The Shores Of Worthington
Inspection history, citations, penalties and survey trends for this long-term care facility in Worthington, Minnesota.
- Location
- 1307 South Shore Drive, Worthington, Minnesota 56187
- CMS Provider Number
- 245596
- Inspections on file
- 26
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 3 (1 serious)
Citation history
Health deficiencies cited at The Shores Of Worthington during CMS and state inspections, most recent first.
A resident with severe cognitive impairment was sexually abused by another resident with a documented history of sexually inappropriate behaviors, including prior breast touching and repeated attempts to touch female residents. Despite referral information and ongoing progress notes describing escalating behaviors such as handholding, rubbing arms and chest, standing over women, and persistent attempts to approach a particular female resident, the facility did not initially incorporate the full sexual behavior history into assessments and care planning, and staff did not consistently prevent physical contact. The abuse occurred when the male resident was found in a common area with his hand under the female resident’s shirt touching her breast while she rested in a recliner, after months of documented, inadequately controlled sexually inappropriate conduct toward female residents.
The facility did not designate a physician to serve as Medical Director after the previous Medical Director retired, leaving the position vacant for an extended period and potentially affecting all 52 residents. The DON reported being solely responsible for reviewing clinical trends and participating in QAPI clinical review, with no physician-level oversight. The Administrator confirmed the ongoing vacancy, noted unsuccessful attempts to secure a contract with local medical groups, and relied on informal conversations with rounding physicians instead of formal Medical Director services. The Administrator also acknowledged uncertainty about how physician-level oversight, contractual obligations, and federal compliance were maintained, despite a written policy that assigns broad clinical and administrative responsibilities to the Medical Director.
The facility did not include a Medical Director on its QAPI committee after the prior Medical Director retired, leaving the position vacant for at least two consecutive quarters. QAPI records showed no Medical Director attendance during this period, and the DON reported being the only person reviewing clinical trends and participating in QAPI clinical review. The Administrator confirmed that the former Medical Director had been a quarterly QAPI attendee and acknowledged uncertainty about how physician-level oversight and regulatory compliance were maintained in the absence of a Medical Director, affecting all residents in the facility.
A resident with diabetes and obesity, requiring extensive hygiene assistance, did not receive prescribed skin treatments for acute dermatitis as ordered. Nursing staff failed to document or report significant skin redness and moisture, and a nursing assistant independently applied antifungal cream without notifying licensed staff or following physician orders. The facility's wound care procedures for assessment, reporting, and documentation were not followed.
A resident with a history of pressure ulcers and moderate risk for skin breakdown did not receive comprehensive skin assessments or physician-ordered wound treatments as prescribed. Staff failed to document wound assessments, did not apply treatments according to orders, and were inconsistent in monitoring the resident's skin condition, leading to inadequate prevention and management of pressure ulcers.
A resident with an indwelling urinary catheter and a history of incontinence experienced repeated UTIs due to improper perineal and catheter care by staff. Observations showed staff using contaminated washcloths and failing to perform hand hygiene or change gloves between tasks, contrary to infection control guidelines. No surveillance or staff education on catheter care was conducted, and the facility's policy for clean technique was not followed.
Staff failed to consistently perform proper hand hygiene during personal care for multiple residents requiring extensive assistance, including those with fractures, intellectual disabilities, and parkinsonism. Observations showed that staff did not always wash or sanitize hands between glove changes or after removing gloves, and sometimes used the same gloves or cleaning utensils for both front and back perineal care. Interviews revealed inconsistent understanding of hand hygiene protocols among staff, despite facility policies requiring these practices.
Surveyors found that the facility did not create or update individualized care plans for several residents with complex medical needs, resulting in missing or inadequate instructions for staff on managing behaviors, monitoring for medication side effects, providing wound and catheter care, and responding to refusals of care. Staff interviews and observations confirmed that care plans were often generic and not revised to reflect changes in residents' conditions or new provider recommendations.
Surveyors identified unsanitary conditions in the kitchen, including dirty food prep surfaces, improper storage of food items, and staff using personal cell phones and sitting on food storage equipment. The ice machine was found with visible mineral and grime buildup, and cleaning logs were not maintained as required by policy and manufacturer guidelines. The dietary manager and registered dietitian acknowledged gaps in cleaning oversight and auditing.
The governing body did not provide adequate oversight to ensure correction of previously identified deficiencies, as QAPI meetings lacked measurable goals, thorough data analysis, and actionable plans for issues such as pressure ulcers, falls, infection control, psychotropic medication use, staffing shortages, and grievances. The facility failed to assign responsibility for follow-up actions, did not ensure staff competency or education on QAPI initiatives, and did not monitor the effectiveness of corrective actions, resulting in ongoing noncompliance.
The facility did not implement its assessment protocol to ensure staff competencies were identified and completed according to their duties, particularly following a merger that brought additional challenges. Leadership had not updated or implemented the facility assessment or related staff education, impacting the ability to provide competent care for all residents during daily operations and emergencies.
The facility did not analyze or document QAPI data with measurable goals or benchmarks, despite department heads presenting data on key areas such as infection control and falls. Interviews confirmed the absence of a formal process to set or monitor goals, and review of policy showed required steps were not being followed.
The QAPI committee did not identify or address facility-specific concerns, failed to implement action plans for identified issues, and did not ensure oversight of systems to maintain quality of care. Despite initiating a PIP for abuse allegations, there was no documentation of goal-setting, progress monitoring, or evaluation of compliance, and no active PIPs were in place during a period of organizational change.
A resident with Hepatitis C was not included in the facility's infection control surveillance, and the care plan did not mention the diagnosis. During the absence of the infection preventionist, no staff member was assigned to oversee the infection control program, and the RN who was supposed to cover was not informed. Infection tracking for staff illnesses was incomplete, with missing return-to-work data, and there was no policy for infection control oversight.
The facility did not ensure proper oversight of its infection control program, failing to track and monitor a resident with chronic Hepatitis C and omitting staff illness return-to-work data from surveillance records. When the infection preventionist went on leave, no qualified staff member was assigned to oversee the program, and key personnel were unaware of their responsibilities or the absence of oversight.
The facility did not provide mandatory training on its QAPI program to staff, as confirmed by interviews with RNs, an LPN, and a nursing assistant who were unaware of QAPI meetings or goals. The DON confirmed no formal QAPI education was provided, and documentation of such training was not available during the survey.
The facility did not consistently include dialysis communication reports in the medical records for two residents receiving hemodialysis and failed to update care plans with necessary dialysis information. Additionally, a resident's new physician orders after a medical appointment were not transcribed or implemented promptly, with some directions missing from the records. Staff interviews indicated that the lack of a medical records staff member contributed to these documentation and communication lapses.
A resident who was cognitively alert and required significant assistance with ADLs was admitted with multiple diagnoses, including malnutrition and diabetes. The facility did not ensure the resident's POLST was signed by a physician after admission, and staff interviews confirmed the required process was not followed according to policy.
A resident with a complex medical and behavioral history persistently refused all care, assessments, and medications, resulting in staff being unable to complete required evaluations. Despite this, staff documented assessment data in the MDS and other records based on assumptions or outdated information rather than direct observation, leading to incomplete and inaccurate documentation.
A resident with severe cognitive impairment and a diagnosis of PTSD was not thoroughly assessed for trauma history or potential triggers, as the facility stopped the PTSD screening after an initial negative response and did not seek further information from family or previous staff. The care plan addressed aggressive behaviors but did not reference the PTSD diagnosis or include interventions specific to trauma-related needs. No documentation or policy was provided to show appropriate assessment or care planning for PTSD.
A resident with major neurocognitive disorder, recent inpatient psychiatric care, and ongoing behavioral issues was admitted without the facility notifying the State Mental Health Authority or coordinating a PASARR Level II assessment. The resident exhibited repeated refusals of care, delusions, and aggressive behaviors, yet the facility relied on an outdated PASARR Level I from a previous facility and did not initiate the required mental health evaluation.
Two residents did not have their care plans updated after new physician orders were received, resulting in staff not consistently implementing required interventions such as leg elevation, compression wrapping, and scheduled repositioning. Staff interviews and observations confirmed a lack of awareness and follow-through on the new care requirements, and the care plans did not reflect the updated orders as required by facility policy.
A resident with multiple chronic conditions did not receive timely and complete implementation of physician orders, including delayed transcription of orders for diuretics, leg wraps, and antifungal powder. Staff were unaware of some new orders, and there was a lack of clear communication and documentation processes, resulting in missed treatments and incomplete care.
A resident with multiple pressure ulcers and intact cognition experienced significant unplanned weight loss, but staff failed to assess the cause or notify the provider as required. Despite electronic alerts and documentation, there was no evidence of timely dietician assessment or interdisciplinary team discussion, and communication lapses between dietary, nursing, and contracted staff contributed to the deficiency.
Two residents requiring dialysis were not consistently monitored or assessed for complications following their treatments. Care plans and order summaries lacked critical information such as dialysis access site location, monitoring instructions, and dialysis schedules. Nursing staff confirmed that pre- and post-dialysis assessments were often incomplete, and access site documentation was missing, making it difficult for staff to provide appropriate care.
A resident with a complex psychiatric and medical history persistently refused care, medications, and assessments, yet staff did not notify the medical director or implement additional interventions to address the resident's mental health needs and questionable capacity to refuse care. Documentation showed that the resident received minimal assessment and care over several months, and the care plan lacked specific strategies for managing ongoing refusals. The medical director was unaware of the situation, and the facility's behavioral health policy did not guide staff on how to proceed when interventions were ineffective.
Controlled medications in the emergency kit refrigerator, specifically Lorazepam, were not reconciled or documented at each shift change as required by facility policy. Nursing staff confirmed that the red tag number and quantity were not being checked or recorded, and the DON and medical director stated that such monitoring was expected to prevent diversion.
A resident with chronic kidney disease, diabetes, and other conditions was admitted with orders for a renal consistent carbohydrate diet, but the facility failed to provide the prescribed therapeutic diet. Staff were unaware of renal diet requirements, and the resident was served standard meals with only portion adjustments for diabetes, not renal needs. On dialysis days, the resident's daughter brought in food, and the facility did not provide or document appropriate meals, resulting in the resident not receiving the ordered renal diet.
A facility failed to implement effective infection control measures, resulting in an RSV outbreak affecting multiple residents. Despite symptoms like coughing and shortness of breath, the facility did not consistently isolate affected residents or enforce PPE use. Residents with underlying health conditions were not adequately monitored, and staff were unaware of necessary precautions. This led to the spread of RSV among residents, highlighting significant lapses in infection control practices.
Two residents in the facility experienced multiple falls due to the lack of comprehensive fall analyses and individualized interventions. Despite being identified as at risk for falls, their care plans were not updated to include specific fall prevention measures. This oversight resulted in one resident sustaining a fracture requiring surgery. The facility's policy on fall management was not followed, leading to deficiencies in care.
The facility failed to ensure that four nursing assistants were deemed competent to provide care, potentially affecting all 45 residents. Employee records lacked documentation of completed orientation and competency training. Interviews revealed that NAs were assisting residents without being signed off for skills competencies. The DON stated that competency records were missing, and the facility's training program requirements were not provided.
The facility failed to report alleged abuse and neglect for two residents in a timely manner. A hospice nurse found a resident in a neglected state but did not report it. Another resident experienced falls resulting in a serious injury that was not reported. The facility's reporting policy was inconsistent with federal standards.
The facility failed to accurately assess and manage pressure ulcers for two residents, leading to inadequate interventions and deterioration of existing wounds. One resident had multiple stage 3 pressure ulcers upon admission, with inconsistent wound assessments and care plans not reflecting necessary interventions. Another resident developed a wound misidentified as MASD, with care plans not updated with current interventions. Staff interviews revealed limitations in care plan individualization and inconsistent monitoring, contributing to the deficiencies.
A facility failed to ensure clear communication between hospice and facility staff for a resident receiving hospice care. The hospice nurse communicated care plan changes to an unidentified nursing assistant instead of the nurse on duty, leading to a lack of documentation in the electronic health record. Interviews revealed no designated staff for coordinating hospice communication, contrary to the facility's policy.
The facility failed to implement enhanced barrier precautions (EBP) and proper hand hygiene for residents requiring such measures. A resident with diabetes and cellulitis received IV antibiotics without the administering RN wearing a gown, despite signage indicating the need for EBP. Additionally, another resident with dementia did not receive proper hand hygiene care during peri care, as the RN did not perform hand hygiene before or after glove use.
A resident fell from a mechanical lift due to improper use, resulting in spinal fractures. The facility failed to ensure correct sling sizes and safety checks for multiple residents, leading to discrepancies between care plans and actual practices. Staff were unaware of proper procedures, increasing the risk of injury.
A resident with severe cognitive impairment and a history of exit-seeking behaviors managed to elope from the facility and drive around the city for 1.5 hours due to inadequate supervision and delayed response to the WanderGuard alarm. The facility failed to implement necessary interventions and revise the care plan despite multiple documented exit attempts.
A resident with severe cognitive impairment and multiple medical conditions was transferred to another facility without the required 30-day notice. The family was not given the opportunity to appeal the discharge, and the Ombudsman was not notified in writing. The facility staff admitted to not following the discharge policy, citing safety concerns.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse by Known Sexually Inappropriate Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a severely cognitively impaired female resident from sexual abuse by a male resident with a known history of sexually inappropriate behaviors. Prior to admission, referral documents from a previous facility clearly identified that the male resident had engaged in public urination, following female residents, rubbing their shoulders and arms, and an incident involving touching a woman’s breast, which had been serious enough to be reported to the State Agency. That prior facility had revised his care plan to include 1:1 supervision to prevent further sexually inappropriate behavior, and progress notes documented that while on 1:1 supervision he had no further incidents of touching female residents. Despite receiving these records, the admitting facility did not initially incorporate this history of sexually inappropriate behaviors into his vulnerability assessment or care plan. After admission, the male resident’s behaviors toward female residents, particularly one female resident with severe cognitive impairment, escalated over several months. Progress notes documented repeated episodes of him holding and rubbing female residents’ hands, rubbing or attempting to touch their arms and chest, standing over or very close to them, staring at them, and attempting to touch their breasts. Staff repeatedly redirected him, but the behaviors persisted and often required frequent or constant redirection. Although the care plan was eventually updated to address “touching of other residents” and directed staff not to allow physical contact, progress notes showed that staff did not consistently prevent physical contact, and the male resident continued to approach and touch female residents, including the cognitively impaired female resident who became the primary focus of his attention. On the day of the abuse incident, a nursing assistant observed the male resident standing over the cognitively impaired female resident, who was resting in a recliner, with his hand under her shirt touching her breast. Another resident pointed toward them, prompting the assistant to intervene, tell him to stop, and direct him away. The female resident, who had severe cognitive impairment and required extensive assistance with ADLs, awoke and questioned what he was doing, indicating she was unable to independently protect herself from the unwanted sexual contact. This event occurred in the context of documented ongoing and escalating sexually inappropriate behaviors by the male resident toward female residents, including this particular resident, and despite prior knowledge from referral records, guardian reports, and internal documentation that he had a pattern of progressing from seeking proximity and handholding to touching women’s breasts.
Failure to Designate a Medical Director for Resident Care Oversight
Penalty
Summary
The facility failed to designate a physician to serve as Medical Director responsible for implementation of resident care policies and coordination of medical care, affecting all 52 residents in the facility. The DON reported that the former Medical Director retired in June or July and that the position had not been filled since that time. The Administrator confirmed that the Medical Director position had been vacant since July 2025 and that the local medical physician group would not contract with the facility. The facility had attempted to contract with two other medical groups and was in ongoing contract negotiations with a physician from one of those groups, but no formal appointment had been made. During interviews, the DON stated she was the only person reviewing clinical trends and participating in QAPI clinical review, indicating that physician-level oversight of these functions was not in place. The Administrator stated that, in the absence of a Medical Director, they had informal conversations with physicians when they rounded at the facility, but there was no formal notification to the Governing Body regarding the vacancy, although ownership was verbally informed in daily conversations. The Administrator was unsure how physician-level oversight, contractual obligations, and compliance with federal requirements had been achieved since July 2025. This situation existed despite a written Medical Director policy, last reviewed on 3/2/25, that outlined extensive responsibilities for the Medical Director, including implementation of resident care policies, coordination of medical care, evaluation of staff adequacy, review of incidents and accidents, and participation in QAPI meetings.
Lack of Medical Director Participation in QAPI Committee
Penalty
Summary
The facility failed to include a Medical Director as a required member of the Quality Assurance Performance Improvement (QAPI) committee, resulting in noncompliance with the requirement that the Quality Assessment and Assurance group have the required members and meet at least quarterly. Review of QAPI documentation from July 2025 through January 2026 showed no Medical Director attendance at QAPI meetings during that period. The facility’s QAPI plan states that the program is to be an ongoing, facility-wide plan to monitor and evaluate the quality and safety of resident care, resolve identified problems, and coordinate quality-related activities across departments and services. Interviews with facility leadership confirmed that the Medical Director position had been vacant since approximately June or July 2025, when the former Medical Director retired, and that no replacement had been appointed. The DON reported that she was the only person reviewing clinical trends and participating in QAPI clinical review during this time. The Administrator stated that the former Medical Director had been a quarterly attendee at QAPI and last attended in June 2025, and acknowledged that this was the second quarter without a Medical Director participating. The Administrator was unsure how physician-level oversight, contractual obligations, and compliance with federal requirements were being achieved since the Medical Director position became vacant. All 52 residents residing in the facility were subject to this deficient practice.
Failure to Assess and Treat Impaired Skin Integrity
Penalty
Summary
The facility failed to comprehensively assess and treat impaired skin integrity for a resident with acute dermatitis. The resident, who had diagnoses including type two diabetes and obesity, was admitted with a history of frequent incontinence and required extensive assistance with personal hygiene and toileting. Hospital discharge orders included specific topical treatments and interventions for skin care, but review of the medication administration record showed no indication that these treatments were applied. The initial skin assessment did not identify issues, but subsequent progress notes and observations revealed persistent redness and moisture under abdominal folds and in the groin area. During care observations, a nursing assistant noted significant redness and soreness in the resident's abdominal fold and groin but did not report these findings to the nurse. Instead, the nursing assistant independently applied antifungal cream without notifying licensed staff or ensuring physician orders were followed. The infection preventionist later confirmed the presence of red and moist skin areas and stated that the issue should have been reported to the nurse and physician for appropriate intervention. The resident reported a history of similar skin issues and described more frequent hygiene interventions at a previous facility, which were not provided at the current facility due to the resident's condition. Interviews with nursing staff and the director of nursing revealed a lack of documentation regarding the skin condition and a reliance on nursing assistants to report new skin issues. The director of nursing acknowledged that it was outside the scope of practice for a nursing assistant to choose and apply treatment products without nurse or physician involvement. The facility's wound care procedure required verification of physician orders and documentation of wound care, which was not followed in this case.
Failure to Provide Comprehensive Pressure Ulcer Care and Monitoring
Penalty
Summary
The facility failed to monitor and complete comprehensive skin assessments, evaluate the effectiveness of interventions, and provide physician-ordered treatments as prescribed for a resident at risk for pressure ulcers with a history of such ulcers. The resident, who was obese, dependent on staff for lower body care, had an indwelling urinary catheter, and was always incontinent of bowels, was identified as having a healed stage III pressure ulcer and a moderate risk for pressure ulcers according to the Braden scale. The care plan included interventions for behavior management and pressure ulcer prevention, but the resident frequently refused care and preferred to sleep in a recliner rather than a bed. Between early March and early April, the treatment administration record indicated that a prescribed mixture of calmoseptime ointment and collagen fibers was applied to the resident's buttocks twice daily. However, there was no corresponding documentation of skin assessments or monitoring of the treated area during this period. During an observed care episode, staff did not follow the physician's order to mix the cream with collagen, nor did they measure or assess the affected areas. The nurse present was not comfortable with wound staging and deferred to the DON for assessment, and staff reported that the resident's behaviors often led to rushed care and missed steps. Interviews with staff revealed inconsistent wound care practices, lack of proper documentation, and uncertainty regarding wound assessment and treatment. The infection preventionist and DON confirmed that the current wound treatment was not appropriate and that staff were expected to document wound conditions daily and seek guidance if unsure. Facility protocols required verification of physician orders and documentation of wound care and assessments, but these were not consistently followed, resulting in a failure to prevent new ulcers and properly manage existing skin breakdown.
Failure to Provide Proper Catheter and Perineal Care Resulting in Repeated UTIs
Penalty
Summary
The facility failed to provide appropriate care and services to prevent urinary tract infections (UTIs) for a resident with an indwelling urinary catheter. The resident had a history of overactive bladder, benign prostatic hyperplasia, and was always incontinent of bowels, requiring total assistance with lower body care. The care plan included monitoring for urinary complaints, pain, urine characteristics, and cognitive changes, with orders for monthly catheter changes and evaluation for signs and symptoms of UTI. Despite these interventions, the resident experienced multiple UTIs, as documented by positive urine cultures and symptoms such as hematuria and hallucinations. Direct observation of care revealed improper perineal and catheter care practices by staff. Nursing assistants used the same washcloth to clean areas contaminated with stool and then proceeded to clean the catheter area without changing cloths or gloves, and without performing hand hygiene between tasks. Staff also failed to change gloves or sanitize hands before applying barrier cream after handling the catheter and perineal area. These actions were inconsistent with infection control guidelines and increased the risk of introducing bacteria to the urinary tract. Interviews with the infection preventionist and director of nursing confirmed that there had been no surveillance or analysis of catheter-related infections, and no audits or education had been conducted to address proper catheter and perineal care. The facility's policy required clean technique when handling catheters, but this was not followed during observed care, contributing to repeated UTIs in the resident.
Failure to Perform Proper Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed by staff during personal care for four residents. Observations revealed that nursing assistants did not consistently perform hand hygiene between glove changes or after removing gloves, particularly during perineal care and when cleaning residents after bowel movements. In several instances, staff used the same gloves or cleaning utensils to clean both the front and back perineal areas, and in some cases, failed to sanitize or wash hands before donning new gloves or after completing care tasks. Residents involved had significant care needs, including assistance with hygiene due to conditions such as fractures, intellectual disabilities, and parkinsonism. Staff were observed providing extensive assistance, including the use of mechanical lifts and enhanced barrier precautions. Despite these measures, lapses in infection control were noted, such as using contaminated washcloths, not changing gloves between different care tasks, and not performing hand hygiene at appropriate times during and after care. Interviews with staff indicated inconsistent understanding and application of hand hygiene protocols. Some staff believed handwashing was only necessary between residents or after particularly messy care, while others were unaware of the need to perform hand hygiene between glove changes. Facility leadership acknowledged the importance of proper hand hygiene and recognized that current practices did not meet expected standards, as confirmed by the facility's own infection prevention policies.
Failure to Develop and Implement Individualized, Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, individualized care plans for multiple residents, as required. Surveyors found that care plans were often generic, lacking specific interventions tailored to each resident's diagnoses, behaviors, and care needs. For example, one resident with multiple complex diagnoses, including hypoparathyroidism, chronic hepatitis C, and behavioral issues, had a care plan that did not address recent behavioral changes or new medical conditions identified by the primary care provider. Staff interviews confirmed that the care plans were difficult to individualize due to the use of pre-programmed templates, resulting in missing or inadequate interventions for new or evolving resident needs. Several residents with significant medical conditions, such as diabetes, chronic kidney disease, pressure ulcers, and use of anticoagulants, had care plans that omitted critical information. For instance, residents on blood thinners did not have care plans instructing staff to monitor for signs of bleeding or when to notify a provider. Residents with pressure ulcers or at risk for skin breakdown lacked scheduled repositioning regimens or instructions for staff on how to respond to refusals of care. In some cases, care plans failed to specify the frequency or method of essential care, such as catheter care or wound treatment protocols, despite these being required by facility policy and resident condition. Direct observations and staff interviews further revealed that staff were often unaware of specific care needs or protocols due to these care plan deficiencies. For example, one resident with pressure ulcers was observed sitting in a wheelchair for extended periods without repositioning, and staff were unsure how often repositioning should occur. Another resident with a Foley catheter had no care plan guidance on catheter care frequency. The facility's own policy required care plans to be person-centered and updated as resident conditions changed, but surveyors found that care plans were not consistently revised to reflect new diagnoses, changes in condition, or provider recommendations.
Sanitation Deficiencies in Kitchen and Ice Machine
Penalty
Summary
Surveyors observed multiple sanitation deficiencies in the facility's kitchen and food preparation areas. A stainless-steel food prep counter had a lower shelf with a dry black/brown substance, a brown liquid covering a large area, and a greasy, sticky buildup with dirt and grime. A plastic container on the shelf, used for condiment cups, was visibly dirty with an unknown brown substance and food crumbs. Staff were observed sitting on the freezer, which is sometimes used to set food on, and using a cell phone in the kitchen, both of which were acknowledged by staff as inappropriate and potential sources of cross-contamination. The dietary manager confirmed that staff were signing off on cleaning tasks, but acknowledged the need for more specific cleaning logs and possible retraining. The registered dietitian stated she had not conducted visual audits of the kitchen and was unaware of the cleanliness issues, expecting the dietary manager to perform regular audits. Additionally, the ice machine located in a hallway was found to have a white crusty buildup resembling mineral deposits and a black/gray/brown spotty buildup inside the door above the ice bin. Some of this buildup was removable with a dry paper towel. The maintenance director reported that he does not keep a log of cleaning and de-scaling the ice machine, performing these tasks approximately every six months, with a deep clean about once a year. Manufacturer guidelines recommend cleaning and sanitizing the ice machine every six months. The facility's own policy requires a written cleaning schedule, assignment of tasks, and staff initials and dates upon completion, but these procedures were not being adequately followed.
Governing Body Failed to Ensure Oversight and Correction of Deficient Practices
Penalty
Summary
The governing body failed to provide appropriate oversight to ensure that previously identified deficient practices were corrected and compliance was achieved. QAPI meeting minutes revealed that while various quality issues such as pressure ulcers, falls, infection control, psychotropic medication use, staffing shortages, and grievances were discussed, there was a lack of measurable goals, thorough data analysis, and actionable plans. For example, the facility did not document current rates for pressure ulcers or falls, nor did they analyze contributing factors or trends. Infection control discussions lacked benchmarks and did not address how the infection preventionist would complete required training or who would oversee the program in the interim. Similarly, open staff positions and their impact on care were not analyzed, and grievances related to call light response, care, and dietary issues were not thoroughly investigated or linked to potential systemic causes. The QAPI committee did not assign responsibility for follow-up actions, nor did it ensure that staff were educated on new QAPI plans or performance improvement projects. There was no evidence of staff competency checks following education, and the facility did not ensure that staff understood or implemented the QAPI program's requirements. The administrator acknowledged a lack of direct oversight and was unaware of gaps in infection control training and supervision. The facility's QAPI policy required the governing body to establish and implement plans to correct deficiencies and monitor their effects, but these steps were not adequately carried out. Additionally, the facility did not ensure that audits and monitoring were effectively implemented to address previous deficiencies, such as those related to psychotropic medication diagnoses and documentation. The absence of clear goals, designated oversight, and comprehensive analysis of data contributed to the ongoing noncompliance. The administrator relied on external consultants for plan of correction development and did not ensure that internal leadership provided the necessary oversight to achieve compliance.
Failure to Implement Facility Assessment Protocol for Staff Competencies
Penalty
Summary
The facility failed to implement its facility assessment protocol to ensure that staff competencies were identified and completed according to the duties performed. During interviews, the medical director confirmed that the facility was responsible for reviewing, identifying, and determining appropriate interventions and oversight of outcomes. The administrator acknowledged that the recent merger of two nursing homes, which included both residents and staff, created additional challenges. He also stated that updates to the facility assessment, including staff education, had not yet been implemented, despite decisions being made regarding resident care, resources, and services. A review of the facility's August 2024 Facility Assessment Tool showed that the leadership team planned to discuss goals to ensure direct care staff were trained to provide necessary services. The assessment identified the need for staff education, training, certifications, testing, and policies to support resident care. The facility also intended to gather input from residents, family members, and staff to address concerns and expectations. However, the report indicates that the facility had not yet updated or implemented these assessments and related staff education, affecting the ability to ensure competent care for all 56 residents during both routine operations and emergencies.
Failure to Analyze and Document QAPI Data with Measurable Goals
Penalty
Summary
The facility failed to ensure that data submitted to the Quality Assurance Performance Improvement (QAPI) committee was properly analyzed and documented, resulting in a lack of oversight for identified areas needing improvement. Review of QAPI meeting minutes over a one-year period showed that department heads brought forward data on topics such as infection control, falls, incident reports, and vaccinations. However, there was no documentation of benchmarks or measurable goals for these areas, nor evidence of ongoing monitoring to determine if goals were met or if continued QAPI oversight was necessary. Interviews with the medical director and administrator confirmed that the facility did not have a formalized process for setting or tracking measurable goals within QAPI activities. The administrator acknowledged that the recent merger of two nursing homes had introduced additional challenges, and that the QAPI committee had not established a process to identify or document improvements. Review of the facility's QAPI policy indicated that benchmarks and data analysis were required, but these steps were not being followed in practice.
Failure of QAPI Committee to Identify and Address Facility-Specific Concerns
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify facility-specific concerns, implement an action plan to address identified issues, or ensure committee participation in the development and oversight of systems to maintain quality of life and care for all residents. Review of QAPI meeting minutes over a one-year period revealed that, although a performance improvement project (PIP) related to abuse allegations was initiated, there was no documentation on how goals would be met, progress monitored, or current measures evaluated for compliance. Interviews with the medical director and administrator confirmed that the facility was expected to review, identify, and determine appropriate interventions and oversight for outcomes, but these steps were not taken. The administrator acknowledged that the recent merger of two nursing homes introduced additional challenges, including the need to streamline resident care, resources, and services, but also stated that no PIPs were currently in place. Review of the facility's QAPI policy indicated that the committee was responsible for establishing benchmarks, analyzing data, and determining root causes, but these processes were not followed.
Failure to Monitor Infectious Disease and Maintain Infection Control Oversight
Penalty
Summary
The facility failed to ensure that a resident with a highly infectious disease, Hepatitis C, was included in the infection control (IC) surveillance data for monitoring. The resident, who had a history of multiple medical conditions and was admitted from a now-closed sister facility, was not listed in the facility's infection tracking system despite a physician's note identifying the diagnosis. Additionally, the resident's care plan did not mention the Hepatitis C diagnosis. This omission occurred even though the facility had previously contracted with a consultant infection preventionist (CIP) to assist with infection control oversight following a prior deficiency. Further review revealed that the facility did not maintain adequate oversight of the IC program, as there was no designated staff member actively managing the program during the infection preventionist's medical leave. The registered nurse who was supposed to oversee the program was not informed of this responsibility and had no knowledge of the infection tracking process. Surveillance records for staff illnesses were incomplete, with missing information on symptoms resolution and return-to-work dates. The director of nursing acknowledged these gaps and confirmed that all relevant data should have been entered to ensure proper tracking and staff management. There was also no policy provided regarding oversight of the IC program.
Failure to Maintain Infection Control Oversight and Surveillance
Penalty
Summary
The facility failed to maintain oversight of its infection control (IC) program, resulting in inadequate tracking, trending, and analysis of infection data. Specifically, the facility did not include a resident with a diagnosis of chronic Hepatitis C in its IC surveillance system, despite the resident's recent hospital stay and documented diagnosis. The resident's care plan also lacked any mention of the Hepatitis C diagnosis. Additionally, the facility's infection surveillance records for staff illnesses were incomplete, with missing information regarding symptoms resolution and return-to-work dates for staff who had reported illnesses. Oversight of the IC program was further compromised when the designated infection preventionist (IP) went on medical leave, and no qualified staff member was assigned to oversee the program in her absence. Interviews revealed that the registered nurse who was supposed to cover the IP's duties was not informed of this responsibility and had no knowledge of the infection tracking process. The contracted infection preventionist had not yet begun providing assistance, and the medical director was unaware that there was no active IP or designated replacement. The facility also lacked a policy related to oversight of the IC program.
Lack of Mandatory QAPI Training for Staff
Penalty
Summary
The facility failed to provide mandatory training to staff on its Quality Assurance and Performance Improvement (QAPI) Program. Multiple staff members, including RNs, an LPN, and a nursing assistant, reported during interviews that they were either unaware of QAPI meetings, had not attended them, or did not know the specific goals or performance improvement projects of the facility. While some staff mentioned attending meetings if their schedules allowed, none could identify current QAPI goals or describe their roles in the program. The admission coordinator was aware of a plan to prevent infection control outbreaks but did not reference formal QAPI training or goals. A review of email correspondence with the director of nursing confirmed that there was no formal QAPI education provided to employees. The administrator stated that QAPI education was given upon employment but acknowledged the need to formalize requirements for all staff. The facility's QAPI policy outlined processes for identifying and addressing areas for improvement, but documentation of employee QAPI training was requested and not provided during the survey. This deficiency had the potential to affect all 57 residents in the facility.
Failure to Maintain Complete Medical Records and Timely Transcription of Physician Orders
Penalty
Summary
The facility failed to maintain complete and accurate medical records for residents receiving dialysis and did not ensure timely transcription and implementation of physician orders following a medical appointment. For two residents with end-stage renal disease and chronic kidney disease, the facility's electronic medical records lacked consistent documentation of dialysis run/communication reports, with only a few reports present and several missing. Additionally, the care plans for these residents did not include essential information such as dialysis schedules, access site details, or monitoring instructions, despite the residents' ongoing need for hemodialysis. Interviews with facility staff revealed that contracted nurses were unable to access hospital records, and the facility no longer employed a medical records staff member responsible for obtaining and scanning external documents into the residents' records. This resulted in incomplete communication between the dialysis center and the facility, contrary to the facility's own policies and agreements, which required sharing of dialysis summaries, complication reports, and care recommendations. In a separate incident, a resident with multiple comorbidities, including heart failure and renal insufficiency, had new physician orders following an appointment that were not transcribed or implemented in a timely manner. Orders for leg wraps, compression stockings, and medication adjustments were delayed by several days, and some directions, such as elevating lower extremities and applying antifungal powder, were not entered into the medication or treatment administration records. Staff interviews confirmed that the process for handling new orders was inconsistent and hampered by the absence of a dedicated medical records staff member, leading to delays and incomplete documentation.
Failure to Obtain Physician Signature on POLST Upon Admission
Penalty
Summary
The facility failed to ensure that a physician signed the Provider Order for Life-Sustaining Treatment (POLST) for one resident following admission. The resident was cognitively alert and required substantial to maximal assistance with activities of daily living, and had diagnoses including malnutrition, anxiety, diabetes, and cirrhosis. The resident's POLST, dated prior to admission, indicated full code status, but there was no documentation that the resident's wishes were communicated to the primary physician, nor was the POLST signed by the physician within 30 days of admission. Interviews with facility staff, including an RN, the DON, and the admission coordinator, confirmed that the process for obtaining and documenting the POLST was not followed as per facility policy. The staff acknowledged that the POLST should have been completed and signed by the physician upon admission, and that this omission was not acceptable practice. Review of the facility's Advance Directive Policy further indicated that the resident's status on the POLST should be obtained and documented upon admission, and the document should be accessible in the medical record.
Failure to Accurately Assess Resident Due to Persistent Refusals
Penalty
Summary
The facility failed to accurately and comprehensively assess a resident who exhibited ongoing refusal of all cares, medications, treatments, and evaluations. Upon admission and throughout the resident's stay, staff were unable to complete required assessments due to the resident's persistent refusals and behaviors, such as not allowing staff entry into the room, refusing to communicate, and declining all personal care and medical interventions. Despite these refusals, staff documented assessment data in the Minimum Data Set (MDS) and other records, often based on assumptions or outdated information, rather than direct observation or current evaluation. For example, vital signs and weights were only recorded at admission and then repeated without new measurements, and staff marked the resident as independent in personal hygiene and continence without being able to verify these statuses. The resident had a complex medical history, including hypoparathyroidism, multiple fractures, hypothyroidism, generalized anxiety disorder, and a history of behavioral health issues. The resident was noted to have delusions, social isolation, and a pattern of refusing all care, including medications and assessments. Staff and the MDS nurse acknowledged that they could not perform comprehensive assessments, and the MDS data submitted was not based on actual, current assessments. The medical director was unaware of the extent of the resident's refusals and the lack of skilled nursing care, and staff interviews confirmed that no direct care, assessments, or treatments had been provided for an extended period. Documentation in the resident's records, including progress notes, MDS assessments, and care tasks, reflected incomplete or inaccurate information due to the inability to assess the resident. Staff entered data into the electronic system to fulfill submission requirements, despite knowing the information was not accurate or current. The facility's failure to ensure a comprehensive and accurate assessment process, as required by federal regulations, was evident in the lack of direct observation, incomplete documentation, and reliance on assumptions or outdated data for the resident who persistently refused care.
Failure to Accurately Assess and Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to accurately and thoroughly assess a resident with a diagnosis of Post-Traumatic Stress Disorder (PTSD). The resident, who had severely impaired cognition and was dependent on staff for all activities of daily living, was identified as feeling down or hopeless several days a week and exhibited verbal behaviors such as screaming, threatening, or cursing. Despite having a diagnosis of PTSD, the facility's PTSD Resident Screening assessment was stopped after the resident answered 'no' to the initial trauma question, and no further attempts were made to gather information from the resident's emergency contact, family, or previous facility staff regarding the cause of the PTSD or potential triggers. The resident's care plan addressed her aggressive behaviors during bathing and included interventions such as administering medications, encouraging verbalization, using diversion techniques, and allowing personal space. However, the care plan did not mention her PTSD diagnosis or any history of trauma, nor did it include strategies specific to managing PTSD-related triggers. The social service designee who completed the trauma assessment could not recall reaching out for additional information and confirmed that no documentation existed regarding assessment for triggers or appropriate care related to the PTSD diagnosis. No relevant policy was provided by the facility during the survey.
Failure to Notify State Mental Health Authority and Complete PASARR Level II Assessment
Penalty
Summary
The facility failed to notify the State Mental Health Authority for a resident with a diagnosis of major neurocognitive disorder, known behavioral issues, and a recent inpatient psychiatric stay prior to admission. Upon review, it was found that the resident had a history of significant mental health concerns, including catatonia, delusions, and repeated refusals of care, medication, and assessments. Despite these ongoing issues, the facility did not coordinate a new PASARR Level II assessment upon the resident's transfer from a now-closed sister facility, relying instead on an outdated Level I screening that did not reflect the resident's current mental health status or recent psychiatric hospitalization. The resident exhibited multiple concerning behaviors after admission, such as chronic refusal of care, delusional statements, fasting due to religious delusions, and aggressive responses to staff interventions. Staff and the primary care provider repeatedly documented the resident's refusals and behavioral health needs, including the administration of antipsychotic medications and attempted transfers to behavioral health services. Despite these interventions and ongoing behavioral health concerns, there was no evidence that the facility referred the resident for a PASARR Level II evaluation or notified the appropriate mental health authorities as required for individuals with significant mental health diagnoses and recent psychiatric treatment. Interviews and documentation confirmed that facility leadership was aware of the resident's refusals and mental health history. The director of nursing acknowledged that, although state law did not require a new PASARR Level I for transfers from the sister facility, staff should have initiated a Level II assessment due to the resident's mental health diagnosis and recent inpatient psychiatric care. No policy or documentation was provided to show that the facility had procedures in place to ensure compliance with PASARR requirements in such cases.
Failure to Revise Care Plans After New Physician Orders
Penalty
Summary
The facility failed to revise the care plans for two residents after receiving new physician orders that required changes in their care. One resident, who had diagnoses including atrial fibrillation, heart failure, renal insufficiency, dementia, and morbid obesity, was ordered to have her lower extremities wrapped daily, compression stockings applied, and her legs elevated as much as possible. Despite these orders, her care plan did not reflect these interventions, and staff were not consistently aware of or implementing the new orders. Observations showed the resident seated in a wheelchair with her legs down and not elevated, and staff interviews revealed a lack of communication regarding the new care requirements. Another resident, with diagnoses including diabetes, dementia, depression, and multiple pressure ulcers, was ordered by a wound consultant to be repositioned every two hours. However, her care plan did not specify the frequency of repositioning, and staff were unsure of how often this should occur. Observations over a two-hour period showed the resident remained in the same position in her wheelchair without being repositioned, despite staff being present and interacting with her. The care plan only mentioned encouraging the resident to shift weight as she allows, without scheduled repositioning. The facility's own policies require that care plans be updated to reflect changes in residents' conditions and new orders, and that interventions be consistent with professional standards of practice. Interviews with staff and the medical director confirmed the expectation that care plans should be revised as residents' needs change. In both cases, the failure to update the care plans resulted in staff not consistently providing the care as ordered by physicians and consultants.
Failure to Timely Implement and Communicate Physician Orders
Penalty
Summary
The facility failed to implement physician orders for a resident with multiple complex medical conditions, including atrial fibrillation, heart failure, renal insufficiency, dementia, anxiety, depression, and morbid obesity. The resident required extensive assistance with activities of daily living and had recently been seen by a physician due to increased swelling in her lower legs. The physician ordered the addition of a diuretic (Lasix), daily application of compression stockings or ace wraps, elevation of the lower extremities as much as possible, and application of antifungal powder under abdominal folds. However, there were delays and omissions in transcribing and implementing these orders. The order for ace wraps was transcribed eight days after receipt, and the increased Lasix dosage was transcribed two days after the order was received. The medication and treatment administration records did not include directions for staff to elevate the resident's lower extremities or to apply antifungal powder as ordered. Observations and staff interviews revealed that the resident was not consistently receiving the ordered treatments. On one occasion, the resident was observed without leg wraps, and staff were unaware of the new orders. Nursing assistants reported that information about new orders was not always communicated during shift reports, and there was confusion regarding the application of antifungal powder. Additionally, the facility lacked a designated medical records person, resulting in delays in scanning and processing physician orders. The original physician order was found unscanned in a pile of papers, and the facility was unable to provide a policy for order transcription and implementation during the survey.
Failure to Assess and Address Significant Weight Loss
Penalty
Summary
The facility failed to properly assess and address significant weight loss in a resident who was identified as having intact cognition, being independent with eating, and having multiple pressure ulcers and venous ulcers. The resident experienced a weight loss of more than 10% over six months, which was not part of a physician-prescribed weight-loss regimen. Despite electronic medical record alerts and documentation of the weight loss, there was no evidence that the provider was notified, and the dietician had not assessed the resident in response to the weight change. The resident was on a regular diet and received Arginade for wound healing, but there was no documentation of additional nutritional interventions specifically for the weight loss. Interviews with facility staff revealed a lack of communication and follow-up regarding the resident's weight loss. The dietary manager was aware of the weight loss alerts in the electronic system but did not confirm whether the provider had been notified or if the dietician had assessed the resident. The dietician only visited monthly and was not made aware of the resident's weight loss, relying on the dietary manager to provide updates. Nursing staff also did not notify the provider, and there was confusion about which department was responsible for monitoring and reporting weight changes. The registered nurse confirmed that the weight loss should have been investigated, and the registered dietician expected to be notified of such changes to perform an assessment. The facility's policy required immediate re-weighing and notification of the dietician for any weight change of 5% or more, with the dietician expected to respond within 24 hours. However, this protocol was not followed, and the interdisciplinary team did not discuss or address the resident's weight loss in a timely manner. The lack of communication and failure to follow established procedures resulted in the resident's significant weight loss not being properly assessed or managed.
Failure to Consistently Monitor and Assess Dialysis Residents Post-Treatment
Penalty
Summary
The facility failed to consistently monitor and assess residents for potential complications related to dialysis treatment post-treatment for two residents with end-stage renal disease. One resident, admitted with chronic kidney disease stage 5 and other comorbidities, had a dialysis port in the right upper chest and was on a renal and consistent carbohydrate diet. The resident's order summary did not mention monitoring the access site for infection, the location of the access site, or the dialysis schedule. The care plan lacked identification and location of the access site, dialysis schedule, and the dialysis provider. Pre- and post-dialysis evaluation assessments were inconsistently completed, with only a portion of required assessments documented over two months. Another resident with end-stage renal disease and multiple comorbidities had a care plan that did not identify dialysis status, access site location, necessary precautions, or monitoring requirements. The order summary also lacked information on access site monitoring and dialysis schedule. Interviews with nursing staff confirmed that pre- and post-dialysis assessments were not consistently completed and that access site locations were not documented, making it difficult for staff, especially contracted nurses, to provide appropriate care. Facility policies and agreements required assessment of dialysis access sites and monitoring for complications, but these were not consistently followed.
Failure to Notify Medical Director and Provide Appropriate Mental Health Services
Penalty
Summary
The facility failed to notify the medical director and provide appropriate treatment and services to a resident who exhibited ongoing mental health and behavioral issues, including repeated refusals of care, medication, and assessments. The resident, who had a complex medical and psychiatric history including major neurocognitive disorder, catatonia, and recent behavioral health hospitalizations, consistently refused all care, medications, and personal hygiene assistance shortly after admission. Despite these ongoing refusals and the resident's questionable capacity to make informed decisions, staff did not implement additional interventions or seek timely guidance from the medical director regarding the resident's ability to refuse care and the risks associated with not receiving necessary services. Documentation and interviews revealed that staff were unable to perform comprehensive assessments, obtain vital signs, or provide basic care such as bathing and laundry for the resident over several months. Progress notes indicated that the resident was largely unassessed, with only minimal documentation of vital signs and weights, and staff often recorded the resident as independent in personal hygiene without direct observation or assessment. The care plan lacked specific interventions for managing the resident's repeated refusals, and staff primarily relied on offering care and notifying the family, without escalating concerns to the medical director or ensuring a formal evaluation of the resident's decision-making capacity. Interviews with nursing staff, the DON, and the medical director confirmed that the medical director was not informed of the resident's ongoing refusals and lack of care. The medical director stated he would have expected to be notified, especially given the resident's inability to make safe decisions regarding his health and safety. The facility's behavioral health policy did not provide clear guidance for staff on how to proceed when current interventions were ineffective, and there was no evidence that the interdisciplinary team took further steps to address the resident's needs or ensure his health and safety in light of his persistent refusals and compromised mental status.
Failure to Reconcile and Document Emergency Kit Controlled Medications
Penalty
Summary
The facility failed to ensure that controlled medications, specifically Lorazepam stored in the emergency kit refrigerator, were reconciled according to facility protocol. During an observation with an RN, it was found that the Lorazepam vials were not being checked or documented at each shift change as required. The RN was unable to locate documentation of reconciliation in the narcotic logbook, and confirmed that the emergency Lorazepam had not been checked at shift change. Both the RN and an LPN acknowledged that the red tag number and the amount of Lorazepam should be monitored and documented at each shift change to prevent diversion. Further interviews with the DON and the medical director confirmed that the expectation was for nursing staff to monitor and document controlled medications each shift. Review of the facility's Controlled Substances policy indicated that reconciliation of controlled medications should occur upon receipt, administration, disposition, and at the end of each shift, with both incoming and outgoing nurses participating in the count. The policy also required documentation and reporting of discrepancies, as well as periodic review by the DON. Despite these protocols, the required monitoring and documentation for the emergency Lorazepam was not being performed.
Failure to Provide Ordered Renal Diet for Resident with Complex Medical Needs
Penalty
Summary
A resident with chronic kidney disease stage 5, anemia, type 2 diabetes mellitus, and vitamin D deficiency was admitted to the facility with physician orders for a renal consistent carbohydrate diet. The resident's care plan did not mention nutritional status or specify the diet to be provided, despite the resident's complex medical needs and dialysis attendance. The dietary department's records and diet slip only indicated a diabetic diet, with no mention of renal-specific restrictions or foods to avoid. Interviews with facility staff revealed a lack of understanding and implementation of the prescribed renal diet. The dietary aide was unaware of what a renal diet entailed, and the cook and dietary manager both reported that the resident received the same meals as other residents, but in smaller portions, based on a diabetic diet. The dietary manager and cook also confirmed that no special renal diet modifications were made, and potassium-rich foods were not specifically avoided. On dialysis days, the resident's daughter frequently brought in outside food, and the facility did not provide a meal tray or document meal intake for those occasions. The registered dietician confirmed that the dietary department should have been knowledgeable about renal diets and that the resident should have been served appropriate meals with limited potassium and other necessary restrictions. The medical director expected the dietary department to provide the prescribed diet as ordered. The facility failed to ensure that the resident received the ordered therapeutic diet, and staff did not consistently communicate or implement the dietary orders, resulting in the resident not receiving the required renal diet.
Inadequate Infection Control Measures Lead to RSV Outbreak
Penalty
Summary
The facility failed to implement effective infection control strategies to mitigate the spread of Respiratory Syncytial Virus (RSV), resulting in an outbreak affecting multiple residents. The initial case was identified on December 28, 2024, but the facility did not adequately isolate affected residents or enforce the use of personal protective equipment (PPE) such as masks and gowns. Observations revealed that residents were not wearing masks in communal areas, and staff were not consistently using PPE when interacting with residents who had tested positive for RSV. Several residents, including those with underlying health conditions such as congestive heart failure, diabetes, and chronic obstructive pulmonary disease, tested positive for RSV. Despite the presence of symptoms like coughing, shortness of breath, and wheezing, the facility did not consistently implement transmission-based precautions or conduct regular respiratory assessments. In some cases, residents were transported to external appointments without masks, and there was no documentation of communication with external facilities regarding the residents' RSV status. The facility's infection preventionist and nursing staff were not fully aware of the RSV test results or the necessary precautions to be implemented. This lack of communication and documentation led to a delay in placing residents on appropriate isolation precautions. The facility's failure to monitor and document symptoms consistently, along with inadequate staff training on infection control measures, contributed to the spread of RSV among residents.
Failure to Prevent Recurrent Falls and Implement Individualized Interventions
Penalty
Summary
The facility failed to conduct comprehensive fall analyses and implement individualized interventions to prevent recurrent falls and mitigate the risk of falls with major injury for two residents. Resident R7, who had severe cognitive impairment and was wheelchair-bound, experienced multiple falls over a period of several months. Despite being identified as at risk for falls, R7's care plan did not include specific interventions to address this risk. The fall incident reports for R7 consistently lacked comprehensive fall analyses and did not result in revisions to the care plan to include immediate fall prevention interventions. This oversight led to R7 sustaining a left tibial fracture that required surgical repair. Resident R5, who also had severe cognitive impairment and was dependent on staff for transfers, experienced multiple falls as well. The fall incident reports for R5 similarly lacked comprehensive analyses, and the care plan was not revised to address the falls. The facility's policy required causal analysis and care plan revisions after falls, but these were not completed, as confirmed by the Director of Nursing during an interview. The facility's failure to adhere to its policy on fall management and prevention resulted in actual harm to R7 and posed a risk to R5. The lack of comprehensive fall analyses and individualized interventions in the care plans for these residents contributed to the recurrence of falls and the potential for further injury. The facility's policy outlined the need for cause identification and treatment management, but these steps were not adequately followed, leading to deficiencies in the care provided to the residents.
Failure to Ensure Competency of Nursing Assistants
Penalty
Summary
The facility failed to ensure that four nursing assistants (NAs) were deemed competent to provide care to residents, which could potentially affect all 45 residents in the facility. The job description for Non-Certified Nursing Assistants (NAs) requires them to complete competency training for resident lifts, transfers, and activities of daily living (ADLs) with the assistance of a Certified Nurse Aide (CNA). However, the employee records for NA-T, NA-D, NA-G, and NA-U lacked documentation of completed orientation and competency training. Interviews with the NAs revealed that they were assisting residents with various tasks, such as dressing, toileting, and transfers, without having been signed off for skills competencies. The Director of Nursing (DON) stated that the Assistant Director of Nursing (ADON) was responsible for performing competencies for all new employees before they worked on the floor. However, the competency records were not found in the employee files, and the DON was unsure of their location. The facility's training program requirements were requested but not received, indicating a lack of proper documentation and oversight in ensuring that nursing assistants were adequately trained and competent to perform their duties.
Failure to Timely Report Alleged Abuse and Neglect
Penalty
Summary
The facility failed to report alleged violations involving abuse and neglect to the State Agency in a timely manner for two residents. One resident, identified as R5, was severely cognitively impaired and receiving hospice care. During a visit, a hospice registered nurse found R5 in a concerning state, with matted eyes, dark material around the mouth, and heavily soiled linens, suggesting neglect. However, the nurse did not report these concerns to the facility staff due to being upset. The facility's Director of Nursing (DON) and Administrator expected hospice staff to report such concerns to the nurse on duty and the DON, but this did not occur. Another resident, R7, who had severe cognitive impairment and was at risk for falls, experienced two unwitnessed falls. After the second fall, R7 was sent to the emergency room and later diagnosed with a left tibia fracture, cellulitis, and an abscess, requiring surgery. The DON acknowledged that the fracture was a serious injury and should have been reported, but it was not. The facility's policy required immediate reporting of suspected abuse, neglect, or injury of unknown source, but this was not adhered to. Additionally, the facility's agreement with the hospice agency had inconsistent reporting requirements compared to federal standards.
Inadequate Pressure Ulcer Assessment and Intervention
Penalty
Summary
The facility failed to accurately and comprehensively assess pressure ulcers for two residents, leading to inadequate individualized interventions to prevent new pressure ulcers and deterioration of existing ones. One resident, who was at risk for pressure ulcers, had multiple stage 3 pressure ulcers upon admission. The care plan for this resident was not consistently evaluated or revised to include necessary pressure-relieving interventions. The wound assessments were inconsistent and not comprehensive, with discrepancies between the evaluations and corresponding photos. The resident's care plan did not reflect the interventions needed to prevent further deterioration, and the resident's refusal of certain treatments was not adequately addressed. Another resident, who was at risk for pressure ulcers but had none initially, developed a wound that was misidentified as moisture-associated skin damage (MASD) rather than a stage 2 pressure ulcer. The care plan for this resident was not updated with current interventions, and the facility's documentation did not accurately reflect the resident's condition. The facility's policies on pressure injuries and wound care did not provide comprehensive guidelines for assessment or interventions, contributing to the deficiencies in care. Interviews with facility staff revealed that the care plans were not individualized due to limitations in the facility's software, and there was a lack of consistent monitoring and updating of care plans. The Director of Nursing acknowledged the inconsistencies in wound assessments and the failure to implement new interventions for deteriorating wounds. The facility's policies did not adequately address the necessary components of a comprehensive assessment or pressure-relieving interventions, leading to the deficiencies observed in the care of the residents.
Failure in Communication Between Hospice and Facility Staff
Penalty
Summary
The facility failed to establish a clear communication process between hospice and the facility staff regarding changes in hospice services for a resident receiving hospice care. The resident, identified with severe cognitive impairment and dependent on assistance for daily activities, was admitted to hospice with a diagnosis of malnutrition. During a hospice nurse's visit, changes to the resident's care plan, including repositioning and oral care every two hours, were communicated to an unidentified nursing assistant instead of the nurse on duty. This lack of direct communication with the appropriate staff led to the changes not being documented in the facility's electronic health record. Interviews with facility staff, including registered nurses and the director of nursing, revealed that there was no designated staff member responsible for coordinating communication with hospice. The hospice nurse did not follow the expected protocol of reporting changes to the nurse on duty, resulting in a failure to update the resident's care plan with the necessary interventions. The facility's Hospice Program Policy emphasized the responsibility of the facility to communicate with hospice providers to ensure resident needs are met, highlighting a gap in the implementation of this policy.
Failure to Implement Enhanced Barrier Precautions and Hand Hygiene
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) and proper hand hygiene for residents requiring such measures. One resident, diagnosed with diabetes mellitus type 2 and cellulitis, was observed receiving intravenous (IV) antibiotics without the administering registered nurse (RN) wearing a gown, despite signage indicating the need for EBP. The RN only wore gloves and did not perform hand hygiene after removing them. The director of nursing confirmed that EBP should be used for residents with IVs, urinary catheters, or wounds, and the facility's policy indicated that EBP is required for residents needing device care. Additionally, another resident, diagnosed with dementia and dependent on staff for mobility, grooming, and hygiene, did not receive proper hand hygiene care from the nursing staff. During peri care for an incontinent bowel movement, the registered nurse did not perform hand hygiene before or after glove use. The nurse acknowledged the lapse in hand hygiene, which is contrary to the facility's policy requiring hand hygiene before moving from a contaminated body site to a clean one during resident care.
Improper Use of Mechanical Lifts Leads to Resident Injury
Penalty
Summary
The facility failed to safely use a mechanical lift according to the manufacturer's recommendations, resulting in a resident falling from the lift and sustaining three fractures to the thoracic and lumbar spine. The incident occurred when staff did not ensure the lift sling was properly secured before transferring the resident, who was severely cognitively impaired and required a mechanical lift for transfers. The resident's care plan indicated the need for a large sling and two staff assistance, but the staff involved were unsure of the sling size and did not check the care plan or the tension of the straps during the transfer. The facility also failed to ensure comprehensive assessments for sling size and care plan development for multiple residents requiring full body mechanical lifts. Observations revealed discrepancies between the sling sizes used and those documented in care plans or required by the residents' conditions. For instance, several residents were observed being transferred with medium slings when their care plans specified large slings, and staff often relied solely on weight to determine sling size without considering other factors such as height and girth. Interviews with staff and the director of nursing highlighted a lack of awareness and adherence to proper procedures for sling sizing and safety checks. Staff admitted to not verifying sling sizes or performing necessary safety checks, increasing the risk of residents falling from lifts. The facility's policy on mechanical lifts emphasized the importance of using the correct sling size and performing safety checks, but these procedures were not consistently followed, leading to the deficiency.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to comprehensively assess and implement interventions to provide adequate supervision for a resident with a history of exit-seeking behaviors. The resident, diagnosed with Alzheimer's, dementia, and senile degeneration of the brain, had severe cognitive impairment and daily wandering behaviors. Despite being identified as a high risk for elopement, the resident's care plan did not include all necessary interventions, such as frequent monitoring. The resident had multiple documented occurrences of attempting to leave the facility without further assessment and revisions to the care plan to manage these behaviors effectively. On the day of the incident, the resident attempted to leave the building twice and was given antipsychotic medications to calm him. However, the resident managed to exit the facility, triggering the WanderGuard alarm. Staff did not respond timely to the alarm, and the resident got into an unlocked vehicle and drove around the city for 1.5 hours until the police stopped him. The facility's staff, including the Director of Nursing and Assistant Director of Nursing, were aware of the resident's exit-seeking behaviors but did not implement adequate measures to prevent the elopement. Interviews with staff revealed that the resident was frequently wandering and exit-seeking, and staff had to always watch him. However, there was not enough staff scheduled to provide 1:1 supervision, and the WanderGuard system did not lock the doors. The facility's policies on wander management and elopement were not effectively followed, leading to the resident's elopement and subsequent driving incident. The facility's failure to provide adequate supervision and timely response to the WanderGuard alarm resulted in the resident's elopement and immediate jeopardy.
Removal Plan
- discharged R1 to a secured memory care facility
- The facility developed a new protocol to have staff always present in the area of the door leading out of the facility
- The facility re-educated staff on response time to the door alarms, and providing adequate supervision for wandering residents
Failure to Provide Timely Discharge Notification
Penalty
Summary
The facility failed to provide timely discharge notification in writing to the resident, the resident's representative, and the Ombudsman. The resident, who had severe cognitive impairment and multiple medical conditions including Alzheimer's, dementia, and was on hospice, was transferred to another facility without the required 30-day notice. The resident's family was not given the opportunity to appeal the discharge prior to the transfer. The facility's Director of Nursing and Social Service Director admitted that they did not follow the 30-day discharge notice policy, citing the resident's safety as the reason for the immediate transfer. The Ombudsman confirmed that the facility did not notify her of the discharge in writing and that the family was opposed to the transfer. The facility's policy requires a post-discharge plan to be developed and reviewed with the resident and family at least 24 hours before discharge, which was not followed in this case. The facility staff acknowledged that they were usually able to manage residents with similar needs through redirection and distraction, but did not provide a specific care plan to address the resident's safety concerns prior to the transfer.
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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