The Estates At Twin Rivers Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Anoka, Minnesota.
- Location
- 305 Fremont Street, Anoka, Minnesota 55303
- CMS Provider Number
- 245298
- Inspections on file
- 31
- Latest survey
- March 27, 2026
- Citations (last 12 mo.)
- 2 (1 serious)
Citation history
Health deficiencies cited at The Estates At Twin Rivers Llc during CMS and state inspections, most recent first.
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 nephrostomy tubes was observed with a urinary leg bag dragging on the floor and being rolled over by a wheelchair due to improper securing and lack of suitable straps. Staff and care plans lacked clear instructions for managing and securing the bag, and facility policy did not address this issue. Additionally, the facility did not maintain ongoing surveillance or tracking of symptomatic illnesses among residents not on antibiotics, relying instead on informal mental notes by the DON, with no formal process for monitoring or trending symptoms.
The facility did not consistently date or properly store fresh and frozen food items, failed to remove expired products, and did not reliably monitor or document freezer and food temperatures. Staff were observed not fully using hair nets or beard restraints as required, and food temperature checks before serving were often missing or incomplete. Facility policies lacked clear guidance on use-by dates and temperature monitoring, contributing to these deficiencies.
Surveyors found that eight double-occupancy rooms did not meet the required 80 square feet per resident, with affected rooms providing only 75 to 76.25 square feet per person. The facility administrator confirmed the deficiency and provided documentation of waivers for these rooms. Residents interviewed did not express concerns about room size.
Multiple insulin pens and inhalers on the TCU medication cart were found without open or expiration dates. An LPN confirmed the absence of required labeling and was unable to determine how long the medications were good for after opening. The DON stated that medications should be labeled with both open and expiration dates, but no facility policy was provided when requested.
Several residents reported that meals were frequently served late, not consistently hot, and lacked variety in alternate options. Observations confirmed delays in meal service, incomplete food temperature logs, and inconsistent adherence to facility policies regarding meal timing and temperature monitoring. Staff interviews acknowledged these issues, and residents expressed dissatisfaction with meal quality, quantity, and wait times.
A resident with nephrostomy tubes and moderate cognitive impairment was observed with a urinary leg bag dragging on the floor due to ineffective securing methods and lack of clear care plan instructions. Staff interviews revealed that the provided straps were inadequate, and facility policies did not address proper management or securing of urinary drainage bags, resulting in a failure to maintain the resident's dignity.
A resident with impaired cognition and multiple diagnoses was administered psychotropic medications, including lorazepam and risperidone, without documented informed consent from the responsible party. Despite facility policy requiring consent and education on medication use and changes, the necessary documentation was not found in the medical record, as confirmed by the DON.
A resident with mobility limitations and a self-care deficit did not receive regular changes of soiled bed linens, despite remaining in bed for meals and expressing frustration about the lack of hygiene. Staff interviews confirmed that linens should be changed on bath days and when soiled, but this was not done. Facility policies lacked specific guidance on maintaining clean linens, and no policy for bed linen changes was provided when requested.
A resident with moderate cognitive impairment and multiple medical conditions was admitted without a completed baseline care plan within 48 hours. Key sections such as communication, nutrition, and diabetes management were left blank, and specific interventions for the resident's needs were not documented. The DON confirmed the care plan was not completed as required, resulting in insufficient guidance for staff to address the resident's immediate care needs.
A resident with multiple complex medical conditions and impaired cognition did not have their hospice plan of care integrated with the facility care plan. Staff were unaware of the hospice visit schedule, documentation of hospice visits was incomplete, and the hospice care plan was not available in the medical record, resulting in a lack of coordination between hospice and facility care.
A resident with left-sided weakness and a self-care deficit did not consistently receive required range of motion (ROM) exercises as directed by their care plan. Documentation showed that ROM was rarely performed, and staff interviews confirmed that these exercises were often deprioritized in favor of other tasks. The resident reported that staff did not assist with ROM, and a visitor was observed providing the exercises instead. Nursing leadership acknowledged the lack of consistent ROM care upon review.
A resident with multiple medical conditions and a history of falls experienced a significant fall with injury during therapy. Despite facility policy requiring incident review and root cause analysis after such events, staff did not complete the necessary documentation or analysis to determine contributing factors or implement interventions to prevent recurrence. This resulted in a deficiency related to inadequate assessment and follow-up after an accident.
A resident with cognitive impairment and multiple medical conditions was prescribed risperidone for agitation and delirium, but the facility did not complete required baseline and ongoing AIMS evaluations to monitor for tardive dyskinesia. The DON confirmed that the necessary assessments were not performed until after surveyors requested documentation, contrary to facility policy.
A resident with multiple medical conditions did not have her preferences for bathing and meal choices honored by staff. She experienced delays in receiving a shower and hair wash, despite repeated requests, and was not provided with menus or consistent access to preferred meal items such as sugar, cream, and straws. Staff were unclear about restrictions related to her surgical incisions and about the process for accommodating meal preferences, resulting in unmet needs and lack of support for resident self-determination.
A resident with multiple medical conditions and recent surgery required assistance with ADLs and had specific preferences for bathing and dressing. The care plan and care sheets did not include updated interventions from therapy, such as use of an EZ stand for transfers or instructions for wheelchair positioning, nor did they specify the resident's preferences for bathing and hair washing. Staff expressed uncertainty about how to manage the resident's spastic rigidity, and the resident reported that staff did not allow enough time during transfers. The care plan was not revised to reflect these needs and preferences, resulting in unclear guidance for staff.
A resident with multiple sclerosis and recent surgery did not receive routine bathing assistance for several weeks, despite requiring help with ADLs and expressing a preference for showers to wash her hair. Staff scheduled baths weekly by room assignment and did not accommodate the resident's requests for a shower outside the assigned schedule. No medical orders restricting bathing were found, and documentation showed repeated lack of bathing assistance until a shower was finally provided after about three weeks.
The facility did not ensure that all required recertification and complaint investigation survey results, including those with cited deficiencies, were available for review by residents, families, staff, and visitors. Only a portion of the necessary documents were present in the designated folder, despite the administrator's awareness of the requirement to make all 2567 forms accessible.
A resident with a history of stroke and noncompliance with the smoking policy did not have an individualized care plan addressing smoking restrictions and supervision. Key information about the resident's smoking plan and safety checks was missing from care sheets used by staff, leading to inconsistent awareness and communication among staff members regarding the resident's needs and restrictions.
A resident with a history of stroke and requiring assistance for mobility was repeatedly found smoking unsupervised in his room, despite a care plan restricting smoking to supervised situations only. Facility care sheets lacked information on the resident's smoking restrictions, and some staff were unaware of his unsafe smoking practices or the need for supervision, leading to multiple incidents of unsupervised smoking and failure to prevent accident hazards.
A resident did not receive prescribed diltiazem for five days due to a pharmacy error, and the facility failed to notify the physician. The resident, with chronic atrial fibrillation, experienced an unresponsive episode potentially linked to the medication lapse. Facility staff were unaware of the error, and the required protocol to report medication errors was not followed.
Two residents in a facility experienced significant health issues due to the failure to administer prescribed medication and maintain oxygen supply. One resident with atrial fibrillation did not receive diltiazem due to a pharmacy error and lack of staff communication, resulting in an unresponsive episode and increased blood pressure. Another resident with COPD was found with an empty oxygen tank, leading to low oxygen saturation and requiring emergency medical intervention. Staff interviews revealed a lack of awareness and communication regarding these deficiencies.
A resident with type two diabetes mellitus experienced multiple instances of low blood sugar levels, but the facility failed to notify the physician as required. Despite the care plan's directive to inform the provider of blood sugar levels below 75 mg/dl, staff did not communicate these critical changes. Interviews revealed miscommunication and assumptions among staff, leading to a lack of timely notification.
A resident with dysphagia and identified as a choking risk was left unsupervised during meals, contrary to their care plan requiring 1:1 supervision. The resident was observed eating alone, leading to coughing episodes, while staff acknowledged being aware of the supervision requirement but cited being busy as the reason for non-compliance.
A resident with impaired cognition and mobility was left in bed for over six hours without being repositioned or having their incontinent brief changed, contrary to their care plan. Staff admitted to being behind schedule, and the resident's room had a strong smell of urine. The facility's policy on individualized care was not followed, resulting in a deficiency.
A resident with impaired cognition and incontinence was not repositioned or had her incontinent brief changed as per her care plan, leading to a deficiency in care. Observations showed the resident remained in the same position for over six hours, with a saturated brief and urine-stained bed. Staff admitted to being behind schedule and failing to provide timely care, while facility policies emphasized person-centered care.
A resident with a PICC line did not receive proper IV medication administration due to an LPN's failure to verify line placement and cleanse the line before use. The LPN, who was agency staff, did not receive specific IV education from the facility and relied on nursing school training. The facility lacked documentation of the LPN's orientation and skills training.
The facility failed to ensure RN coverage for eight consecutive hours on multiple dates, potentially affecting all 30 residents. Staffing schedules showed gaps in RN coverage, and interviews confirmed the issue was due to call-ins. The facility now schedules two RNs for open shifts to address this problem.
The facility failed to provide the required 80 square feet of floor space per resident in eight rooms, affecting nine residents. Although most residents did not have roommates and expressed no concerns, the rooms did not meet the regulatory minimum square footage requirement.
A facility failed to ensure a resident was comprehensively assessed for self-administration of medications. Despite a CNP order to leave melatonin and trazodone at the resident's bedside, the order lacked parameters, and the resident's EHR did not include an assessment for self-administration. Interviews revealed that the necessary assessment was not completed, and the facility's policy requiring interdisciplinary team approval and documentation was not followed.
A facility failed to install bed rails for a resident who had been assessed and had orders for them to assist with repositioning and pain management. Despite the resident's repeated requests and proper documentation, the bed rails were not installed after the resident moved to a new room. Observations and staff interviews confirmed the deficiency.
The facility failed to ensure proper storage, labeling, and dating of food items. Surveyors found improperly stored frozen pork sausage and green onions, undated food items in dry storage and the refrigerator, and items requiring refrigeration stored at room temperature. Personal items and cleaning products were also found inappropriately stored in the kitchen. The culinary director acknowledged these issues and the need for proper food handling practices.
The facility failed to maintain sanitary conditions in the kitchen, affecting all 36 residents who ate food prepared there. Observations included a thick brown substance on various surfaces, dark gray and brown fuzz on vents, and peeling ceiling material. The Culinary Director acknowledged the need for a deep clean and stated the ceiling had been in poor condition for a long time.
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 Secure Urinary Leg Bags and Lack of Infection Surveillance
Penalty
Summary
The facility failed to ensure that a resident's urinary leg bags were effectively secured, resulting in the leg bag dragging on the floor and being rolled over by the resident's wheelchair. The resident, who had moderate cognitive impairment and multiple medical conditions including nephrostomy tubes, was observed with the urinary leg bag on the floor, and staff did not immediately secure it. Staff interviews revealed that the straps provided for securing the leg bag were not suitable, and alternative straps had not been made available, leading to improper securing of the bag. The care plan and CNA work list lacked specific instructions for the management and securing of nephrostomy bags, and the facility's policy did not address proper placement or securing of urinary drainage bags. Additionally, the facility did not conduct ongoing surveillance for infection control to track and trend symptomatic illnesses among residents who were not on antibiotics. The DON, who also served as the infection preventionist, relied on mental notes from reviewing progress notes rather than maintaining a written list or using a formal process to monitor symptomatic residents. There was no system in place to track or trend symptoms, and staff illnesses were not regularly discussed or compared with resident illnesses to identify potential outbreaks. Facility policies referenced the use of surveillance tools for infection control, but in practice, these tools were not utilized to record or monitor infections, symptomatic illnesses, or staff illnesses. The lack of documentation and formal tracking limited the facility's ability to recognize and respond to infection trends, potentially affecting all residents in the facility.
Deficiencies in Food Storage, Temperature Monitoring, and Staff Hygiene
Penalty
Summary
The facility failed to consistently follow proper food storage, labeling, and dating procedures for both fresh and frozen items. During inspection, multiple food items in the refrigerator were found to be either undated, improperly wrapped, or stored beyond acceptable use-by dates. Items such as bacon, cheese, butter, black olives, ham, bologna, sausage, onions, and sour cream were either not dated, dated incorrectly, or kept past the recommended seven-day period. In the freezer, ham and vegetables were found with excessive ice crystals, indicating possible improper cooling or prolonged storage, and a bag of chili sauce was found thawed despite being in the freezer. Facility policies lacked clear definitions for use-by dates, contributing to inconsistent practices among staff. The facility also failed to maintain consistent monitoring and documentation of freezer temperatures. Temperature logs for one freezer showed several instances where the temperature exceeded the required threshold of zero degrees Fahrenheit, with no evidence of follow-up or corrective action. Additionally, there were gaps in temperature monitoring, with several dates missing afternoon temperature checks. Staff were unaware of these temperature deviations, and the required documentation of actions taken in response to out-of-range temperatures was not present, despite policy requirements. Food safety practices related to personal hygiene were not consistently implemented. Staff, including the culinary director and dietary assistants, were observed wearing hair nets that did not fully contain their hair, and one staff member with facial hair was not wearing a beard restraint. The facility lacked beard nets at the time of observation. Furthermore, food temperature monitoring before serving meals was inconsistently documented, with several meals lacking recorded temperatures. Policies required food temperatures to be checked and logged prior to serving, but this was not consistently done, and the policies themselves lacked clear guidance on timing and parameters for temperature checks.
Failure to Meet Minimum Room Size Requirements for Double Occupancy
Penalty
Summary
The facility failed to provide the required minimum floor space of 80 square feet per resident in eight of its double-occupancy rooms, affecting seven current residents. During the survey, it was observed and confirmed through document review and interviews that these rooms measured between 150 and 152.5 square feet, resulting in only 75 to 76.25 square feet per resident. The administrator acknowledged that these rooms did not meet the regulatory requirements and stated that waivers were in place for the affected rooms. A list of rooms with waivers, including their measurements and square footage, was provided by the administrator. Interviews with residents and the administrator further confirmed the ongoing use of these rooms for double occupancy, depending on census needs. One resident reported not having a roommate at the time but indicated that neither she nor her previous roommates had issues with the room size or its functionality. The deficiency was identified through direct observation, interviews, and review of facility documentation, which collectively demonstrated that the facility was not meeting the required space standards for resident rooms.
Failure to Label Multi-Use Medications with Open and Expiration Dates
Penalty
Summary
Surveyors observed that multiple insulin dial-up pens and inhalers on the transitional care unit (TCU) medication cart were not labeled with open dates or expiration dates. During the review, an LPN confirmed that these medications lacked the required labeling and was unable to state when the medications were opened or how long they remained effective after opening. The LPN also did not know the appropriate duration for use of opened insulins or inhalers and indicated the need to consult a supervisor. The director of nursing stated that the facility's expectation was for medications to be labeled with both open and expiration dates to ensure staff were aware of their usability. No facility policy on dating and disposal of multi-use medications was provided when requested.
Failure to Provide Palatable, Timely, and Properly Tempered Meals
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, at a pleasing temperature, and provided in a timely manner, as evidenced by observations, interviews, and document reviews involving four residents. Residents reported that meals were often not warm, with one resident specifically stating that the food was never hot and the coffee was cold. Another resident noted that meal trays were consistently late and that there were no ready alternatives to the main entrée, requiring the culinary director to prepare an alternate protein on the spot. Additional concerns included the lack of variety in alternate meal options and inconsistent food temperatures, with some residents stating they did not request reheating when food was not at the desired temperature. Observations during meal service revealed delays in the start of meal distribution, with meals being served up to 25 minutes after the scheduled mealtime. On multiple occasions, beverages were served before the meal, and the steam table with hot food arrived late to the serving area. Documentation review showed that food temperature logs were incomplete, with no temperatures recorded for several days and missing entries for multiple meals in the preceding weeks. The culinary staff admitted to not consistently recording food temperatures as required. Interviews with the Regional Culinary Director and Registered Dietitian confirmed that food temperatures should be checked before each meal and that delays in meal service had occurred. Facility policies required meals to be served within 45 minutes of the scheduled time and for food temperatures to be monitored throughout service, but these procedures were not consistently followed. Residents also expressed concerns about the quality and quantity of meals, as well as extended wait times for food.
Failure to Maintain Dignity and Proper Management of Urinary Leg Bags
Penalty
Summary
The facility failed to implement appropriate interventions to maintain a dignified appearance for a resident with indwelling nephrostomy tubes and urinary leg bags. The resident, who had moderate cognitive impairment and required assistance with activities of daily living, was observed with a urinary leg bag dragging on the floor as he self-propelled his wheelchair. Staff were aware of the issue but did not immediately secure the bag, and the care plan lacked specific instructions for managing and securing the nephrostomy bags. Certified nursing assistants reported that the straps provided for securing the bags were too large and ineffective, resulting in the bags sliding down and sometimes being visible or on the floor. Interviews with staff, including a CNA, LPN, clinical coordinator, and DON, confirmed that the leg bags were not being properly secured due to inadequate equipment and lack of clear guidance in the care plan and work lists. The facility's policy on indwelling catheter care did not address the management or securing of urinary drainage bags to ensure privacy and dignity. The deficiency was identified through observation, interview, and document review, highlighting the facility's failure to maintain the resident's dignity and prevent potential infection control issues.
Failure to Obtain Informed Consent for Psychotropic Medication Use
Penalty
Summary
The facility failed to obtain proper informed consent for the use of psychotropic medications for one resident with impaired cognition and multiple complex medical diagnoses, including dementia, encephalopathy, anxiety, depression, and visual hallucinations. The resident required assistance with activities of daily living and was prescribed lorazepam and risperidone for agitation, anxiety, and delirium. Record review showed that lorazepam was administered multiple times with documented effectiveness, and risperidone was started and administered according to the medication administration record. However, there was no documentation in the medical record that informed consent had been obtained from the resident's responsible party upon admission or when changes were made to medication dosing or frequency. Interviews with the DON confirmed that informed consent for psychotropic medications is expected to be completed within the first week of admission and updated with any new medications or changes in dosage. Despite this policy, the required documentation for informed consent for both lorazepam and risperidone could not be located in the resident's medical record or uploaded files. The facility's own policy mandates obtaining and documenting informed consent, including education on medication indications, side effects, risks, and benefits, as well as notification of dose changes, but these steps were not followed in this case.
Failure to Provide Clean Bed Linens and Maintain Resident Hygiene
Penalty
Summary
A resident with multiple sclerosis, malnutrition, and a self-care deficit related to post-surgical status required assistance with activities of daily living (ADLs), including dressing, grooming, bathing, mobility, and incontinence care. The resident remained in bed for meals due to mobility concerns and expressed frustration about not receiving a bath or a change of bed linens since admission. Observations revealed that the resident's bed linens were visibly soiled with crumbs and coffee stains, and the bottom sheet was not properly fitted. Despite the resident receiving a shower and hair wash, the same soiled linens were placed back on the bed without being changed. Interviews with staff confirmed that linens should be changed on bath days and as needed if soiled, but this was not done for the resident in question. The facility's policy on ADLs emphasized person-centered care and quality of life but did not include specific guidance on maintaining a clean, hygienic environment or the provision of fresh bath and bed linens. Additionally, when requested, the facility was unable to provide a policy specifically addressing the change of bed linens.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to ensure that a baseline care plan was developed and implemented within 48 hours of admission for a resident with significant care needs. The resident, who had moderate cognitive impairment and functional limitations due to left-sided weakness following a cerebral infarction, required assistance with activities of daily living such as dressing, grooming, bathing, and mobility. The resident's medical history included cerebral infarction, heart failure, hypertension, diabetes, muscle weakness, and unsteady gait. Despite these complex needs, the 48-hour baseline care plan was not completed in a timely manner and lacked critical information and specific interventions. Upon review, several sections of the baseline care plan were left blank, including communication, nutrition, psychotropic medication use, respiratory, skin, hospice, dialysis, smoking, and enhanced barrier precautions. The care plan did not address the resident's diagnosis of type 2 diabetes, nutritional needs, insulin administration, or provide instructions for monitoring blood sugars and signs of hyper- or hypoglycemia. Additionally, while the resident was identified as having visual impairment, the care plan only referenced this in relation to fall risk and did not include specific goals or interventions for the impairment itself. The director of nursing confirmed during an interview that the baseline care plan was not completed within the required 48-hour timeframe and acknowledged its importance in directing staff on the care needed. The lack of a completed and comprehensive baseline care plan resulted in inadequate direction for staff to address the resident's immediate and ongoing care needs upon admission.
Failure to Integrate Hospice Plan of Care with Facility Care Plan
Penalty
Summary
The facility failed to ensure that the hospice plan of care was integrated with the facility care plan for a resident receiving hospice services. The resident, who had impaired cognition and multiple complex medical diagnoses including cancer, atrial fibrillation, hypertension, arthritis, dementia, anxiety, depression, and chronic pain, required assistance with activities of daily living. The care plan indicated the need for communication and coordination with hospice, including maintaining contact, informing hospice of changes in condition, and involving hospice in care conferences. However, upon review, the hospice plan of care was not found in the resident's medical record, and only hospice encounter notes were present. Staff were unaware of the hospice visit schedule, and documentation of hospice visits was incomplete, with missing entries for several months. Interviews with facility staff revealed a lack of awareness regarding the frequency and scheduling of hospice visits, as well as the location of the hospice care plan in the medical record. The director of nursing confirmed that the hospice care plan was not available for review, and the social worker stated that hospice was invited to care conferences but did not have information on visit schedules. The facility's agreement with the hospice provider required coordination and periodic review of the hospice plan of care, but this was not demonstrated in practice, leading to a deficiency in integrating hospice services with the facility's care planning process.
Failure to Provide Routine Range of Motion (ROM) Care
Penalty
Summary
A deficiency was identified when staff failed to provide routine assistance with range of motion (ROM) exercises to a resident with left-sided weakness and a self-care deficit. The resident's care plan, which was updated to reflect fall risk and impaired vision, directed staff to follow physical and occupational therapy instructions and to provide ROM to the left upper extremity as ordered. Documentation and care sheets indicated that ROM was to be performed daily, with specific instructions posted in the resident's room for staff reference. Despite these directives, a review of task documentation over a one-month period showed that ROM was not performed on most days, with only three days showing partial completion. Interviews with staff revealed that ROM exercises were rarely completed, as staff prioritized other tasks such as feeding and showers. The resident confirmed that therapy had stopped and that staff were not performing the exercises, relying instead on a visitor to assist with ROM when present. Further interviews with nursing staff and the DON confirmed that ROM was not consistently completed as required by the care plan and facility policy. The facility's policy on activities of daily living emphasized maintaining residents' abilities but did not provide specific procedures for ROM, and staff were unaware of the lack of consistent ROM care until it was brought to their attention during the survey.
Failure to Analyze and Document Fall with Injury
Penalty
Summary
The facility failed to assess and analyze a fall with significant injury for one resident who was identified as a fall risk. The resident had a history of falls, multiple medical diagnoses including anemia, coronary artery disease, hypertension, diabetes, muscle weakness, and peripheral autonomic neuropathy, and required assistance with activities of daily living. The care plan identified the resident as impulsive at times and directed staff to monitor safety, review past falls, determine causes, and educate the resident and family about fall risks. Despite these measures, the resident experienced a fall during therapy, resulting in a cut under the left eye and a head injury that required hospital evaluation. Following the incident, documentation in the medical record indicated that the fall occurred with therapy and resulted in facial injuries, but there was no evidence that a formal fall analysis or root cause investigation was completed. The narrative notes lacked details regarding the circumstances of the fall, contributing factors, or any analysis to determine interventions to prevent recurrence. Interviews with facility staff, including the clinical coordinator and director of nursing, confirmed that required risk management and incident review documents were not completed as per facility policy. The facility's fall prevention and management policy required staff to complete an incident review and analysis after a fall, including clarifying the details of the incident and identifying possible causes. However, in this case, the required documentation and analysis were not performed, and there was no evidence that the effectiveness of interventions was monitored or documented following the fall. This failure to follow established protocols resulted in a deficiency related to the facility's responsibility to assess and analyze accidents to prevent future occurrences.
Failure to Monitor for Tardive Dyskinesia in Resident Receiving Antipsychotics
Penalty
Summary
The facility failed to ensure adequate monitoring for tardive dyskinesia (TD) in a resident who was prescribed antipsychotic medication. The resident, who had impaired cognition and multiple medical diagnoses including dementia, encephalopathy, and behavioral disturbances, was receiving risperidone for agitation and delirium. The care plan directed staff to follow mental health provider recommendations but did not include baseline monitoring for side effects of antipsychotic medication. Review of the resident's medical record showed no evidence that an Abnormal Involuntary Movement Scale (AIMS) evaluation had been completed prior to the surveyors' request. The Medication Administration Record confirmed ongoing administration of risperidone, but documentation of required AIMS testing was absent. The DON acknowledged that AIMS evaluations are important for assessing TD and should be completed at admission and every six months for residents on antipsychotics. However, the AIMS evaluation for this resident was only completed after surveyors requested documentation, indicating a lapse in timely monitoring as required by facility policy.
Failure to Facilitate Resident Preferences for Bathing and Meals
Penalty
Summary
A cognitively intact resident with multiple medical diagnoses, including multiple sclerosis, malnutrition, and recent laparoscopic surgery, was admitted to the facility and required assistance with activities of daily living (ADLs) such as dressing, grooming, bathing, mobility, and incontinence care. The resident's care plan emphasized the importance of honoring her preferences for bathing methods and meal choices, and directed staff to provide assistance accordingly. Despite these documented preferences and needs, the facility failed to facilitate the resident's choices regarding bathing and meals. The resident reported not receiving a bath or shower since admission, despite expressing a desire for a shower, particularly before medical appointments. Staff attempted to provide a sponge bath, which the resident declined in favor of a shower to wash her hair, but was told she would have to wait for the next scheduled shower day. There was confusion among staff regarding whether the resident was restricted from showering due to her surgical incisions, but no provider order or policy was found to support such a restriction. The resident eventually received a shower and hair wash, but only after a significant delay and after her concerns were raised during a care conference. Regarding meals, the resident was unaware of her meal selections, did not receive a menu in her room, and was unsure how to order alternatives or what options were available. She also did not consistently receive requested items such as sugar, cream, and straws with her meals, despite these preferences being noted on her tray slip. The dietary staff and registered dietitian were unclear about the process for providing updated menus to residents who dined in their rooms, and there was a lack of clarity about how resident preferences were communicated and honored. The facility's policies stated an intent to provide person-centered care and honor resident choices, but these were not consistently implemented in practice for this resident.
Failure to Update Care Plan with Resident Preferences and Therapy Recommendations
Penalty
Summary
The facility failed to revise and update the care plan for a resident who was cognitively intact and required assistance with activities of daily living (ADLs) such as dressing, grooming, bathing, mobility, and incontinence care. The resident had multiple medical diagnoses, including multiple sclerosis, malnutrition, thrombocytosis, and pseudobulbar affect, and had recently undergone a laparoscopic hysterectomy with four surgical sites. The comprehensive assessment identified the resident's preferences for bathing and clothing choices, but the care plan did not specify these preferences or provide detailed instructions for staff regarding transfers, wheelchair positioning, or the amount of time the resident should spend in a wheelchair. Despite therapy recommendations for the use of an EZ stand for transfers and for the resident to be up in a chair three times daily, these interventions were not reflected in the care plan or the nursing assistant care sheet. The care sheet also lacked information on interventions to facilitate easier transfers and mobility, particularly in relation to the resident's spastic rigidity caused by multiple sclerosis. Staff interviews revealed uncertainty about how to manage the resident's care needs, including safe transfers and addressing her rigidity, and the resident reported that staff did not allow her sufficient time to relax during transfers, which exacerbated her rigidity. Additionally, the care plan and care sheet were not updated to reflect the resident's expressed preferences for bathing and hair washing, even after these concerns were raised during a care conference. The director of nursing confirmed that care plans should be updated to reflect resident preferences and therapy recommendations, and that changes made to care sheets should be mirrored in the care plan. However, the documentation reviewed did not show that these updates were made, resulting in a lack of clear direction for staff on how to provide care according to the resident's needs and preferences.
Failure to Provide Routine Bathing Assistance for Resident Requiring ADL Support
Penalty
Summary
A deficiency occurred when a resident with multiple sclerosis, post-surgical status, and other medical conditions did not receive routine bathing assistance as required. The resident was cognitively intact and required assistance with activities of daily living (ADLs), including bathing, dressing, and grooming, as documented in the Minimum Data Set (MDS) and care plan. The care plan specified that the resident should be bathed according to her preferences and receive assistance with transfers and self-care, but lacked specific instructions regarding management of surgical sites or any restrictions on showering. Despite being on enhanced barrier precautions, there were no documented orders restricting bathing or showering due to surgical incisions. The resident and her family reported that she had not received a bath or shower since admission, and that she wished to have her hair washed before medical appointments, but this was not accommodated. Staff offered a sponge bath, which the resident declined in favor of a shower, but she was told she would have to wait for the next scheduled shower day. The resident stated that neither physical nor occupational therapy had worked with her on shower transfers, and staff documentation showed repeated entries of 'not applicable' for bathing assistance over several weeks. The first documented shower and hair wash occurred approximately three weeks after admission. Interviews with staff, including the physical therapy assistant, clinical coordinator, and director of nursing, revealed that bathing was scheduled weekly based on room assignment, with limited flexibility for resident preferences. Staff were unaware of any medical restrictions on showering, and no provider orders restricting bathing were found in the resident's records. Facility policy required person-centered care and support for resident preferences in ADLs, but documentation and interviews confirmed that the resident did not receive the necessary assistance with bathing for an extended period.
Failure to Make All Survey Results Available for Review
Penalty
Summary
The facility failed to ensure that all recertification survey results and additional complaint investigation findings were available for review by residents, families, staff, and visitors. During an observation, only some of the required survey results were found in the designated folder outside the Social Services office. Specifically, the folder contained results from the most recent recertification and a limited number of complaint investigations, while several other complaint investigation results with cited deficiencies were missing. The administrator confirmed responsibility for managing the posting of survey results and acknowledged awareness of the requirement to make all 2567 forms available for review, but admitted that not all necessary documents had been printed or placed in the folder. Further review of the facility's records against the Aspen Central Office (ACO) documentation revealed that multiple complaint investigations with deficiencies were not present in the facility's survey results folder. The licensed social worker reported having temporarily removed some documents due to disarray but returned them to the administrator. Despite this, a comparison with ACO records showed that several required survey results remained unavailable for public review. The facility's policy, referencing Minnesota Statute § 144A.10, Subdivision 3, mandates the posting of all correction orders and notices of noncompliance in a conspicuous and accessible location, a requirement that was not fully met.
Failure to Provide Individualized Smoking Care Plan and Staff Communication
Penalty
Summary
The facility failed to provide an individualized care plan addressing all the needs of a resident with a history of cerebral infarction who required assistance with personal care, transfers, and mobility. The resident had a documented history of noncompliance with the facility's smoking policy, including incidents of smoking in his room. Although the care plan stated that the resident was not allowed to smoke at the facility and could only smoke outside with family supervision, this information was not included on the care sheets used by nursing assistants and nurses. The care sheets lacked any mention of the resident's smoking plan, restrictions, or required safety checks, and there was no updated smoking assessment after a noted incident. Staff interviews revealed inconsistent awareness and communication regarding the resident's smoking restrictions and safety measures. Some staff were unaware of the resident's recent unsafe smoking practices or the suspension of his smoking privileges, as this information was not documented on care sheets or communicated during shift reports. The facility's policy required care plans to be used in developing daily care routines and to be updated as residents' needs changed, but this was not followed in the resident's case, resulting in a lack of clear, accessible guidance for staff responsible for his care.
Failure to Supervise Resident with Unsafe Smoking Behaviors
Penalty
Summary
The facility failed to provide adequate supervision and implement effective interventions to prevent a resident from smoking unsafely in his room, despite a documented history of noncompliance with the facility's smoking policy. The resident, who had a diagnosis of cerebral infarction and required assistance with personal care, transfers, and mobility, was repeatedly found smoking in his room on multiple occasions. His care plan indicated he was not allowed to smoke at the facility except under family supervision and that he was not safe to store or handle his own smoking materials. However, the care sheets used by nursing assistants and nurses lacked any information regarding his smoking plan, restrictions, or required safety checks. Staff interviews confirmed that the care sheets did not provide direction on the resident's smoking status, and some staff were unaware of his restrictions or recent unsafe smoking incidents. Despite the resident's repeated noncompliance and the facility's policy requiring supervision and assessment for residents who smoke, there was no updated smoking assessment after a certain date, and the resident continued to access and use smoking materials unsupervised. Progress notes and staff interviews documented multiple instances where the resident was found actively smoking in his room, with evidence such as ashes and cigarette butts present. The lack of clear communication and documentation regarding the resident's smoking restrictions and supervision requirements contributed to the ongoing unsafe behavior, resulting in a failure to maintain a safe environment free from accident hazards.
Failure to Notify Physician of Medication Error
Penalty
Summary
The facility failed to notify the physician of a significant medication error involving a resident who did not receive their prescribed blood pressure medication, diltiazem hydrochloride, for five days. The resident, who was admitted to the facility with diagnoses including chronic atrial fibrillation, chronic kidney disease, and weakness, was supposed to receive 120 mg of diltiazem daily. However, the medication was not administered on several occasions due to it being unavailable, and the pharmacy had discontinued the order upon the resident's admission. Despite this, the facility's staff did not inform the physician or update the medication order, leading to a lapse in the resident's treatment. The deficiency was further compounded when the resident experienced an unresponsive episode during physical therapy, which was potentially linked to the lack of medication. Interviews with the Director of Nursing and a nurse practitioner revealed that neither was aware of the medication error until after the incident. The facility's policy required that any medication error be reported to the medical provider, but this protocol was not followed. The nurse practitioner confirmed that the absence of diltiazem could have caused the resident's unresponsive episode and contributed to an irregular heartbeat and increased blood pressure.
Failure to Administer Medication and Oxygen Leads to Resident Hospitalization
Penalty
Summary
The facility failed to ensure that prescribed blood pressure medication and oxygen were administered to two residents, leading to significant health issues. Resident R3, who was diagnosed with chronic atrial fibrillation, did not receive his prescribed diltiazem hydrochloride due to a pharmacy error and lack of communication among the nursing staff. The medication was noted as unavailable on several occasions, and despite the nurse's concerns, the issue was not resolved. This resulted in R3 experiencing an unresponsive episode and increased blood pressure, necessitating a hospital transfer. Resident R1, diagnosed with Chronic Obstructive Pulmonary Disease (COPD), was found with an empty oxygen tank, which led to a significant drop in oxygen saturation levels. Despite the care plan directing staff to monitor oxygen levels and ensure tanks were filled, R1's oxygen supply was not maintained, resulting in a critical condition that required emergency medical intervention. R1 was diaphoretic, lethargic, and had low blood pressure, prompting a transfer to the emergency department. Interviews with facility staff revealed a lack of awareness and communication regarding the medication and oxygen deficiencies. The Director of Nursing and other staff members were not informed of the medication unavailability or the empty oxygen tank until after the incidents occurred. The facility's policy on medication errors emphasizes the importance of addressing errors promptly, but in these cases, the necessary actions were not taken, leading to significant health risks for the residents.
Failure to Notify Physician of Low Blood Sugar Levels
Penalty
Summary
The facility failed to provide timely notification to the physician regarding a change in condition for a resident with type two diabetes mellitus. The resident's care plan required staff to monitor blood sugars and inform the provider as per resident orders. On multiple occasions, the resident's blood sugar levels fell below the threshold of 75 mg/dl, as indicated in the provider's orders, yet there was no documentation that the provider was notified. Specifically, on January 4th, the resident's blood sugar was recorded at 53 mg/dl and 54 mg/dl, and on January 6th, it was recorded at 65 mg/dl twice, without any indication of provider notification. Interviews with facility staff revealed a lack of communication and follow-through on the provider's orders. An LPN and RN involved in the resident's care on January 6th did not ensure the provider was notified of the low blood sugar readings. The RN assumed the LPN had notified the provider, while the LPN did not confirm this action. Additionally, an RN on duty on January 4th admitted to forgetting to notify the provider due to being busy. The facility's policy required timely notification to the physician for changes in the resident's condition, which was not adhered to in this case.
Failure to Provide 1:1 Supervision During Meals for Choking Risk Resident
Penalty
Summary
The facility failed to provide 1:1 supervision during meals for a resident identified as a choking risk. The resident, who had diagnoses including muscle weakness, dysphagia, and oropharyngeal phase, required a mechanically altered diet and staff supervision for all meals and drinks. Despite these requirements, the resident was observed eating alone on multiple occasions, without the necessary supervision, leading to episodes of coughing while eating ice cream and oatmeal. Staff members acknowledged being aware of the supervision requirement but cited being busy as the reason for not providing the necessary oversight. The resident's care plan and provider orders clearly indicated the need for 1:1 supervision during meals, with reminders to swallow and no use of straws, as recommended by the speech therapist. However, observations showed that staff did not adhere to these directives, leaving the resident unsupervised during meals. The director of nursing and other staff confirmed the importance of following the care plan to prevent risks such as choking and aspiration, yet the facility's policy on activities of daily living was not followed, resulting in a deficiency in care.
Failure to Implement Care Plan for Resident
Penalty
Summary
The facility failed to implement the care plan for a resident who required assistance with activities of daily living (ADLs), specifically in repositioning and changing incontinent briefs. The resident, who had moderately impaired cognition and was dependent on staff for personal hygiene and mobility, was observed to have been left in the same position for an extended period without being repositioned or having their incontinent brief changed. The resident's care plan required staff to check and change the brief and reposition the resident every two to three hours, but this was not adhered to. Observations and interviews revealed that the resident was left in bed from early morning until after 1:00 p.m. without being repositioned or having their brief changed, despite the room having a noticeable smell of urine. Nursing assistants admitted to being behind schedule and acknowledged that the resident was left in bed longer than usual. The resident expressed discomfort from being in the same position for several hours, and it was noted that the resident's brief was saturated with urine, and the bed was stained. Interviews with staff, including the administrator and clinical coordinator, confirmed that the care plan was not followed, and there was a lack of consistent documentation regarding the care provided. The facility's policy emphasized the importance of individualized care and maintaining residents' quality of life, but the staff failed to meet these standards in this instance, leading to the deficiency.
Failure to Implement Care Plan for Resident's ADLs
Penalty
Summary
The facility failed to implement the care plan for a resident who required assistance with activities of daily living (ADLs), specifically in repositioning and changing incontinent briefs. The resident, who had moderately impaired cognition and was always incontinent of bowel and bladder, was observed multiple times over a period of several hours lying on her left side in bed with a noticeable smell of urine in the room. The care plan required staff to check and change the resident's incontinent brief and reposition her every two to three hours, but this was not done. Observations and interviews revealed that the resident had been left in the same position from before 6:30 a.m. until after 1:00 p.m. without being repositioned or having her incontinent brief changed. Nursing assistants admitted to being behind schedule and acknowledged that the resident had been left in bed longer than she should have been. The resident expressed discomfort and a desire to have been dressed earlier in the day. The nursing assistant confirmed that the resident's brief was saturated with urine, and the bed was stained with urine, indicating a lack of timely care. Interviews with facility staff, including the administrator and clinical coordinator, confirmed that the care plan was not followed, and there was a lack of consistent and accurate charting regarding the resident's care. The facility's policy emphasized the importance of providing person-centered care and maintaining the resident's quality of life, which was not upheld in this instance. The failure to adhere to the care plan and provide necessary services for the resident's ADLs resulted in a deficiency in care.
Improper IV Medication Administration via PICC Line
Penalty
Summary
The facility failed to ensure the safe and sterile administration of intravenous (IV) medication via a peripherally inserted central catheter (PICC) for a resident. The resident, who was admitted from a hospital with an IV access and had diagnoses of a multidrug-resistant organism and paraplegia, was observed receiving medication from an LPN who did not follow proper procedures. The LPN did not check for blood return to verify the placement of the PICC line before administering the medication, which is a standard practice to ensure the line is correctly positioned. During the medication administration, the LPN also failed to cleanse the end of the PICC line before attaching the antibiotic tubing, which is necessary to prevent bacterial contamination and potential infection. The LPN stated that he had not received specific IV education from the facility and was relying on his nursing school training. The facility's floor manager confirmed that staff were expected to cleanse the PICC line before each access and verify placement by checking for blood return, but there was uncertainty about whether agency staff were required to complete the same skills education. The facility was unable to provide documentation of the LPN's orientation or skills training, and the Director of Nursing (DON) acknowledged that the facility did not provide IV administration education for agency staff. The DON stated that agency staff were expected to follow nursing practice standards learned in college. The facility's policy and skills checklist outlined the proper procedures for PICC line flushing and medication administration, which were not followed in this instance.
Failure to Ensure RN Coverage for Eight Consecutive Hours
Penalty
Summary
The facility failed to ensure the services of a registered nurse (RN) were available onsite for eight consecutive hours seven days a week, potentially affecting all 30 residents. Review of staffing schedules from 10/1/23 to 12/31/23 revealed that there was no RN coverage for eight consecutive hours on 10/1/23, 10/8/23, 10/14/23, and 10/15/23. During an interview on 4/24/24, a trained medication aide (TMA) confirmed that only two licensed nurses were employed, necessitating the use of agency nurses. The TMA was unaware of any specific instances where an RN was unavailable for eight consecutive hours. The administrator also confirmed the lack of RN coverage on the specified dates, attributing it to call-ins and stating that the facility's policy was to have an RN on duty for eight consecutive hours. The administrator mentioned that the facility now schedules two RNs for open shifts to mitigate the issue of call-ins.
Failure to Provide Adequate Room Space
Penalty
Summary
The facility failed to provide the required 80 square feet of floor space per resident in eight of its rooms, affecting nine residents. The rooms in question were double occupancy but did not meet the minimum square footage requirement, with each resident having only 75 to 76.25 square feet of space. During the entrance conference, the facility administrator acknowledged that there had been no changes in room sizes and mentioned that waivers were in place for the non-compliant rooms. Observations and interviews with the affected residents revealed that most of them did not have roommates at the time and were utilizing the entire room space for their personal items, including power wheelchairs. None of the residents expressed concerns about the room size during the interviews. Interviews with staff, including a trained medication aide, confirmed that some rooms were tight on space when occupied by two residents. However, the aide also noted that there had been no complaints from residents regarding the room size or issues with roommates. Despite the lack of resident complaints, the facility's failure to meet the required minimum square footage per resident constitutes a deficiency in providing adequate living space as mandated by regulations.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident was comprehensively assessed for self-administration of medications. The resident, who had intact cognition and was independent with all activities of daily living, had a significant change Minimum Data Set (MDS) indicating various diagnoses including stroke, hemiplegia, depression, asthma, muscle wasting, muscle weakness, cellulitis, and long-term use of anticoagulants. Despite a certified nurse practitioner (CNP) order to leave melatonin and trazodone at the resident's bedside, the order lacked parameters for the time when medications could be left, and the resident's electronic health record (EHR) did not include an assessment for self-administration of medications. During interviews, a trained medication aide (TMA) confirmed that she had left the medications at the resident's bedside several times, and the director of nursing (DON) acknowledged that an assessment was required to ensure the resident could safely self-administer and store medications. The DON was unaware of the provider's order and confirmed that the necessary assessment had not been completed. The facility's policy indicated that the interdisciplinary team must determine if self-administration is clinically appropriate and safe, and this decision must be documented in the medical record and care plan, which was not done in this case.
Failure to Install Bed Rails for Resident
Penalty
Summary
The facility failed to ensure reasonable accommodation of a resident's need for a repositioning device. The resident, who had intact cognition and was independent with all activities of daily living, had a history of stroke, hemiplegia, chronic right shoulder pain, and other medical conditions. The resident had been assessed and had orders for bed rails to assist with repositioning and getting in and out of bed due to pain. However, after moving from room one to room two, the bed rails were not installed on the new bed despite the resident's repeated requests and the presence of proper assessment and orders in the electronic health record. Observations over several days confirmed that the bed rails were not installed on the resident's bed in room two. Interviews with staff, including a TMA and the DON, corroborated that the resident used bed rails for mobility and pain management. The maintenance request log showed no work order for installing bed rails in the new room, and the facility's bed rail policy was not provided upon request. The DON acknowledged the importance of bed rails for the resident's ease of mobility, independence, and pain management, confirming the deficiency in accommodating the resident's needs.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The facility failed to ensure proper storage, labeling, and dating of room temperature and refrigerated food items. During a kitchen observation, surveyors found two packages of sealed frozen pork sausage and green onions improperly stored in a food preparation sink, along with a bucket of soapy water with soiled utensils nearby. Additionally, several food items in the dry storage area and refrigerator were opened without any dates, including crispy onions, stovetop stuffing, yogurt and berries, imitation crab meat, and tortillas. Items that required refrigeration after opening, such as sweet and sour sauce, teriyaki sauce, lemon juice, and grated parmesan cheese, were found stored at room temperature. A cup of light pink liquid and a box of SOS soap pads were also found inappropriately stored in the lower food cabinet. Personal items, such as a weekly pill organizer and an uncovered beverage cup, were observed on the food preparation counter, further compromising food safety standards. The culinary director (CD-A) verified these findings and expressed concern about the improper use of the food preparation sink and the lack of proper labeling and dating of food items. CD-A acknowledged that cleaning products should be stored separately from food products and that personal items, such as the pill organizer and open beverage, should not be in the kitchen. CD-A also confirmed that the light pink liquid in the lower food cabinet was used oil for making egg rolls. In the resident personal food item refrigerator/freezer, surveyors found leftovers labeled with a resident's name but lacking a date, an expired container of Miracle Whip, an open bottle of Diet Coke, and a bright blue substance on the walls of the freezer. CD-A confirmed that all food items in the resident refrigerator should be labeled with the name and date and that the refrigerator should be cleaned weekly. The facility's policies on food receiving and storage, as well as handling food brought in for residents' individual consumption, were not followed. These policies directed that all foods should be labeled and dated, cleaning products should be stored separately from food, and personal items should not be in the kitchen. The facility failed to comply with these policies, leading to the observed deficiencies in food storage, labeling, and overall kitchen cleanliness. The culinary director acknowledged these issues and the need for proper food handling practices to ensure the safety and well-being of the residents.
Sanitary Conditions in Kitchen Not Maintained
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which had the potential to affect all 36 residents who ate food prepared there. During a tour of the kitchen, a thick brown substance was observed on the baseboards, under counters, refrigerators, freezers, dry storage shelves, oven, and dishwashing area. The microwave, toaster, and lower shelves were also covered in the same substance. Additionally, a vent between the dry storage area and the food preparation area had a dark gray fuzz matter, and the ceiling vent over the food preparation counter had a dark brown fuzz matter extending approximately 3 feet in all directions. The ceiling material was peeling and had a bubbled appearance around the vent. The Culinary Director (CD) verified these findings and acknowledged that the kitchen was in need of a deep clean and that the ceiling had been in this condition for a long time. The facility's Dietary Guidelines policy directed that sanitary conditions be maintained in the storage, preparation, and distribution of food, and that effective procedures for cleaning all equipment and work areas be followed consistently.
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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