to this deficiency, as well as the resident's medical history or condition at the time, are not provided in the report.
Failure to Implement Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to implement baseline care plans for three residents who required enhanced safety monitoring upon admission. Each resident's baseline care plan specified the need for 1:1 staff care and 15-minute safety checks due to cognitive concerns, recent surgeries, or a history of falls. However, observations, interviews, and record reviews revealed that these interventions were not carried out as documented. For example, one resident with a recent craniotomy and sepsis was admitted for rehabilitation and required close monitoring, but there was no documentation or evidence of 1:1 care or 15-minute checks, and the resident experienced a fall within hours of admission. Staff interviews indicated a lack of awareness and understanding regarding the care plan requirements. Nursing staff reported that 1:1 care and 15-minute checks were not feasible due to staffing limitations, and some staff were unaware that these interventions were listed in the care plans. Residents also reported that staff only entered their rooms for routine tasks such as delivering medications or meals, and not for the specified safety checks. Continuous observation confirmed that residents were not receiving the required monitoring, as staff did not enter their rooms at the prescribed intervals. Further interviews with facility leadership and staff revealed confusion about how the 1:1 care and 15-minute checks were included in the care plans. The Director of Nursing and Social Worker were uncertain about the origin of these interventions in the plans, and the Administrator stated that such checks were meant as examples rather than actual directives. The facility's policy required a baseline care plan to be implemented within 48 hours of admission to address immediate needs, but the documented interventions were not followed, leading to a failure to meet the residents' immediate safety needs as outlined in their care plans.
Failure to Document and Complete Required Neuro Checks After Resident Fall
Penalty
Summary
The facility failed to provide fundamental quality of care and adhere to professional standards of practice for one resident who experienced a fall. The resident, who had a complex medical history including glioblastoma with recent craniotomy revision, sepsis, and a diabetic wound, was admitted for rehabilitation and required close monitoring due to his high fall risk. Despite the baseline care plan indicating the need for safety monitoring, including 15-minute safety checks and a 1:1 staff-to-resident ratio, there was no documentation that these safety checks were performed. After the resident was found on the floor, the incident note did not specify what the resident was doing prior to the fall, where he fell from, or provide details of immediate or follow-up neurological checks. Following the fall, the facility's documentation was inconsistent and incomplete. Although the facility's policy required neuro checks if a head injury was suspected or confirmed, and ongoing monitoring for 72 hours post-fall, there was no evidence that these assessments were completed or documented in the resident's medical record. The electronic medical administration record (EMAR) indicated that neuro checks and post-fall monitoring were initiated several hours after the fall, rather than immediately as required. Staff interviews revealed confusion about the completion and documentation of neuro checks, with some staff stating they were done on hard copy sheets, but these could not be located during the survey. The nurse manager and administrator were unable to provide the requested documentation of neuro checks or clarify what post-fall assessments were performed. Family members expressed concern about the resident's condition following the fall, noting increased confusion, shortness of breath, and combative behavior. They reported that staff were not performing the expected neuro checks or responding promptly to call lights. The facility was unable to provide a policy specific to neuro checks and could not produce documentation to show that the required post-fall assessments and monitoring were completed according to facility policy. This lack of documentation and adherence to protocol constituted a failure to provide care in accordance with professional standards and the resident's care plan.
Failure to Include VP Shunt Management in Comprehensive Care Plan
Penalty
Summary
The facility failed to ensure that a comprehensive care plan addressed the presence of a ventriculoperitoneal (VP) shunt and included interventions for monitoring shunt malfunction for a resident with a history of traumatic brain injury, dementia, and a VP shunt. The resident's care plan did not mention the VP shunt or provide guidance on recognizing or responding to signs and symptoms of shunt malfunction, despite the resident having a documented diagnosis of mechanical complication of ventricular intracranial shunt and physician orders related to wound care at the shunt site. The care plan only addressed risks related to skin integrity and wandering, omitting any reference to the shunt or its management. Interviews with nursing staff and facility leadership revealed a lack of awareness and documentation regarding the resident's VP shunt. Staff were not initially informed of the shunt upon the resident's admission, and the care coordinator was unsure if the care plan included the shunt. The director of nursing acknowledged that a care plan for the VP shunt should have been in place, and the administrator confirmed that the absence of such a care plan would hinder appropriate nursing response to shunt-related complications. The facility's care planning policy required interventions to be based on comprehensive assessment, which was not followed in this case.
Failure to Uphold Resident Dignity
Penalty
Summary
The facility failed to provide care that promoted dignity for two residents, leading to dignity concerns. One resident, who was cognitively intact and frequently incontinent of bowel, was found by a family member with stool on his hands and legs while in the dining room, and his bed lacked sheets. This incident was corroborated by photographs taken by the family member. Interviews with a nursing assistant and a registered nurse confirmed that the resident would have been embarrassed by the situation, and other residents would not appreciate seeing stool on his hands. Another resident, also cognitively intact, expressed dissatisfaction with sleeping on a bed without sheets, which was confirmed by a nursing assistant and the resident herself. The social worker and the director of nursing acknowledged that residents should have sheets on their beds for comfort and hygiene if it was their preference. The facility's administrator confirmed that there were enough sheets available and that residents should have sheets on their beds if they preferred. Despite this, the facility did not have a specific policy related to dignity, although their general policy on residents' rights emphasized upholding these rights.
Failure to Adhere to NPO Orders for Resident
Penalty
Summary
The facility failed to ensure that a resident, who was supposed to remain nothing per oral (NPO) and receive nutrition via tube feeding, was properly managed according to hospital discharge orders. The resident, who had Parkinson's disease, hemiplegia, and severe cognitive impairment, was at risk for malnutrition and dehydration due to dysphagia. Despite the discharge orders indicating the resident should be NPO with continuous tube feeding, facility documentation showed that the resident received oral intake of food on multiple occasions between January 1 and January 27. Interviews with facility staff revealed a lack of awareness regarding the resident's NPO status. A licensed practical nurse (LPN) and a registered nurse (RN) both stated they were unaware of the NPO order after the resident's discharge from the hospital. The speech-language pathologist (SLP) also confirmed she was not informed of the NPO status and would not have approved oral intake without a swallow study. The nurse practitioner acknowledged that the NPO order was overlooked, and the resident was at high risk for aspiration. The director of nursing (DON) admitted that the facility had an ineffective process for checking and signing off on diet orders, as evidenced by the failure to sign off on the NPO order. The facility's policy on therapeutic diets required physician prescriptions to support the resident's treatment and plan of care, but there was no policy for reconciling physician orders. This oversight led to the resident receiving oral food intake contrary to the prescribed NPO status, potentially compromising the resident's health.
Failure to Implement Physician-Ordered Weight Monitoring
Penalty
Summary
The facility failed to implement physician-ordered weights for two residents, R3 and R4, as part of their nutritional care plans. R3, who had a history of malnutrition and was undergoing dialysis, had a physician order for daily weights to monitor fluid shifts. However, the Medication Administration Record (MAR) for October 2024 showed that weights were not recorded daily as ordered, with several days missing. Additionally, there were discrepancies in recorded weights, such as a significant drop from 120.3 pounds to 102 pounds in one day, which was not addressed or reweighed. The nurse manager and nursing assistants were unable to explain the missing weights or discrepancies, and the physician was not notified of the missed weights or significant changes. R4, who had diagnoses including traumatic brain injury and malnutrition, was ordered to have weekly weights due to significant weight loss and poor oral intake. The facility's records showed inconsistencies in the days weights were recorded, with some weights missing entirely. The care plan and provider orders were not followed, as evidenced by the lack of recorded weights on specified dates. Interviews with nursing staff revealed confusion about the correct days for weighing R4, with discrepancies between the shower sheet and group sheet used to guide staff. The facility's failure to adhere to physician orders for weight monitoring was acknowledged by the director of nursing, who noted that the weights obtained were not accurate due to improper equipment use. The facility's weight policy emphasized the importance of accurate and consistent weight monitoring, especially for residents at high risk of nutritional decline. However, the policy was not effectively implemented, leading to deficiencies in the care provided to R3 and R4.
Failure to Prevent Resident-to-Resident Abuse in Memory Care Unit
Penalty
Summary
The facility failed to protect residents from harm, specifically in a secure memory unit, where two residents were involved in an incident of resident-to-resident abuse. Resident R82, who had a history of aggressive behavior and dementia, struck Resident R17 in the face, resulting in a subconjunctival hemorrhage that required emergency medical attention. The incident occurred in R17's room, and it was reported that R82 had entered the room and struck R17 without provocation. R82's care plan and treatment administration record indicated a history of aggressive behaviors, including physical altercations with other residents. Despite this, the facility's documentation lacked daily records of R82's behaviors and the interventions implemented to manage them. R82's care plan included interventions such as redirecting the resident during periods of agitation, but these measures were not effectively preventing incidents of aggression. Additionally, R82's care plan had not been updated following a previous verbal altercation with R17, indicating a lack of proactive measures to prevent further incidents. R17's care plan identified him as a vulnerable adult with dementia, at risk for abuse and neglect. Despite this, there were no effective interventions in place to prevent altercations with other residents. R17's room was supposed to have a stop sign to deter other residents from entering, but it was often removed by R17 himself, and staff failed to ensure it was consistently in place. The facility's failure to update care plans and implement effective interventions contributed to the incident, highlighting a lack of adequate measures to protect residents from harm.
Failure to Promote Dignified Environment and Resident Engagement
Penalty
Summary
The facility failed to promote a dignified environment for several residents, as observed during a survey. One resident, identified as R108, who had severe cognitive impairment, was left waiting for breakfast in the dining room from 7:00 a.m. until 8:35 a.m. without any food, leading to restlessness and loudness among the residents. The staff's process of getting residents up early for convenience resulted in residents sitting idly in the dining room, with no interaction or engagement from the staff. The clinical coordinator acknowledged that the breakfast timing had changed, causing longer waiting periods, and suggested that residents could be entertained in the TV room to reduce the institutionalized feel. Additionally, the facility was found to have dignity concerns related to visible clothing labels. Resident R108 was observed wearing slippers with her first and last name visible on the outside, which was confirmed by the clinical coordinator and the laundry aide as a dignity issue. The expectation was for labels to be placed inside clothing to maintain residents' dignity, but this was not adhered to, affecting the residents' right to a dignified existence. Another resident, R49, who had moderate cognitive impairment and communication difficulties due to a stroke, was often left sitting alone in the dining room without any activities or entertainment. Despite his care plan indicating a preference for watching television, R49 was observed facing a wall and not offered assistance to join other residents watching TV. This lack of engagement and failure to assess and accommodate R49's preferences after meals was acknowledged by the nurse manager and the DON, who expressed that such inaction could lead to feelings of sadness for the resident.
Failure to Maintain Dignity with Uncovered Catheter Bag
Penalty
Summary
The facility failed to maintain a dignified and homelike environment for six residents, particularly concerning the management of a catheter bag for a resident with severe cognitive impairment. The resident, who had been admitted to the facility with multiple medical conditions including benign prostatic hyperplasia and urinary retention, was observed with an uncovered catheter bag hanging above the bladder level, which was visible to other residents and staff. Despite the care plan noting the resident's history of refusing to cover the catheter bag, there were no documented interventions or alternatives offered to address this refusal. Interviews with staff, including registered nurses and nursing assistants, confirmed that the uncovered catheter bag was not acceptable and should be covered for dignity and privacy. Other residents expressed discomfort and displeasure at having to see the uncovered catheter bag, especially during meal times. The Director of Nursing acknowledged the lack of guidance in the care plan for addressing the resident's refusal to cover the catheter bag and noted that discussions had occurred without documentation in the medical record. The facility's policy on dignity was requested but not provided.
Unattended and Unlocked Medication Cart Found in Dining Room
Penalty
Summary
The facility failed to ensure that medications were kept locked or under direct observation of authorized staff, which could potentially affect 32 current residents on the unit. During an observation, an unlocked medication cart was found at the entrance of the 2S dining room, where 12 residents were present, and numerous staff were walking past. A registered nurse (RN-C) noticed the unattended cart and locked it, acknowledging that the cart should be locked and the laptop closed for privacy. The licensed practical nurse (LPN-B) responsible for the cart admitted it was a violation to leave it unlocked. The director of nursing (DON) confirmed that medication carts should always be locked when unattended. The facility's policy on medication storage was requested but not provided.
Infection Control Deficiencies in Medication Administration and Meal Service
Penalty
Summary
The facility failed to adhere to infection control practices during medication administration through a gastrostomy tube for a resident with severe cognitive impairment and multiple diagnoses, including hemiplegia, stroke, and Parkinson's. The LPN administering the medication did not stop the enteral feeding 30 minutes prior as required and allowed the piston syringe to touch the resident's gown, risking contamination. The facility's policy mandates stopping the feeding at least 30 minutes before medication administration and ensuring the syringe does not contact the resident's clothing. The facility also failed to implement and maintain enhanced barrier precautions (EBP) for residents with conditions requiring such measures. One resident with diabetic foot ulcers and moisture-associated skin damage was not properly identified as needing EBP, leading to staff entering the room without appropriate PPE. Another resident on EBP due to enteral feeding was not provided with a PPE garbage can in the room, and staff exited the room without removing PPE, contrary to facility policy. Additionally, the facility did not ensure proper hand hygiene practices during meal service and assistance. Staff were observed delivering meal trays and assisting multiple residents with eating without performing hand hygiene between tasks, increasing the risk of cross-contamination. The facility's policy and CDC guidelines emphasize the importance of hand hygiene to prevent the spread of infections, especially when dealing with residents on enhanced barrier precautions.
Privacy Breach of Resident's Medical Records
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of a resident's medical records, specifically for one resident reviewed for privacy. During an observation, an unattended medication cart was found at the entrance of the second-floor dining room with a laptop open to the resident's medication list. The dining room was occupied by 12 residents and numerous staff members were passing by the cart. A registered nurse (RN) noticed the unattended cart and closed the laptop screen, acknowledging that the cart should be locked and the laptop closed to ensure privacy. The licensed practical nurse (LPN) responsible for the cart admitted it was a violation to leave the medical record visible and stated the laptop should be turned off in compliance with HIPAA regulations. The director of nursing (DON) confirmed that medication carts should always be locked and laptops turned off when staff are not present. The facility's policy, revised in 2019, states that residents have the right to personal privacy and confidentiality of their medical records.
Failure to Conduct Timely Care Conferences
Penalty
Summary
The facility failed to ensure timely person-centered care conferences for a resident, identified as R93, who was severely cognitively impaired and had multiple diagnoses including hemiplegia, stroke, depression, gastrostomy, and Parkinson's. The resident's electronic medical record (EMR) showed that while Minimum Data Set (MDS) assessments were completed regularly, care conferences were not conducted as expected. Specifically, care conferences were missing for several assessment dates, including 4/12/22, 7/22/22, 10/5/22, 6/9/23, and 12/28/23. Interviews with the Director of Nursing (DON) and the Social Services Director (SS-D) confirmed that care conferences should occur quarterly and with significant changes in status, but acknowledged that they were not conducted for a year for this resident. The facility's policy on care conference timing was requested but not provided.
Deficiencies in Personal Hygiene and Communication
Penalty
Summary
The facility failed to provide routine personal hygiene assistance to two residents, R28 and R56, as observed during the survey. R28, who was admitted to the facility in 2012 and had intact cognition, was found with black matter under her fingernails on multiple occasions. Despite the facility's policy that nurses and nursing assistants are responsible for nail care, R28 reported that no one asked to clean her nails, and the staff confirmed that nail care was not consistently provided. Similarly, R56, who required partial assistance for shaving, was observed with a half-inch facial beard, indicating a lack of regular shaving assistance. Although R56 expressed a preference for an electric razor and felt better after shaving, the staff did not consistently offer shaving assistance, which was supposed to be provided weekly on shower days. The facility also failed to implement an effective communication system for R93, a resident with severe cognitive impairment and a primary language of Vietnamese. Despite having a care plan that included using an interpreter phone line and a communication board, staff interviews revealed that these tools were not utilized. Nursing assistants and nurses admitted to relying on facial expressions and yes/no questions to communicate with R93, without using the interpreter line or communication board. The director of therapeutic services and a family member confirmed the availability of these resources, but they were not visible or included in the care plan for staff to use. The facility's policies on Activities of Daily Living and Interpreter Services were not adequately followed, leading to deficiencies in personal hygiene care and communication for the residents involved. The lack of adherence to these policies resulted in unmet needs for R28, R56, and R93, affecting their quality of life and dignity. The observations and interviews conducted during the survey highlighted these deficiencies, indicating a need for improved staff training and adherence to established care plans and policies.
Failure to Provide Individualized Activities for Residents
Penalty
Summary
The facility failed to ensure that a resident's preferred activities for individual entertainment were available, as evidenced by the case of a resident who was severely cognitively impaired and had multiple diagnoses including hemiplegia, stroke, depression, and Parkinson's. The resident's care plan included interventions for one-on-one activities, but records indicated that the resident was not provided or offered activities on several dates. Interviews with family and staff revealed that the resident enjoyed watching TV and sitting by a window, but these preferences were not accommodated, and the resident did not have a TV or radio in the room. Another resident in the transitional care unit, who was also severely cognitively impaired and dependent on staff for activities of daily living, reported feeling bored and lonely. Recommendations from a psychological assessment included strategies such as leaving the TV on, playing music, and providing one-on-one activities. However, the resident's electronic medical record lacked an initial therapeutic recreational evaluation, and observations showed the resident alone in the room without music or TV on. Staff interviews confirmed the resident's interest in activities like music and TV shows, but these preferences were not consistently met. The facility's therapeutic recreational director confirmed that all residents should be assessed at admission for social history and activities of interest, but this was not done for the transitional care unit resident. The director of nursing stated that the expectation was for comprehensive assessments to be conducted upon admission. Despite requests, the facility's policy on activities was not provided, indicating a lack of adherence to established procedures for ensuring residents' activity needs are met.
Deficiencies in Range of Motion and Mobility Care
Penalty
Summary
The facility failed to provide adequate care to maintain or improve the range of motion for a resident, R93, who was severely cognitively impaired and had conditions such as hemiplegia, stroke, depression, and Parkinson's. Despite having a care plan that included interventions for contractures and self-care deficits, the facility did not implement passive range of motion (PROM) exercises or appropriate contracture care. Observations revealed that R93's right hand was contracted with a rolled-up washcloth, and staff were unaware of the purpose of the washcloth or the need for PROM exercises. Interviews with staff, including nursing assistants and licensed practical nurses, confirmed a lack of awareness and documentation regarding the necessary care for R93's hand and PROM exercises. Additionally, the facility failed to maintain a walking program for another resident, R108, who had severe cognitive impairment but no physical impairments to her extremities. Despite physician orders and care plans directing staff to walk R108 to meals three times a day using a four-wheeled walker, observations showed that R108 was instead wheeled to meals in a wheelchair. Interviews with nursing assistants and the clinical coordinator confirmed that the care sheets were not being followed, and R108 was not being walked as required to maintain her mobility. The facility's policies on maintaining abilities and activities of daily living were not adhered to, as evidenced by the lack of implementation of PROM exercises for R93 and the failure to follow the walking program for R108. The director of nursing acknowledged the deficiencies in care and documentation, highlighting a systemic issue in ensuring that staff are informed and compliant with care plans and physician orders.
Inadequate Pain Management for Resident with Mobility-Related Pain
Penalty
Summary
The facility failed to ensure appropriate pain management for a resident, identified as R92, who experienced pain with mobility. Despite being on a scheduled pain medication regimen, R92 reported moderate pain, particularly during repositioning and transfers, which was not effectively managed. The resident's care plan included interventions for pain relief, but these were not adequately implemented or reassessed, as evidenced by the lack of non-pharmacological interventions and ineffective medication management. Observations and interviews revealed that R92 consistently reported pain, especially when being moved or repositioned, yet the facility staff did not comprehensively reassess or address these complaints. The resident's pain levels were recorded as zero in the Medication Administration Record, despite ongoing complaints of pain. Interviews with nursing staff indicated a lack of awareness and communication regarding the resident's pain with mobility, and the facility's pain management protocol was not followed as required. The facility's documentation and assessments were insufficient in capturing the resident's pain experience, particularly with mobility-related activities. The Director of Nursing acknowledged the oversight in monitoring and reassessing the resident's pain, highlighting a gap in the facility's adherence to its pain management policy. The failure to conduct a comprehensive evaluation and adjust the pain management plan accordingly contributed to the deficiency in providing adequate pain relief for the resident.
Inconsistent Monitoring of Dialysis Site
Penalty
Summary
The facility failed to ensure consistent monitoring and documentation of a resident's post-dialysis access site, which is crucial for continuity of care and reducing the risk of complications such as bleeding and infection. The resident, who had moderate cognitive impairment and required dialysis due to kidney disease, had a central venous catheter (CVC) placed on the left chest after the closure of a fistula on the right upper extremity. Despite the presence of orders to monitor the dialysis site for signs of infection and bleeding, these assessments were not consistently documented in the treatment administration record. Interviews with nursing staff revealed a lack of clarity and communication regarding the monitoring of the resident's dialysis catheter. A registered nurse acknowledged the absence of an order for monitoring the CVC, which could lead to confusion for new staff members. The nurse manager and director of nursing both emphasized the importance of daily assessments for infection and bleeding, yet the administration record did not reflect these checks. Additionally, a licensed practical nurse responsible for the resident's care was initially unaware of the exact location of the dialysis site, further highlighting the inconsistency in monitoring practices.
Failure to Address PTSD Triggers in Resident Care Plan
Penalty
Summary
The facility failed to comprehensively assess and implement care plan interventions for a resident with a history of post-traumatic stress disorder (PTSD). The resident, who was admitted to the facility with diagnoses including PTSD, had a care plan that mentioned the need for trauma-informed care but lacked specific triggers to avoid re-traumatization. Interviews with the resident revealed that she had not been asked about her PTSD, and she identified triggers such as harsh tones and yelling, which were not documented in her care plan or nursing assistant care sheets. Staff interviews, including those with nursing assistants and registered nurses, confirmed that the care sheets did not list PTSD or the resident's triggers, which they expected to be included for proper care. The Director of Nursing acknowledged that the care plan was generic and not patient-specific, lacking the necessary details to prevent re-traumatization. The social worker director also confirmed that the care plan interventions did not identify the resident's triggers, despite the facility's policy requiring such information to be included for residents with a history of trauma.
Failure to Address Medication Regimen Review for Psychotropic Use
Penalty
Summary
The facility failed to address and respond to the consulting pharmacist's medication regimen review (MRR) for two residents receiving psychotropic medications. For one resident, the MRR indicated uncertainty about whether the resident's falls were related to their medication and recommended reducing the dosage of Hydroxyzine. Despite multiple falls and the presence of medications that could increase fall risk, the electronic medical record lacked evidence of physician or prescriber response or follow-up. The resident's care plan documented several falls, but no action was taken based on the pharmacist's recommendations. For another resident, the MRR noted that the use of Seroquel lacked an appropriate diagnosis, as the resident's dementia did not include psychotic features. The resident's medical record indicated a diagnosis of schizophrenia, which was not documented, and there was no evidence of provider follow-up or response regarding the necessity of antipsychotic use. The facility's process for handling MRRs was ineffective, with reports being misplaced due to staff turnover, leading to missed follow-ups. The facility's policy required MRR recommendations to be documented and acted upon, but this was not adhered to in these cases.
Inadequate Monitoring and Diagnosis for Antipsychotic Use
Penalty
Summary
The facility failed to ensure that a resident taking an antipsychotic medication had an appropriate diagnosis for its use and was monitored for target behaviors. The resident, who had severe cognitive impairment and was independent with ambulation, was receiving antipsychotics and antidepressants. The medical record review indicated that the resident was prescribed Seroquel without an appropriate diagnosis, as the diagnosis of dementia with behavioral disturbances lacked psychotic features. Additionally, the resident's electronic medical record did not contain evidence of specific target behaviors or monitoring for behaviors, which is crucial for assessing the effectiveness of antipsychotic medication. The facility's process for handling medication regimen reviews (MRR) was ineffective, as highlighted by the clinical coordinator and LPN, who noted that the MRRs were not being properly addressed. The director of nursing acknowledged that the MRR process was flawed due to turnover in the health unit coordinator position, leading to MRR forms being misplaced and follow-up actions being missed. Despite attempts to contact the consultant pharmacist, there was no response, further complicating the situation. The facility's policy on psychotropic medication use emphasized the necessity of these medications for specific conditions, but the interdisciplinary team failed to gather and document the required information to clarify the resident's behavior and symptoms.
Failure to Implement Pneumococcal Vaccination Standards
Penalty
Summary
The facility failed to implement the current standards of vaccinations regarding pneumonia for a resident over the age of 65. The resident's immunization record indicated that they had received the PPSV23 vaccine in 2013 and the PCV13 vaccine in 2016. However, there was no evidence in the immunization record of any other pneumococcal vaccinations being offered, refused, or completed. Additionally, the resident's Care Conference Form, which should have addressed immunizations, was incomplete, lacking any information about the resident's pneumococcal vaccination status. The Director of Nursing (DON), who also serves as the infection preventionist, confirmed that she oversees immunizations and that nurse managers are responsible for reviewing and determining the necessary immunizations for residents. The DON verified the resident's eligibility for the PCV20 vaccine and acknowledged that the nurse manager had lost the list of residents needing the vaccine. Although the nurse manager eventually contacted the resident's guardian for approval to administer the PCV20, the delay in offering the vaccine indicates a lapse in following the facility's policy to offer pneumococcal vaccines according to the guidelines set by the Advisory Committee on Immunization Practices (ACIP), CDC, and the state Department of Health.
Failure to Repair Broken Closet Door in Resident's Room
Penalty
Summary
The facility failed to ensure timely repair of a broken closet door in a resident's room, compromising the safety and homelike environment. The closet door was observed to be in disrepair, with the door and frame pulled away from the wall, exposing multiple construction nails. The resident, who had intact cognition and was mostly bed-bound, reported that the closet had been broken for a couple of weeks and expressed fear that the door might fall onto his bed. Despite the resident's request for a work order to be completed, no action was taken, and the issue was not reported to maintenance staff. During the survey, a nursing assistant observed the disrepair and attempted to move the door, which then fell off completely. The director of maintenance confirmed that no work order had been submitted, and maintenance staff were unaware of the issue until the survey. The director noted that the door required multiple staff members to repair and emphasized the safety risk posed by the disrepair. A work order was finally created during the survey, but there was no evidence of prior notification or action taken to address the broken door.
Failure to Ensure Call Light Accessibility and Cleanliness
Penalty
Summary
The facility failed to ensure a resident call light was within reach for one resident and failed to ensure call light cords were adequately cleaned for two residents. Resident 3, who was cognitively intact but dependent on staff for various activities and had visual impairment, was observed unable to reach their call light, which was soiled with a crusty brownish substance. Resident 3 stated that staff seldom placed the call light within reach and that the cord was never cleaned. Similarly, Resident 1, who was also cognitively intact and dependent on staff, was observed with a call light cord covered in brown crusted smears and spots. Resident 1 expressed discomfort with the dirty cord but had become accustomed to it. Interviews with staff revealed inconsistencies in the cleaning responsibilities for call light cords. Registered nurses and housekeeping staff had conflicting understandings of who was responsible for cleaning the cords. The Director of Nursing confirmed that staff were expected to ensure call lights were within reach and clean to prevent infection. The facility's Call Light Policy required call cords to be within reach of each resident, but there was no specific policy for cleaning the cords. The administrator confirmed the absence of a cleaning policy for call light cords.
Failure to Provide Adequate Toileting and Repositioning Assistance Due to Equipment Shortage
Penalty
Summary
The facility failed to provide adequate toileting and repositioning assistance for a resident (R3) who was dependent on staff for these activities. R3, who had multiple medical conditions including morbid obesity and chronic pain, was observed to have not had their incontinence brief changed for several hours, despite being dependent on staff for toileting and repositioning. R3 reported that they were only allowed to get out of bed once per day and were left in bed for the rest of the day if they were put back to be changed. This led to R3 sitting in a soiled brief for extended periods, increasing the risk of infections and pressure sores. The facility also failed to follow R3's care plan, which required turning and repositioning every 2-3 hours and using a Hoyer lift with a large bariatric sling for transfers. The facility also failed to follow another resident's (R1) preference for getting out of bed due to a lack of Hoyer lift and sling availability. R1, who had multiple medical conditions including super morbid obesity and a history of pressure ulcers, was observed to have not had their incontinence brief changed since the previous night and was unable to get out of bed at their preferred time. Staff reported that there were not enough slings or Hoyer lifts in the facility, leading to delays in getting residents out of bed and providing necessary care. R1 expressed frustration with the wait times and reported that they often had to sit in a soiled brief due to the delays. Interviews with staff revealed that the facility had a shortage of slings, particularly for bariatric residents, and that this shortage was exacerbated by slings not being returned from the hospital when residents were transferred. Staff also reported that the facility had only one functional Hoyer lift on the floor, which was insufficient to meet the needs of all the residents requiring mechanical lift transfers. The director of nursing and the administrator acknowledged the shortage of slings and the impact it had on resident care, but stated that they had ordered replacements, which had not yet arrived.
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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