The Gardens At Foley Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Foley, Minnesota.
- Location
- 253 Pine Street, Foley, Minnesota 56329
- CMS Provider Number
- 245325
- Inspections on file
- 24
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at The Gardens At Foley Llc during CMS and state inspections, most recent first.
A resident with traumatic brain injury, seizures, major depressive disorder, and morbid obesity reported using the call light to request toileting assistance and sometimes waiting an hour or more, leading to incontinence and feelings of embarrassment and frustration. Call light logs showed multiple response times exceeding 30 minutes, including waits of about 42, 58, and 60 minutes. The DON acknowledged increasing call light times and that extended waits leading to incontinence could be a dignity issue, while the Administrator stated that 45–60 minutes or longer was unreasonable and noted grievances about long call light waits, in conflict with resident rights and dignity expectations.
A resident with a history of cancer and recent radiation therapy was admitted with buttock redness that was not thoroughly assessed, documented, or communicated to providers by nursing staff. The initial and ongoing skin assessments lacked detail, and there was no evidence of follow-up or provider notification when the redness persisted or worsened. The resident later developed a stage 2 pressure ulcer, with incomplete documentation and missed opportunities for intervention and monitoring by the facility.
A resident with osteomyelitis and staph infections experienced significant medication errors when antibiotics were administered late and missed entirely. The errors led to symptoms such as confusion, fever, and skin issues, resulting in hospitalizations. The facility's Director of Nursing was unaware of the initial delay, and an agency nurse responsible for a subsequent error was not adequately supervised.
The facility failed to document post-fall neurological assessments for three residents who experienced falls. Despite protocols requiring frequent assessments, documentation was missing due to unavailable forms. Residents had conditions such as dementia and a history of falls, and incidents involved low oxygen saturation, minor bleeding, and self-transferring attempts. Staff acknowledged the protocol but did not document assessments consistently.
During a COVID outbreak, staff at the facility failed to follow CDC guidelines for mask usage. A therapeutic recreation aide and an RN were observed with masks under their chins, not covering their mouths or noses, while near residents. The facility's policy requires proper mask usage, but staff did not comply, contributing to the deficiency.
The facility failed to submit accurate staffing data to CMS for Q2 2024, as required by the PBJ system. Discrepancies were found in weekend staffing levels, with extra staff scheduled despite float staff availability. HR was responsible for agency staff data, while corporate handled facility staff hours. The CNL noted overscheduling due to un-canceled agency staff when facility staff volunteered.
A resident with severe cognitive impairment was observed in a reclined position in a wheelchair that did not provide adequate back support, leading to discomfort and back pain. The facility failed to ensure proper wheelchair positioning, as the last occupational therapy evaluation did not identify the need for intervention, and the current therapist was unaware of the issue.
A facility failed to ensure safe medication administration for three residents. A trained medication aide pre-dished medications for multiple residents at once, contrary to facility policy. The aide signed off on the EMR indicating medications were administered, although they were not given at that time. The DON confirmed that staff were instructed to prepare and administer medications for one resident at a time and document only after administration. The facility's policy prohibited pre-pouring medications in advance.
The facility failed to properly label and store eye drops for two residents, as observed during a medication cart review. Two open bottles of artificial tears lacked labels indicating the specific resident, the date opened, or the expiration date. The LPN acknowledged the oversight, and the DON stated that the facility's policy required using individually packaged dose vials with proper dating. This failure to adhere to policy resulted in a deficiency in medication storage and labeling.
A facility failed to follow infection control practices during eye drop administration. A TMA-C inadvertently touched a resident's eyelid with the tip of an eye drop bottle, contaminating it, but was unaware and returned the bottle to the medication cart. The DON confirmed that the facility's policy requires the dropper tip to avoid contact with the eye or any surface.
A cognitively intact resident with a history of debility, cardiorespiratory conditions, heart failure, anemia, and arthritis fell and sustained a thoracic fracture, leading to hospitalization and death. The resident had gait/balance problems, weakness, and a tendency to self-transfer without assistance. The facility's care plan included an intervention to offer assistance with setting out clothing for the resident's shower, which was not followed by the nursing assistant. The resident's preference for independence and reluctance to ask for help were contributing factors. Staff interviews revealed varying levels of adherence to the care plan.
The facility failed to post required nursing staff data daily before each shift, with 81 out of 176 expected days missing postings. The scheduling coordinator was responsible but was often unavailable, and no audits were conducted to ensure compliance.
Failure to Respond Timely to Call Lights Resulting in Dignity Concerns
Penalty
Summary
The facility failed to provide timely toileting assistance and call light response for a resident, resulting in a dignity concern. The resident had diagnoses including unspecified focal traumatic brain injury, seizures, major depressive disorder, and morbid obesity, and reported being aware of the need to have a bowel movement and using the push-button call light system to request transfer to the toilet or a commode. The resident stated that at times he waited an hour or more for staff to answer his call light, which resulted in episodes of incontinence. He reported feeling upset, frustrated, "like a little kid," and embarrassed when this occurred. Review of the resident’s call light logs showed multiple instances of significantly delayed responses, including unanswered call lights for 42 minutes and 42 seconds, 57 minutes and 59 seconds, 60 minutes and 22 seconds, and 32 minutes and 5 seconds on various dates. The DON acknowledged that staff were encouraged to answer call lights as quickly as possible, that call light times had been increasing, and that extended call light waits resulting in incontinence could negatively affect residents and constitute a dignity issue. The Administrator stated that an acceptable response time was about 6–8 minutes, acknowledged that 45–60 minutes or longer was unreasonable, and confirmed awareness of long call light times and related resident/family grievances. Both the DON and Administrator recognized that prolonged call light response times could negatively affect residents’ quality of life and dignity, contrary to the facility’s Resident Rights policy and the Combined Federal and State Resident Rights requirements.
Failure to Assess, Document, and Communicate Skin Impairments
Penalty
Summary
The facility failed to adequately assess, document, and communicate changes in a resident's skin condition, specifically regarding buttock redness and subsequent open areas, upon admission and during the resident's stay. Upon admission, the resident, who had a history of vulvar cancer, recent chemotherapy, radiation therapy, and a left humerus fracture, was noted to have buttock redness during the initial skin assessment. However, the assessment lacked detailed documentation regarding the extent, size, and characteristics of the redness, and there was no evidence of follow-up actions or provider notification. The baseline care plan referenced perineal and buttock wounds, but the admission assessment only mentioned buttock redness, and no comprehensive wound assessment or monitoring was initiated for the buttock area. Throughout the resident's stay, there were multiple missed opportunities for timely and thorough skin assessments, documentation, and communication among staff and with providers. Nursing staff did not consistently document the status of the buttock redness or any progression to open areas, and there was no evidence that the provider or wound care team was notified when the skin impairment failed to resolve or worsened. Progress notes and treatment records lacked specific information about the wounds, and the required weekly skin assessment was not completed or documented. Staff interviews revealed a lack of clarity and follow-through regarding protocols for skin impairment assessment, documentation, and escalation, with several staff members unable to recall the resident or the care provided. The resident later reported increased pain and was found by a nurse practitioner to have a stage 2 pressure ulcer with sloughing on the buttocks, which was subsequently confirmed and further described during a hospital admission. The facility's own post-discharge skin evaluation form was incomplete, lacking measurements and detailed descriptions. Interviews with facility leadership and staff confirmed that expected protocols for assessment, documentation, provider notification, and intervention were not followed, and the medical record did not reflect appropriate monitoring or care management for the identified skin impairments.
Significant Medication Errors in Antibiotic Administration
Penalty
Summary
The facility failed to ensure that a resident received antibiotics as per physician orders, resulting in significant medication errors. The resident, who was admitted with osteomyelitis and methicillin-susceptible staphylococcus aureus infections, was supposed to receive a continuous infusion of oxacillin. However, the medication was administered over five hours late on one occasion, and on another occasion, it was missed entirely for 12 hours. These errors were discovered through a review of the Medication Administration Record and a Medication Error Report. The resident's condition was compromised due to these medication errors. On one occasion, the resident exhibited symptoms such as confusion, congestion, a nonproductive cough, and a high fever, leading to hospitalization. On another occasion, the resident developed significant pitting edema and skin issues, prompting another hospital visit. The errors were attributed to a lack of proper communication and oversight, particularly involving an agency nurse who was not adequately familiar with the facility's procedures. The Director of Nursing was unaware of the initial delay in administering the antibiotic and acknowledged that the agency nurse, who was responsible for the second error, was not properly supervised. The facility's policy on medication procedures emphasizes the importance of considering the resident's condition, the drug category, and the frequency of errors when determining the significance of a medication error. Despite these guidelines, the errors occurred, highlighting a lapse in adherence to established protocols.
Failure to Document Post-Fall Neurological Assessments
Penalty
Summary
The facility failed to complete post-fall vital signs and neurological assessments for three residents, R1, R2, and R3, who were reviewed for post-fall assessment and monitoring. R1, who had diagnoses of dementia and heart failure, was found on the floor with low oxygen saturation and was minimally responsive. Despite being sent to the emergency department, R1's medical record lacked frequent post-fall neurological assessments from the time of the fall until he was sent to the hospital. The assistant director of nursing and registered nurses confirmed that post-fall neurological assessments were part of the facility's protocol, but the assessments were not documented. R2, who had a history of falls and was at risk for falls, was found on the floor with minor bleeding on his forehead. Although vital signs were noted, R2's chart lacked frequent post-fall neurological assessments for the 12 hours prior to being sent to the emergency room due to a change in condition. The registered nurses acknowledged that the facility's protocol required frequent post-fall neurological assessments, but the assessments were not documented due to the unavailability of the necessary form. R3, who had severe cognitive impairment and a history of falls, was found on the floor and was thought to be self-transferring. Although neurological assessments were reportedly started and within normal limits, the progress notes lacked post-fall assessment details. The licensed practical nurse stated that she completed the post-fall assessments per protocol but was unable to locate the form in R3's medical record. The facility's neurological procedure document outlined the required frequency of neurological assessments following a fall, but these were not consistently documented for the residents involved.
Improper Mask Usage During COVID Outbreak
Penalty
Summary
The facility failed to adhere to the CDC's Infection Control Guidance for SARS-CoV-2, which requires implementing source control measures to cover a person's mouth and nose to prevent the spread of respiratory secretions. On multiple occasions, staff members were observed not wearing masks properly during a COVID outbreak in the facility. Specifically, a therapeutic recreation aide and a registered nurse were seen with their masks positioned under their chins, not covering their mouths or noses, while in close proximity to residents. This occurred despite the facility's policy and the CDC's guidance requiring masks to be worn correctly in common areas. The Director of Nursing confirmed the facility was experiencing a COVID outbreak, with seven residents affected across different units. The facility's COVID policy, dated March 7, 2024, mandates adherence to infection prevention and control practices, including the proper use of personal protective equipment (PPE). Both the Infection Prevention Nurse and the Medical Director reiterated the expectation for staff to wear masks properly in common areas during the outbreak. Despite these policies and expectations, staff members were observed not complying with the mask-wearing guidelines, contributing to the deficiency noted in the report.
Inaccurate Staffing Data Submission to CMS
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to CMS for the second quarter of 2024, as required by the Payroll Based Journal (PBJ) system. This deficiency was identified during a review of staffing schedules and timecard verifications, which revealed discrepancies in weekend staffing levels. Although the facility maintained licensed nursing staff 24/7 and documented registered nurse (RN) coverage for 8 consecutive hours per day, the PBJ report indicated excessively low weekend staffing. However, the facility's schedules showed that several weekends had two extra staff members scheduled, despite the presence of float staff to assist with normal staffing levels. These extra staff members were not listed as being in training, unlike other schedules reviewed. During an interview with the director of nursing (DON), corporate registered nurse (CRN), corporate nurse lead (CNL), administrator in training (AT), and human relations (HR), it was revealed that HR was responsible for gathering information on agency and contractual staff, while corporate utilized the payroll system for facility staff hours. The CNL, who was the DON during the quarter in question, explained that the scheduler had overscheduled on some weekends by not canceling agency staff when facility staff volunteered for open shifts. This oversight may have contributed to the appearance of more heavily scheduled weekends. The facility's policy on PBJ staffing data submissions, which follows CMS guidelines, was also reviewed.
Inadequate Wheelchair Positioning for Resident
Penalty
Summary
The facility failed to ensure appropriate wheelchair positioning for a resident, identified as R45, who was severely cognitively impaired and dependent on assistance for most activities of daily living. Observations revealed that R45 was frequently found sleeping in a reclined position in his wheelchair, with the vinyl back of the wheelchair not providing adequate support. This improper positioning caused R45 to arch over the back of the wheelchair, leading to discomfort and back pain, as reported by the resident. The wheelchair's back was noted to be too narrow and too short, failing to provide sufficient support. R45's medical records indicated that the last occupational therapy evaluation was conducted in September 2023, and it was determined that no treatment or interventions were necessary at that time. However, during a recent observation, the contracted occupational therapist identified the inadequacy of the wheelchair's back support. The therapist had not been informed of any issues with R45's wheelchair prior to this observation. The facility's policy on maintaining abilities in activities of daily living emphasizes providing necessary care and services based on comprehensive assessments, which was not adhered to in this case.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure safe medication administration for three residents, identified as R19, R40, and R61, during a survey. Observations revealed that a trained medication aide (TMA-D) was pre-dishing medications for multiple residents at once, which is against the facility's policy. The medication cups, containing unidentified pills, were labeled only with the residents' initials and were placed in the medication cart. TMA-D had signed off on the electronic medical record (EMR) indicating that the medications had been administered, although they had not been given to the residents at that time. Further observations showed TMA-D removing prefilled medication cups from the cart and entering the residents' rooms without administering the medications. The director of nursing (DON) confirmed that the staff were instructed to prepare and administer medications for one resident at a time and to document the administration only after the resident had received the medication. The facility's policy, dated December 2019, emphasized the importance of adhering to the five rights of medication administration and specifically prohibited pre-pouring medications in advance of the medication pass or for more than one resident at a time.
Improper Labeling and Storage of Eye Drops
Penalty
Summary
The facility failed to ensure proper labeling and storage of eye drops for two residents, R8 and R16, as observed during a medication cart review. Two open multidose bottles of artificial tears were found in the cart without labels indicating the specific resident, the date opened, or the expiration date. The LPN present during the observation stated that these were stock medications used for the residents and acknowledged that staff should have labeled the bottles with an opened and expiration date. However, the exact date of when the bottles were opened was unknown. The Director of Nursing (DON) indicated that the facility's policy was to use individually packaged dose vials of artificial tears, which should be dated with an 'Opened on' and 'Expires on' sticker. The facility's policy from January 2018 required that when a manufacturer's container or vial is initially opened, it should be dated, and a new expiration date should be noted, typically 30 days from opening. The failure to follow this policy led to the deficiency in medication storage and labeling for the residents involved.
Infection Control Breach in Eye Drop Administration
Penalty
Summary
The facility failed to adhere to proper infection control practices during the administration of eye drops to a resident. During an observation, a trained medication aide (TMA-C) was seen administering artificial tears to a resident. The TMA-C donned a glove and attempted to place a drop in the resident's left eye, but the resident squeezed their eyes shut, causing the tip of the medication bottle to touch the inside of the resident's lower left lid. The TMA-C was unaware of the contact and placed the bottle back into the medication cart, despite acknowledging that a contaminated bottle should not be reused. The director of nursing confirmed that staff are required to ensure the tip of the dropper does not touch the eye or any surface, as per the facility's policy dated December 2019.
Resident Fall Resulting in Thoracic Fracture and Subsequent Death
Penalty
Summary
The report details a deficiency in a nursing home's care practices that resulted in harm to a resident (R4) who fell and sustained a thoracic fracture, ultimately leading to his hospitalization and subsequent death. R4, a [AGE] year-old resident with a history of debility, cardiorespiratory conditions, heart failure, anemia, and arthritis, was identified as cognitively intact in his annual Minimum Data Set (MDS) assessment. Despite being free of falls in the prior three months, R4 was noted to have gait/balance problems, weakness, and a tendency to self-transfer without assistance, as outlined in his risk for falls care plan. The deficiency stemmed from the facility's failure to follow a care planned intervention aimed at reducing R4's risk of falls. Despite the care plan directing staff to offer assistance with setting out clothing for R4's shower, the nursing assistant (NA) responsible for R4 documented offering assistance but did not actually provide it. R4's strong preference for independence in selecting his clothing and his tendency to self-transfer without notifying staff or using his call light were noted as contributing factors to the incident. The investigation revealed that the fall likely led to the thoracic fracture, highlighting the missed opportunity for staff to assist R4 and prevent the fall. Multiple staff interviews conducted post-incident indicated varying levels of awareness and adherence to the care plan among the nursing assistants involved. While some staff members acknowledged the need to follow the plan of care and ensure accurate documentation, others noted R4's reluctance to ask for help and the challenges in providing assistance due to his independent nature.
Failure to Post Daily Nursing Staff Data
Penalty
Summary
The facility failed to ensure required nursing staff data was posted daily before each shift, potentially affecting all 74 residents, staff, and visitors. On 4/15/24, it was observed that the nursing staff data posting was dated 4/11/24, indicating a lapse in daily updates. The regional director of operations and the administrator confirmed the outdated posting and explained that the scheduling coordinator (SC) was responsible for the postings but was out ill that day. The director of nursing (DON) acknowledged the expectation for daily postings and admitted that no audits were conducted to ensure compliance. The DON was unsure of the process when SC was absent, leading to the breakdown in the system. Further observations on 4/15/24 and 4/16/24 revealed inconsistencies in the postings, with the plastic holder being empty at times and a different format being used on 4/16/24. SC admitted to being unaware of the posting requirements and the process when she was not in the building, including weekends. She also mentioned that on days she worked direct care, the postings were not done. A review of the saved Daily Headcount postings from 10/23/23 to 4/15/24 showed that 81 out of 176 expected days were missing postings, with various dates lacking postings across different months. The facility's Nursing Hours Posting policy, dated 10/2/22, directed that nursing staffing data be posted daily at the beginning of each shift.
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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