The Lutheran Home: Belle Plaine
Inspection history, citations, penalties and survey trends for this long-term care facility in Belle Plaine, Minnesota.
- Location
- 611 West Main Street, Belle Plaine, Minnesota 56011
- CMS Provider Number
- 245590
- Inspections on file
- 24
- Latest survey
- December 30, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at The Lutheran Home: Belle Plaine during CMS and state inspections, most recent first.
A nursing assistant transferred a resident using an EZ stand lift without the required second staff member, despite the care plan and care cards specifying two-person assistance due to the resident's cognitive impairment, hemiplegia, and history of letting go of the lift handles. During the transfer, the resident let go, slipped from the harness, and fell, resulting in a closed fracture of the right humerus and severe pain requiring emergency care.
A resident with CHF experienced a 16-pound weight gain over 10 days while on diuretics and fluid restriction, but staff failed to comprehensively assess for fluid overload, monitor intake and output, or notify the physician of significant weight changes. The lack of timely assessment and communication led to hospitalization for acute kidney injury and CHF exacerbation.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities, as required.
A resident with Alzheimer's and urinary issues was hospitalized, but the facility failed to provide written notice of transfer to the resident's representative and ombudsman. Interviews revealed confusion among staff about who was responsible for this task, and no policy was in place to ensure compliance.
A resident with Parkinson's disease and limited range of motion did not receive recommended daily passive range of motion exercises due to the facility's failure to implement therapy recommendations. Despite therapy evaluations advising daily exercises to prevent worsening muscle contractures, these were not included in the resident's care plan or orders. Observations and interviews confirmed the lack of exercises, although the resident's functional ability was not further impaired due to already severe limitations.
The facility failed to properly store a controlled substance, lorazepam, in a separately locked compartment within the medication refrigerator. During a shift change narcotic reconciliation, an LPN and an RN discovered the medication stored improperly on a refrigerator shelf. The DON was unaware of the requirement for separate locking of schedule IV medications.
The facility did not inform residents or their representatives of their right to refuse signing the arbitration agreement as a condition of admission or continued care. The Admission Agreement included an Arbitration Agreement Clause without clearly stating that signing was optional. Interviews revealed that staff did not consistently communicate this right, and the administrator confirmed the lack of written documentation regarding the non-mandatory nature of the arbitration agreement.
A resident with Alzheimer's and a history of UTIs had their urinary drainage bag improperly handled by nursing assistants, who placed it on the floor while emptying it. This action violated the facility's catheter care policy, which requires the bag to be kept off the floor unless a barrier is used. The nursing assistant, RN, and DON acknowledged this practice could introduce bacteria and contribute to infections.
The facility failed to maintain accurate and up-to-date nurse staffing postings, affecting all residents and visitors. A trained medication assistant was called in due to a nurse's absence, but the outdated posting from two days prior remained displayed. Interviews revealed confusion over responsibility for updating postings, with the scheduler often finding outdated information still posted on Mondays. The DON confirmed the issue, and no policy on staffing posts was provided.
A resident with cognitive impairment reported a sexual assault to an LPN, but the facility failed to report the allegation to the State Agency within the required two-hour timeframe. The report was submitted over two hours late due to staff's lack of awareness and communication issues. The resident had a history of delusional behavior, which initially led staff to misinterpret the allegation.
Failure to Follow Care Plan for Resident Transfer Results in Fall and Fracture
Penalty
Summary
A deficiency occurred when a nursing assistant (NA) independently transferred a resident who required the assistance of two staff members, as specified in the resident's care plan and functional abilities assessment. The resident, who had mild cognitive impairment, hemiplegia, vascular dementia, chronic pain, osteoporosis, and was non-ambulatory, was being transferred using an EZ stand mechanical lift. The care plan and facility documentation clearly indicated that two staff were required for all transfers due to the resident's history of letting go of the lift handles and periods of unresponsiveness, especially when fatigued. During the transfer, the NA attached the harness and straps to the EZ stand and attempted to help the resident hold onto the handlebars. However, the resident let go of the handles and began slipping out of the harness. The NA, who had only been employed for a few weeks, attempted to retrieve the wheelchair but was unable to prevent the resident from falling. The resident fell to the floor, initially reported shoulder pain, and was later diagnosed with a closed fracture of the proximal end of the right humerus after being sent to the emergency department. The resident's pain was severe, and she required narcotic pain medication and a sling for her right arm. Interviews with staff revealed that the expectation for two-person assistance during transfers was well established in the care plan, care cards, and among experienced staff. The NA involved in the incident was aware of the care plan instructions but stated that other NAs had told her transfers could be done with one person, leading her to believe it was acceptable. Other staff confirmed that the resident's care plan had been updated to require two-person assistance due to her declining strength and tendency to let go of the lift handles. The failure to follow the care plan directly resulted in the resident's fall and injury.
Failure to Monitor and Notify Physician of Fluid Overload in CHF Patient
Penalty
Summary
A deficiency occurred when the facility failed to comprehensively assess and monitor a resident with congestive heart failure (CHF) for signs and symptoms of fluid overload, despite the resident being on diuretics and requiring daily weights. The resident experienced a significant weight gain of 16 pounds over 10 days, with daily weights showing a steady increase. There was no evidence that the facility compared fluid intake with urine output, nor did they conduct comprehensive assessments to determine if the weight gain was due to fluid retention or nutritional factors. Additionally, the facility did not notify the physician of the resident's weight gain, which exceeded the facility's own parameters for physician notification. The resident's care plan and physician orders included daily weights and fluid restriction, but lacked specific parameters for when to notify the physician or interventions for managing fluid volume status. Staff interviews revealed that nurses and aides did not consistently assess for edema, listen to lung sounds, or document and report changes in the resident's condition, such as increased weight, edema, or shortness of breath. Several staff members noted the resident appeared puffy or had increased edema, but these observations were not communicated to the nursing or medical team in a timely manner. The facility's electronic medical record system flagged the weight gain only after a significant increase had already occurred. As a result of these failures, the resident developed acute kidney injury and worsening CHF, ultimately requiring hospitalization for diuresis. The hospital record indicated the resident had fluid retention, acute kidney injury, and was discharged home on hospice care. The lack of timely assessment, monitoring, and physician notification directly contributed to the resident's decline and the identification of Immediate Jeopardy by surveyors.
Removal Plan
- Identification of like residents at-risk.
- Addition of baseline weight to daily weight orders along with parameters for weight gain and to contact the physician for a specified increase, edema assessments with baseline edema listed in physician's order, lung sounds added to interventions and care plans updated.
- Developed a new significant weight change policy and reviewed other applicable policies such as weight management and vital signs.
- Developed a fluid restriction guideline/worksheet.
- New admission order set created for residents admitting with diagnosis of CHF, edema, use of diuretics, and compression which includes edema checks, lung sounds, weights with specified parameters.
- Residents who have a diagnosis of heart failure and edema, but currently not at-risk, facility added baseline weights on their weight assessment and edema checks with primary bath/skin checks.
- Clinical coordinators are responsible for assessing and monitoring the resident for a change in condition with subsequent notification of medical provider.
- Staff completed review of newly developed significant weight change policy and procedure.
- Direct education reviewing how to assess for edema along with early recognition of heart failure symptoms completed before each licensed nurse's next scheduled shift and availability of staff not regularly scheduled.
- Education also included in orientation of all newly hired staff.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's actions or inactions regarding the reporting process for such incidents, as required by regulations. The report indicates that there was a delay or failure in notifying the appropriate authorities about the suspected event and in communicating the outcome of the internal investigation.
Failure to Provide Written Notice of Transfer for Hospitalized Resident
Penalty
Summary
The facility failed to provide written notice of transfer to a resident and their representative, as well as the ombudsman, for a resident who was hospitalized. The resident, who had Alzheimer's disease, urinary retention, and a urinary tract infection, was dependent on staff for most activities of daily living and had impaired cognition. The resident was hospitalized overnight in April 2024 due to a urinary tract infection, but the family member did not recall receiving a written notice of transfer. The facility's electronic medical record did not contain this documentation. Interviews with facility staff revealed a lack of clarity and responsibility regarding who should complete the written notice of transfer. The registered nurse, director of nursing, and resident and family liaison each indicated that they did not complete the written notice, and there was no policy in place for this process. The resident and family liaison mentioned informing the ombudsman monthly about resident transfers, but no formal written notice was provided at the time of the transfer.
Failure to Implement Therapy Recommendations for Resident's Range of Motion
Penalty
Summary
The facility failed to implement therapy recommendations in a timely manner for a resident with Parkinson's disease, age-related physical debility, and weakness, who was reviewed for range of motion (ROM). The resident's admission Minimum Data Set (MDS) assessment indicated limited ROM on both sides of upper and lower extremities and required physical assistance with personal hygiene, bed mobility, dressing, toilet use, and transfers. Despite therapy recommendations from both physical and occupational therapists for daily passive range of motion (PROM) exercises to prevent worsening muscle contractures, these were not included in the resident's care plan or orders. Observations and interviews revealed that the resident had not received the recommended exercises, as confirmed by the resident and a registered nurse. The occupational therapist stated that the lack of PROM did not cause a change in functional ability due to the resident's already severely impaired active movement, but noted that the resident would still benefit from the exercises. The director of nursing expressed an expectation for timely implementation of PROM recommendations to prevent decline in functional abilities. The facility's policy on prevention of decline in ROM emphasized the provision of interventions and therapy to maintain or improve ROM based on comprehensive assessments.
Improper Storage of Controlled Substance in Medication Refrigerator
Penalty
Summary
The facility failed to ensure that doses of a controlled substance were stored in a manner that reduces the risk of theft and/or diversion. During an observation, two nurses, an LPN and an RN, were performing a shift change narcotic reconciliation at the Mainstreet nurses station. At the end of the narcotic count, it was noted that the narcotics in the refrigerator also needed to be counted. Upon inspection of the small dorm-size refrigerator in the locked medication room, an opened, multi-dose bottle of lorazepam concentrate, a schedule IV medication, was found on a shelf on the door of the refrigerator, rather than in a separately locked, permanently affixed compartment as required. During an interview, the DON was informed of the observation and stated she was unaware that lorazepam needed to be stored in a separately locked, permanently affixed compartment in the refrigerator. The facility's Medication Storage policy indicated that if a medication was supplied in a unit-dose system, schedule III-IV medications could be stored in trays with other medications.
Failure to Inform Residents of Arbitration Agreement Rights
Penalty
Summary
The facility failed to inform residents or their representatives of their right to not sign the arbitration agreement as a condition of admission or to continue receiving care. The Admission Agreement included an Arbitration Agreement Clause, but it did not explicitly state that signing the arbitration agreement was not mandatory for admission or continued care. The agreement also included a Notice of Right to Rescind Binding Arbitration Clause, which allowed residents to rescind the agreement within 30 days, but this was not clearly communicated as an option to refuse arbitration altogether. Interviews with facility staff revealed inconsistencies in the understanding and communication of the arbitration agreement. The director of nursing stated that no residents or representatives had signed the arbitration agreement, while the admissions coordinator indicated that all residents had signed it as part of the admission agreement. The admissions coordinator also admitted to not informing residents or their representatives of their right to refuse the arbitration agreement. The administrator confirmed that the current agreement did not include written documentation that arbitration was not a requirement for admission or continuation of care.
Improper Handling of Urinary Drainage Bag
Penalty
Summary
The facility failed to adhere to proper infection prevention and control procedures when emptying a urinary drainage bag for a resident diagnosed with Alzheimer's disease, urinary retention, and a history of urinary tract infections (UTIs). The resident, who was cognitively impaired and dependent on staff for most activities of daily living, had a physician's order to monitor Foley catheter output each shift. The care plan required the drainage bag to be emptied every shift to manage the catheter and prevent UTIs. During an observation, nursing assistants were seen placing the urinary drainage bag directly on the floor while emptying it, which is against the facility's catheter care policy. The nursing assistant acknowledged that this practice could introduce bacteria into the urinary drainage system, potentially leading to infections. The registered nurse and the director of nursing confirmed that placing the drainage bag on the floor was improper and could contribute to UTIs, as it violated the facility's policy that required the drainage bag to be kept off the floor unless a barrier was provided.
Inaccurate and Outdated Nurse Staffing Postings
Penalty
Summary
The facility failed to ensure that nurse staffing postings were accurate and up-to-date on a daily basis, potentially affecting all 50 residents and any visitors who may have wished to view the information. On 8/4/24, a trained medication assistant was called in to work due to a nurse calling in for the shift, yet the staff posting dated 8/2/24 remained displayed. The posting included details such as the date, census, and staffing hours for RNs, LPNs, TMAs, and NAs, all listed as 8 hours per shift. Interviews revealed that the receptionist was not responsible for updating the staffing postings, and the scheduler (S-D) indicated that she often finds the Friday posting still up on Monday. S-D mentioned that she reviews the working schedules to make corrections for any changes over the weekend, such as call-ins, but these changes are typically made after the postings are taken down. The Director of Nursing confirmed that the outdated posting remained and stated that there is always a charge nurse in the building on weekends. No policy or procedure on nursing staffing posts was provided upon request.
Failure to Timely Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident with moderate cognitive impairment and multiple diagnoses, including dementia and psychotic disorder, to the State Agency within the required two-hour timeframe. The resident, who required maximum assistance for hygiene and bed mobility, informed an LPN of the alleged assault. However, the report was submitted four hours and 11 minutes after the resident's disclosure, exceeding the mandated reporting period by two hours and 11 minutes. The delay in reporting was attributed to a lack of awareness and communication among staff. The LPN was unaware of the immediate reporting requirement and initially dismissed the allegation due to the resident's history of delusional behavior and past trauma discussions. The RN, upon reviewing the progress notes, realized the allegation was current and reported it to the DON. The DON and the administrator confirmed the late submission of the report, acknowledging the communication breakdown and the need for immediate reporting to ensure resident safety.
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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