The Villas At Brookview
Inspection history, citations, penalties and survey trends for this long-term care facility in Golden Valley, Minnesota.
- Location
- 7505 Country Club Drive, Golden Valley, Minnesota 55427
- CMS Provider Number
- 245186
- Inspections on file
- 31
- Latest survey
- March 17, 2026
- Citations (last 12 mo.)
- 20 (1 serious)
Citation history
Health deficiencies cited at The Villas At Brookview during CMS and state inspections, most recent first.
Medications were not stored securely when a medication cart on one unit was left unlocked and unattended in a hallway between resident rooms on two separate occasions. An employee walked away from the cart while it was unlocked, during which time a resident and multiple NAs passed by. Later the same day, the same cart was again observed unlocked and unattended as several NAs walked by, until the DON locked it and acknowledged it should have been secured. Facility policy required that medication supplies be accessible only to authorized staff and that medication carts be locked when not attended.
A resident was admitted with documented moderate to severe pain that interfered with sleep and activities, and with a chronic Stage IV sacral pressure ulcer. Admission assessments, PT evaluation, and provider notes all recorded ongoing pain and the presence of a significant wound, yet the 48-hour baseline care plan only noted that the resident experienced pain and was on Enhanced Barrier Precautions, without specifying any pain-relief or wound-care interventions. The baseline care plan also did not document that the resident or representative was offered a copy or the opportunity to sign it, despite staff statements and facility policy indicating that pain, pressure ulcers, and related treatments should be addressed and that residents should receive and sign the baseline care plan.
A resident with intact cognition and a diagnosis of malnutrition had a care plan that identified a potential nutritional problem but lacked specific interventions for poor meal intake, directions on when to provide ordered nutritional supplements, and documentation of food preferences. During one noon meal, the resident ate only a small portion and stated dislike of the food, yet staff did not offer alternative food choices or eating assistance and had not reviewed the care plan. One staff member inaccurately charted higher meal intake without observing the resident eat, while another acknowledged the resident’s low intake but still did not implement typical interventions. The care plan was not updated to reflect the resident’s actual eating patterns or preferences, and the DON later confirmed that expected monitoring and care plan interventions for poor intake had not been carried out.
Two residents at risk for pressure ulcers did not consistently receive ordered prevention and offloading interventions. One resident with severe cognitive impairment, paralysis, diabetes, and documented friction/shear risk was care planned for heel floating and turning/repositioning every 2–3 hours, but the care plan lacked friction/shear precautions and family reported staff only used a towel under the shoulder instead of proper repositioning with pillows. Another resident with malnutrition, pneumonia, respiratory failure, and significant lower-extremity edema had orders for TED hose, ACE wraps, and turning/repositioning with offloading every 2–3 hours, yet was observed lying on her back for an extended period with her heels resting on a pillow instead of floated, a pillow placed on top of her feet, tight socks leaving indentations, and no TED hose or ACE wraps in place, which the nurse acknowledged was inconsistent with the orders and facility policy.
A resident with heart failure, morbid obesity, and total dependence for transfers, weighing over 500 pounds, was transferred from bed using an EZ Stand mechanical lift by a single NA, despite the care plan, physician orders, and facility practice requiring two staff and “care in pairs.” The NA confirmed she performed the transfer alone because she could not find another staff member, acknowledged knowing the resident required paired care, and recognized that injury could occur without a second staff. Other staff and the DON stated that all mechanical lift transfers require two staff for safety, and facility policy called for implementing interventions to minimize serious consequences of falls.
A resident admitted with a history of chronic pain from transverse myelitis and long-term opioid use reported ongoing moderate to severe pain that interfered with sleep and daily activities, but arrived without an order for her usual Percocet. Although PRN oxycodone-acetaminophen and a lidocaine patch were later ordered and administered for pain scores up to 9/10, nursing notes and the MAR did not document the use of non-pharmacological interventions such as repositioning, rest, or other comfort measures, despite these being listed on the care plan and required by facility policy. The baseline care plan initially lacked specific pain-relief interventions, and staff interviews, including with the DON, confirmed that expected pain assessments, non-medication strategies, and documentation of interventions and resident responses were not completed for this resident.
Nurses and nurse aides lacked competency in administering sublingual and slurry medications for a hospice resident with brain cancer, cognitive impairment, and swallowing difficulties. Hospice documentation showed staff requested discontinuation of comfort meds due to swallowing issues and administered solutab meds mixed with applesauce that drained from the resident’s mouth, despite orders for soluble lorazepam and morphine solutabs, including instructions to slurry and give sublingually. A family member reported seeing staff repeatedly attempt to have the resident swallow morphine solutabs, causing coughing and gurgling. Several licensed nurses later admitted they did not know what sublingual medications or slurries were, and one stated she had hospice patients swallow meds ordered to be slurried and given sublingually, while the facility lacked a medication administration policy addressing these methods.
A resident was given a 16-fold overdose of methadone after a handwritten order was incorrectly transcribed into the electronic health record and not properly double-checked. The nurse administered the dose listed in the MAR despite noticing a discrepancy with the medication bottle, resulting in the resident requiring Narcan and ICU admission for opioid overdose.
A resident with significant cognitive and physical impairments was identified as a fall risk, and staff placed a fall mat by her bed as a precaution. However, the use of the fall mat was not documented in the resident's care plan, despite staff awareness and facility policy requiring individualized interventions to be included in the care plan.
A resident with multiple medical conditions was found to be self-administering Tylenol lidocaine 4% gel without a comprehensive assessment, provider order, or documentation in the medical record. Staff observed the medication in the resident's room on several occasions but did not remove it or address its presence, and facility leadership was unaware of the situation. No policy for self-administration of medication was provided.
A resident lost the ability to perform ADLs without a documented medical reason. The facility did not ensure that the decline in the resident's functional abilities was clinically unavoidable, as required by regulations.
A resident with a history of diabetes, dermatitis, prurigo, and prior MRSA infection developed open and scabbed lesions on the lower extremity that were not timely identified, assessed, or documented by staff. Nursing assistants and RNs were unaware of the lesions for several days, and the provider was not notified as required by the care plan, resulting in a failure to follow established protocols for monitoring and reporting non-pressure related skin concerns.
A resident who was edentulous and at risk for nutritional deficits did not receive recommended dentures due to a lack of communication and follow-up between facility staff and the dental provider. The resident remained without dentures and was not informed about their status, while staff interviews revealed no documentation or policy to ensure dental needs were addressed.
A resident with diabetes, dermatitis, and a history of MRSA skin infection was observed to have excessively long fingernails with a dark substance underneath, despite being dependent on staff for ADLs. Staff interviews revealed that nail care responsibilities were not consistently carried out, and there was no documentation of refusals or completed care, leading to a deficiency in providing necessary hygiene.
A resident with a diabetic foot ulcer experienced a worsening of the wound, including increased size and new open areas, as documented in wound care records and observed by staff. Despite these changes, there was no documented notification to the resident's primary care physician or nurse practitioner, and no updates to treatment orders or the care plan were made. Facility policy required such notifications, but staff interviews and record reviews confirmed that this did not occur.
Two residents with surgical wounds did not receive wound care in accordance with provider orders because detailed instructions from hospital discharge and orthopedic follow-up visits were not transcribed into the EHR. Nursing staff were unaware of the specific requirements, and wound care was performed without following the prescribed steps, contrary to facility policy and professional standards.
The facility did not comprehensively assess non-pressure related skin wounds for two residents and failed to administer wound treatments according to physician orders for one resident. One resident with a surgical wound and wound VAC experienced a device failure, leading to an unapproved dressing change and a subsequent suction burn injury that was not properly assessed or treated per hospital discharge instructions. Another resident with a surgical hip incision did not receive complete wound assessments, lacking measurements and essential wound details. A third resident with a diabetic foot ulcer had incomplete wound documentation and an unrecognized increase in wound size.
A resident with a non-pressure chronic ulcer and recent surgery required wound VAC therapy, but several wound care treatments—including a wet-to-dry dressing change after device failure and subsequent dressing changes—were not documented in the medical record or TAR. Nursing staff confirmed the lack of documentation and absence of a physician order for the wet-to-dry dressing, resulting in incomplete and inaccurate medical records.
A resident was discharged from a facility without necessary services and medications due to inadequate discharge planning. The facility failed to complete a waiver evaluation, resulting in the resident lacking a personal care assistant (PCA). Incorrect orders led to the provision of a home health aide instead of a skilled nurse, and medications were not ordered correctly. The resident missed essential appointments and had to rely on family for assistance, highlighting significant gaps in the facility's discharge process.
The facility failed to maintain a current CLIA waiver, necessary for blood testing, affecting residents requiring routine glucose monitoring for diabetes. The waiver had expired, and there was no updated certificate or documentation of renewal application. Numerous residents with diabetes were impacted, with monitoring frequencies ranging from daily to four times a day. The facility also lacked a policy for maintaining the CLIA waiver.
A resident with end-stage renal disease and diabetes did not receive the prescribed double meat/protein portions due to a failure in documenting dietary orders on the tray ticket. The resident, who had a history of skin integrity issues, expressed dissatisfaction with meal portions and resorted to purchasing additional food. Staff interviews revealed a lack of communication and documentation regarding the resident's dietary needs.
The facility failed to properly clean and disinfect a community-use glucometer between resident uses. An LPN used an alcohol wipe instead of the required purple top Sani wipe, as confirmed by the RN and DON. The correct procedure involves a two-minute kill time for the disinfectant.
Unlocked Medication Cart Left Unattended on Unit
Penalty
Summary
The deficiency involves failure to keep medications stored securely in a medication cart on the 400 unit. During an observation, an employee identified as E-I walked away from a medication cart in the hallway between resident rooms, leaving it unlocked and unattended from 12:27 p.m. to 12:37 p.m. During this time, one resident wheeled by the cart and two nursing assistants walked past it. The Director of Social Services checked only the narcotics drawer, confirmed it was locked, and then left, while the rest of the cart remained unlocked. E-I later acknowledged that the cart was unlocked when she left and stated it should have been locked to prevent other staff and residents from taking medications from the cart, which could make them sick. In a separate observation the same day at 2:27 p.m., the same medication cart on the 400 unit was again found unlocked and unattended in the hallway between resident rooms. From 2:27 p.m. to 2:47 p.m., nursing assistants walked by the unlocked cart five times. At 2:47 p.m., the DON walked by, pushed the lock to secure the cart, and stated it was not good that the cart was unlocked, that medications could go missing, and that the cart was supposed to be locked when staff walked away. The facility’s Storage of Medications policy dated May 2022 stated that the medication supply was accessible only to licensed nursing personnel or staff lawfully authorized to administer medications, and that medication carts were to be locked when not attended by authorized personnel.
Failure to Develop and Share Adequate Baseline Care Plan for Resident With Pain and Pressure Ulcer
Penalty
Summary
Surveyors found that the facility failed to develop and implement an adequate baseline (48-hour) care plan for a newly admitted resident with significant pain and a chronic pressure ulcer, and failed to provide a summary of that plan to the resident or representative. On admission, nursing assessment documented that the resident had frequent moderate pain over the prior five days, rated 5/10, which made it hard to sleep and limited day-to-day activities. The assessment also identified a wound on the coccyx, described as an opening on the right buttock, and progress notes documented admission with a chronic Stage IV sacral ulcer. A PT evaluation noted that pain interfered with functional activity and sleep and indicated that nursing would address the pain. A provider progress note and subsequent pain ratings showed ongoing pain scores ranging from 5/10 to 8/10 over the first several days after admission. Despite these findings, the 48-hour baseline care plan dated two days after admission only indicated that the resident experienced pain, without including any interventions to relieve that pain. The baseline care plan also noted the resident was on Enhanced Barrier Precautions related to wounds but did not document that the resident had skin issues or specify interventions to treat the wounds. The care plan further failed to indicate whether the resident or the resident’s family/representative was offered a copy of the 48-hour care plan or given the opportunity to sign it. Staff interviews confirmed that pain, pressure ulcers, and related interventions should be included on the baseline care plan and that residents should be offered a copy and the opportunity to sign. The facility’s own baseline care plan policy stated that the baseline care plan should include any services and treatments to be administered by the facility until a comprehensive assessment and person-centered care plan are developed.
Failure to Develop and Implement Comprehensive Nutrition Care Plan for Malnourished Resident
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively develop and implement a care plan for a resident with a diagnosis of malnutrition and poor nutritional intake. The resident’s admission MDS showed intact cognition, a need for set-up assistance with meals, and diagnoses including pneumonia and malnutrition. The care plan dated 2/2/26 identified a potential nutritional problem related to moderate malnutrition and included interventions such as assisting with meal set-up, recording nutritional intakes, taking orders at meals, and offering alternatives. However, the care plan did not include specific interventions for when the resident did not eat meals, nor did it provide direction on when to offer the ordered nutritional supplement. The care plan also lacked documentation of the resident’s food preferences. On observation, the resident was seen eating only a small portion of a noon meal, using fingers to eat a few bites of fish, drinking fluids, and not consuming the pasta and vegetables, stating she did not like the meal. One staff member removed the tray after confirming the resident was done, estimated intake at about 10%, and acknowledged knowing the resident disliked the facility food but did not offer an alternative or assistance, and had not reviewed the care plan. Another staff member charted that the resident ate 50% of the meal without having seen the resident eat or removed the tray, later admitting this was inaccurate and that actual intake was about 25%. This staff member also acknowledged not offering assistance or an alternative food choice despite typical practice to do so. Review of the care plan days later confirmed it had not been updated with interventions for poor intake or food preferences, and the resident reported staff had not asked about her food preferences. The DON stated that documentation showed 50–75% intake for that meal and described expectations that staff offer alternatives, notify appropriate clinical staff, and increase monitoring when a resident does not eat well, but acknowledged this was not done and that such interventions were expected to be in the care plan.
Failure to Implement Ordered Pressure Ulcer Prevention and Offloading Measures
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered pressure ulcer prevention interventions for residents identified as at risk. One resident with severe cognitive impairment, right-sided paralysis, diabetes, and a brain tumor was care planned to have heels floated with a pillow and to be turned and repositioned every two to three hours and as needed, and had provider orders for weekly skin inspections and an air mattress to prevent skin breakdown. Progress notes documented that this resident could only make slight body position changes and had friction and shear identified as a potential problem, but the care plan did not include precautions for friction and shear despite this documented risk. Hospice notes described poor skin turgor and anasarca, and the resident’s family reported that staff’s method of turning consisted of placing a towel under the shoulder, which hospice staff considered inadequate, while an employee stated a towel alone could not properly position a resident and that pillows should be used. Another resident, admitted with intact cognition but at risk for pressure ulcers, had diagnoses including malnutrition, pneumonia, and respiratory failure, and was ordered to receive TED hose daily and ACE wraps in the morning and off at bedtime for edema management, along with a care plan for turning, repositioning, and offloading every two to three hours and as needed. Provider documentation noted significant lower extremity edema and weight gain related to fluid retention. During an extended observation period, this resident remained on her back with the head of the bed elevated, feet resting directly on a pillow, and another pillow placed on top of her feet, which she described as feeling heavy. At that time, she was not wearing the ordered TED hose or ACE wraps, her socks were leaving indentations in her swollen feet, and her heels were on the pillow rather than floated off the bed. The nurse acknowledged the resident’s edema, the risk of sores from tight socks, that the heels were not properly floated, and that the resident was not wearing TED hose as ordered, and admitted having placed the pillow on the feet earlier and forgetting to remove it. The facility’s policy required implementation of appropriate preventive skin measures, including mobility, repositioning, and pressure redistribution plans, and updating the care plan to identify risks for skin breakdown.
Failure to Use Required Two-Person Assistance for Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure safe transfers and adequate supervision when a nursing assistant (NA-A) transferred a resident (R5) alone using an EZ Stand mechanical lift, despite the resident’s care plan and facility practice requiring two staff for all mechanical lift transfers. R5’s annual MDS indicated intact cognition, dependence on staff for all transfers, and diagnoses including heart failure and morbid obesity. R5’s care plan dated 6/3/24 documented the need for assistance of two staff with the EZ Stand and identified a risk for falls related to impaired mobility, and a subsequent care plan dated 9/3/24, as well as orders dated 2/10/26, specified “care in pairs.” Provider notes documented that R5 weighed 543 pounds. During an observation, surveyors saw NA-A exit R5’s room alone with the EZ Stand after R5 thanked her for helping her out of bed, with no other staff present in or near the room. In interviews, R5 confirmed that only NA-A assisted with the EZ Stand transfer and reported that staff sometimes used one person instead of two when another staff member could not be found. Staff member E-J stated that R5 required two staff for EZ Stand transfers and that all residents using mechanical lifts required two staff. NA-A acknowledged transferring R5 without a second staff member, stated she was aware R5 was supposed to have care in pairs due to past allegations against staff, and admitted she should have waited for help and that she knew she could get in trouble and that injury could occur without another staff present. Another employee, E-D, stated R5 always transferred with two staff for safety and that if she observed a one-person EZ Stand transfer, she would educate the staff on safe transfer procedures. The DON confirmed that all mechanical lifts in the facility required two staff for safe transfers and that staff could seek assistance from various nursing personnel or wait for help. The facility’s Fall Prevention and Management policy indicated staff would identify and implement relevant interventions to minimize serious consequences of falling.
Failure to Implement and Document Adequate Pain Management Interventions
Penalty
Summary
The deficiency involves the facility’s failure to sufficiently manage pain and implement or document non-pharmacological pain interventions for a resident admitted with frequent, moderate pain. On admission, the resident’s nursing assessment documented pain rated 5/10 over the prior five days, interfering with sleep and daily activities, and the PT evaluation and provider notes also identified pain that interfered with function and sleep. The resident had a diagnosis of transverse myelitis and a history of long-term opioid use, but arrived without an order for her usual Percocet. Initial documentation on the day of admission noted pain rated 5/10 but did not indicate what pain interventions were provided. Over the following days, the resident’s pain scores ranged from 5/10 to 9/10, with multiple documented assessments showing moderate to severe pain. Provider orders were obtained for a lidocaine 4% patch and PRN oxycodone-acetaminophen 10-325 mg every six hours, with the first Percocet dose administered two days after admission. Nursing progress notes and the MAR showed administration of Percocet for pain scores of 6/10 and 9/10, and one note indicated the medication was effective, but the records consistently lacked documentation of non-medication pain interventions attempted before or along with opioid use. The resident’s 48-hour baseline care plan noted admission with pain but did not include specific interventions to relieve pain, while the subsequent care plan listed non-medicinal interventions such as positioning, rest, and massage without evidence in the notes that these were implemented or documented. Interviews with staff, including the DON, confirmed that facility expectations and the written Pain Management Protocol required pain assessment on admission, use and documentation of non-pharmacological interventions, and obtaining alternative medications or interventions if there was a delay in pain medication. Staff acknowledged that non-medication interventions and thorough pain assessments, as well as documentation of interventions and resident responses, were not carried out or recorded for this resident as required.
Inadequate Nurse Competency in Sublingual and Slurry Medication Administration
Penalty
Summary
The facility failed to ensure nurses were timely and competently trained on the administration of oral and sublingual medications for a resident with complex needs. The resident had frontal lobe brain cancer, was significantly cognitively impaired, dependent for ADLs, had difficulty or pain with swallowing, and was receiving scheduled and PRN pain medications. Hospice notes documented that during the early morning hours, a facility nurse contacted hospice to request discontinuation of all medications because the resident was having difficulty swallowing, including Synthroid and morphine. Hospice staff educated the nurse that lorazepam and morphine were comfort medications and could still be administered. Later that morning, hospice documented that the resident’s family requested morphine and lorazepam be given as a slurry, and provider orders were written for lorazepam soluble and morphine solutab, including an order allowing the medications to be slurried in a small amount of water and given sublingually. Despite these orders, hospice documentation and interviews showed that facility staff did not understand how to properly administer solutab and sublingual medications or slurries. Hospice reported that staff were providing solutab comfort medications mixed with applesauce, which drained out of the resident’s mouth when the resident was unable to swallow, and that staff had requested discontinuation of comfort medications because they did not know the medications dissolved in the mouth without swallowing. The resident’s family member reported witnessing staff trying repeatedly to get the resident to swallow morphine solutabs, during which the resident coughed and gurgled. Multiple licensed nurses interviewed later stated they did not know what sublingual medication was, confused it with liquid medication, and did not know what a slurry was. One nurse stated that for hospice patients she had them swallow medications ordered to be slurried and given sublingually. The DON described how a slurry should be prepared and administered but the facility’s pain management policy did not contain instructions on sublingual or slurried pain medication administration, and a medication administration policy was requested but not provided.
Significant Medication Error Due to Transcription and Administration Failures
Penalty
Summary
A significant medication error occurred when a resident was administered 40 mg of methadone, which was 16 times the prescribed dose of 2.5 mg. The error originated from a handwritten order by a hospice RN, which incorrectly indicated the volume to be administered and did not comply with Board of Pharmacy requirements for prescription clarity. The order was then transcribed into the electronic health record as 4 mL instead of the correct 0.25 mL, due to misinterpretation of the handwriting and lack of a leading zero. The medication bottle from the pharmacy had a different instruction, indicating a dose of 0.5 mL (5 mg), further adding to the confusion. The resident, who had no cognitive impairment but was dependent on staff for activities of daily living and had diagnoses including a femur fracture and COPD, received the incorrect dose via g-tube. The nurse administering the medication noticed the discrepancy between the MAR and the medication bottle but proceeded to give the dose listed in the MAR, believing it to be the most current order. The nurse did not seek clarification despite the mismatch. The double-check process for new orders was not completed, as the order sheet was left next to the computer without verification by another nurse, contrary to facility protocol. Following administration, the resident exhibited symptoms of opioid overdose, including lethargy, low respiratory rate, low oxygen saturation, and unresponsiveness. Narcan was administered at the facility, and the resident was transferred to the hospital, where they required intensive care and a continuous Narcan infusion due to persistent symptoms of methadone overdose. Interviews with staff confirmed that the medication should not have been administered when discrepancies were noted, and that the double-check process was not followed due to a busy shift.
Removal Plan
- Suspend the nurse who administered the incorrect dose and educate all nurses.
- Educate the nurse manager on clarification of any orders that are scribbled, dose increase that is too high or the handwriting is not legible.
- Educate the nurse who administered the incorrect dose that whenever a discrepancy on the MAR and the medication bottle or bubble pack, the order must be clarified, and the medication should not be administered.
- Educate hospice agency nurse related to transcription error and conflicting orders from the hospice doctor and the nurse.
- Revise hospice agency procedure for ordering medications.
- Audit all hospice residents' provider orders and correct any errors. Audit all new orders.
- Educate all licensed nursing staff/contracted agency nurses on the rights of medication administration, transcription of medications, processing of medications, narcotic administration and side effects, and what to do when a med error occurs. Ensure all staff receive education before their next shift.
- Develop a system to ensure appropriate transcription and order double check. Nurses confirm knowledge of the new transcription procedure into the electronic health record system. Add triple check of all new orders to the night shift nurse duty list.
- Review policies and procedures related to medication administration, transcription, and transcription errors.
- Review hospice contracts for medication management.
Failure to Update Care Plan with Individualized Fall Prevention Intervention
Penalty
Summary
The facility failed to revise the care plan for a resident with multiple diagnoses, including Down syndrome, right shoulder dislocation, Alzheimer's, dementia, intellectual disabilities, and epilepsy, to include an individualized intervention—a fall mat—despite its use at the bedside. The resident was identified as a fall risk due to her medical conditions and history of a fall prior to admission. The care plan, developed after admission, included general fall prevention interventions such as following therapy instructions, monitoring safety, and reviewing past falls, but did not specify the use of a fall mat as an intervention. Observations confirmed that a fall mat was present by the resident's bed, and staff interviews revealed that the mat was used as a precaution because the resident was known to roll out of bed, although she had not fallen since admission. Multiple staff members, including a nursing assistant and registered nurses, acknowledged the presence and purpose of the fall mat but confirmed that it was not documented in the resident's care plan. The facility's care planning policy requires individualized, person-centered care plans developed by the interdisciplinary team, but this intervention was omitted from the written plan.
Failure to Assess and Document Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident was comprehensively assessed for self-administration of medications. The resident, who had diagnoses including Type 2 diabetes mellitus, dermatitis, prurigo, and bipolar disorder, was noted to have intact cognition and required staff assistance with activities of daily living. The resident's care plan directed staff to administer medications per orders but did not include any direction or assessment for self-administration of medication. There was no provider order for lidocaine 4% gel or for self-administration, and the electronic health record did not contain an assessment for self-administration of medication. Observations revealed that a container of Tylenol lidocaine 4% was present and accessible in the resident's room, and the resident reported self-applying the medication for shoulder pain. Nursing staff observed the medication in the room on multiple occasions but did not remove it or address its presence. Interviews with staff confirmed that an assessment and provider order are required for self-administration, and that the medication should be documented in the medication administration record. The nurse manager and regional nurse consultant were unaware of the medication's presence and stated that staff are expected to act if such medications are found. The facility was unable to provide a policy for self-administration of medication.
Failure to Prevent Unnecessary Decline in ADL Abilities
Penalty
Summary
Residents experienced a loss in their ability to perform activities of daily living (ADLs) without a documented medical reason. The facility failed to ensure that residents maintained their highest practicable level of functioning in ADLs, as required, unless a decline was clinically unavoidable due to a medical condition. This deficiency was identified through surveyor observation and review of resident records, which did not provide evidence of a medical justification for the decline in ADL performance.
Failure to Assess and Monitor Non-Pressure Skin Lesions
Penalty
Summary
The facility failed to adequately assess and monitor non-pressure related skin abrasions for a resident with a history of Type 2 diabetes mellitus, dermatitis, prurigo, bipolar disorder, and previous MRSA skin infection. Despite the resident's care plan instructing staff to monitor skin integrity and report concerns, documentation and observation revealed that open and scabbed lesions on the resident's right lower extremity (knee to thigh) were not identified, assessed, or documented in a timely manner. Weekly skin inspection records and nursing progress notes did not reflect the presence of these lesions, and staff interviews confirmed that the lesions had been present for several days without being reported to the provider or nurse manager. Nursing assistants and registered nurses were unaware of the new and existing lesions until prompted by surveyor observation and interviews. The nurse manager confirmed that there was no documentation or provider notification regarding the new and scabbed lesions, despite the resident's history of skin infections. The facility's process for monitoring and reporting non-pressure related skin concerns was not followed, as evidenced by the lack of timely assessment, documentation, and communication among staff regarding the resident's skin condition.
Failure to Provide Recommended Dental Services for Edentulous Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident received recommended dental services. The resident, who was cognitively intact and independent with activities of daily living, was identified as edentulous and at risk for nutritional deficits. Despite being aware of his need for dentures and expressing dissatisfaction with having no teeth, the resident had not received dentures and was not informed about the status of obtaining them. Documentation showed that the dental group initially did not proceed with denture fabrication because the resident was expected to be discharged soon, as communicated by the social worker. However, when the resident remained in the facility beyond the anticipated discharge date, there was no evidence that the dental group was updated about the change in the resident's status. Interviews with facility staff revealed a lack of communication and follow-up regarding the resident's dental needs. The social services staff did not have direct contact with the dental service and did not notify them when the resident's discharge plans changed. The medical records director was unaware if the upcoming dental exam would address the denture issue and could not find documentation of any update to the dental group. The LPN confirmed that the resident had repeatedly expressed his desire for dentures. Additionally, the facility was unable to provide a policy or procedure regarding dental services when requested.
Failure to Provide Nail Care for Dependent Resident with Skin Conditions
Penalty
Summary
The facility failed to ensure that nail care was completed for a resident who was dependent on staff for activities of daily living (ADLs). The resident had multiple diagnoses, including Type 2 diabetes mellitus, dermatitis, prurigo, and a history of MRSA skin infection, and required staff assistance with ADLs. Observations over several days revealed that the resident's fingernails were excessively long, with a dark, brown substance underneath, and the resident had open lesions from scratching. Documentation showed no evidence that the resident refused nail care or assistance with cleaning under the nails during the review period, and there was a lack of progress notes indicating refusals or attempts to provide nail care. Interviews with nursing staff and nursing assistants confirmed that nail care for diabetic residents was the responsibility of licensed staff, while cleaning under the nails was to be performed by nursing assistants. Both groups acknowledged the importance of maintaining clean and trimmed nails, especially given the resident's history of skin infections and scratching. However, staff were unable to recall recent attempts to clean the resident's nails, and there was no documentation of refusals or completed care. The facility's policy for nail care was requested but not provided.
Failure to Notify Physician of Wound Deterioration
Penalty
Summary
The facility failed to notify a resident's physician of the deterioration of a non-pressure related skin wound. The resident, who was admitted with multiple diagnoses including a non-pressure chronic ulcer of the left heel, diabetes, and morbid obesity, had a care plan and treatment orders in place for a diabetic foot ulcer. Over the course of several weeks, wound care documentation and photographs showed that the resident's left heel ulcer increased in size, developed additional open areas, and exhibited worsening periwound erythema. Despite these changes, there was no documented notification to the resident's primary care physician or nurse practitioner regarding the wound's deterioration. Interviews with facility staff, including a nurse manager (LPN), a registered nurse, and the DON, confirmed that the wound had worsened and that the primary care provider should have been notified. The LPN acknowledged that the wound was no longer improving and appeared worse compared to previous evaluations, but could not provide documentation that the physician had been informed. The nurse practitioner covering for the resident's usual provider also confirmed there was no documentation of notification and stated that such notification would be expected when a wound increases in size or develops new open areas. Facility policy required that changes in a resident's condition, including wound deterioration, be promptly reported to the attending physician and documented. However, the review of records and staff interviews indicated that this notification did not occur, and there was no evidence of updated treatment orders or changes to the plan of care in response to the wound's decline.
Failure to Transcribe and Implement Wound Care Orders
Penalty
Summary
The facility failed to ensure that professional standards of practice for treatment orders were followed for two residents with non-pressure related skin wounds. In the first case, a resident with a surgical wound and wound VAC therapy was discharged from the hospital with detailed wound care orders, including specific instructions for dressing changes and the application of an alginate dressing to protect the periwound area. These orders were not transcribed into the facility's electronic health record (EHR), and the wound care provided did not follow the hospital's instructions. Observations confirmed that the required dressing components were missing, and the nurse responsible was unaware of the detailed orders. The nurse manager and DON both confirmed that the orders had not been transcribed and that the wound care provided was not in accordance with the physician's instructions. In the second case, another resident with a surgical incision following orthopedic surgery was seen by an orthopedic provider, who gave specific wound care orders, including allowing Steri-Strips to fall off naturally and permitting the incision to get wet in the shower. These orders were documented in the resident's paper chart but were not transcribed into the EHR. The nurse manager confirmed that only monitoring orders were present in the EHR and that the specific wound care instructions from the orthopedic provider were missing. The DON acknowledged that the facility was reviewing charts to ensure all post-appointment orders were transcribed. Facility policy required that treatment orders be transcribed accurately and in a timely manner and that ongoing treatments for skin issues follow provider orders. Despite these policies, the failure to transcribe and implement the detailed wound care orders for both residents resulted in care that did not meet professional standards. Interviews with nursing staff and management confirmed that the lack of transcription could disrupt the continuous plan of care and lead to inappropriate wound management.
Failure to Comprehensively Assess and Treat Non-Pressure Skin Wounds per Physician Orders
Penalty
Summary
The facility failed to comprehensively assess non-pressure related skin wounds for two of three residents reviewed, and did not administer wound treatments in accordance with physician orders for one resident. One resident with a surgical wound and wound VAC to the right buttock experienced a malfunction of the wound VAC device, resulting in the application of a wet-to-dry dressing without a corresponding physician order or documented provider notification. After hospital readmission, this resident returned with a suction burn injury to the periwound area, but the facility did not complete a comprehensive assessment of this new wound, nor did they transcribe or follow the detailed hospital discharge wound care orders, including specific dressing change instructions and use of alginate dressing. Documentation of wound assessments repeatedly lacked details about the new suction injury, and wound care was not performed as ordered. Another resident with a surgical incision to the right hip following orthopedic surgery was not comprehensively assessed upon admission or during subsequent wound evaluations. Initial and weekly wound assessments lacked measurements and did not include required details such as wound bed description, periwound condition, or evidence of infection. The nurse manager confirmed that the wound assessments were incomplete and did not meet the standard for a comprehensive evaluation. A third resident with a diabetic foot ulcer had weekly wound care provider notes and corresponding evaluations that included wound measurements and progress, but the documentation consistently omitted required details in the wound bed, exudate, periwound, pain, and treatment sections. Additionally, there was a failure to identify deterioration of the wound, as the wound size increased over time without documentation of this change or a comprehensive assessment of the wound's status. These deficiencies were identified through observation, interview, and document review.
Incomplete Documentation of Wound Care Treatments
Penalty
Summary
The facility failed to maintain complete, accurate, and up-to-date medical records for a resident who was receiving wound care for a non-pressure related skin injury. The resident had a history of a non-pressure chronic ulcer of the buttock, recent major surgery for repair of a deep ulcer, and required a wound VAC with specific dressing change orders. Documentation was missing for several wound care treatments, including a wound VAC dressing change performed by a wound care provider, a wet-to-dry dressing change performed by an LPN after the wound VAC device failed, and a subsequent wound VAC dressing change performed by an RN prior to the resident's transfer to the hospital. Additionally, there was no physician order documented for the wet-to-dry dressing that was applied when the wound VAC failed. Interviews with nursing staff and the nurse manager confirmed that these treatments were not documented in the resident's medical record or treatment administration record (TAR), and that the medical record was therefore incomplete and inaccurate. The nurse manager and interim DON both acknowledged the importance of accurate documentation for continuity of care and confirmed that the expected documentation was missing. The facility's policy regarding the contents of medical records was requested but not provided.
Inadequate Discharge Planning Leads to Resident's Lack of Care
Penalty
Summary
The facility failed to develop and implement a comprehensive discharge plan for a resident, resulting in the resident being discharged without necessary services and medications. The resident, who was cognitively intact and required moderate assistance for daily activities, was discharged without a personal care assistant (PCA) due to an incomplete waiver evaluation. Additionally, the facility incorrectly transcribed orders, providing a home health aide instead of a skilled nurse, and failed to correctly order the resident's medications and dialysis. The resident's community case manager repeatedly communicated with the facility's social worker to ensure the necessary services were in place for the resident's discharge. However, the facility did not complete the CADI waiver assessment, leading to the resident being discharged without PCA services. The resident also missed a dialysis appointment and a primary care physician appointment due to the lack of assistance and incorrect scheduling by the facility. Interviews with facility staff revealed a lack of communication and follow-up regarding the resident's discharge needs. The social worker admitted to faxing medication orders to an incorrect pharmacy and did not verify the completion of the orders. The nurse practitioner intended for the resident to receive skilled nursing services, but this was not communicated effectively, resulting in the resident receiving inadequate care upon discharge. The facility's discharge planning policy was not followed, leading to significant gaps in the resident's post-discharge care.
Expired CLIA Waiver Affects Blood Testing Services
Penalty
Summary
The facility failed to maintain a current Clinical Laboratory Improvement Amendments (CLIA) waiver, which is necessary for performing blood testing. This deficiency was identified during a review of the facility's certifications, which revealed that the CLIA waiver had expired and there was no updated certificate on file. The administrator confirmed that the facility was in the process of renewal but lacked documentation of the application for renewal. This oversight had the potential to affect residents who required routine blood glucose monitoring. The report specifically identified numerous residents who were receiving blood glucose monitoring for conditions such as Diabetes Mellitus Type II and other diabetes-related diagnoses. These residents had varying frequencies of blood glucose monitoring, ranging from daily to four times a day. The absence of a current CLIA waiver could impact the quality and reliability of the blood testing services provided to these residents. Additionally, the facility did not have a policy available for the maintenance of the CLIA waiver, as confirmed by the administrator.
Failure to Follow Dietary Orders for Resident with Complex Medical Needs
Penalty
Summary
The facility failed to follow physician orders for a resident with end-stage renal disease and diabetes, leading to inadequate nutritional intake. The resident, who was cognitively intact and had a complex medical history including anemia, peripheral vascular disease, and a history of skin integrity issues, was supposed to receive a regular diet with double meat/protein portions. However, during an observation, the resident was served a single sandwich without the prescribed double portion of meat, and the tray ticket did not indicate the need for double meat/protein. The resident expressed dissatisfaction with the meal portions and mentioned having to purchase additional food independently to meet his nutritional needs. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's dietary orders. The nutritional consultant stated that residents with orders for double meat/protein should automatically receive double portions, but this was not reflected on the resident's tray ticket. The clinical manager and assistant director of nursing confirmed the oversight and acknowledged the need for staff education to ensure dietary orders are accurately documented and followed. The registered dietitian amended the resident's tray ticket after being informed of the issue, but also noted that the resident frequently consumed outside food, which was not always in line with his dietary restrictions.
Improper Cleaning of Community-Use Glucometer
Penalty
Summary
The facility failed to ensure that a community-use glucometer was properly cleaned and disinfected between resident uses. During an observation, an LPN used an alcohol wipe to clean the glucometer after performing a blood sugar reading for a resident. The LPN then placed the glucometer back in the medication cart without using the appropriate disinfectant. The RN and DON later confirmed that the correct procedure involved using a purple top Sani wipe with a two-minute kill time, not an alcohol wipe, to clean the glucometer. The deficiency was identified when the LPN was observed using the glucometer for a resident and then cleaning it improperly. The RN and DON both stated that the facility's protocol required the use of a specific disinfectant wipe, which was not followed in this instance. The instruction manual for the blood glucose monitoring system also indicated that an EPA-registered disinfectant should be used, and if blood was visible, two wipes should be used—one for cleaning and one for disinfecting.
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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