The Terrace At Crystal Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Crystal, Minnesota.
- Location
- 3245 Vera Cruz Avenue North, Crystal, Minnesota 55422
- CMS Provider Number
- 245289
- Inspections on file
- 70
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 77 (3 serious)
Citation history
Health deficiencies cited at The Terrace At Crystal Llc during CMS and state inspections, most recent first.
The facility failed to administer long-acting insulin at consistent times as directed by the manufacturer for two residents with type 2 DM receiving Lantus. One resident’s order for twice-daily long-acting insulin was transcribed on the MAR with broad time windows, and actual administration times for the evening dose varied widely from night to night. Another resident’s once-daily Lantus order was also entered with a wide morning window, and documented administration times fluctuated significantly from early morning to midday. Staff, including an LPN, an RN, the nurse manager, and the DON, reported that long-acting insulin is often scheduled using time windows when specific times are not written by the provider, despite acknowledging it should be given at the same time each day. A pharmacist stated that long-acting insulin should be given within a very small time window and that variable timing could lead to hyperglycemia, hypoglycemia, or ketoacidosis.
A resident with dementia, a history of stroke, repeated falls, and documented moderate cognitive impairment was allowed to leave independently on multiple occasions without a comprehensive assessment of community safety needs or individualized interventions. Hospital orders indicated the resident required ongoing supervision, and therapy staff later stated the resident would need supervision in the community, yet no formal community safety assessment was completed. Elopement risk tools repeatedly labeled the resident as low risk, the resident was not listed as needing an escort, and facility policies lacked clear criteria for independent community access. The resident twice signed out and left, once during the night and once in the evening, leading to missing person reports by police before the resident returned, while the family expressed concern about the resident’s impaired decision-making and lack of phone service.
A resident with a history of stroke, HTN, repeated falls, and cognitive communication deficit had an order for clonidine TID with specific BP and HR hold parameters. On an evening when the resident left the facility and did not return until the next day, the MAR and medication audit showed a scheduled clonidine dose documented as administered, including a BP and pulse reading, even though the resident was not present. An LPN reported giving all evening medications at once because the resident preferred this and later entered the clonidine administration to appear as if it was given at the ordered time, and could not explain conflicting vital sign entries. The DON verified that documentation showed the resident was out of the building when the dose and vitals were charted, contrary to facility policies requiring immediate, objective, complete, and accurate documentation.
Two residents with chronic pain conditions, including one with severely impaired cognition and another with a stage 3 pressure ulcer and COPD, received multiple PRN doses of acetaminophen and oxycodone without documented evidence that non-pharmacological pain interventions were offered or attempted beforehand, despite care plans and facility policy specifying such measures (e.g., ice, heat, massage, repositioning, music, relaxation). Both residents reported ongoing pain and some relief with repositioning, while interviews with LPNs, the NP, and the DON confirmed that non-pharmacological options were expected to be offered and documented prior to PRN pain medication administration, which was not reflected in the January MARs and progress notes.
The facility failed to document required weekly baths and head-to-toe skin assessments for two residents who were at high risk for skin breakdown and required extensive assistance with hygiene and ADLs. One resident with multiple medical conditions, severe cognitive impairment, high skin breakdown risk, and existing abrasions had only one weekly skin assessment documented during a three-week stay, despite dressing orders and scheduled weekly baths. Another resident with morbid obesity, a surgical wound, Foley catheter, bowel incontinence, anxiety, PTSD, and Fournier disease had only two documented weekly skin assessments over more than two months, even though multiple baths were scheduled. Staff interviews confirmed that policy required a weekly bath/shower with a documented skin assessment, but the TAR functioned only as a reminder and did not show whether the bath or assessment was completed, resulting in missing documentation for these residents.
A resident did not receive appropriate care for pressure ulcers, and necessary measures to prevent new ulcers were not consistently implemented, resulting in a deficiency related to pressure ulcer management.
Surveyors found that staff failed to properly date and discard opened milk, inadequately monitored refrigerator temperatures and food quality, and did not consistently use required hair or beard coverings during food preparation and service. Additional issues included improper storage of dry and frozen foods, undated and improperly sealed food items, and stacking wet pans, all of which contributed to unsanitary conditions.
Surveyors observed orangish blackish substances on top of the dish machine, identified as rust sediment falling from the hood above. Dietary and maintenance staff were aware of the issue, but cleaning routines and maintenance had not resolved the accumulation. The facility's warewashing policy lacked specific guidance on cleaning frequency for the dish machine.
A deficiency was identified due to the absence of a pest control program to prevent or manage mice, insects, or other pests within the facility.
A resident with severe cognitive impairment and dependent on staff for eating was referred to as a "feeder" by a nursing assistant during meal service, resulting in the dietary aide withholding the resident's meal. Staff interviews confirmed that using the term "feeder" is inappropriate and could be hurtful to residents.
A resident with dysphagia and cognitive impairment was not served the ordered pureed diet, instead receiving a full piece of pork loin that she could not chew. Staff later replaced the meal with minced meat, and interviews revealed inconsistencies in providing the correct diet texture due to lack of pureed food availability and lapses in following established procedures.
Multiple residents complained that their meals were frequently served cold and unappetizing, with staff failing to consistently check and record food temperatures as required by facility policy. Observations and interviews confirmed that food was not always temped before serving, and temperature logs were incomplete, leading to dissatisfaction among residents and concerns about meal quality.
Two residents with severe cognitive impairment and complex medical histories were administered psychotropic medications without documented informed consent or explanation of risks and benefits. Family members and staff confirmed that required consent forms were missing from the medical records, and the facility's policy did not address the informed consent process for these medications.
A resident who did not have a personal phone was only offered the use of a corded phone at the nursing station, a public area with staff present, despite requesting a more private setting for personal calls. Staff confirmed there was no cordless phone or private area available, and the facility's policy requiring private phone access for residents was not followed.
Staff did not promptly inform a resident, the resident's doctor, and a family member about important events such as injury, decline, or room changes, as required. This lapse in communication was identified during the survey.
A resident with diabetes and other chronic conditions repeatedly voiced concerns about not receiving appropriate diabetic diet options, resulting in significant weight gain. Despite staff awareness of these complaints, there was no documentation or follow-up in the resident's medical record or the facility's grievance log, and the grievance officer confirmed no formal grievances were filed.
A resident prescribed Olanzapine and other psychotropic medications, with a high fall risk and an order for monthly orthostatic blood pressure monitoring, did not have these checks completed or documented for two months. Staff interviews confirmed the monitoring was not performed, despite facility policy requiring side effect monitoring for antipsychotic use.
A resident with multiple medical conditions was admitted from a hospital, but the facility failed to complete the required MDS assessment section on preferences for daily routine and activities. The resident's family was not consulted, and documentation of an assessment was missing, with the responsible RN confirming the section was left incomplete.
Two residents with significant medical conditions did not have their quarterly MDS assessments fully completed, specifically in the areas of cognition and mood. Required evaluations, such as the BIMS and PHQ-9, were either not conducted or not documented, leaving key sections of the MDS blank or marked as 'Not Assessed.' A nurse confirmed these omissions and noted that staff had been made aware of the issue.
A resident's MDS was incorrectly coded to indicate discharge to a hospital, while documentation and staff interviews confirmed the resident was actually discharged home with medications and instructions. Staff acknowledged the error, and facility policy requires assessments to accurately reflect resident status.
A resident who was cognitively intact had only one care conference since admission, despite facility policy and staff expectations for quarterly interdisciplinary care plan reviews. Staff interviews confirmed that the care team did not meet quarterly to review and update the care plan, even though the resident had concerns about her care.
A resident with hemiplegia and significant ADL assistance needs did not receive proper fingernail care as required by their care plan and facility policy. Despite staff being directed to check, trim, and clean nails regularly, observations showed the resident's nails were overgrown and dirty, and the resident expressed a desire for nail care. Documentation and staff interviews revealed inconsistencies in providing and recording this care.
A resident was repeatedly left in a reclined Broda wheelchair during meals, requiring significant leaning forward to eat, without staff intervention or documented assessment for alternative positioning. Another resident with lymphedema and CHF did not consistently receive ordered TED stockings or lymphedema wraps, with documentation showing infrequent application and staff interviews revealing lack of consistent assessment or alternative approaches. Facility policies on these care areas were not provided when requested.
A resident experienced a decline in range of motion or mobility because the facility did not provide appropriate care to maintain or improve ROM, and there was no documented medical reason for the decline.
The facility did not adequately assess or implement interventions for two residents with substance abuse histories and suspected current use, as well as for one resident at high risk for falls. Staff observed and reported signs of substance use, but no care planning or monitoring was documented. After a recent fall, no new interventions or therapy were initiated for a resident at high risk, despite facility protocols requiring such actions.
A resident with multiple chronic conditions experienced a 35.8% weight gain after admission, with no documented interventions or follow-up from dietary or nutrition services despite being on a diabetic diet. The resident reported concerns about food quality and lack of dietician involvement, while staff interviews confirmed awareness of the weight gain but no action taken, contrary to facility policy requiring evaluation of significant weight changes.
A resident with a history of severe injuries and chronic pain did not receive adequate pain management, as staff failed to consistently monitor pain, did not document or offer non-pharmacological interventions, and did not respond effectively to complaints of uncontrolled pain. Staff interviews confirmed that pain assessments were not routinely performed and non-pharmacological options were not utilized, despite facility policy supporting their use.
A resident with PTSD and other mental health diagnoses had known triggers related to staff behavior, but staff did not assess, identify, or document these triggers, nor were they included in the care plan. Staff interviews revealed a lack of awareness about the resident's trauma history and triggers, and care documentation did not reflect individualized trauma-informed interventions as required by facility policy.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
Two residents were affected by failures in medication management: one continued to receive a nicotine patch without dose reduction despite pharmacist and CDC recommendations, and another received an antibiotic eye drop without a specified end date or ongoing assessment. Staff did not consistently monitor, clarify, or document the necessity and effectiveness of these medications, contrary to facility policy.
A resident experienced a significant medication error due to a failure in the medication administration process. The report does not provide further details about the circumstances or the resident's condition.
Three residents with documented food allergies or preferences were served meals containing restricted ingredients, such as soybean oil, eggs, and seafood, despite care plans and meal tickets indicating these restrictions. Staff were often unaware of the specific dietary needs, and official records were not consistently updated to reflect allergies, leading to repeated incidents where residents received inappropriate meals.
A resident with type 1 diabetes was readmitted from the hospital with a discharge order for a consistent carbohydrate diet, but the facility failed to enter or implement this therapeutic diet order. Instead, the resident received a regular diet, and staff were unaware of the need for a diabetic diet, despite multiple high blood sugar readings. The required process for entering and verifying diet orders was not followed, and the appropriate order was not documented in the EMR.
A nursing assistant failed to perform hand hygiene or change gloves during personal care for a resident with multiple medical conditions, continuing to assist with various tasks after perineal care. This was observed and confirmed through staff interviews and review of facility policy, which requires hand hygiene at specific points during care to prevent cross-contamination.
A deficiency was cited when a resident's care plan did not include all necessary interventions, lacked measurable timetables, and failed to specify actions to address the resident's needs, as evidenced by incomplete documentation in the resident's records.
Drugs and biologicals were not labeled according to professional standards, and medications, including controlled drugs, were not stored in locked or separately locked compartments as required.
The facility did not ensure that the most recent survey results, including complaint surveys, were posted in prominent and accessible locations throughout the building. Residents were unaware of where to find these results, and survey outcomes were not discussed during resident council meetings. The administrator confirmed that the binders were incomplete and signage did not indicate that additional results were available upon request, contrary to facility policy.
A resident with chronic respiratory failure was observed self-administering an albuterol inhaler and keeping multiple medications at the bedside without a documented assessment or physician order for self-administration. Staff confirmed that no assessment had been completed and the care plan did not reflect permission for self-administration or bedside storage, contrary to facility policy requiring interdisciplinary assessment and documentation.
A resident with complex medical needs was discharged without a comprehensive discharge plan or confirmed home care services, resulting in worsening wounds and hospital admission. The care plan lacked discharge interventions, the social worker did not arrange services before discharge, and nursing staff assumed care was in place without verification. The facility did not follow its own discharge planning policy, and the resident was not adequately prepared for a safe transition.
Three residents were discharged without required documentation, including discharge summaries, recapitulation of stay, final status summaries, and medication reconciliation. The care plans lacked discharge focus, and staff interviews revealed uncertainty about discharge documentation requirements and processes. Residents with complex medical needs and cognitive impairments did not receive comprehensive discharge planning or clear information about post-discharge care.
Surveyors found that the facility did not have an effective system for the timely disposal of discontinued non-narcotic medications, resulting in the accumulation of approximately 153 medication cards in trash bags and bins in locked medication rooms. Staff interviews revealed confusion and inconsistency in the process, with some staff unsure of the proper steps and lacking access to the medication destruction system. The facility's policy required immediate disposal, but this was not consistently followed.
A resident with impaired cognition and significant mobility needs was provided with bed rails without documented assessment, risk/benefit discussion, or informed consent. The resident and her POA did not recall being informed about the risks, and staff interviews confirmed that required evaluations and documentation were not completed prior to bed rail application, contrary to facility policy.
A resident was admitted to a facility with a discharge order for Furosemide, a diuretic, but did not receive the medication for sixteen days due to a lack of follow-up and clarification of the order. This oversight led to the resident's hospitalization for congestive heart failure exacerbation. Interviews with staff revealed issues with communication and order verification processes.
The facility failed to adhere to infection control practices, including not following enhanced barrier precautions for a resident with an open wound, improper placement of a urinal, and inadequate maintenance of a C-pap machine. Additionally, a resident's room was not cleaned after a toilet overflow, and clean clothes were transported uncovered. These deficiencies pose a risk of spreading infections among residents, staff, and visitors.
The facility failed to implement a comprehensive antibiotic stewardship program, leading to inadequate monitoring and documentation of antibiotic use for residents with infections. The infection surveillance logs were incomplete, lacking critical information such as diagnostics, culture results, and resolution dates. Interviews revealed that the facility did not effectively use available tools to track infections, impacting the ability to manage and prevent infections.
The facility did not schedule a registered nurse (RN) for a minimum of eight consecutive hours on certain Sundays, potentially affecting all 62 residents. The staffing coordinator confirmed the absence of scheduled RNs on these dates, and the administrator noted the requirement for daily RN coverage. Despite attempts to obtain payroll information, it was not provided, violating the facility's policy of RN coverage every 24 hours.
The facility failed to serve meals at appropriate temperatures, affecting two residents' satisfaction and nutritional intake. Observations showed delays in meal delivery, with trays left on a cart, leading to cold and bland food. The facility's policy emphasized timely delivery to maintain meal quality, but practices did not align, resulting in the deficiency.
The facility failed to provide routine bathing, nail care, and grooming for five residents, and assistance with hearing aids for one resident. Residents were observed with unkempt appearances, and staff interviews revealed inconsistencies in care provision and documentation. The facility's policy on addressing care refusals was not followed.
The facility failed to provide activities of interest to enhance the quality of life for four residents. A resident with multiple sclerosis was often alone and asleep in a Broda chair, with no documented participation in activities. Another resident, cognitively impaired and dependent on staff, had minimal activity documentation over 30 days. Two other residents, one with Alzheimer's and another with Parkinson's, also lacked engagement in activities, with staff unaware of their preferences. The director of activities acknowledged the need for more engagement but had not implemented changes.
Insulin pens were found unsecured on a nurse's station counter in a memory care unit, accessible to residents, staff, and guests. The pens were not stored in a locked compartment as required, and staff interviews confirmed the expectation for secure storage. The facility's policy mandates that all medications be stored securely when not in use.
Inconsistent Timing of Long-Acting Insulin Administration
Penalty
Summary
The deficiency involves the facility’s failure to administer long-acting insulin at consistent times in accordance with manufacturer instructions for two residents prescribed Lantus (a long-acting insulin). One resident had type 2 diabetes with diabetic polyneuropathy and long-term insulin use, with a care plan directing diabetes medications to be administered as ordered. The physician ordered Basaglar 62 units twice daily, which was transcribed on the March 2026 medication administration record (MAR) as Lantus 62 units twice daily with administration windows of 7:00 a.m.–11:00 a.m. and 7:00 p.m. (HS). The manufacturer’s package insert for Lantus states it may be taken at any time of day but must be taken at the same time every day. MAR review showed the evening doses were given at varying times, including examples such as 9:41 a.m. and 10:32 p.m., 9:17 a.m. and 9:43 p.m., 8:29 a.m. and 10:42 p.m., and 9:04 a.m. and 8:27 p.m., rather than at a consistent time. Another resident with type 2 diabetes, on a therapeutic diet and receiving insulin injections seven days per week, had a physician order for Lantus 20 units daily. The March 2026 MAR listed Lantus 20 units in the morning with an administration window of 7:00 a.m.–11:00 a.m., but actual administration times varied, including 8:27 a.m., 10:00 a.m., 8:52 a.m., 12:09 p.m., and 7:58 a.m. Staff interviews confirmed that long-acting insulin should be given at the same time every day for effectiveness, and that nurses transcribed orders using time windows when specific times were not provided. The RN nurse manager acknowledged that Lantus might be one medication where a specific time is preferred, and the DON stated that long-acting insulin orders are not always written with specific times unless the provider specifies one. The consulting pharmacist stated that long-acting insulin should be given with a very small window and that giving doses at different times daily could result in hyperglycemia or hypoglycemia and potentially ketoacidosis. The facility’s insulin administration policy described long-acting insulin characteristics but did not prevent the inconsistent timing documented on the MARs.
Failure to Assess Community Safety and Supervise Cognitively Impaired Resident Leaving Independently
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively evaluate and implement individualized safety interventions for a cognitively impaired resident who was allowed to leave the facility independently on multiple occasions. The resident had diagnoses including stroke, hypertension, repeated falls, and a cognitive communication deficit. Hospital discharge orders specified that the resident needed ongoing supervision due to continued need for help with moving, thinking, safety, and eating. A SLUMS score of 15/30 indicated dementia, and multiple BIMS assessments showed moderate cognitive impairment. The admission MDS documented moderately impaired cognition, a need for maximum assistance with transfers, dependence on staff for wheelchair mobility, and that ambulation was not attempted due to medical or safety concerns. Despite these documented cognitive and functional limitations, the resident’s elopement risk assessments on admission and later dates consistently indicated a low risk for elopement. The care plan addressed impaired cognitive function and fall risk, with interventions such as cueing, reorientation, supervision as needed, and assistance with ADLs and mobility, but it did not include a comprehensive assessment of the resident’s ability to be safely unsupervised in the community. The record from admission through early February and again from early February through early March did not contain any detailed assessment of the resident’s level of supervision needed in the community, nor did it identify vulnerabilities or risks while the resident was in the community independently. Therapy staff were not asked to perform a community safety assessment, even though the OTA and speech therapist later stated that, based on the SLUMS score, the resident would need supervision in the community. The lack of assessment and individualized interventions contributed to two separate episodes in which the resident left the facility independently. In the first incident, around 3:30 a.m., the resident informed an LPN she was leaving; after attempts to convince her to stay, the resident signed out and left, and the family later contacted police and filed a missing person report before the resident was confirmed to be at a family member’s home. In the second incident, the resident told the receptionist she was leaving, signed out, and did not return by early morning the next day, prompting staff to search the facility, attempt to call her, and then contact police to file another missing person report before the resident returned. Interviews with the resident and family confirmed that the resident’s phone did not have active cellular service, that the facility had not provided safety instructions for being in the community, and that the family was upset and concerned about the resident’s decision-making. Staff interviews revealed inconsistent understandings of criteria for independent community access, reliance on BIMS and elopement lists, and acknowledgment by the nurse manager and DON that no formal process or assessment for community safety existed. Facility policies did not address protocols or criteria for residents to leave independently, and the elopement policy only addressed preventing unsupervised departure and responding to missing residents.
Inaccurate Documentation of Clonidine Administration for Absent Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurately documented medical record for a resident with a history of stroke, hypertension, repeated falls, and cognitive communication deficit. The resident had a provider order for clonidine 0.3 mg by mouth three times a day for hypertensive urgency, with instructions to hold the dose if the heart rate was less than 60 beats per minute or if systolic blood pressure was less than 100 mmHg. Nursing notes documented that the resident told the receptionist she was leaving the facility in the evening and did not return overnight, prompting staff to search the facility, call her cell phone, and eventually contact the police and file a missing person report. The resident did not return until the following day around midday. Despite the resident being out of the building during this time, the February medication administration audit and medication administration record showed that a scheduled dose of clonidine was documented as administered late that evening, with a recorded blood pressure of 121/74 and pulse of 72, and an administration time that did not match the resident’s actual absence from the facility. During interview, the LPN who documented the dose stated he had given all of the resident’s evening medications at the same time because she preferred to take all pills together and would often refuse a second approach, and he admitted entering the clonidine administration later so it would appear as though it was given as ordered. He could not explain conflicting blood pressure readings, having stated he only approached the resident once for medications and vitals. The DON confirmed that, according to the documentation, the resident was out of the building at the time the clonidine dose and blood pressure check were recorded as given, and facility policies required that medication administration be documented immediately after, never before, and that all charting be objective, complete, and accurate.
Failure to Offer and Document Non-Pharmacological Interventions Before PRN Pain Medications
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess pain and to offer or attempt non-pharmacological pain interventions prior to administering PRN pain medications for two residents. One resident had severely impaired cognition, cellulitis of the right leg, type 2 diabetes, and chronic pain syndrome, with an admission MDS indicating frequent pain that interfered with day-to-day activities and use of both scheduled and PRN pain medications. This resident’s care plan included multiple non-pharmacological pain interventions such as ice, heated blankets, massage, repositioning, music, essential oils, food/drink, and relaxation breathing. Despite this, the MAR and corresponding progress notes for multiple PRN administrations of acetaminophen and oxycodone in January did not document any non-pharmacological interventions being attempted or offered prior to medication administration. The second resident had intact cognition, a stage 3 pressure ulcer, COPD, and chronic pain, with a quarterly MDS indicating almost constant pain and use of scheduled and PRN pain medications. This resident’s care plan identified a focus on pain risk related to generalized chronic pain and lower back pain, with interventions that included offering non-pharmacological pain relief prior to pain medication administration, listing the same types of non-pharmacological options as for the first resident. However, the MAR for January showed several PRN oxycodone administrations, and the associated progress notes documented that the medication was given and effective but did not include any record of non-pharmacological interventions being offered or attempted beforehand. Interviews with both residents confirmed that they experienced ongoing pain and used PRN pain medications, and each reported that repositioning sometimes helped relieve their pain. Interviews with LPN staff, the NP, and the DON established that facility practice and expectations were that non-pharmacological interventions should be offered prior to PRN pain medication administration and that such offers and any refusals should be documented in the PRN medication administration note or progress note. The DON confirmed that the medical records for the two residents did not contain documentation of non-pharmacological interventions being offered or refused prior to every PRN pain medication administration. The facility’s Pain Assessment and Management policy stated that pain management is based on appropriate assessment and treatment, including the use of non-pharmacological interventions alone or with medications, and provided examples of environmental, physical, exercise, and cognitive/behavioral interventions, which were not consistently reflected in the documentation for these residents.
Failure to Document Weekly Baths and Skin Assessments for High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to accurately document weekly baths and complete current head-to-toe skin assessments for two residents, despite facility policy requiring a weekly bath or shower with a full skin assessment documented on a weekly skin assessment form. For one resident (R1), records showed admission in mid-December with a care plan identifying high risk for skin breakdown and interventions such as keeping fingernails short, using pressure-relieving devices, and preventing him from hitting his extremities. R1 required extensive assistance with hygiene and had a scheduled weekly bath. His TAR showed a dressing order for abrasions on multiple body areas to be treated three times weekly, yet only one weekly skin assessment form was found for his three-week stay, and that assessment documented a shower with no skin issues observed. The TAR for the following month showed weekly skin assessments acknowledged on two dates, but there was no associated documentation indicating the type of bath or any skin integrity findings. For another resident (R3), who required assistance from two staff for bathing, dressing, and toileting, and who had a Foley catheter, bowel incontinence, morbid obesity, a surgical wound, anxiety, PTSD, and Fournier disease affecting the vaginal and vulvar areas, documentation showed only two completed weekly skin assessments over a period of more than two months. Her TAR indicated scheduled baths on multiple dates, but there was no corresponding documentation of weekly skin assessments for each scheduled bath. Staff interviews confirmed that all residents were to receive a weekly bath or shower with a concurrent skin assessment documented on the weekly skin assessment form, and that the TAR only served as a reminder that a bath was due and did not capture whether the bath or skin assessment was actually completed. A nurse reported being able to locate only one weekly skin assessment for R1 during his entire stay, confirming the lack of required documentation for both residents.
Failure to Provide Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent the development of new ulcers. This deficiency was identified through surveyor findings that indicated lapses in the care provided to residents at risk for or experiencing pressure ulcers. The report notes that the necessary interventions to manage existing pressure ulcers and prevent new ones were not consistently implemented, as required by care standards.
Deficient Food Handling, Storage, and Sanitation Practices
Penalty
Summary
The facility failed to ensure proper handling, storage, and monitoring of food and dairy products, leading to multiple deficiencies. Opened milk was observed being served to residents well beyond the recommended seven-day usage period after opening, with one instance of milk being used ten days after opening and another instance where the milk was past its commercial 'best by' date. Staff members were unclear about the correct procedures for dating and discarding milk, and the contracted dietary manager confirmed that milk should be used or discarded within seven days of opening. Additionally, the facility's labeling and dating policy required all time/temperature control for safety foods to be labeled and dated, but this was not consistently followed. The unit refrigerator was inadequately monitored for temperature and food quality. The temperature log had not been updated for over two weeks, and the refrigerator contained expired, undated, and moldy food items, including gravy, stew, rice, and biscuits. Staff interviews revealed a lack of clarity regarding responsibility for monitoring the refrigerator, with both dietary and nursing staff expressing uncertainty. The refrigerator was used for resident food items, some of which were brought in by family members, but there was no consistent process for checking dates or discarding expired items, as required by facility policy. During kitchen observations, staff were found not wearing required hairnets or beard nets while preparing and serving food. There were also issues with food storage, such as scoops being left in flour bins, personal water bottles stored in freezers with resident food, and opened cheese packages not being dated or properly sealed. Additionally, metal pans were stacked while still wet, with condensation observed between them, contrary to the facility's warewashing policy. These actions and inactions directly contributed to the deficiencies identified during the survey.
Unclean Dish Machine and Rust Sediment from Hood in Kitchen
Penalty
Summary
During an initial tour of the kitchen, surveyors observed several orangish blackish substances on top of the dish machine. Dietary staff reported that dishes coming through the machine were clean, and that the outside of the dish machine was washed every one to two days. However, the culinary director stated that staff wiped the dish machine daily and was unsure about the origin of the substances. The culinary district manager identified the sediment as coming from the hood above the dish machine, noting that staff attempted to keep the area clean but faced challenges because Ecolab did not service the hood or custom pieces. The facility was in the process of seeking a company to address the hood issue. The administrator confirmed that maintenance was contacting vendors to install or replace the hood vent, as Ecolab did not work on the hood and available parts did not fit. The maintenance director explained that hot steam from the dish machine caused the metal in the hood to rust and fall, and acknowledged awareness of the issue for several months, but had prioritized other facility needs. The maintenance director was not aware of the severity of the rust falling from the hood. The facility's warewashing policy did not specify when to clean the dish machine, though task descriptions for cooks and aides did indicate scheduled cleaning assignments.
Lack of Pest Control Program
Penalty
Summary
The facility did not have a pest control program in place to prevent or address the presence of mice, insects, or other pests. This deficiency was identified based on the lack of measures or systems to manage and control pests within the facility environment.
Failure to Provide Dignified Dining Experience Due to Inappropriate Language
Penalty
Summary
During a meal service, a nursing assistant referred to a resident who required assistance with eating as a "feeder" out loud in the presence of other residents and staff. The dietary aide, upon hearing this, withheld the resident's meal by placing the plate on top of the steam table instead of serving it directly. The resident in question had severely impaired cognitive skills and was dependent on staff for eating, as documented in their care plan and Minimum Data Set. Interviews with staff, including the dietary aide, a registered nurse, and the director of nursing, confirmed that referring to residents as "feeders" is inappropriate, not humane, and could be hurtful or belittling. Another resident also reported that staff commonly used the term, which likely made residents feel bad.
Failure to Provide Ordered Pureed Diet Texture
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment, dysphagia, and multiple diagnoses including Alzheimer's disease and gastro-esophageal reflux was not provided with the ordered pureed diet texture. The resident's care plan and physician orders specified a regular diet with pureed texture and thin liquids, and a recent speech language pathology evaluation confirmed the need to maintain this diet due to safety concerns. During a meal observation, the resident was served a full piece of pork loin, which she was unable to chew, instead of the required pureed texture. Staff replaced the pork loin with minced meat after noticing the issue, and the resident was then able to eat independently. Interviews with dietary and nursing staff revealed reliance on meal tickets to determine diet orders, but also indicated inconsistencies in the availability and serving of pureed foods. The dietary aide confirmed that pureed pork was not available that day and that only mechanically cut-up pork was served, including to the resident in question. Staff interviews further indicated that while there were systems in place, such as spreadsheets and meal tickets, to communicate diet orders, there were lapses in ensuring the correct texture was always provided. Facility policies required meals to be assembled according to individualized diet orders and for nursing staff to verify meal accuracy, but these procedures were not followed in this instance.
Failure to Serve Meals at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that meals were served in a warm, palatable manner, as evidenced by complaints from three residents who reported that their food was often cold and unappetizing. Interviews with these residents revealed dissatisfaction with the temperature and quality of the food, with one resident describing the meals as 'garbage' and 'nasty,' and another stating that food was 'always freezing cold when it should be hot.' One resident also expressed concern about the lack of appropriate food options for their diabetes. Observations during meal service showed that food temperatures were not consistently checked before serving, and staff were unclear about procedures for recording and monitoring food temperatures. Staff interviews indicated confusion regarding the requirement to temp food after placing it in steam tables, and review of temperature logs confirmed that not all items were recorded as temped. The facility's own policies required food to be served at safe and appetizing temperatures and for staff to record final cooking temperatures and check food temperatures when placed in hot holding units. Despite these policies, there was a lack of adherence to proper temperature monitoring and documentation, resulting in meals being served at suboptimal temperatures and multiple resident complaints.
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain and document informed consent, including an explanation of risks and benefits, prior to administering psychotropic medications to two residents. One resident, who had severe cognitive impairment and multiple medical conditions including heart failure, dementia, and a history of stroke, was admitted from an acute care hospital and was prescribed duloxetine, haloperidol, and mirtazapine. The resident's family member, who was actively involved in care decisions, reported not being informed about the antidepressant medications or their side effects. Review of the medical record confirmed the absence of signed or verbal consent forms for these medications, and staff interviews verified that the required documentation was missing. A second resident, also with severely impaired cognitive skills and multiple diagnoses such as aphasia, traumatic brain injury, epilepsy, anxiety disorder, and depression, was prescribed risperidone for severe, recurrent major depressive disorder with psychotic symptoms. The medical record for this resident similarly lacked evidence of informed consent for the antipsychotic medication. Staff interviews indicated that the admitting nurse was responsible for obtaining consents, but the required documentation was not found in the resident's record at the time of review. The facility's policy on antipsychotic medication use directed staff to gather and document information regarding the resident's condition and symptoms but did not specifically address the process for obtaining informed consent or educating residents or their representatives about the risks and benefits of psychotropic medications. Multiple staff members, including the DON, acknowledged that obtaining and documenting informed consent for these medications was expected but had not been completed for the residents in question.
Lack of Private Phone Access for Resident
Penalty
Summary
The facility failed to provide reasonable access to private phone use for a resident who did not have a personal phone. The resident, who resided on the third floor and used a wheelchair, was observed making a phone call at the nursing station desk, surrounded by multiple staff members and in a public area between two hallways and in front of an elevator. The resident reported that he had requested a more private location for his phone call, specifically asking staff to bring the phone to his room, but was told this was not possible. As a result, he had to conduct his personal conversation in a public setting, which he stated did not provide sufficient privacy, especially when speaking with his wife. Interviews with staff, including a TMA, LPN, and the third-floor nurse manager, confirmed that the only phone available for residents without personal phones was the corded phone at the nursing station, and that there was no cordless phone or private area available for resident use. The administrator stated that a phone could be installed in a resident's room only if the resident could pay for it; otherwise, residents were limited to using the nursing station phone. The facility's own policy indicated that telephones should be available in areas that offer privacy and accommodate wheelchair-bound residents, which was not followed in this instance.
Failure to Immediately Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors during the review of facility practices and records. The deficiency centers on the facility's failure to ensure that all required parties were promptly informed when significant events impacting the resident occurred.
Failure to Address Repeated Grievances Regarding Diabetic Diet
Penalty
Summary
The facility failed to appropriately address and follow up on repeated grievances voiced by a resident regarding the adequacy of food provided for a diabetic diet. The resident, who was cognitively intact and had diagnoses including diabetes, hypertension, peripheral vascular disease, hyperlipidemia, and asthma, experienced a significant weight gain of 35.8% since admission. Despite having an order for a diabetic, regular textured diet, the resident's electronic medical record lacked any progress notes from dietary or nutritional services and did not document the resident's ongoing food concerns. The facility's grievance log for the past six months also did not include any mention of the resident's complaints about the food provided. Multiple staff interviews confirmed that the resident had repeatedly voiced concerns about not receiving appropriate diabetic diet options, such as sugar-free items, and often chose not to eat the food served. Staff members, including LPNs and the certified dietary manager, acknowledged awareness of the resident's complaints, but there was no evidence of formal documentation or follow-up by dietary or grievance personnel. The grievance officer confirmed that no formal grievances had been filed for the resident, despite the facility's policy requiring staff to guide residents in filing written complaints when concerns are voiced.
Failure to Monitor Orthostatic Blood Pressure in Resident on Antipsychotic Medication
Penalty
Summary
The facility failed to ensure appropriate monitoring for side effects of antipsychotic medication, specifically orthostatic hypotension, for one resident who was prescribed Olanzapine and other psychotropic medications. The resident was cognitively intact, had a high risk for falls, and had a physician's order for monthly orthostatic blood pressure checks due to the use of psychotropic medications. However, a review of the resident's electronic medical record, including medication and treatment administration records, vital signs, and progress notes, showed no evidence that these orthostatic blood pressure readings had been obtained or documented for the past two months. Interviews with facility staff, including medication aides, LPNs, and the nurse manager, confirmed that the order for monthly orthostatic blood pressure monitoring was present but had not been carried out or recorded. Staff indicated that such orders should appear in the medication administration record, but none were found for any residents, including the one in question. The facility's policy required monitoring for side effects and adverse consequences of antipsychotic medications, including cardiovascular effects like orthostatic hypotension, but this was not followed in this case.
Incomplete MDS Assessment for Resident Preferences
Penalty
Summary
The facility failed to complete a comprehensive Minimum Data Set (MDS) assessment for a resident upon admission, as required by federal guidelines. Specifically, the section of the MDS related to Preferences for Customary Routine and Activities (Section F) was either left blank or marked as 'Not Assessed.' There was no evidence in the resident's medical record that an evaluation of their daily routine or activity preferences was conducted during the assessment reference date (ARD) period. The resident in question had multiple medical conditions, including heart failure, dementia, and a history of stroke/transient ischemic attack, and was admitted from an acute care hospital. Interviews with the resident's family member revealed that they had not been consulted regarding the resident's activity preferences, and the resident had not participated in activities or left her bed. The registered nurse responsible for MDS completion confirmed that sections of the MDS were left incomplete and acknowledged that staff should have performed the necessary assessments within the ARD period to ensure accurate coding. Facility policy requires timely and complete assessments in accordance with federal and state requirements, but this was not followed in this instance.
Incomplete MDS Assessments for Cognition and Mood
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed thoroughly for two residents, specifically in the areas of cognition and mood. For both residents, the relevant sections of the MDS—Section C (Cognitive Patterns) and Section D (Mood)—were either marked as 'Not Assessed' or left blank, with no evidence in the medical records that the required assessments, such as the Brief Interview for Mental Status (BIMS) or the Patient Health Questionnaire-9 (PHQ-9), were conducted during the assessment reference date (ARD). This lack of assessment meant that critical indicators of cognitive status and potential depressive symptoms were not evaluated as required by the Centers for Medicare and Medicaid Services (CMS) guidelines. One resident had multiple medical conditions, including high blood pressure, renal insufficiency or failure, and dementia, while the other had a history of stroke and aphasia. Despite these significant health issues, the facility did not complete the necessary cognitive and mood assessments for either resident. A registered nurse responsible for MDS completion confirmed that these sections were not filled out and acknowledged that staff had been informed this was unacceptable. The facility's policy required timely and complete assessments in accordance with federal and state guidelines, but this was not followed in these cases.
Inaccurate MDS Coding for Resident Discharge Status
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was accurately coded to reflect the discharge status of a resident who was reviewed for hospitalization. The MDS indicated that the resident was discharged to a short-term general hospital, but nursing progress notes and interviews with staff and the resident confirmed that the discharge was actually to home with medications and instructions provided to family members. Multiple staff, including an LPN, the MDS facility liaison, and the MDS clinician, acknowledged upon review that the MDS was coded incorrectly and did not accurately reflect the resident's actual discharge destination. Facility policy requires that the information captured on the assessment accurately reflects the resident's status during the observation period.
Failure to Hold Routine Interdisciplinary Care Conferences
Penalty
Summary
The facility failed to provide routine care conferences for a resident who was cognitively intact and had been admitted to the facility. Documentation showed that the resident had only one care conference since admission, despite policy and staff statements indicating that care conferences and care plan reviews should occur at least quarterly, in conjunction with the MDS assessment cycle. The resident confirmed participation in only one care conference and expressed concerns about her care. Interviews with facility staff, including a licensed social worker and the director of nursing, revealed that the interdisciplinary team is expected to meet quarterly to review and update care plans, even if the resident declines to participate. The social worker acknowledged that no care conference had been held for the resident due to her lack of agreement, but also stated that the team should still meet to discuss the resident's care. Facility policy also requires quarterly interdisciplinary review and update of care plans. The failure to hold these routine care conferences resulted in a lack of regular interdisciplinary review and update of the resident's care plan.
Failure to Provide Required Assistance with Fingernail Care
Penalty
Summary
A deficiency was identified when a resident with a history of stroke, hemiplegia, and hemiparesis, who required substantial to maximal assistance with most activities of daily living (ADLs), did not receive adequate fingernail care. The resident's care plan directed staff to check, trim, and clean nails on bath days and as necessary, with documentation of any refusals. Despite these directives, observations on multiple occasions revealed the resident's fingernails were overgrown with dark debris underneath. The resident expressed a desire to have his nails cut and stated that staff assisted him with nail care. Documentation did not indicate that fingernail care was provided or refused, and staff interviews revealed inconsistent accounts regarding refusals and plans to address nail care. The facility's policy required daily cleaning and regular trimming of nails, with documentation of refusals and interventions. However, the resident's records, including the Treatment Administration Record and Weekly Bath Audit, did not reference fingernail care or refusals. Staff interviews confirmed that nail care was expected to be completed with weekly showers and as needed, but the resident's nails remained untrimmed and uncleaned over several days. The lack of proper documentation and follow-through on care plan directives led to the failure to provide necessary assistance with personal hygiene for the resident.
Failure to Ensure Proper Positioning and Edema Device Application
Penalty
Summary
The facility failed to ensure proper wheelchair positioning for a resident during meal times, as observed on multiple occasions. The resident, who had dementia and was on hospice care, was consistently seated in a Broda-style wheelchair in a reclined position while eating. This positioning required the resident to lean forward significantly, approximately 12 to 14 inches, to reach the meal plate, which was positioned at chest level due to the low height of the wheelchair seat relative to the table. Staff did not attempt to correct the resident's posture during meal service, and there was no evidence in the medical record of a comprehensive evaluation or assessment for alternative interventions to improve eating posture. Interviews with staff revealed a lack of awareness and evaluation regarding the resident's eating position, and no facility policy on wheelchair positioning was provided. Additionally, the facility failed to ensure that medical devices for edema management were consistently applied for another resident with lymphedema and congestive heart failure. Physician orders required the use of TED stockings for 12 hours on and 12 hours off, as well as daily lymphedema wraps. However, documentation showed that these devices were rarely applied, with most days marked as refused, sleeping, or hospitalized. The resident reported not having worn TED stockings since returning from the hospital and never having used lymphedema wraps. Staff interviews indicated a lack of consistent application and assessment of the resident's preferences or alternative approaches to device use, especially considering the resident's sleep patterns and refusals. In both cases, the facility did not provide documentation of relevant policies (wheelchair positioning or edema management) when requested. The deficiencies were identified through observation, interviews, and document review, highlighting failures to provide care and treatment according to physician orders and resident needs, specifically regarding proper positioning for eating and consistent application of medical devices for edema management.
Failure to Maintain or Improve Resident Range of Motion
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide appropriate care to maintain and/or improve a resident's range of motion (ROM), limited ROM, and/or mobility. The facility did not ensure that care was provided unless a decline was for a documented medical reason. This resulted in a resident experiencing a decline in ROM or mobility without evidence that the decline was medically unavoidable.
Failure to Assess and Intervene for Substance Abuse and Fall Risk
Penalty
Summary
The facility failed to comprehensively assess and implement interventions to reduce the risk of accidents or injury for residents with a history of substance abuse and for a resident at high risk for falls. For two residents with substance abuse histories and suspected current use, there was a lack of documented interventions, assessments, or monitoring protocols in their electronic medical records. Staff reported concerns and observed signs of possible substance use, such as glassy eyes, slurred speech, and the smell of burning, but these concerns were not addressed through care planning or monitoring. The facility's own policy required assessment and individualized care planning for substance abuse, but this was not followed, and staff interviews confirmed the absence of such measures. One resident with a history of substance use was observed by staff to display symptoms consistent with intoxication, and staff reported these concerns to management multiple times without any documented follow-up or intervention. Another resident admitted to past drug use and was reported by a peer to be using illicit substances in the facility, including barricading the door and threatening others. Despite these reports and a care plan noting substance use disorder, the only intervention offered was chemical use counseling, which the resident declined. There was no evidence of ongoing monitoring or comprehensive assessment as required by facility policy. For a resident at high risk for falls, the facility did not implement new interventions following a recent fall. The care plan listed previous interventions, but after the most recent incident, there was no evidence of therapy involvement or updated interventions. Staff interviews revealed that therapy orders were not obtained, and the director of rehabilitation confirmed that no new therapy had been initiated. The facility's protocols required immediate intervention and care plan updates after a fall, but these actions were not taken, leaving the resident without additional support to prevent further incidents.
Failure to Address Significant Weight Gain and Nutritional Status
Penalty
Summary
The facility failed to recognize and respond to a significant weight gain in a resident, resulting in a lack of interventions to maintain acceptable nutritional status. The resident, who was cognitively intact and had diagnoses including hypertension, peripheral vascular disease, hyperlipidemia, asthma, and diabetes, was admitted at 165 pounds and later recorded at 231 pounds, reflecting a 35.8% increase in weight. Despite an order for a diabetic, regular textured diet, the resident's electronic medical record showed no follow-up or intervention from dietary or nutrition services regarding the substantial weight gain. The most recent nutrition data noted the weight increase but did not include any interventions, only indicating that the registered dietician would follow up as needed. Interviews revealed that the resident expressed concerns about the quality and appropriateness of the food provided, stating it was not suitable for a diabetic diet and that no dietician had addressed her weight gain or dietary concerns. The dietary manager acknowledged awareness of the resident's complaints but had not discussed the weight gain with the resident, citing the resident's right to choose their food. A licensed practical nurse confirmed the significant weight gain and noted that the dietician typically monitored nutritional status but had not followed up in this case. Facility policy required evaluation and intervention for undesirable weight changes, but this process was not followed for the resident.
Failure to Provide Adequate Pain Management and Non-Pharmacological Interventions
Penalty
Summary
The facility failed to provide adequate pain management for a resident with a history of significant injuries and ongoing pain. The resident, who was cognitively intact and had diagnoses including injuries from a motor vehicle accident, intervertebral disc degeneration, and chronic back pain, did not have a pain assessment documented in the Minimum Data Set (MDS). The electronic medical record (EMR) included orders for pain medications and required pain monitoring every shift, but there was no evidence that pain monitoring was consistently documented. Additionally, the EMR lacked documentation of non-pharmacological pain interventions being offered or their effectiveness, and the pain assessment form left the section for non-medication interventions blank. Observations and interviews revealed that the resident experienced visible and severe pain, reported that prescribed medications were not effective, and stated that staff did not respond adequately to her pain complaints. Staff interviews confirmed that pain levels were not routinely assessed and that non-pharmacological interventions were not being used. The facility's policy indicated that non-pharmacological interventions should be considered, but these were not implemented for the resident in question. The care plan included some interventions, such as positioning with pillows and administering pain medication, but did not address the lack of consistent pain monitoring or the use of alternative pain relief methods.
Failure to Identify and Care Plan Trauma Triggers for Resident with PTSD
Penalty
Summary
The facility failed to identify and document trauma triggers or develop an individualized trauma-informed care plan for a resident with a history of post-traumatic stress disorder (PTSD) and other mental health diagnoses. The resident, who was cognitively intact and independent in activities of daily living, reported having known triggers related to staff behavior, such as loud noises and being abruptly awakened. Despite the resident's willingness to discuss these triggers, no staff had engaged her in such conversations, and her care plan did not include any identified triggers or strategies to avoid re-traumatization. Review of the resident's assessments and care documentation revealed that trauma history was acknowledged, but specific triggers were either marked as "none" or left as "unknown," and there was no follow-up to clarify or update this information during subsequent assessments. Interviews with nursing staff and aides indicated a lack of awareness regarding the resident's PTSD diagnosis and potential triggers, and the care plan lacked individualized trauma-informed interventions. The facility's policy required assessment and documentation of triggers, but this was not reflected in the resident's records or care planning.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated.
Failure to Ensure Drug Regimens Were Free from Unnecessary Medications
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary medications in two separate cases. In the first case, a resident with a history of smoking and nicotine dependence was prescribed a nicotine transdermal patch. Despite repeated recommendations from the consulting pharmacist and CDC guidelines to gradually decrease and discontinue the nicotine patch, especially if the resident continued to smoke, the facility did not implement a dose reduction. The resident was documented as both currently smoking and as having not smoked for a period, with conflicting reports from staff and the resident. The pharmacist’s recommendations to decrease the patch were acknowledged by the provider, but the resident refused the reduction, and the facility did not pursue alternative strategies or document a clear plan for dose reduction, as required by facility policy. In the second case, the facility failed to monitor, assess, and clarify an antibiotic order for a resident with severe cognitive impairment and multiple medical diagnoses, including a history of traumatic brain injury and ocular issues. The resident was prescribed moxifloxacin ophthalmic solution for bacterial conjunctivitis and later for other eye conditions, but the order lacked a specified end date. Review of the resident’s medical records showed ongoing administration of the antibiotic without clear documentation of the duration or ongoing need, and there was no evidence of regular assessment for effectiveness or side effects. Staff interviews revealed uncertainty about the resident’s follow-up appointments and the necessity of continuing the antibiotic, and the facility’s own policy required antibiotic orders to include a stop date or duration, which was not followed in this case. Both deficiencies were identified through interviews, document reviews, and observations, which showed a lack of adherence to facility policies and best practices regarding medication management. The facility did not ensure that medications were regularly reviewed for necessity, that dose reductions were attempted as appropriate, or that antibiotic stewardship protocols were followed, resulting in residents receiving medications without adequate justification or monitoring.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident received a significant medication error, indicating a failure in the medication administration process. Specific details about the actions or inactions leading to the error, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Accommodate Food Allergies and Preferences
Penalty
Summary
The facility failed to ensure that food allergies, intolerances, and preferences were consistently accommodated for three residents. One resident with documented allergies to cornstarch, gluten, and soybean oil was repeatedly served eggs cooked in an oil blend containing 90% soybean oil, despite clear care plan instructions and meal ticket notations to avoid soybean oil. Kitchen staff were unaware of the need to use alternative cooking oils for this resident, and the resident reported ongoing issues with being served foods containing allergens, leading her to purchase her own food to avoid adverse reactions. Another resident with a regular diet requiring pureed textures had a care plan indicating an intolerance to eggs unless cooked into food, and a preference to avoid strawberries and nuts. Despite this, the resident was served pureed scrambled eggs at breakfast, contrary to the meal ticket which specified no eggs at breakfast due to an egg yolk allergy. Staff interviews revealed a lack of awareness regarding the resident's allergies, with reliance on meal tickets for guidance, but the system failed to prevent the serving of restricted foods. A third resident, who reported allergies to fish and seafood, continued to be served these items, including a recent incident where shrimp was served despite the allergy being listed on the meal ticket. The resident's allergy was not documented in the official allergy list or care plan, and staff, including nursing assistants and LPNs, were unaware of the dietary restrictions. The facility's policies required staff to follow individualized diet orders and meal tickets, but these were not consistently referenced or updated, resulting in repeated failures to prevent exposure to known allergens.
Failure to Implement Therapeutic Diet Order for Diabetic Resident After Hospital Readmission
Penalty
Summary
The facility failed to ensure that a therapeutic diet was ordered and implemented for a resident with type 1 diabetes upon readmission from the hospital. The resident's hospital discharge summary specified a consistent carbohydrate diet, but upon return to the facility, no diet order was entered into the electronic medical record (EMR) until two days later, when a regular diet was entered. There was no documentation of an order for a regular diet, and the resident continued to receive a regular diet instead of the prescribed diabetic diet. Interviews with nursing staff confirmed that the process for entering and verifying orders, including diet orders, was not followed, and the resident's EMR did not reflect the required therapeutic diet order. The resident, who was independent in all activities of daily living and required insulin for diabetes management, experienced multiple high blood sugar readings during this period. Staff interviews revealed a lack of awareness regarding the resident's dietary needs and the absence of the appropriate diet order. The facility's policy required that diet orders from authorized prescribers be accepted and entered by licensed nurses, but this was not adhered to, resulting in the resident not receiving the prescribed therapeutic diet upon readmission.
Failure to Follow Infection Control Standards During Resident Personal Care
Penalty
Summary
A deficiency occurred when a nursing assistant (NA-I) failed to follow current infection control standards during personal care for a resident diagnosed with diabetes, stroke, and heart disease. The resident required significant assistance with bed mobility, dressing, toileting, and transferring. During observed care, NA-I, after performing perineal care with gloved hands, continued to assist the resident with applying a new pad, putting on shorts, positioning on a stand aide, and adjusting glasses, all without changing gloves or performing hand hygiene between tasks. NA-J, another nursing assistant, performed hand hygiene before leaving the room, but NA-I only removed gloves and disposed of trash before leaving, without hand hygiene during the care process. Interview with NA-I revealed that he was not aware of the need to perform hand hygiene during care, only before and after. The director of nursing confirmed that facility policy requires hand hygiene before applying gloves, when changing gloves, after glove use, and after tasks such as perineal care to prevent cross-contamination. The facility's hand hygiene policy also specifies hand hygiene before moving from a contaminated to a clean body site, after contact with intact skin, and after removing gloves. The failure to follow these protocols was directly observed and confirmed through staff interviews and policy review.
Incomplete Care Plan Lacking Measurable Actions
Penalty
Summary
A deficiency was identified due to the facility's failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This deficiency was observed through review of the resident's records, which did not contain comprehensive or measurable interventions to address the resident's identified needs.
Failure to Properly Label and Secure Medications
Penalty
Summary
Drugs and biologicals in the facility were not labeled in accordance with currently accepted professional principles. Additionally, all drugs and biologicals were not stored in locked compartments, and controlled drugs were not kept in separately locked compartments as required. These actions resulted in a failure to meet regulatory standards for the labeling and secure storage of medications and biologicals. No specific details about individual residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Post and Communicate Survey Results
Penalty
Summary
The facility failed to ensure that the most recent State agency survey results were posted in a prominent location and readily accessible at all times, as required. During a resident council meeting, several residents reported they did not know where to find the survey results and had not discussed them during council meetings. A tour of the facility revealed that while binders labeled with survey years were present on each floor, the most recent survey results were not always included, and complaint survey results were missing from the binders. The signage above the binders did not indicate that additional survey results were available upon request. The administrator confirmed that both recertification and complaint survey results should be included in the binders and accessible on each floor, as some residents do not leave their floor. The activities director also stated that survey results had not been discussed during resident council meetings. Facility policy requires that information about the location of the three most recent survey reports be posted on the resident bulletin board and at each nurses' station, but this was not observed during the survey.
Failure to Assess and Document Self-Administration of Medication
Penalty
Summary
The facility failed to complete a comprehensive assessment for self-administration of medication for one resident with chronic respiratory failure and hypoxia. The resident had physician orders for albuterol inhaler use as needed for shortness of breath, with specific instructions for administration. Observation revealed that the resident kept an albuterol inhaler, nystatin powder, and a nebulizer machine at the bedside and self-administered the inhaler without staff supervision. The resident stated that staff had given clearance to use the inhaler independently. However, the care plan did not document self-administration of medications or permission for medications to be kept at the bedside, and no assessment for self-administration was found in the medical record. Interviews with nursing staff and the DON confirmed that there was no order or completed assessment for the resident to self-administer medications or to keep them at the bedside. Staff acknowledged that medications should not be kept at the bedside without proper assessment and physician order. The facility's policy requires an interdisciplinary team assessment to determine if self-administration is safe and appropriate, with documentation in the medical record and care plan, and secure storage of self-administered medications. These steps were not followed in this case.
Failure to Arrange and Prepare for Safe Discharge
Penalty
Summary
A resident with significant medical needs, including a recent surgical amputation, immunodeficiency, diabetes, and open wounds requiring complex wound care, was discharged from the facility without a comprehensive discharge plan or proper arrangements for home care services. The resident's care plan did not include any discharge focus, goals, or interventions, and the Minimum Data Set lacked a cognitive assessment. Although the provider ordered skilled nursing and occupational therapy for the home, there was no evidence that these services were arranged prior to discharge. The facility's social worker, who was responsible for setting up home care services, was not present at the time of discharge and did not begin searching for agencies until after the resident had already left. Multiple home care agencies were contacted after the discharge, but all denied services. The resident was not contacted by the facility following discharge, and there was a lack of communication regarding which agency would provide the necessary care. Nursing staff assumed that home care services were in place, but there was no confirmation or follow-up. As a result, the resident went home without the ordered home care services, leading to worsening of his wounds and subsequent hospital admission. The facility's policy required a post-discharge plan developed by the interdisciplinary team, including arrangements for follow-up care and support, but this process was not followed. Interviews with staff revealed gaps in training and understanding of discharge procedures, and the resident was not adequately prepared or oriented for a safe transition home.
Failure to Provide Required Discharge Documentation and Medication Reconciliation
Penalty
Summary
The facility failed to ensure that appropriate discharge documentation was present in the medical records for three residents. For each of these residents, the records were missing essential discharge summaries, a recapitulation of their stay, a final summary of their status, and a reconciliation of all pre-discharge and post-discharge medications, including both prescribed and over-the-counter drugs. The care plans for these residents did not indicate any discharge focus, goals, or interventions, and there was no evidence of a comprehensive discharge summary assessment being completed. One resident, who had significant medical needs including aftercare for surgical amputation, immunodeficiency, diabetes, and required assistance with most activities of daily living, was discharged without a documented discharge care plan or information about the home care agency providing follow-up services. Another resident, who was cognitively impaired and dependent on staff for daily care, was discharged with orders for home care services and a seven-day supply of medications, but the documentation lacked a full recapitulation of her stay, a final summary of her status, and a medication reconciliation. The resident's family also reported not receiving a discharge care plan or understanding the medication reconciliation process. A third resident, who was cognitively intact but dependent for daily care due to multiple chronic conditions, was discharged with home care services arranged, but the facility's records did not include a completed discharge summary. Interviews with facility staff revealed a lack of awareness regarding the requirements for discharge documentation and the absence of a streamlined discharge process. The facility's policy required comprehensive discharge summaries and individualized post-discharge plans, but these were not completed as required for the residents in question.
Failure to Properly Dispose of Discontinued Medications
Penalty
Summary
The facility failed to establish and maintain an effective system for the reconciliation and proper disposal of discontinued medications for 20 out of 29 residents reviewed. During observations, surveyors found trash bags and bins in locked medication rooms on two floors containing approximately 153 medication cards of non-narcotic medications that had been discontinued but not yet disposed of. These medications belonged to both current and discharged residents, and the accumulation of discontinued medications was noted to have the potential to affect all sixty residents in the facility. Interviews with staff revealed a lack of clarity and consistency in the process for handling discontinued medications. Medication assistants and nurses reported that when a medication was discontinued, it was typically removed from the medication cart and either given to a nurse or placed in the medication room. However, staff were often unsure of the next steps, and not all staff had access to the system used for medication destruction. The DON stated that discontinued medications should be disposed of immediately or by the next business day, but acknowledged that when she was not present, licensed staff did not have access to her office where the medication destruction box was located. The facility's policy on discarding and destroying medications, dated April 2019, required staff to dispose of medications immediately after discontinuation and no later than three days after discontinuation. Despite this policy, the observed practice did not align with these requirements, as discontinued medications were left accumulating in medication rooms for an undetermined period. Staff interviews confirmed that the process was not consistently followed, and there was confusion regarding responsibilities and procedures for medication disposal.
Failure to Assess, Educate, and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to ensure that side rails were comprehensively assessed for appropriateness and safety, that the risks and benefits were discussed, and that informed consent was obtained prior to use for a resident. One resident with moderately impaired cognition, a right humerus fracture, and requiring maximum assistance for bed mobility and transfers, was observed with raised bilateral quarter siderails. The resident's care plan did not include information about bed rails, and the electronic medical record lacked evidence of a side rail assessment, education on risks, or a completed consent form. Interviews revealed that the resident did not recall being asked about side rail use or being informed of the risks. The resident's power of attorney stated she requested the side rails but was not informed of the associated risks. Facility staff, including an LPN and the DON, were unclear about the assessment process and confirmed that no bed rail evaluation was present in the resident's record. The facility's policy required alternatives to be tried, interdisciplinary evaluation, resident assessment, and informed consent prior to bed rail use, but these steps were not documented or completed for this resident.
Failure to Administer Prescribed Diuretic Leads to Hospitalization
Penalty
Summary
The facility failed to ensure that a resident, identified as R1, received their prescribed diuretic medication, Furosemide, upon admission. R1 was admitted to the facility from the hospital with a discharge order for Furosemide 40 mg to be taken twice daily for conditions including congestive heart failure and high blood pressure. However, due to a lack of follow-up and clarification of the medication order, R1 did not receive the medication for sixteen days, leading to a significant medication error. The deficiency occurred because the initial attempt to clarify the medication order with the hospital was unsuccessful, and no further follow-up was conducted. The LPN who admitted R1 attempted to contact the hospital for clarification but did not receive a callback and failed to ensure the order was clarified and entered into the system. This oversight was compounded by a lack of communication and verification among the nursing staff, as the process for double-checking orders was not effectively implemented, resulting in the medication not being administered. As a result of not receiving the prescribed diuretic, R1 experienced an exacerbation of congestive heart failure, leading to hospitalization. Interviews with facility staff, including LPNs, the nurse practitioner, and the medical director, revealed concerns about the facility's process for handling medication orders, highlighting issues with communication, order verification, and staff turnover. The facility's failure to administer the medication as ordered directly contributed to R1's hospitalization.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure enhanced barrier precautions (EBP) were followed for a resident with an open wound on the chest. Despite the presence of EBP signs on the resident's door, staff members, including nursing assistants and an occupational therapist, did not wear gowns during personal care and transfers. Interviews with staff revealed that they were aware of the need for gowns but neglected to use them, posing a risk of spreading infections. The facility's policy on transmission-based precautions was not adhered to, as staff did not consistently follow the required infection control measures. Infection control practices were also inadequate for several residents. One resident's urinal was improperly placed on a bedside table among personal items and food, creating a contamination risk. Another resident's C-pap machine was not maintained by the staff, with the resident's family member taking responsibility for its care without receiving proper instructions from the facility. Additionally, a resident used a personal container for urination that was not cleaned or labeled, leading to concerns about infection control due to visible debris and lack of maintenance. The facility also failed to maintain proper hygiene in the environment and during laundry procedures. A resident's room was not cleaned promptly after a toilet overflow, leaving the resident exposed to unsanitary conditions. Furthermore, clean clothes were transported uncovered, with some items dragging on the floor, which was acknowledged as an infection control issue by the staff. These lapses in infection prevention and control practices have the potential to affect all residents, staff, and visitors within the care center.
Inadequate Antibiotic Stewardship Program
Penalty
Summary
The facility failed to develop and implement a comprehensive antibiotic stewardship program, which resulted in inadequate monitoring and documentation of antibiotic use for all 11 residents reviewed. The infection surveillance tracking logs for January and February 2025 were incomplete, lacking critical information such as diagnostics performed, specimen sources, diagnostic results, completion of antibiotic time outs, and resolution dates of infections. This deficiency affected the facility's ability to effectively track and manage infections, potentially impacting all 69 residents. Specific cases highlighted in the report include residents with various infections such as cellulitis, urinary tract infections, and pneumonia. For instance, one resident with cellulitis was prescribed cephalexin, but the log did not document when the infection was resolved. Another resident with a urinary tract infection was prescribed levofloxacin, yet the log lacked culture results and documentation of a 72-hour antibiotic time out. These omissions were consistent across all reviewed cases, indicating a systemic issue in the facility's infection tracking and antibiotic management. Interviews with the infection preventionist and the director of nursing revealed that the facility did not utilize the Minnesota Department of Health tool or any other effective system to identify and trend infections. The infection preventionist admitted to using the tool only for tracking residents receiving antibiotics, acknowledging the logs' deficiencies and the inability to perform preventative actions. The facility's policy on antibiotic stewardship, which mandates the collection and documentation of antibiotic usage and outcomes, was not adhered to, contributing to the deficiency.
Failure to Schedule RN for Required Hours
Penalty
Summary
The facility failed to ensure a registered nurse (RN) was scheduled for a minimum of eight consecutive hours a day, which had the potential to affect all 62 residents residing at the facility. The Payroll Based Journal (PBJ) Staffing Data Report for the fourth quarter of 2024 showed no RN hours on specific dates, all of which were Sundays. The staffing coordinator, who had recently started the position, confirmed that no RN was scheduled on those dates and acknowledged the requirement for at least eight hours of RN coverage daily. The administrator also expected daily RN coverage and noted that the PBJ data was submitted by the corporate office. Despite efforts to obtain RN payroll information for the specified dates, it was not provided. The facility's policy required a registered nurse to provide services at least eight consecutive hours every 24 hours, seven days a week.
Deficiency in Meal Temperature and Palatability
Penalty
Summary
The facility failed to ensure that meals were served at a palatable and appropriate temperature, affecting the quality of life and nutritional intake for two residents with intact cognition. Both residents reported dissatisfaction with the temperature and quality of the food, with one resident specifically mentioning that meals were consistently cold and another noting that the food was not served at the correct temperature and that there were issues with the availability and quality of beverages. Observations during meal service revealed that the process of preparing and delivering room trays was inefficient, leading to delays and resulting in meals being served cold. During the meal service, the dietary staff set up a steam table and prepared trays for delivery to resident rooms. However, the process was delayed as trays were left on a metal cart while drinks were prepared, leading to a backlog of trays waiting to be delivered. A sample tray tested by an LPN confirmed that the food was bland and cold. The facility's policy on time and temperature control emphasized the importance of timely meal delivery to maintain palatability and resident satisfaction, but the observed practices did not align with this policy, contributing to the deficiency.
Deficiencies in Resident Care and Documentation
Penalty
Summary
The facility failed to provide routine bathing, nail care, and grooming for five residents, as well as assistance with hearing aids for one resident. Resident R173, who was admitted with multiple diagnoses including lumbar spinal stenosis and cerebral infarction, did not receive a shower since admission, and there was no documentation of bathing in the electronic medical record. Interviews with staff revealed a lack of awareness and documentation regarding the resident's bathing schedule. Resident R16, who required substantial assistance with personal hygiene, was observed with long, jagged fingernails and stained clothing. The care plan did not address grooming or nail care needs, and staff acknowledged the resident's unkempt appearance, citing infection control and dignity concerns. Similarly, Resident R5, who was dependent on staff for ADLs, had greasy, uncombed hair and was observed in a hospital gown over several days. The care plan lacked documentation of refusals or preferences for bathing, and staff interviews confirmed the absence of regular bathing. Resident R51, who was dependent on staff for all ADLs, was observed with matted, greasy hair and lacked documentation of bathing in the past 30 days. Staff interviews indicated that showers were not offered consistently, and refusals were not documented. Resident R43, with severely impaired cognition, was observed without hearing aids and with unshaven facial hair. The care plan did not address bathing refusals or interventions, and staff interviews highlighted inconsistencies in offering and documenting care. The facility's policy required staff to provide assistance based on care plans and to address refusals with alternative approaches, which was not adhered to in these cases.
Failure to Provide Resident Activities
Penalty
Summary
The facility failed to provide activities of interest to enhance the quality of life for four residents, as observed through multiple instances of inactivity and lack of engagement. Resident R10, who has multiple sclerosis and other health conditions, was frequently observed alone and asleep in a Broda chair in the TV room, with no documented participation in activities. The director of activities admitted to not having assessed R10 and was unaware of the resident's participation in activities, indicating a lack of engagement and oversight. Resident R16, who is cognitively impaired and dependent on staff for mobility, was also observed alone and inactive in the TV room. Despite having a care plan that encouraged family involvement and leisure activities, there was minimal documentation of R16's participation in activities over a 30-day period. The director of activities acknowledged the need for more activities and socialization for residents but had not yet implemented changes. Residents R5 and R51 also experienced a lack of engagement in activities. R5, who has Alzheimer's disease and other health issues, was observed in bed with no music or TV playing and had no documented activities offered in the last 30 days. Similarly, R51, who has Parkinson's disease and dementia, had no documented activities in the last 14 days. Staff members were generally unaware of the residents' activity preferences, and the director of activities confirmed the absence of documentation for activities offered to these residents.
Insulin Pens Left Unsecured at Nurse's Station
Penalty
Summary
The facility failed to ensure the secure storage and supervision of insulin pens on the memory care unit, which could potentially affect residents, staff, and guests. During an observation, 12 insulin pens were found stored on top of the counter at a nurse's station in a gray wash basin, either in a clear plastic bag or case. Insulin needles were also stored in an open plastic container behind the nurse's station. The area was accessible by a half door that could be opened by reaching over and turning the doorknob. The nurse's station was located adjacent to a resident activity/TV room and the main elevators, and during the observation period, several residents, guests, and staff members walked past the unsupervised insulin pens. Interviews with staff revealed that the insulin pens should have been stored in a locked medication storage room or cart when not in use. RN-B, who was responsible for administering and storing insulin, acknowledged that there was not enough room in the treatment cart for the insulin pens and confirmed that they should have been locked away to prevent tampering by confused residents. The Director of Nursing (DON) emphasized the expectation for staff to store all medications securely and supervise them during use to prevent theft, tampering, or improper use. The facility's policy on medication storage, revised in November 2020, mandates that all drugs and biologicals be stored in locked compartments when not in use, accessible only to authorized personnel.
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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