The Villas At New Brighton
Inspection history, citations, penalties and survey trends for this long-term care facility in New Brighton, Minnesota.
- Location
- 825 First Avenue Northwest, New Brighton, Minnesota 55112
- CMS Provider Number
- 245164
- Inspections on file
- 41
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 8 (1 serious)
Citation history
Health deficiencies cited at The Villas At New Brighton during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, on hospice, and dependent for all transfers was care planned to receive two-person assistance with a mechanical lift, with a low bed and floor mat as fall interventions. Video showed two NAs manually dragging and repositioning the resident from a floor mattress to the bed by pulling on the gown and manipulating the resident’s limbs, leaving the resident prone and partially exposed without undergarments, instead of using the ordered mechanical lift. Staff later acknowledged they knew the lift was required but had repeatedly used similar manual methods due to perceived space limitations in the room and did not report these difficulties or their deviation from the care plan to nursing leadership, resulting in psychosocial harm as determined under the reasonable person concept.
A resident with heart and respiratory failure, severe cognitive impairment, and dependence for all ADLs was care planned as a fall risk with a floor mat and need for extensive assistance, but no care conference was ever held to involve the resident or representative in person-centered care planning despite facility policy and staff statements that such conferences should occur shortly after admission and quarterly. Surveyors observed the resident eating breakfast from a tray placed on a floor mattress, leaning on one elbow with food falling onto the mattress, while staff reported she often crawled onto the floor, was only placed in a wheelchair when family were present, and routinely received bed baths instead of showers. The social services director, LPN, DON, and administrator confirmed that a care conference should have occurred to address preferences and needs, and a family member reported never being offered a conference, disagreed with the resident being left on the floor for hours, preferred toileting and showers, and stated that eating on the floor was not consistent with their culture.
Staff failed to follow infection control practices when a nursing assistant performed incontinence care for a resident with heart failure, respiratory failure, severe cognitive impairment, and frequent incontinence. After removing a soiled brief and wiping the perineal area, the NA did not change gloves or perform hand hygiene before proceeding with clean tasks, including applying barrier cream, repositioning the resident, adjusting bedding and the call light, and handling the resident’s oxygen tubing. A family member reported similar observations via a room camera, and a grievance documented that an LPN had been informed that staff were not changing gloves between peri care and oxygen tubing adjustment. Facility staff interviews and the written handwashing policy confirmed that gloves should be changed between dirty and clean tasks and that hand hygiene should be performed before and after glove use and after changing incontinent products.
Surveyors found that the facility failed to develop and update care plans to address repeated bath/shower refusals and assistance needs for two residents. One resident with stroke-related paralysis and total dependence for bathing frequently refused showers over several weeks, yet the care plan lacked interventions for refusals, did not document offering alternate times, and did not include the resident’s preference for certain staff. Another resident with traumatic brain injury, seizure disorder, heart and lung disease, and weakness was care planned as independent with bathing despite needing supervision or touch assistance and refusing showers for multiple consecutive weeks. This resident appeared disheveled with body odor and reported not bathing weekly and not being offered help, while nursing staff acknowledged missed baths, lack of documented independent showers, and absence of care plan interventions to address refusals or promote regular bathing, contrary to the facility’s stated expectations and care planning policy.
A resident with multiple medical conditions fell and sustained a femur fracture during a transfer with a full body mechanical lift when staff failed to attach the sling correctly, placing a strap at the top instead of the bottom of the hook. Despite staff believing they knew the correct procedure, the improper attachment led to the sling detaching and the resident falling, requiring surgical intervention.
A resident with intact cognition and multiple diagnoses was found with several medications at her bedside without completed self-administration assessment or provider orders. Staff interviews confirmed that the required process for self-administration and secure medication storage was not followed, and facility policy regarding safe storage was not adhered to.
A resident with multiple medical conditions suffered a femur fracture after falling from a full mechanical lift during a transfer, due to staff not following manufacturer instructions for sling attachment. The incident, which resulted in hospitalization and surgery, was not reported to the State Agency as required by facility policy, despite being a serious injury.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact circumstances or individuals involved.
The facility did not submit accurate and complete staffing data to CMS for a reviewed quarter, as PBJ data showed low weekend staffing while daily schedules indicated adequate coverage. The regional director of operations was unsure of the cause for the discrepancy, and the facility's policy was not provided when requested.
A resident with anxiety, mood disorder, and a surgical wound reported multiple grievances about inadequate pain management and staff response, stating her complaints were not followed up on or resolved. Documentation showed delays and discrepancies in pain medication administration and incomplete wound care, while grievance forms lacked evidence of proper investigation or resolution, contrary to facility policy.
A resident with multiple risk factors for skin breakdown developed severe pressure ulcers due to failures in assessment, documentation, and communication among staff. Despite being dependent on staff for repositioning and care, the resident's wounds were not promptly identified or reported, and appropriate interventions were not consistently implemented. The resident was ultimately hospitalized with multiple advanced pressure ulcers and wound infections, which were determined to have developed over several weeks prior to admission.
A resident with multiple comorbidities and a g-tube did not receive comprehensive assessment and monitoring of the g-tube site, as staff failed to consistently perform head-to-toe skin checks and document findings. Nursing staff sometimes relied on nursing assistants for skin observations and did not always remove clothing for full assessments. The resident was later hospitalized with infection and skin breakdown at the g-tube site, which had not been properly documented or reported.
Nursing staff failed to perform thorough weekly skin assessments for a high-risk resident, relying on incomplete visual checks and aide reports rather than direct inspection. As a result, extensive pressure wounds and skin breakdown went undocumented and unreported until hospital admission, where multiple severe wounds were discovered. The nurse involved lacked specific training on skin assessments, and facility policy for documentation and communication was not followed.
A nursing assistant failed to wear a gown and did not consistently follow proper PPE and hand hygiene protocols while emptying the urinary catheter bag of a resident on enhanced barrier precautions due to an indwelling device and history of infections. The assistant struggled with the catheter spout, resulting in urine splashing, and handled contaminated items without appropriate glove changes or use of alcohol swabs, despite facility policy and posted signage requiring both gown and gloves for such care.
A resident with respiratory and cardiac diagnoses, who was cognitively intact, repeatedly smoked on the designated patio while using oxygen, despite a care plan and signed contract requiring oxygen to be left inside. The facility did not provide direct staff supervision of the smoking area, lacked follow-up assessments, and did not enforce the smoking contract, resulting in ongoing unsafe smoking practices.
A facility failed to prevent medication diversion, resulting in the misappropriation of controlled substances for 30 residents. A TMA improperly signed out narcotics without proper documentation, leading to significant discrepancies between doses signed out and those administered. Residents with various medical conditions were affected, and the TMA was found to be performing tasks outside their scope of practice, including administering G-tube medications.
A facility failed to secure narcotics and properly label and store insulin pens, affecting medication safety. A resident's discontinued oxycodone was still signed out, raising diversion concerns. Insulin pens lacked proper labeling and storage, risking contamination and errors. Staff confirmed these deficiencies, and the facility's policy for medication checks was not consistently followed.
The facility did not post daily nurse staffing information as required, with outdated postings observed on three occasions. This failure potentially affected all 57 residents and their visitors, as the information was not readily accessible as per the facility's policy.
A resident with severe cognitive impairment and hemiplegia was repeatedly observed in a hospital gown in public areas, despite her preference for her own clothing. The facility staff cited issues with the resident's clothes ripping, but the care plan did not reflect a preference for a hospital gown, and there was a lack of communication with the resident's guardian regarding clothing options.
A resident, who was cognitively intact and had diagnoses of CHF and diabetes, was found with medications on his dresser without a proper assessment of his ability to self-administer. Despite a previous evaluation indicating he was unsafe to do so, the facility failed to include this in his care plan and did not follow their policy requiring a comprehensive assessment.
A facility failed to report an allegation of sexual abuse involving a resident to the state agency and law enforcement. The resident, who was cognitively intact and dependent on staff, was allegedly abused by a CNA. Despite being informed, the administrator and other staff did not report the incident, as required by facility policy. The resident expressed fear due to the CNA's continued presence, indicating a failure to ensure her safety.
A resident, who was cognitively intact and dependent on staff, reported an alleged sexual abuse incident involving a CNA. The facility failed to thoroughly investigate the allegation, as the administrator did not interview the resident or staff and did not report the incident to the State Agency or police. The CNA continued to work with the resident without suspension. The facility's policy required immediate investigation and reporting, which was not followed, leading to a deficiency.
The facility failed to develop comprehensive care plans for two residents. One resident's care plan lacked critical dialysis information, such as the use of an AV fistula and related care instructions. Another resident's care plan did not include passive range of motion exercises or document her clothing preferences, impacting her dignity. Staff were unaware of these omissions, highlighting deficiencies in care planning and communication.
A facility failed to provide a resident with prescribed passive range of motion (PROM) exercises following a stroke, as indicated in the occupational therapy discharge summary. The resident, who was severely cognitively impaired and had functional limitations due to hemiplegia, did not have PROM exercises included in their care plan. Staff interviews revealed a lack of communication and documentation regarding the resident's refusal of the ROM program, which could lead to decreased mobility and contractures.
A facility failed to properly assess and monitor a resident receiving dialysis through an AV fistula. The care plan inaccurately reflected the dialysis access method, and staff were unaware of the need to remove a pressure dressing within four hours, risking complications. Blood pressure readings were incorrectly taken on the access arm, and documentation was not updated to reflect the use of the fistula, contrary to facility policy.
The facility had an 8% medication error rate, exceeding the acceptable 5% threshold. Two residents were involved in errors during medication passes. One resident received metoprolol tartrate despite a low pulse, and another was nearly given an incorrect dose of quetiapine fumarate. LPNs acknowledged the errors, and the DON emphasized the need for adherence to medication administration policies.
The facility failed to ensure safe storage of medications, with instances of unlocked and unattended medication carts and medications left unattended in a resident's room. Staff acknowledged the errors, and the DON emphasized the importance of keeping medication carts locked and medications attended.
The facility failed to perform proper hand hygiene during tracheostomy care for a resident, as staff did not wash hands between glove changes. Additionally, a resident's catheter drainage bag was repeatedly found on the floor, and the spout was not cleaned with an alcohol wipe before being secured. These actions were contrary to the facility's policies on handwashing and catheter care.
A resident with severe cognitive impairment and cardiac conditions received metoprolol tartrate despite a physician's order to hold the medication if the pulse was below 60 beats per minute. An LPN administered the medication after recording a pulse of 55, and medication records showed repeated instances where the medication was not held as ordered, with no documentation to indicate otherwise. Staff interviews and facility policy confirmed the requirement to follow such parameters.
A resident with a history of acute embolism and thrombosis was mistakenly given Buprenorphine HCL Buccal Film instead of the prescribed sublingual tablets for pain. The error occurred because an LPN could not find the sublingual medication and assumed the film could be used as a substitute. The resident, who was aware of the error, attempted to inform the LPN, but was not believed. The sublingual tablets were available in the facility, and the LPN failed to perform necessary safety checks or contact the provider as required by facility policy.
A facility failed to make a psychiatric referral for a resident with bipolar disorder and malnutrition, as ordered by a physician. The resident was not currently receiving services from the Associated Clinic of Psychology (ACP) despite a physician's order due to a lack of communication and awareness among staff. The LPN and social services staff were unaware of the referral order, and no policy was in place to ensure such orders were processed.
A resident with severe cognitive impairment and multiple health issues developed a left toe ulcer that led to an amputation. The facility failed to notify the resident's family about the wound's progression, despite regular monitoring and treatment. Interviews revealed that the family was unaware of the condition until the resident was hospitalized. Facility staff showed inconsistency in following notification policies, leading to a significant communication oversight.
A resident with a full code status was found unresponsive in a LTC facility, but CPR was not initiated, leading to the resident's death. Despite being trained and certified in CPR, staff failed to follow the protocol, resulting in a critical deficiency.
A facility failed to properly manage methadone treatment for a resident with opioid dependence, leading to missed doses and unauthorized tapering. The facility did not coordinate with the methadone clinic, resulting in withdrawal symptoms for the resident. Additionally, there were significant lapses in narcotic documentation and waste procedures, with incomplete records and improper handling of methadone doses.
Improper Manual Transfer and Handling Causing Psychosocial Harm
Penalty
Summary
The deficiency involves staff failing to provide care and transfers in accordance with the resident’s care plan, professional standards, and facility policy for a resident with severe cognitive impairment who frequently moved from the bed to a floor mattress. The resident’s room contained a hospital bed in the lowest position with a hospital mattress placed on the floor alongside the bed, and the resident was known to occasionally lie on the floor mat. The resident’s admission history and physical documented cognitive impairment, limited capacity to understand instructions, significant hearing impairment, and dependence on others for mobility, with hospice care in place. The MDS and care plan identified the resident as a fall risk, dependent for all cares and transfers, and required assistance of two staff with a mechanical (Hoyer) lift and a medium sling for transfers, with a fall mat and low bed as interventions. Video review from the resident’s room showed that on the morning in question, the resident was partially on the bed and partially on the floor, lying on her back with her hips and legs on the floor and upper body on the bed, dressed in a gown without undergarments. One nursing assistant stood at the center of the bed, bent over, grasped the front of the resident’s gown near each armpit with both hands, and dragged the resident from the floor mattress onto the bed. The assistant paused with the resident partially on the bed, then, together with a second nursing assistant, manually manipulated the resident’s legs and hips to reposition her fully onto the bed. The resident was turned into a prone position with her head at the head of the bed, feet at the bottom, face down, initially with one arm tucked under her chest; when the assistant pulled that arm out, the resident moaned. The resident was left in a prone position on the bed, exposed from the waist down without undergarments. Interviews confirmed that staff were aware the resident’s care plan and NA guide required two-person assistance with a mechanical lift for transfers and that the facility’s Safe Resident Handling policy directed that residents unable to bear weight be transferred with lift equipment instead of manual lifting. One nursing assistant stated the resident frequently crawled off the bed to the floor mattress and acknowledged knowing a mechanical lift and two staff were required, but reported that she and another assistant had been transferring the resident back to bed in a similar manual manner over previous weeks because they felt there was not enough room in the room to use the lift around the large floor mattress. Neither assistant reported these challenges or their deviation from the care plan to nursing staff, the clinical leader, or the DON. Family reported hearing the resident say “hurt, hurt” in her language while viewing the video and described the transfer as abusive and not consistent with the resident’s cultural preferences, and the surveyors applied the reasonable person concept to determine psychosocial harm from the noncompliant transfer and handling.
Failure to Involve Resident and Representative in Person-Centered Care Planning
Penalty
Summary
The deficiency involves the facility’s failure to provide a resident the opportunity to participate in the development and implementation of a person-centered care plan. The resident had diagnoses of heart failure and respiratory failure, severe cognitive impairment, spoke Hmong, and was dependent for all cares and transfers. Her care plan identified her as a fall risk with a fall mat at the bedside and required assistance with eating, bed mobility, and transfers using two staff and a full body mechanical lift. However, the electronic medical record lacked documentation of any care conference since her admission, despite facility policies and staff statements indicating that care conferences should occur within 5–21 days of admission and then quarterly, with resident and/or representative participation. Surveyors observed the resident seated on the edge of a floor mattress with her breakfast tray placed on the mattress to her left. She was leaning on her left elbow and using her right hand to eat, with food falling onto the mattress as she tried to eat. Nursing assistants reported that the resident frequently crawled off her bed onto the floor mattress and that staff only placed her in a wheelchair when family were present to watch her. They also stated that she received bed baths instead of showers because it would take up to three staff to shower her, and one nursing assistant commented that some cultures, like Hmong, like to be on the floor, and was unsure whether eating on the floor bothered the resident. The social services director, clinical leader/LPN, DON, and administrator each confirmed that care conferences are intended to elicit resident preferences, discuss medications, cares, comfort, complaints, and ensure needs are met, and that such a conference should have been held for this resident within the required timeframe. They acknowledged that no care conference had been held and no documentation could be located. The resident’s family member stated she was never offered a care conference and, while agreeing with the use of a floor mattress for safety, expressed dissatisfaction that the resident was left on the floor mattress for hours, preferred that the resident be offered the toilet or commode, preferred showers instead of bed baths, and stated it was not their culture to eat on the floor. Facility policies on Resident Rights and Care Planning required that residents be informed of and supported in their right to participate in person-centered care planning, including incorporating personal and cultural preferences, which did not occur for this resident.
Failure to Perform Hand Hygiene and Change Gloves Between Dirty and Clean Tasks
Penalty
Summary
The deficiency involves staff failure to follow established hand hygiene and glove-use practices during incontinence care for one resident. During an observation, a nursing assistant removed a soiled brief, wiped the resident’s perineum and buttocks, discarded the soiled brief and wipes, and then continued with clean tasks without removing gloves or performing hand hygiene. While still wearing the same gloves used for peri care, the nursing assistant placed a clean brief under the resident, applied barrier cream to the perineum, fastened the brief, positioned the draw sheet, assisted with repositioning the resident, adjusted bedding, clipped the call light to the bedding, and repositioned the resident’s oxygen tubing in her nostrils before finally removing gloves and performing hand hygiene. The resident involved had an admission MDS indicating diagnoses of heart failure and respiratory failure, severe cognitive impairment, frequent bowel and bladder incontinence, and dependence on staff for all cares and transfers, and was Hmong speaking. Her care plan and NA guide documented the need for assistance with bed mobility, transfers, and incontinence care every 2–3 hours. A grievance form documented that an LPN was made aware that staff were not changing gloves between changing the resident’s brief and adjusting her oxygen tubing. A family member reported observing staff not changing gloves after peri care via a camera in the resident’s room. Facility staff, including the nursing assistant, LPN, and DON, each stated in interviews that gloves should be changed between dirty and clean tasks and that hand hygiene should be performed before donning and after removing gloves, consistent with the facility’s Handwashing Policy, which requires handwashing after changing incontinent products and before and after glove use.
Failure to Care Plan for Bath/Shower Refusals and Assistance Needs
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and update comprehensive care plans addressing residents’ refusals of baths/showers. One resident with intact cognition, paralysis on one side related to a stroke, and full dependence on staff for bathing had a care plan noting a self-care deficit, left-sided weakness, a history of refusing ADLs, and the need for staff assistance with bathing. However, the care plan did not include any interventions for refusals of bathing or showers. Weekly skin assessments over several weeks documented that this resident refused showers, and nursing assistants reported that the resident frequently refused showers, sometimes only allowing certain staff to assist, but these preferences and alternate shower times were not reflected in the care plan or medical record. Nursing staff acknowledged that the resident missed baths, had a history of refusals, lacked a risk/benefit form, and that the care plan did not contain interventions for staff to follow when refusals occurred. Another resident with intact cognition and diagnoses including traumatic brain injury, seizure disorder, heart disease, and lung disease had a care plan indicating a self-care deficit related to weakness but incorrectly documented the resident as independent with bathing and did not reflect the need for supervision or touch assistance. Weekly skin inspections over multiple weeks showed this resident refused showers, and during observation the resident appeared disheveled with body odor and reported not bathing weekly due to feeling physically weak, stating staff did not offer help or ask about showers and being unsure of the last shower. Nursing staff later acknowledged that the resident did not bathe weekly, had refused showers for four consecutive weeks, and had no documented independent showers during that period, and that the care plan lacked interventions to promote bathing when the resident refused or did not bathe independently. The DON stated that the expectation was for staff to conduct risk/benefit education, notify the provider and power of attorney, and try different approaches when residents refused baths, and that successful interventions should be added to the care plan and updated with changes, but confirmed this had not been done for these residents despite missed baths over several weeks.
Improper Mechanical Lift Use Results in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when a resident, who required total assistance with transfers using a full body mechanical lift, fell from the lift due to improper attachment of the sling. The resident had intact cognition and medical diagnoses including colon cancer, a previous left humerus fracture, and hemiplegia. The care plan specified the use of a mechanical lift with a particular sling size, and the transfer was being performed by two staff members from the bed to a shower chair. During the transfer, one of the sling's straps was not attached to the lift according to the manufacturer's instructions. Specifically, the lower right strap was placed at the top of the hook instead of the lower part, resulting in the strap coming off during the transfer. This caused the resident to fall approximately three feet to the floor, leading to an acute left femur fracture that required surgical intervention. The incident was witnessed on video by a family member, who confirmed the improper attachment of the sling. Interviews with staff involved in the transfer revealed that they believed they knew the correct procedure for attaching the sling, but failed to secure it properly. The manufacturer’s representative confirmed that improper attachment could result in sling detachment and injury. The facility’s policy and the manufacturer’s instructions both required that sling loops be secured at the bottom of the hooks, which was not followed in this incident.
Removal Plan
- Suspend staff involved in the incident pending investigation.
- Remove the lift and sling from use.
- Educate staff on identifying sling size, locating resident's sling size, attaching the sling to the lift, and actions to take if the care plan does not identify sling size or if the proper sling size is not available.
- Competency test all nursing staff on use of the full mechanical lift.
- Require staff who have not completed education or competency test to complete both at the start of their next scheduled shift.
Failure to Complete Self-Administration Assessment and Secure Medication Storage
Penalty
Summary
The facility failed to ensure that a proper assessment for self-administration of medications was completed and that provider orders were obtained for all medications kept at bedside for one resident. The resident, who had intact cognition and diagnoses including femur fracture, severe obesity, and asthma, was observed with multiple medication containers (Tums, Tussin DM, multi-vitamin, and anti-diarrheal medication) on her bedside table. The self-administration evaluation indicated it was acceptable for the resident to self-administer after nurse setup, but the assessment was incomplete, as key sections regarding the resident's ability to manage and store medications were not checked. Additionally, the provider order list did not include orders for several of the medications found at the bedside. Interviews with staff confirmed that the resident was allowed to self-administer medications after nurse setup, but the process was not being followed correctly. The LPN acknowledged that medications should have been kept in the nurse's cart and that provider orders were missing for some medications. The DON stated that an assessment and provider order are required for self-administration and that medications should be stored securely, not on a bedside table. The facility's policy also requires self-administered medications to be stored in a safe and secure place, which was not adhered to in this case.
Failure to Report Serious Injury from Improper Mechanical Lift Use
Penalty
Summary
The facility failed to report a serious bodily injury to the State Agency after a resident experienced a fall from a full mechanical lift, resulting in a femur fracture. The incident occurred when two staff members were transferring the resident from bed to a shower chair using the lift, and one loop of the sling handle detached from the lift hook. This caused the resident's right leg to slip out of the sling, leading to a fall onto the floor. The resident, who had intact cognition and diagnoses including colon cancer, a previous left humerus fracture, and hemiplegia, was subsequently transported to the hospital and underwent surgery for the femur fracture. Despite the severity of the injury, the administrator determined that the event was not the result of abuse, neglect, exploitation, or misappropriation, and therefore did not report it to the State Agency. However, a review of the incident video by the DON revealed that the nursing assistants did not follow the manufacturer's instructions when attaching the sling to the lift. Facility policy required reporting all serious injuries, including those considered accidental, if they resulted from improper care or procedures. The incident was not found in the Minnesota Adult Abuse Reporting Center records, indicating it was not reported as required.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved.
Failure to Submit Accurate Staffing Data to CMS
Penalty
Summary
The facility failed to submit accurate and complete direct care staffing information to CMS for one reviewed quarter, as required. Payroll Based Journal (PBJ) data for the specified quarter indicated excessively low weekend staffing, while daily staff schedules for the same period showed adequate staffing levels on weekends. During an interview, the regional director of operations acknowledged awareness of the report indicating low weekend staffing and stated she would analyze the cause, suggesting possible factors such as bonuses, on-call nurse managers, or use of pool staff, but was uncertain about the specific reason for the discrepancy. The administrator was unavailable during the survey, and the facility's policy was requested but not provided.
Failure to Investigate and Resolve Resident Grievances
Penalty
Summary
The facility failed to ensure that a resident's grievances and complaints were properly investigated and resolved. The resident, who was cognitively intact and had a history of anxiety, mood disorder, and a surgical wound, reported filing multiple grievances during her stay. She expressed that her complaints were not followed up on or resolved, particularly regarding inadequate pain management, with her pain consistently rated between 7 and 9 out of 10. Documentation showed that the resident's requests for pain medication were not always addressed promptly, and there were discrepancies in the records regarding the timing and administration of pain medication. Review of grievance forms revealed that the facility's documentation did not accurately reflect the events as described by the resident. For example, a grievance form indicated that the resident received her requested pain medication at 1:00 p.m., but records showed it was not administered until 3:01 p.m. Additionally, a dressing change for her surgical wound was not completed as required. The facility's investigation into these grievances was insufficient, lacking evidence of a thorough investigation or a clear resolution provided to the resident. Interviews with facility staff, including the DON and regional nurse consultant, confirmed that grievances were reviewed but did not result in appropriate follow-up or resolution. The facility's own grievance policy required that all complaints be investigated and a written summary provided, including steps taken and any corrective actions, but this process was not followed in the resident's case. The lack of proper investigation and resolution of the resident's grievances constitutes a deficiency in honoring the resident's right to voice grievances without discrimination or reprisal.
Failure to Prevent and Treat Pressure Ulcers Resulting in Immediate Jeopardy
Penalty
Summary
A resident with a history of stroke, hemiplegia, malnutrition, diabetes, and other comorbidities was identified as high risk for pressure ulcer development, with a Braden score of 12. The resident was dependent on staff for mobility, repositioning, and personal care, and was frequently incontinent. Despite these risk factors, documentation and interviews revealed that staff failed to consistently and thoroughly assess, document, and report changes in the resident's skin condition. Weekly skin assessments were incomplete, often performed without fully removing clothing, and relied heavily on nursing assistants' observations rather than direct nurse assessment. There was a lack of detailed documentation regarding the size, appearance, and progression of skin issues, and communication gaps existed between nursing staff, nurse managers, and providers. Multiple staff members, including nursing assistants and LPNs, observed wounds developing on the resident's sacral area and heel, but these findings were not promptly or adequately reported to the provider or wound care team. The resident did not consistently have a pressure-relieving cushion in her wheelchair, and interventions such as repositioning and use of barrier creams were inconsistently documented. When wounds were noted, there was confusion about who was responsible for notifying the provider and initiating treatment. The resident's care plan directed staff to monitor skin integrity daily, perform weekly skin inspections, and report changes, but these interventions were not effectively implemented or documented. The resident was eventually found unresponsive and sent to the hospital, where she was diagnosed with multiple advanced pressure ulcers, including a large necrotic sacral wound, deep tissue injury to the heel, and additional skin breakdowns. Hospital staff noted that the wounds were extensive and had developed over several weeks, indicating a prolonged period of inadequate care. Interviews with facility staff and hospital personnel confirmed that the wounds were present prior to hospital admission and that there were significant lapses in assessment, reporting, and treatment of the resident's skin issues.
Failure to Assess and Monitor G-Tube Site Leading to Skin Breakdown
Penalty
Summary
A deficiency occurred when the facility failed to comprehensively assess and monitor a resident's gastrostomy (g-tube) site and provide appropriate interventions for skin irritation. The resident, who had multiple comorbidities including diabetes, stroke, hemiplegia, malnutrition, and was at high risk for pressure ulcers, required substantial assistance with mobility and was dependent on staff for all transfers and personal care. Orders were in place for staff to monitor the skin around the g-tube site and change the dressing every shift, as well as to conduct weekly skin inspections by a licensed nurse. Documentation showed that staff signed off on these tasks, but interviews and record reviews revealed gaps in the thoroughness and accuracy of these assessments. Nursing staff, including LPNs, reported that weekly skin assessments were sometimes performed without fully removing the resident's clothing, limiting the ability to visualize the entire body and the g-tube site. The LPN responsible for weekly assessments admitted to relying on nursing assistants to report skin issues and was unsure of the full requirements for the assessment. She noted minimal red bloody drainage on the g-tube dressing over several weeks but did not document this finding. The facility's wound care provider and DON confirmed that staff were expected to perform head-to-toe assessments with clothing removed and to document and report any skin concerns, including those at the g-tube site, but this was not consistently done. The resident was later hospitalized with altered mental status, hypotension, and signs of infection. Hospital records documented redness, purulent drainage, and erosion at the g-tube site, with cultures growing bacteria. Interviews with facility staff indicated that the nurse practitioner was unaware of the g-tube site irritation and would have expected to be notified. The facility's enteral tube site care competency outlined specific steps for assessment and care of g-tube sites, including cleaning, inspection, and documentation, but these procedures were not fully followed, leading to the deficiency.
Failure to Ensure Competent Weekly Skin Assessments by Nursing Staff
Penalty
Summary
Licensed nursing staff failed to demonstrate and acknowledge the required competency skills for completing weekly skin assessments for a resident identified as high risk for pressure ulcers and with worsening skin conditions. The resident had multiple comorbidities, including stroke, aphasia, hemiplegia, malnutrition, diabetes, and was dependent on staff for mobility and personal care. Despite being at high risk for skin breakdown, documentation and interviews revealed that weekly skin assessments were incomplete, with the nurse often relying on nurse aides' observations rather than conducting a thorough visual inspection of all skin areas. The nurse admitted to not always removing the resident's clothing and not assessing all areas, particularly those covered by clothing, and was unsure of the full requirements for weekly skin assessments. The resident's medical records indicated that prior to hospital admission, there were only minimal notes about skin redness and bruising, with no detailed documentation of open wounds or significant changes. However, upon hospital admission, the resident was found to have extensive skin breakdown, including a large, necrotic, unstageable pressure wound on the sacrum, deep tissue injuries on the thigh and heel, and other lesions. Hospital staff noted that these wounds were present on admission and were of significant size and severity, suggesting they had developed over a period of weeks. Interviews with hospital staff and facility nurse practitioners confirmed that the wounds could not have developed overnight and should have been identified earlier through proper skin assessments. Further review of the nurse's education and competency records showed no evidence of recent or specific training on skin assessments. Facility policy required weekly skin inspections by licensed staff, notification of providers and family for new or worsening skin issues, and detailed documentation of findings. However, these procedures were not followed, as evidenced by the lack of comprehensive skin assessments, failure to document and report changes, and inadequate communication among staff. The deficiency had the potential to affect all residents in the facility due to the systemic nature of the competency and documentation failures.
Failure to Follow Enhanced Barrier Precautions During Indwelling Catheter Care
Penalty
Summary
A deficiency occurred when a nursing assistant failed to follow proper personal protective equipment (PPE) protocols while providing care to a resident on enhanced barrier precautions (EBP) due to an indwelling urinary catheter and a history of urinary tract infections and wounds. The resident, who had multiple medical conditions including diabetes, cerebral palsy, neurogenic bladder, paraplegia, and was dependent on staff for all personal care, required staff to don both gown and gloves during high-contact care activities as indicated by facility policy and signage posted outside the room. During the observed incident, the nursing assistant entered the resident's room wearing only gloves and a mask, but did not wear a protective gown as required. While emptying the urinary catheter bag, the assistant struggled with the catheter spout, resulting in urine splashing onto the floor and paper towels. The assistant handled the catheter tubing and collection container without consistently changing gloves or using proper hand hygiene between steps, and at times used bare hands to handle potentially contaminated items. The end of the catheter tubing was not wiped with an alcohol swab prior to emptying, contrary to facility policy, and the assistant acknowledged a lack of understanding regarding the specific PPE requirements for EBP. Interviews with other staff confirmed that the expectation was to use both gown and gloves when providing care to residents with indwelling catheters under EBP. Facility policies clearly outlined the need for enhanced barrier precautions for residents with indwelling medical devices, and signage was present to direct staff. The failure to adhere to these protocols was directly observed and acknowledged by the staff involved.
Failure to Supervise Resident Smoking with Oxygen
Penalty
Summary
The facility failed to implement and enforce a process to supervise and monitor a resident who was known to smoke while using oxygen, despite clear risks associated with this behavior. The resident had a history of acute respiratory failure with hypoxia, heart failure, asthma, and tobacco use, and was cognitively intact. The resident's care plan and a signed smoking contract required that oxygen tanks be left inside the facility or at the entrance to the smoking patio, with staff assistance if needed, and indicated that non-compliance would result in a review of smoking privileges. However, there was no evidence of follow-up smoking assessments after a prior incident, and progress notes indicated the resident was observed smoking at unassigned times. Multiple observations and interviews confirmed that the resident continued to smoke on the designated patio while using oxygen, including a family member providing photographic evidence and reporting the behavior to the facility. The resident himself acknowledged being aware of the risks but did not believe his personal oxygen tank posed a danger and refused to comply with the policy. Other residents also reported witnessing similar unsafe behaviors. Staff interviews revealed there was no established plan to monitor the smoking area, and the designated patio was not directly supervised by staff, with only video surveillance available in the administrator's office and not accessible to other staff members. The facility's smoking policy stated that non-compliance could result in loss of smoking privileges but did not specifically address smoking with oxygen. The administrator confirmed that the resident had previously been observed smoking with oxygen and had been educated on the risks, but no consistent monitoring or enforcement measures were in place. The lack of direct supervision, absence of regular assessments, and failure to enforce the smoking contract led to ongoing unsafe smoking practices involving oxygen use.
Removal Plan
- Conduct a smoking assessment for R3
- Revoke R3's smoking privileges at the facility
- Revise R3's care plan to indicate his smoking privileges have been revoked
- Review the smoking policy with R3
- Notify R3's nurse practitioner
- Receive an order for nicotine lozenges for R3
- Place R3 on safety checks
- Provide education to all staff regarding designated smoking areas of the facility
- Educate staff that no oxygen is allowed on the smoking patio
- Assign the nurse on the unit closest to the smoking patio responsibility to monitor the smoking patio and document
- Require any resident who uses oxygen to exchange their oxygen for their smoking materials with the nurse
- Hold a quality assessment performance quality improvement (QAPI) meeting to review and determine a process to monitor for safe smoking practices
- Instruct staff to provide education to residents regarding safe smoking
- Instruct staff to notify the nurse if residents are non-compliant with smoking safety
- Instruct staff to document instances of non-compliance
- Instruct staff to notify the administrator or nurse on-call of non-compliance
- Post the smoking policy on the door to the smoking patio
- Post a sign indicating no oxygen allowed in the smoking patio area
Medication Diversion and Misappropriation in LTC Facility
Penalty
Summary
The facility failed to implement a system to prevent the diversion of medications, resulting in the misappropriation of controlled substances prescribed to 30 residents. A trained medication assistant (TMA) was found to have signed out narcotics from the narcotic log without consistently documenting their administration in the Medication Administration Record (MAR). This discrepancy was identified when a registered nurse (RN) noticed that narcotics were being administered via a G-tube by the TMA, which was outside the TMA's scope of practice. The facility's narcotic records showed significant discrepancies between the doses signed out and those documented as administered in the MAR. Several residents, including those with cognitive impairments and various medical conditions such as epilepsy, heart failure, and chronic pain, were affected by these discrepancies. For instance, one resident's narcotic record indicated 25 doses of oxycodone were signed out, but only 19 doses were documented as administered. Another resident's record showed 34 doses signed out, with only 18 documented as administered. These discrepancies were consistent across multiple residents, indicating a pattern of medication misappropriation. Interviews with staff revealed that the TMA had been improperly handling narcotics, including setting up medications for nurses and administering G-tube medications, which should have been performed by licensed nurses. The TMA also denied giving discharged medications to residents and claimed to have counted narcotics with licensed staff, although the documentation did not support this. The facility's policies on medication administration and controlled substance accountability were not adhered to, leading to the diversion of medications and potential harm to residents.
Deficiencies in Narcotic Security and Insulin Pen Storage
Penalty
Summary
The facility failed to implement a secure system for storing narcotics, as evidenced by the case of a resident who had discontinued medication still being signed out and administered. The resident, who was cognitively intact and had a history of a leg fracture, osteoporosis, and heart failure, had an order for oxycodone that was discontinued, yet doses were still signed out after the discontinuation date. The resident reported not using any pain medication recently and had no increased pain, raising concerns about potential medication diversion. Additionally, the facility did not ensure proper labeling and storage of medications, particularly insulin pens, across multiple medication carts. Insulin pens were stored without separation devices, lacked dosing instructions, and were not properly labeled with open dates or resident identification. This improper storage and labeling were confirmed by several nurses and care coordinators, who noted that the pens were stored in cups or boxes without plastic bags or pharmacy labels, leading to potential contamination and administration errors. The facility's policy required medications to be checked for the five rights (right resident, right drug, right dose, right route, and right time) by comparing the medication administration record with the medication label. However, the report indicates that this process was not consistently followed, as the insulin pens were not labeled correctly, and the dosing information was not available on the pens themselves. The director of nursing acknowledged the ongoing need for education on proper medication administration checks.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the required nurse staffing information was posted daily for 3 out of 6 days reviewed, potentially affecting all 57 residents and their visitors. On three separate occasions, surveyors observed that the posted nurse staffing information was outdated. On 2/3/25 at 2:29 p.m., the information was dated 2/2/25; on 2/5/25 at 7:17 a.m., it was dated 2/4/25; and on 2/11/25 at 9:52 a.m., it was dated 2/10/25. According to the facility's Nursing Hours Posting policy, revised on 10/2/22, the facility was required to post nursing staffing data daily at the beginning of each shift, ensuring it was readily accessible to residents and visitors.
Failure to Honor Resident's Clothing Preferences
Penalty
Summary
The facility failed to honor a resident's right to a dignified existence by not allowing her to dress in a manner of her choosing. The resident, who was severely cognitively impaired and required assistance with dressing due to hemiplegia following a stroke, was observed multiple times wearing a hospital gown in public areas of the facility. The resident's guardian expressed concerns about the resident being dressed in a hospital gown and had attempted to discuss clothing options with the facility's social worker, but communication was unsuccessful. Interviews with facility staff revealed that the resident's clothes had ripped and would fall off her shoulders, leading to the decision to dress her in a hospital gown. However, the resident's care plan did not specify a preference for a hospital gown, and the social worker acknowledged the importance of honoring a resident's clothing preferences for dignity. The facility's policy for clothing preferences was not followed, as there were no documented attempts to contact the guardian regarding the resident's clothing needs, and the care plan did not reflect the resident's preferences.
Failure to Assess Resident's Ability to Self-Administer Medications
Penalty
Summary
The facility failed to properly assess a resident, identified as R39, who wished to self-administer medications. R39 was cognitively intact and had diagnoses of congestive heart failure and diabetes, receiving high-risk medications such as anticoagulants and diuretics. Despite this, R39's care plan did not include an assessment of his ability to self-administer medications. An evaluation from 2021 indicated that R39 was unsafe to administer medications independently, yet medications were found on his dresser during an observation. During interviews, it was revealed that R39 had experienced an adverse reaction to Tamiflu and had stopped taking it, with the facility being aware of this. However, there was no self-administration assessment or physician order found for R39, and medications were left in his room unattended. The facility's policy required a comprehensive assessment by an interdisciplinary team to document a resident's ability to safely self-administer medications, which was not followed in this case.
Failure to Report and Address Allegation of Sexual Abuse
Penalty
Summary
The facility failed to immediately report an allegation of sexual abuse involving a resident, identified as R57, to the state agency and law enforcement. R57, who was cognitively intact and dependent on staff for most activities of daily living, was alleged to have been sexually abused by a certified nursing assistant (CNA-A). The incident was reported by a family member (FM-A) who observed CNA-A leaving R57's room and noted suspicious circumstances, including a white substance on R57's mouth and her blankets being disturbed. Despite being informed of the allegation, the facility's administrator did not report the incident to the authorities, as she did not believe the allegation based on her review of hallway video footage. The administrator and other staff members, including a social worker (SW-1) and a licensed practical nurse (LPN-A), failed to follow the facility's policy on abuse reporting. The administrator was notified of the incident via text message but did not take action until the next business day. SW-1 also received a report of the incident but deemed the family member not credible and did not report it to the authorities. LPN-A, who was informed of the incident during the night shift, did not report it to the state agency or law enforcement and did not remove CNA-A from providing care to R57 or other residents. The facility's policy required all staff to report any suspected abuse to the Office of Health Facility Complaints within two hours of forming the suspicion. However, this policy was not adhered to, resulting in a failure to protect R57 from potential further abuse. R57 expressed fear and discomfort due to CNA-A's continued presence in the facility, highlighting the facility's failure to ensure her safety and well-being.
Failure to Investigate Alleged Sexual Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of sexual abuse involving a resident who was cognitively intact and dependent on staff for most activities of daily living. The resident's care plan indicated she was a vulnerable adult and required care in pairs. On the night of the incident, a family member reported seeing a CNA leaving the resident's room and alleged that the CNA had sexually abused the resident. The family member took pictures of the alleged evidence and reported the incident to the social worker and administrator. The administrator, upon being notified, reviewed video footage but did not find it necessary to investigate further, as she believed the CNA was not in the room long enough to commit the alleged act. The administrator did not interview the resident, the reporting staff, or any other residents or staff. The investigation file contained minimal documentation, and the incident was not reported to the State Agency or police by the facility staff. The social worker also doubted the credibility of the family member and did not pursue further investigation. The facility's policy required immediate investigation and reporting of abuse allegations, but this was not followed. The CNA continued to work with the resident without any suspension or education following the allegation. The police were only informed of the incident by the family member nearly a month later, and the facility had not provided the police with their internal investigation. The lack of a thorough investigation and failure to report the incident to the appropriate authorities constituted a deficiency in the facility's handling of the situation.
Deficiencies in Care Planning for Dialysis and Clothing Preferences
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident receiving dialysis, identified as R72. The care plan did not include critical information such as the use of an AV fistula on the resident's left forearm for dialysis, which had been in use since December 23, 2024. The care plan also omitted instructions to avoid taking blood pressure or drawing blood from the left arm and to monitor for a thrill and bruit at the fistula site. Despite the presence of a pressure dressing over the fistula access site, there were no physician orders or nursing tasks related to the fistula, and the nursing staff, including the nurse manager and director of nursing, were unaware of the specifics of the resident's dialysis access and care requirements. Additionally, the facility failed to address clothing preferences and passive range of motion (PROM) exercises in the care plan for another resident, identified as R59, who was severely cognitively impaired and had functional limitations due to a stroke. The care plan did not include instructions for PROM exercises, which were part of the resident's occupational therapy discharge summary. Furthermore, the care plan did not specify the resident's clothing preferences, despite the resident's desire to wear her own style of dress, which was important for her dignity. Staff interviews revealed that the resident's clothing preferences were not documented in the care plan, and there was a lack of coordination to ensure the resident's dignity and comfort in her attire.
Failure to Provide Prescribed Range of Motion Exercises
Penalty
Summary
The facility failed to ensure that a resident, identified as R59, received the necessary range of motion (ROM) exercises. R59, who was severely cognitively impaired and had functional limitations in range of motion due to hemiplegia following a stroke, was observed without receiving the prescribed passive range of motion (PROM) exercises. The occupational therapy discharge summary had included a plan for PROM to the resident's right upper extremity, but the care plan did not reflect these instructions. Additionally, the medical record lacked updates regarding the resident's refusal of the ROM program. Interviews with staff revealed a lack of clarity and communication regarding the resident's PROM exercises. Nursing assistants were unsure if R59 received the exercises, and the nursing manager could not specify when or why the exercises were discontinued. The nurse practitioner and director of therapy both indicated that the facility should have documented and communicated any refusals of the program to therapy. The failure to provide the prescribed ROM exercises could lead to decreased mobility and contractures, as noted by the director of therapy.
Failure to Monitor Dialysis Care for Resident
Penalty
Summary
The facility failed to provide proper assessment and monitoring for a resident, identified as R72, who required dialysis services. R72, who was cognitively intact, had diagnoses of end-stage renal disease and heart failure. The care plan for R72 did not accurately reflect the current dialysis access method, as it mentioned monitoring for signs of bleeding at a central dialysis catheter port site, while R72 was actually receiving dialysis through an arteriovenous (AV) fistula on the left arm. Observations and interviews revealed that R72 had a pressure dressing over the fistula access site, which should have been removed within four hours to prevent complications such as clotting, narrowing of blood vessels, and infection. However, there was no indication that staff were aware of or addressed the presence of the pressure dressing after dialysis sessions. Additionally, the facility's documentation and orders were not updated to reflect the use of the fistula for dialysis until February 5, 2025, despite the fistula being in use since December 23, 2024. Blood pressure readings were inappropriately taken on the left arm, which could compromise the fistula's function. Interviews with facility staff, including the nurse manager and director of nursing, revealed a lack of awareness and monitoring of the dialysis site, as well as a failure to adhere to the facility's dialysis policy, which required ongoing assessment and evaluation of the resident's condition, including monitoring for infection and ensuring no blood pressure or blood draws were conducted on the access arm.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in an 8% error rate during medication passes. Two errors were identified among 25 opportunities, involving two residents. The first resident, who was severely cognitively impaired and diagnosed with coronary artery disease, hypertension, and dementia, was administered metoprolol tartrate despite having a pulse below the prescribed parameter. The LPN acknowledged the error, confirming the medication should not have been given. The nursing manager expected nurses to verify pulse parameters before administering medication, and the nurse practitioner highlighted the risk of worsening bradycardia from such errors. The second error involved a resident with unspecified psychosis and dementia with behavioral disturbance. The LPN prepared and nearly administered an incorrect dose of quetiapine fumarate, exceeding the scheduled amount. The LPN confirmed the error upon comparing the medication cup to blister pack cards. The consultant pharmacist noted the increased risk of side effects from incorrect dosing, which could have been avoided with proper checks. The director of nursing emphasized the importance of adhering to provider orders and verifying medication labels against the electronic medication administration record, as outlined in the facility's medication administration policy.
Medication Storage and Security Deficiency
Penalty
Summary
The facility failed to maintain safe storage of medications, as observed in multiple instances. On one occasion, a medication cart on the LTC unit was left unlocked and unattended for several minutes, with no staff in direct sight. A staff member walked past the cart without securing it, and it was eventually locked by a care coordinator. In another instance, a medication cart on the TCU was also found unlocked and unattended, with residents nearby. Additionally, during a medication pass, an RN left a resident's medications unattended in the resident's room while retrieving alcohol wipes from the medication cart. The room door was partially open, and other residents were walking past. The RN acknowledged the error, stating she was aware that medications should not be left unattended. The DON confirmed that medication carts should always be locked when not in use and that medications should never be left unattended in a resident's room.
Inadequate Hand Hygiene and Catheter Care
Penalty
Summary
The facility failed to conduct appropriate hand hygiene during tracheostomy care for a resident who was severely cognitively impaired and dependent on all cares. During the observation of tracheostomy care, the LPN and RN assisting did not perform hand hygiene after removing gloves and before donning new ones, despite acknowledging the importance of hand hygiene to prevent infections. The Director of Nursing confirmed the expectation for staff to perform hand hygiene when changing gloves between cares. Additionally, the facility failed to ensure proper catheter drainage bag care for a resident with a foley catheter. The urinary catheter drainage bag was observed lying on the floor on multiple occasions, which was acknowledged by staff as inappropriate due to cleanliness and dignity concerns. Furthermore, the LPN did not cleanse the catheter bag spout with an alcohol wipe before securing it back in the holder, despite having alcohol wipes available. The facility's policies on handwashing and indwelling catheter care were not followed, contributing to these deficiencies.
Failure to Hold Medication for Low Pulse as Ordered
Penalty
Summary
A resident with severe cognitive impairment and diagnoses including coronary artery disease, hypertension, and dementia had a physician's order for metoprolol tartrate to be administered twice daily, with specific parameters to hold the medication if the apical pulse was less than 60 beats per minute. During a medication pass observation, an LPN measured the resident's pulse at 55 beats per minute but proceeded to administer the metoprolol tartrate, contrary to the order. The LPN confirmed during an interview that the medication should not have been given when the pulse was below the specified parameter. Review of the resident's medication administration records over a three-month period revealed multiple instances where the medication was administered despite recorded pulses below 60 beats per minute, with no indication that the medication was held as ordered. Facility staff interviews confirmed the expectation that nurses verify vital signs are within ordered parameters before administering medications. The facility's medication administration policy also required medications to be given in accordance with written orders, including verification of the five rights prior to administration.
Medication Administration Error Due to LPN's Assumption
Penalty
Summary
The facility failed to adhere to professional standards of practice for medication administration for one resident. The resident, who was cognitively intact and had a diagnosis of acute embolism and thrombosis of the deep vein of the left lower extremity, was supposed to receive Buprenorphine HCL sublingual tablets for pain. However, on two occasions, the resident was mistakenly given Buprenorphine HCL Buccal Film instead. The error occurred because the LPN could not find the sublingual medication and assumed the film could be administered as a substitute. The resident was aware of the medication error and attempted to inform the LPN, but the LPN did not believe the resident and proceeded with the administration of the incorrect medication. The investigation revealed that the sublingual tablets were available in the facility's narcotic box at the time of the error, and the LPN failed to perform the necessary safety checks to ensure the right medication, dose, form, and person. The error was identified when the resident reported the issue, and it was confirmed that the medication had been delivered and administered correctly on previous days. The facility's policy required staff to contact the provider in the event of a medication error, but the LPN did not do so. The interim DON noted that the root cause of the error was the LPN's inability to locate the tablets and the assumption that the film could be used instead, without provider approval.
Failure to Make Psychiatric Referral for Resident
Penalty
Summary
The facility failed to ensure a referral was made to an outside agency for psychiatric services as ordered by a physician for a resident diagnosed with bipolar disorder, protein-calorie malnutrition, and adult failure to thrive. The resident had a physician order for a referral to the Associated Clinic of Psychology (ACP) due to concerns about restrictive/avoidant eating. However, the resident was not currently being seen by ACP, and the last visit occurred several months prior. A licensed practical nurse confirmed the lack of a current referral and was unaware if a new referral had been made. The social services staff, responsible for submitting referrals, was also unaware of the order. The interim director of nursing stated that staff would typically notify social services of such orders, but no policy was available to guide this process.
Failure to Notify Family of Resident's Wound Progression
Penalty
Summary
The facility failed to notify a resident's family of changes in the resident's condition, specifically regarding the development and progression of a left toe ulcer that ultimately led to an amputation. The resident, who had severe cognitive impairment and was non-verbal, was admitted with multiple health issues, including hemiplegia, diabetes, and vascular dementia. Despite being a high-risk patient with diabetic ulcers on both great toes, the facility did not inform the resident's power of attorney (POA) about the condition of the wounds until the situation necessitated a hospital visit and subsequent amputation. The facility's records show that the resident's toe ulcers were being monitored and treated regularly, with notes indicating the wounds were stable but showed minimal improvement. However, there was no documentation of communication with the family regarding the wounds from the time they were first noted until the resident was sent to the hospital. Interviews with family members revealed that they were unaware of the resident's toe wounds and the involvement of a wound care clinic until the hospital informed them of the need for an amputation due to infection. Interviews with facility staff, including nurses and the Director of Nursing (DON), indicated a lack of clarity and consistency in the process of notifying families about changes in wound conditions. The staff expected the nurse practitioner (NP) to update families, but the NP had no contact with the family. The facility's policies required notification of changes in a resident's condition to the resident's representative, but this was not adhered to in this case, leading to a significant oversight in communication.
Failure to Initiate CPR for Full Code Resident
Penalty
Summary
The facility failed to follow the Provider Orders for Life Sustaining Treatment (POLST) for a resident who wished to have cardiopulmonary resuscitation (CPR) in the event of cardiopulmonary arrest. The resident was found unresponsive, without a pulse or respirations, and CPR was not initiated despite the resident's full code status. This resulted in the resident's death, as no resuscitative efforts were made. The incident occurred when a Licensed Practical Nurse (LPN) found the resident unresponsive and failed to initiate CPR. The LPN checked for a pulse and respirations, found none, and did not proceed with CPR, believing it was too late. The LPN did not contact the Director of Nursing (DON) or the on-call nurse for guidance and instead contacted the facility administrator, leading to a miscommunication about the actions taken. Other staff members, including a Registered Nurse (RN), confirmed that CPR was not performed, and the Automated External Defibrillator (AED) was not used. The staff were aware of the resident's full code status but did not act accordingly. Interviews with other staff members revealed that they were trained and certified in CPR and understood the protocol for initiating CPR for a full code resident, yet the protocol was not followed in this instance.
Deficiency in Methadone Management and Narcotic Documentation
Penalty
Summary
The facility failed to implement appropriate policies and procedures for the administration and management of methadone hydrochloride for a resident undergoing treatment for opioid dependence. The resident, who was cognitively intact and had a history of substance use, was receiving methadone treatment from a methadone clinic. However, the facility did not coordinate effectively with the clinic, leading to missed doses and unauthorized tapering of the medication. The facility's actions included altering the methadone doses without consulting the methadone clinic, which was against regulations, and resulted in the resident experiencing withdrawal symptoms. The facility also failed to ensure proper handling and documentation of narcotic medications, including methadone. There were significant lapses in the documentation of narcotic counts and the co-signing of narcotic waste, as required by facility policy. The facility staff did not follow proper procedures for the destruction of unused methadone, and there was a lack of communication and coordination with the methadone clinic regarding dose adjustments and the provision of urine samples for testing. Additionally, the facility's narcotic books were incomplete, lacking necessary information such as prescribing provider details, prescription numbers, and dates. The facility's failure to maintain accurate records and follow established protocols for controlled substances contributed to the deficiency. The facility did not have a policy in place for managing methadone for addiction, which further exacerbated the situation and led to the resident being cut from the methadone program.
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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