The Villas At Osseo Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Osseo, Minnesota.
- Location
- 501 Second Street Southeast, Osseo, Minnesota 55369
- CMS Provider Number
- 245629
- Inspections on file
- 37
- Latest survey
- February 6, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at The Villas At Osseo Llc during CMS and state inspections, most recent first.
A resident with a right femur fracture and chronic low back pain received PRN oxycodone-acetaminophen multiple times without consistent evidence that non-pharmacological (non-pharm) interventions were attempted or documented beforehand. The care plan and facility pain protocol called for measures such as repositioning, ice, heat, and massage, and the MAR included a task list for non-pharm options, but documentation showed only once-per-shift entries, mostly offering food and rarely repositioning, rather than entries tied to each PRN dose. Nursing notes lacked comprehensive pain assessments, including pain location and characteristics, and did not record which non-pharm interventions were offered, attempted, refused, or their effectiveness. In interviews, the resident reported that ice and repositioning helped when requested, and clinical staff and leadership described an expected process of assessing pain, trying conservative measures first, and documenting all interventions, which was not reflected in the resident’s record.
A resident with gas gangrene and a foot ulcer was discharged from the hospital with an order for amoxicillin-pot clavulanate to be given twice daily starting on the day of admission and stopping on a specified later date. Although the facility’s physician order matched the hospital discharge order, the MAR was transcribed with a start date one day later, so the medication did not populate for administration until the following evening. As a result, the resident missed two ordered doses. The pharmacist, RN staff, NP, and DON all confirmed that medications are expected to start on the day of admission unless a different start date is ordered, that the first dose was not given until the next day’s evening shift, and that the order had not been transcribed accurately in accordance with facility policy.
A resident with complex medical needs received five times the prescribed dose of Methadone over three days due to staff failing to verify the medication concentration and dosage on the prescription label, instead relying on outdated records. Multiple nurses administered the incorrect dose, resulting in the resident experiencing impaired speech, inability to verbalize needs, decreased oral intake, and increased lethargy.
A resident with multiple chronic conditions experienced a significant weight loss and decreased appetite over several weeks. Despite care plan directives and staff observations of declining intake, the resident's family was not promptly notified of the change in condition or related medical interventions. Documentation and interviews confirmed that the facility did not follow its policy for timely communication with the resident's representative.
A non-verbal resident with multiple serious health conditions did not receive appropriate pain management due to staff failing to use the correct pain assessment tool, discontinuing pain medication orders before new ones were entered, and not consistently monitoring or documenting pain. The resident experienced unmanaged pain, with family and hospice staff reporting distress and delays in receiving pain relief.
The facility failed to assess the safety and necessity of side rails for two residents before use. One resident with a history of falls and diabetes was observed with raised side rails without documented assessment or consent. Another resident with a lumbar fracture had assist bars without proper assessment or consent. Staff confirmed the lack of necessary evaluations.
A resident with cognitive and physical impairments suffered a fall and injury due to neglect and rough handling by a nursing assistant. The assistant failed to follow the care plan, which required a mechanical standing lift for transfers, and instead used a non-care planned approach. Despite the resident's voiced pain and distress, the assistant continued with unsafe handling, resulting in a fall and a distal femur fracture requiring hospitalization.
A resident with cognitive impairments and a history of elopement risk managed to remove her wanderguard and exit the facility without staff knowledge, remaining outside in cold weather for 30 minutes. The facility failed to ensure consistent monitoring and documentation of the wanderguard, and staff did not adhere to the elopement policy, resulting in a breakdown of communication and protocol adherence.
A resident with cognitive intactness and physical impairments was not treated with dignity when a nursing assistant refused to assist her to the smoking area, contrary to her care plan. The resident, who was at high fall risk, had previously fallen when unassisted. The DON acknowledged inappropriate communication and ongoing staff training.
A resident with dementia experienced two falls resulting in a hip and neck fracture. The facility failed to notify the resident's representative due to incorrect contact information, despite attempts to correct it. The facility's policy requires immediate notification of such incidents, which was not followed.
A resident with dementia and a history of falls did not receive a falls assessment upon admission, leading to multiple falls and a hip fracture. The facility staff acknowledged the oversight, as the assessment was only completed after the resident's hospital return.
A facility failed to update a resident's care plan with fall interventions after the resident, who had dementia and a history of falls, experienced a hip fracture and a subsequent neck fracture. The care plan included interventions like physical therapy and a toileting plan, but was not updated after the resident's hospital re-entry. Interviews revealed communication gaps and a lack of specific intervention suggestions, contrary to the facility's care planning policy.
The facility failed to provide medications as ordered for three residents, resulting in deficiencies. An LPN's error led to a missed INR test and Coumadin doses for one resident. Another resident did not receive niacin for hypertension due to stock issues, and a third resident missed nicotine patches. The LPNs did not notify supervisors or providers about the missing medications, and facility procedures for documenting and reporting errors were not followed.
The facility failed to follow proper infection control practices during blood glucose checks for two residents with diabetes. An LPN used an alcohol wipe instead of the required disinfectant wipe for cleaning the glucometer, and another LPN placed the glucometer directly on surfaces without proper disinfection. The clinical manager confirmed the facility's procedure required bleach wipes, which were not used.
The facility inaccurately reported staffing data to CMS for Q2 2024, showing low weekend staffing despite adequate levels. The administrator noted that contracted staff hours were not recorded as regular hours, causing the discrepancy. A policy on PBJ reporting was not provided.
A facility failed to use professional interpreter services for a resident who frequently experienced pain and spoke Ukrainian. Despite having a care plan that required interpreter use, staff relied on the resident's personal phone and a translator app, which was ineffective. The resident became distressed during care, and staff did not offer to contact the professional service, leading to communication breakdowns and increased frustration.
A facility failed to notify the Ombudsman of a resident's hospitalization, missing a required written notification. The resident had multiple health issues and was hospitalized, but the facility did not send the necessary notification to the Ombudsman. The oversight was acknowledged by the facility's administrator and social service director, who noted a reporting issue that led to the omission.
A facility failed to complete a Level II PASARR for a resident with anxiety disorder and schizophrenia. Although a Level I PASARR indicated the need for a Level II screening before admission, it was not completed. The social worker admitted to a lack of communication with the lead agency, and the administrator stressed the importance of completing the screening to meet the resident's needs. A policy on PASARR was requested but not provided.
The facility failed to implement interventions for two residents to prevent decreased range of motion and mobility. One resident with Parkinson's disease did not receive prescribed daily stretches, and documentation showed tasks were not completed. Another resident with multiple myeloma was not offered walking with a walker and brace as prescribed, and a standing recommendation was not relayed from therapy. The DON confirmed the lack of follow-up on incomplete tasks.
A resident with multiple medical conditions sustained a hematoma on the right leg during a transfer involving a defective lift. The facility failed to report the injury to the State Agency, despite policy requirements and a family member witnessing a rough transfer. The administrator was unaware of the injury's cause and did not report it, believing there was no intent to harm.
A resident with multiple medical conditions was found with a hematoma on her leg, but the facility failed to investigate the cause. Despite reports of a rough transfer and the resident's leg hitting a mechanical lift, no follow-up was conducted. The facility's policy requires immediate investigation, but this was not completed due to the unavailability of the DON.
A resident on hospice care experienced a seizure, and the facility nurse initially denied the seizure and attempted to administer Ativan instead of calling 911 as requested by the family. The family called 911, and the resident was transported to the hospital, where she continued to have seizures and later passed away. The facility failed to honor the family's treatment decisions and adequately address their concerns.
A facility failed to recognize and report a potential allegation of neglect to the State Agency in a timely manner for a resident with stage IV cancer. The resident's family reported concerns about unsanitary and unsafe room conditions, bruising and bleeding in the mouth, delayed patient care, and a nurse refusing to contact 911. Despite these concerns, no report was filed, and the facility did not take immediate action to investigate the allegations properly.
The facility failed to administer medications according to physician orders for 10 residents, resulting in late or missed doses. Staff did not update providers or managers about the delays, causing distress and potential health risks for the residents.
The facility failed to administer insulin according to physician orders for four residents, resulting in delayed and omitted doses. An LPN was responsible for 25 residents and was unable to administer insulin on time, leading to potential risks of hypo/hyperglycemia. The facility's policies for timely medication administration were not followed, and there was a lack of communication with providers and supervisors about the delays and omissions.
Failure to Use and Document Non-Pharmacological Interventions Before PRN Narcotics
Penalty
Summary
The facility failed to ensure non-pharmacological pain interventions were attempted, offered, and documented prior to administering PRN narcotic pain medication for one resident. The resident had diagnoses including a right femur fracture, hypotension, and low back pain, and her admission MDS indicated no cognitive impairment with occasional pain that interfered with daily activities, therapy, and sleep. Her care plan identified altered comfort related to the femur fracture and low back pain, with interventions such as positioning, rest, and massage. A provider order authorized oxycodone-acetaminophen 10-325 mg every six hours PRN for chronic pain, without specifying the pain location. The MAR for the month showed 17 administrations of oxycodone-acetaminophen and included a task to document non-pharmacological interventions each shift, such as ice, heated blankets, massage, repositioning, music, essential oils, food or drink, and relaxation breathing. However, documentation of non-pharmacological interventions was completed only once per shift rather than in relation to each PRN narcotic administration, and the entries showed the resident was offered food 20 times and repositioning once, with no other interventions recorded. Between admission and the survey review period, the record lacked comprehensive pain assessments that would identify pain location and characteristics. Nursing notes documented the date and time of PRN narcotic administration but did not indicate what, if any, non-pharmacological measures were attempted or offered beforehand, nor did they document the effectiveness of any such interventions when they were used. During interviews, the resident reported that ice and repositioning helped her leg pain and that staff would bring ice if she asked but did not offer it before giving a pain pill. Multiple nursing staff, the NP, and the DON all described an expected process that included assessing pain location and intensity, offering non-pharmacological measures first, and documenting interventions and effectiveness, and the DON confirmed that R3’s record did not show non-pharmacological interventions offered, attempted, or refused prior to PRN narcotic administration, despite the facility’s Pain Management Protocol requiring such comforting and complementary interventions.
Failure to Accurately Transcribe Antibiotic Order Resulting in Missed Doses
Penalty
Summary
The deficiency involves the facility’s failure to accurately transcribe and initiate an antibiotic order as written by the physician for one resident. The resident had diagnoses including gas gangrene and a foot ulcer and was discharged from the hospital with an order for amoxicillin-pot clavulanate 875-125 mg, one tablet twice daily, to start on the day of discharge and stop on a specified later date. The facility’s physician order matched the hospital discharge order, including the start and stop dates. However, the January and February MARs listed the start date as the day after admission, with the first scheduled administration on the evening shift, resulting in the evening dose on the day of admission and the morning dose the following day not being given. The resident’s MDS indicated no cognitive impairment and documented that the resident was administered an antibiotic. Interviews confirmed that the antibiotic was delivered to the facility on the day of admission and that medications are expected to start on the day of admission unless a different start date is ordered. The pharmacist stated that medications should start on the day of admission in the absence of a specific alternate start date. Nursing staff reported that medications appear on the MAR based on the transcribed start date and confirmed that the first dose of the antibiotic was not given until the evening of the day after admission, acknowledging that it should have started the prior day. The NP stated that medications should start on the day of admission unless otherwise specified and that the provider should be notified of missed doses, but did not recall being notified of the two missed doses. The DON acknowledged that the order was not transcribed accurately, as the start date should have been the day of admission, which resulted in two missed doses, contrary to the facility’s policy requiring accurate and timely transcription of medication orders including correct start and stop dates.
Failure to Follow Five Rights of Medication Administration Leads to Significant Methadone Overdose
Penalty
Summary
Facility staff failed to follow the five rights of medication administration for a resident with multiple complex medical conditions, including Multiple Sclerosis, paraplegia, and chronic pain. The staff did not compare the written order on the Medication Administration Record (MAR) with the prescription label on the Methadone bottle before administration. As a result, the resident received five times the prescribed dose of Methadone over the course of three days, totaling nine incorrect administrations. The error occurred because staff administered Methadone based on outdated or incorrect information, specifically using the concentration and dosing instructions from a discontinued medication bottle rather than the current prescription. Multiple nurses, including agency staff, RNs, and LPNs, administered the incorrect dose, each failing to verify the medication concentration and dosage as indicated on the new prescription bottle. The MAR and narcotic record contained conflicting information, and staff relied on these records without cross-checking the actual medication label, leading to repeated overdoses. The resident experienced a significant decline following the medication errors, including impaired speech, inability to verbalize needs, decreased oral intake, lethargy, and increased weakness. Observations and interviews with staff and the resident's significant other confirmed these changes, noting that the resident was previously able to speak and eat but became largely nonverbal and unable to tolerate food or oral medications after the errors. The medication error was discovered during a medication count, and subsequent interviews revealed that staff had not recognized the change in medication concentration or the impact of the error until the resident's condition had significantly deteriorated.
Removal Plan
- Provide education to nurses on medication administration and transcription, the five rights of medication administration, ensuring medication labels match physician orders, and contacting pharmacy or physician for clarification.
- Educate all nurses on medication types, prevention of errors, high risk medications, and compliance with national safety standards.
- Review pain medication management for accuracy and ensure the label on the bottle matches the physician order in the medical record.
- Review orders and liquid medication labels for all like residents to ensure labels on bottles match the orders in the medical record.
- Initiate compliance audits.
Failure to Timely Notify Family of Resident's Significant Weight Loss
Penalty
Summary
The facility failed to notify a resident's representative in a timely manner following a significant change in the resident's condition, specifically an 8.9-pound weight loss over 27 days. The resident had multiple medical diagnoses, including cancer, diabetes, heart failure, seizure disorder, and depression, and was noted to be cognitively intact and independent with activities of daily living. The care plan included monitoring for nutritional problems and weight changes, but despite documented weight loss and decreased appetite, there was no evidence that the family was promptly informed. Medical records and staff interviews revealed that the resident experienced a notable decline in appetite and food intake, with staff observing the resident eating alone in her room, refusing dining room meals, and not wanting assistance. Orders were placed by the nurse practitioner for laboratory tests and medication adjustments in response to the weight loss and anorexia, but no new interventions were initiated based on the results. The registered dietician assessed the weight loss and communicated with the nurse practitioner but did not contact the family until much later, after the issue was identified during the survey. The resident's family member reported only being notified of the weight loss by the nurse practitioner and not by facility staff, and was unaware of the earlier changes in condition and medical interventions. The facility's policy required timely notification of changes in a resident's condition to the resident and/or their representative, but documentation and interviews confirmed that this did not occur in this case. Progress notes lacked evidence of communication with the family regarding the weight loss, and staff interviews indicated a lack of clarity about who was responsible for family notification.
Failure to Provide Safe, Appropriate Pain Management for Non-Verbal Resident
Penalty
Summary
A deficiency occurred when the facility failed to comprehensively assess and implement appropriate pain monitoring and management for a non-verbal resident receiving palliative and hospice care. The resident had multiple serious medical conditions, including pneumonia, obesity, hypertension, congestive heart failure, atrial fibrillation, and was on long-term insulin. The care plan directed staff to use non-pharmacological interventions and pain medications as ordered, and to monitor for pain and medication side effects. Despite these directives, staff did not consistently use an appropriate pain assessment tool for the resident's non-verbal status, instead documenting pain using a numerical scale that required verbal input, which the resident could not provide. A significant lapse occurred when the resident went nearly four hours without access to pain medication due to a medication transcription error. Previous pain medication orders were discontinued before new orders were entered into the system, leaving the resident without any pain management options during this period. Multiple staff interviews confirmed that the correct procedure would have been to continue the previous pain orders until the new medications were available, but this was not followed. The resident's family and hospice staff reported distress over the resident's unmanaged pain, and documentation showed the resident was observed to be in pain, with behaviors such as calling out, groaning, and agitation. Further review revealed that after the medication orders were changed, staff failed to document any pain assessments for the resident, and when assessments were documented, they were often done incorrectly using a numerical scale rather than a non-verbal pain assessment tool like PAINAD. Staff interviews indicated a lack of understanding and adherence to proper pain assessment protocols for non-verbal residents. The facility's own policies required timely and accurate transcription of medication orders and individualized pain management plans, but these were not followed, resulting in the resident experiencing unmanaged pain and discomfort.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to ensure that side rails were comprehensively assessed for safety and necessity before use for two residents. One resident, who had intact cognition and a history of repeated falls and type 2 diabetes with a foot ulcer, was observed with side rails raised on both sides of the bed. The resident's care plan did not include information about bed rails, and there was no evidence in the electronic medical record (EMR) of a side rail assessment or informed consent. The resident did not recall being informed about the risks associated with side rails. Another resident, also with intact cognition and diagnoses including lumbar fracture and muscle weakness, was observed with raised assist bars. This resident's care plan similarly lacked information about bed rails, and the EMR did not show evidence of a side rail assessment or informed consent. The resident remembered being asked about the use of assist bars but could not recall being informed of the risks. Staff confirmed the lack of assessments and the director of nursing stated that assessments were necessary to ensure safety and appropriateness of side rail use.
Resident Suffers Injury Due to Neglect and Rough Handling
Penalty
Summary
The facility failed to protect a resident from abuse and neglect, resulting in a fall and injury. The resident, who was moderately cognitively impaired and required extensive physical assistance for bed mobility and transfers, was deprived of her care-planned needs. Despite voicing pain and showing signs of distress, the resident was handled roughly by a nursing assistant who did not follow the care plan, which required the use of a mechanical standing lift for transfers. The resident's care plan indicated she needed assistance due to conditions such as a stroke, right-sided hemiplegia, severe morbid obesity, and chronic pain syndrome. However, the nursing assistant attempted to transfer the resident without the required mechanical lift, instead using a non-care planned approach. This resulted in the resident being placed in unsafe positions and ultimately falling, leading to a distal femur fracture that required hospitalization and surgical intervention. Video footage revealed the nursing assistant's rough handling and failure to communicate effectively with the resident, who was visibly struggling and in pain. The nursing assistant did not seek additional help or alter her approach, despite the resident's distress. The facility's investigation confirmed that the nursing assistant did not follow the care plan, contributing to the resident's fall and injury.
Removal Plan
- Internal investigation was initiated.
- Ad Hoc QAPI meeting was held.
- NA-B was placed on suspension.
- OHFC report was filed, along with a police report.
- Staff education with associated quiz was initiated regarding Abuse, Safe Patient Handling, Resident Rights, and Care Planning.
- Observation transfer and resident treatment audits were initiated.
- Like resident care plans and care guides were reviewed to ensure current reflection of transfer needs.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent an elopement incident involving a resident who was at risk for elopement and had a history of removing her wanderguard. The resident, who was moderately cognitively impaired and had multiple medical conditions including COPD, diabetes, and schizophrenia, managed to remove her wanderguard and exit the facility without staff knowledge. She was outside in 17-degree weather for approximately 30 minutes before being found by staff. The resident was not immediately assessed upon reentry, and the provider, family, and managerial staff were not promptly informed of the elopement. The resident's care plan included the use of a wanderguard to alert staff of her movements, but there was a lack of consistent monitoring and documentation regarding the wanderguard's placement and functionality. Despite previous incidents where the resident had removed her wanderguard, staff failed to ensure it was properly secured and functioning. The resident's medical record lacked evidence of consistent monitoring of the wanderguard, and staff documented checks that were not actually performed. Interviews with staff revealed a lack of understanding and adherence to the facility's elopement policy. The LPN responsible for monitoring the resident's wanderguard admitted to not physically checking it and was unaware of where to find replacements. The DON and administrator were not informed of the missing wanderguard or the resident's elopement in a timely manner, indicating a breakdown in communication and protocol adherence within the facility.
Removal Plan
- Internal investigation initiated.
- LPN-A placed on suspension.
- OHFC report filed, Risk Management and Incident review and analysis initiated.
- R1's skin assessed (no injuries observed), elopement risk evaluation completed (score of 7), behavioral monitoring for emotional distress and exit seeking behavior initiated, care plan reviewed and updated, provider and family notification completed, placed on 15-minute checks, wanderguard placed on right wrist and w/c.
- All wanderguards tested for functionality.
- Staff education with associated quiz initiated regarding elopement policy and procedure, including interventions, response, and reporting.
- Wanderguard placement audits conducted on the 3 residents identified for wanderguard use.
- All resident Elopement Evals reviewed to ensure up to date.
- Ad Hoc QAPI meeting held.
Failure to Uphold Resident Dignity and Communication
Penalty
Summary
The facility failed to communicate in a dignified manner with a resident who was reviewed for dignity. The resident, who was cognitively intact and had conditions such as depression, paraplegia, hemiparesis, and hemiplegia, required maximum assistance with daily activities and used a wheelchair. The resident's care plan indicated that staff should accompany her to and from the smoking area after meals due to her high fall risk. However, during an observation, a nursing assistant was seen arguing with the resident about going outside to smoke, and the resident expressed that the nursing assistant was rude and refused to assist her, despite her care plan requirements. The incident was further corroborated by interviews with staff. A registered nurse confirmed that the resident had previously fallen while trying to return from the smoking area unassisted, leading to a plan for staff to assist her. The director of nursing acknowledged that the nursing assistant's tone and language were inappropriate and mentioned ongoing training on communication with residents. The facility's policy on resident rights emphasized the importance of treating residents with respect and dignity, which was not upheld in this instance.
Failure to Notify Resident's Representative After Falls
Penalty
Summary
The facility failed to notify a resident's representative in a timely manner following two separate incidents where the resident experienced falls resulting in injuries. The resident, who had a diagnosis of dementia and mild cognitive impairment, was hospitalized twice due to falls, first with a hip fracture and later with a neck fracture. Despite the care plan indicating the resident was at risk for falls and required assistance, the facility did not successfully contact the resident's power of attorney (POA) after these incidents. The first incident occurred when the resident fell while attempting to go to the bathroom, resulting in a hip fracture. Although staff attempted to contact the family, they were unable to reach them due to an incorrect phone number in the system. The resident was sent to the hospital for surgical repair without the family being informed. The second incident involved the resident falling and hitting their head, leading to a neck fracture. Again, staff attempted to contact the family but were unsuccessful due to the same incorrect phone number. Interviews with the family member revealed that they were upset about not being informed of the hospitalizations and had previously corrected the phone number with the facility. However, the business office manager had reverted the number back to the incorrect one, leading to repeated communication failures. The facility's policy requires immediate notification of the resident's representative in such events, which was not adhered to in these cases.
Failure to Conduct Initial Falls Assessment
Penalty
Summary
The facility failed to complete an initial comprehensive assessment for a resident upon admission, specifically neglecting to conduct a falls assessment. The resident, who had a diagnosis of dementia and mild cognitive impairment, experienced multiple falls after admission. The resident required partial assistance with activities of daily living and had a history of falls, yet the necessary fall risk evaluation was not performed upon admission. This oversight was confirmed by interviews with facility staff, who acknowledged that the falls assessment was only completed after the resident returned from the hospital following a hip fracture. The resident experienced several falls, including one incident where they were found on the floor outside the transitional care unit entrance, and another where they fell next to their bathroom, resulting in a hip fracture. The facility's failure to conduct a timely falls assessment upon admission contributed to these incidents. Despite the resident's known history of falls and cognitive impairment, the necessary precautions and assessments were not implemented, leading to repeated falls and subsequent injury.
Failure to Update Care Plan with Fall Interventions
Penalty
Summary
The facility failed to update the care plan with identified fall interventions for a resident (R3) who was at risk for falls. R3's admission Minimum Data Set (MDS) indicated a diagnosis of dementia, mild cognitive impairment, and a history of falls since admission. The care plan, dated 11/07/24, identified R3's risk factors for falls, including gall bladder surgery, muscle weakness, and dementia. Interventions included physical therapy, keeping the room clutter-free, and a toileting plan. However, the care plan was not updated with new interventions after R3's re-entry from the hospital following a hip fracture on 10/16/24, and an additional fall on 11/08/24 resulted in a neck fracture. Interviews with the Director of Nursing (DON) and a Certified Occupational Therapist Assistant (COTA) revealed gaps in communication and implementation of fall interventions. The DON stated that the toileting intervention was added after R3's hospital re-entry, but it was not effectively updated in the care plan. The COTA mentioned that R3 was impulsive and that the facility did not use bed or chair alarms, and she did not recall any specific intervention suggestions for R3. The facility's care planning policy requires that care plans be modified and updated as the resident's condition and care needs change, which was not adhered to in this case.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to provide medication as ordered by the physician for three residents, leading to deficiencies in pharmaceutical services. For Resident 1, a physician's order directed to hold warfarin on specific dates and recheck INR on a subsequent date. However, due to an error by an LPN in entering the lab order into the computer system, the INR test was missed, and the resident did not receive the prescribed Coumadin from August 23 to August 27. The case manager confirmed the error, and the LPN admitted to the mistake in entering the order. Resident 2 was prescribed niacin for hypertension, but the medication was not available in stock, and the resident did not receive it for two days. The LPN responsible did not inform her supervisor or the provider about the unavailability of the medication. Similarly, Resident 3 was prescribed a nicotine patch, but it was not administered on multiple occasions due to it being on order. The LPN did not notify the provider or her supervisor about the missing medication, nor did she start a medication error report. The facility's procedures for documenting and reporting medication errors were not followed, contributing to the deficiencies.
Inadequate Infection Control During Blood Glucose Checks
Penalty
Summary
The facility failed to maintain proper infection control practices during blood glucose checks for two residents diagnosed with diabetes mellitus. The first resident's blood glucose was checked by an LPN who placed the glucometer on the bed linens and then on the over-the-bed table without following the correct cleaning protocol. The LPN used an alcohol wipe to clean the glucometer, unaware of the requirement to use a designated disinfectant wipe that should remain in contact with the glucometer for two minutes. Similarly, another LPN conducted a blood glucose check for a second resident and placed the glucometer directly on the over-the-bed table. After the procedure, the LPN placed the glucometer back into the bin without disinfecting it, later using an alcohol wipe instead of the required bleach wipe. The clinical manager confirmed that the facility's procedure required the use of bleach wipes, with the glucometer wrapped in the wipe for one minute, which was not followed in these instances.
Inaccurate Staffing Data Submission to CMS
Penalty
Summary
The facility failed to submit complete and accurate staffing data to the Centers for Medicare and Medicaid Services (CMS) for the second quarter of the fiscal year 2024. The Payroll Based Journal (PBJ) report indicated excessively low weekend staffing levels, which contradicted the facility's daily staff schedules and staffing reports that showed adequate staffing on weekends. During an interview, the administrator acknowledged that the staffing levels did not change from weekdays to weekends and explained that contracted staff hours were not recorded as regular staff hours, leading to inaccuracies in the PBJ report. The facility was unable to provide a policy related to PBJ reporting when requested.
Failure to Utilize Professional Interpreter Services
Penalty
Summary
The facility failed to utilize professional interpretive services for a resident who was cognitively intact and frequently experienced pain. The resident, who spoke Ukrainian and had a care plan indicating the need for communication via an interpreter, was instead communicated with using a personal cell phone and a translator app, which was ineffective. During multiple interactions, the resident became tearful and agitated due to the inability of staff to communicate effectively, leading to distress during wound care and other personal care activities. Despite the availability of a professional interpreter service, staff relied on the resident's phone, which failed to translate correctly, and did not offer to contact the professional service. Interviews with staff revealed a lack of consistent use of the professional interpreter service, with some staff stating they only used it if they could not understand the resident's needs. The Director of Nursing acknowledged the expectation to use the service if the resident was upset and the phone was not working. A traveling nursing assistant was not informed about communication methods with the resident, highlighting a gap in staff training. The resident expressed that using the professional service would have reduced frustration, but felt staff were reluctant to use it due to perceived wait times.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to ensure that a written notification of transfer or discharge was sent to the office of the Ombudsman for a resident who was hospitalized. The resident, identified as R30, had a significant change in their Minimum Data Set (MDS) which included diagnoses such as high blood pressure, renal insufficiency, diabetes, cerebral vascular accident, aphasia, hemiplegia, anxiety, depression, and chronic obstructive pulmonary disease. The resident was hospitalized from May 5 to May 10, 2024, but the medical record lacked evidence that a written notification of this transfer was sent to the Ombudsman. The facility's administrator and social service director acknowledged the oversight. The administrator provided a list of notifications sent from January through May, which was submitted on August 22, 2024, indicating an attempt to rectify the missed notification. The social service director explained that they were responsible for generating and sending the report to the Ombudsman but realized in May that not all appropriate residents were included in the report. They confirmed that no notification was sent for the resident in question, emphasizing the importance of such notifications as the Ombudsman serves as an advocate for residents. The facility's policy on Bed-Holds and Returns, updated in February 2023, requires that copies of notices for emergency transfers be sent to the Ombudsman.
Failure to Complete Level II PASARR for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure a Level II Preadmission Screening and Resident Review (PASARR) was completed for a resident with a serious mental illness diagnosis. The resident, identified as R25, had diagnoses including anxiety disorder and schizophrenia. A Level I PASARR was completed prior to admission on 5/12/23, indicating that a Level II PASARR was required before the resident's admission to the nursing facility. However, no Level II PASARR was found in the resident's medical record. During an interview, a social worker stated that the normal process involved completing a Level II PASARR prior to admission, but acknowledged that there had been no communication with the lead agency regarding this requirement for several months. The facility administrator confirmed that it was the responsibility of the social services department to request and ensure the completion of the Level II screening before admission. The administrator emphasized the importance of having the Level II PASARR completed to ensure the facility could meet the resident's individual needs. A policy related to PASARR was requested but not provided.
Failure to Implement Mobility and ROM Interventions
Penalty
Summary
The facility failed to implement interventions to prevent further development of decreased range of motion and mobility for two residents. The first resident, diagnosed with Parkinson's disease and contracture of the left ankle and foot, was observed with feet not resting on wheelchair foot pedals and no brace or positioning device in use. Despite a physical therapy discharge summary recommending daily stretches and a restorative ROM program order, documentation showed the task was mostly marked as not applicable, indicating it was not completed. The care coordinator confirmed the lack of follow-up on the incomplete tasks. The second resident, diagnosed with multiple myeloma and arthritis, reported not being offered the opportunity to walk with a walker and brace as prescribed. The resident's care plan included instructions to walk with assistance three times per week, but documentation showed the task was mostly marked as not applicable. The LPN confirmed the absence of documentation for the therapy recommendation to stand daily, which was not relayed from therapy. The DON acknowledged the lack of follow-up on the incomplete tasks and the failure to start the standing recommendation due to missing documentation.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the State Agency, involving a resident who sustained a hematoma on the right leg. The resident, who had intact cognition and multiple medical conditions including acute kidney disease and respiratory failure, was involved in an incident during a transfer from bed to wheelchair. The incident report indicated that a defective full-body lift was the root cause of the injury, leading to a bruise on the resident's left lower extremities. However, a subsequent assessment revealed a swollen lower right extremity, with the resident experiencing significant pain and requiring hospitalization. Interviews revealed that the facility administrator was unaware of how the injury occurred and did not report it to the State Agency, as they believed there was no intent to harm and no grievances were filed. However, a family member witnessed a rough transfer where the resident's right leg hit the mechanical lift, correlating with the location of the hematoma. The facility's policy requires reporting injuries of unknown sources, especially when the injury is suspicious due to its extent or location, but this was not adhered to in this case.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for a resident who was reviewed for abuse. The resident, who had intact cognition and multiple medical conditions including acute kidney disease and muscle weakness, was found with a hematoma on her right leg. The injury was discovered by a nursing assistant and reported to a registered nurse, who assessed the resident and sent her to the emergency department for evaluation. However, no measurements of the injury were taken, and there was no investigation conducted to determine how the injury occurred. Interviews with staff and family members revealed that the resident had experienced a rough transfer, during which her leg hit a piece of the mechanical lift, potentially causing the hematoma. Despite this information being shared with the facility administrator, no follow-up or investigation was conducted. The facility's policy requires an immediate investigation of such incidents, but this was not completed, as the director of nursing, who usually leads investigations, was unavailable. The facility's failure to investigate the injury violated their Abuse Prohibition/Vulnerable Adult Policy.
Failure to Allow Family Participation in Treatment Decisions
Penalty
Summary
The facility failed to allow a resident's legal representative to participate in treatment decisions for a resident who was on hospice care. The resident, who had a history of stage IV metastatic rectal cancer and other serious health conditions, experienced a seizure. Despite the family's insistence on calling 911, the facility's nurse initially denied the seizure and attempted to administer Ativan instead, as directed by the hospice nurse. The family ultimately called 911 themselves, and the resident was transported to the hospital, where she continued to have seizures and later passed away. The resident's care plan indicated she was on hospice care and had a do-not-resuscitate (DNR) order. The care plan also directed staff to maintain communication with hospice and involve them in care conferences. However, during the incident, the facility nurse did not immediately honor the family's request to send the resident to the hospital, leading to a delay in medical treatment. The family reported concerns about the resident's condition, including visible blood in her mouth, bruising, and allegations of mistreatment by staff, which were not adequately addressed by the facility. Interviews with the family, facility staff, and hospice personnel revealed inconsistencies in the facility nurse's account of the events. The hospice supervisor confirmed that the family had the right to call 911 and that the facility nurse should have complied with the family's wishes. The facility's investigation lacked evidence of timely communication with the family and corrective actions for the staff involved. The facility's policy on resident rights emphasizes the importance of upholding residents' rights and ensuring they are fully informed and involved in treatment decisions, which was not followed in this case.
Failure to Report Alleged Neglect and Abuse
Penalty
Summary
The facility failed to recognize and report a potential allegation of neglect to the State Agency in a timely manner for a resident who had a malignant carcinoid tumor of the sigmoid colon and malignant neoplasm of the rectum stage IV. The resident's family reported concerns about unsanitary and unsafe room conditions, bruising and bleeding in the mouth due to forceful medication administration, delayed patient care, and a nurse refusing to contact 911 at the family's request. Despite these concerns being communicated to the facility through an email and direct conversations, no report was filed with the State Agency, and the facility did not take immediate action to investigate the allegations of neglect and abuse properly. The resident's interdisciplinary progress notes indicated that the director of nursing (DON) contacted the hospital for an update and learned that the resident was admitted with seizures, emaciated skin, a coccyx wound, and mouth sores. The family member (FM) reported that the resident had been communicating concerns daily, including new bruising, delayed call light responses, and jerking movements that were dismissed by the nurse as a panic attack. The family member also reported wanting to call 911 but was told by staff that hospice needed to be contacted first. The family member eventually called 911 herself, and the resident was taken to the emergency room, where she continued to have seizures and later passed away. The facility consultant DON stated that he was not informed about the family's concerns until the next day and conducted an internal investigation, which found no signs of abuse. However, the facility lacked evidence of filing a report with the State Agency regarding the suspected abuse and neglect. The facility's abuse prohibition policy required prompt reporting and investigation of all incidents of alleged or suspected abuse/neglect, which was not followed in this case.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure medications were administered in accordance with physician orders for 10 residents. Medications were provided outside of ordered parameters by three staff members on three separate units. This included instances where medications were administered late, not administered at all, or administered without proper documentation and provider updates. For example, Resident 11 reported that her medications were often provided up to two hours late, which caused her significant distress, particularly with her Ativan, which she relied on to stay calm. Similarly, Resident 10 stated that her medications were frequently administered hours after she expected them, and she had communicated these concerns to the staff, but the issue persisted. During observations, it was noted that several residents had past due medications. For instance, LPN-D was observed to be behind schedule, with multiple residents' medications being past due. LPN-D failed to locate certain medications and did not update the provider or the unit manager about the delays. This included Resident 16, whose 8:00 a.m. medications were not administered until after 10:00 a.m., and Resident 13, who did not receive her 8:00 a.m. medications until 11:03 a.m. Additionally, Resident 11's 8:00 a.m. medications were administered at 11:17 a.m., and she was not given her Breo Ellipta inhaler as it could not be found. The facility's staff, including LPN-C and LPN-E, acknowledged the delays and the failure to update the provider or the unit manager. The Director of Nursing (DON) and the consulting pharmacist were also unaware of the extent of the medication administration issues. The DON stated that medications should be administered as ordered and that any deviations should be reported immediately. The consulting pharmacist expected medications to be administered as ordered and was unaware of any adverse effects experienced by the residents due to the delays. The nurse practitioner also emphasized the importance of following medication orders precisely and updating the provider when issues arise.
Insulin Administration Deficiency
Penalty
Summary
The facility failed to ensure insulin medication was administered in accordance with physician orders for four residents. The report details multiple instances where insulin was administered outside of the ordered parameters and manufacturer recommendations. For example, one LPN administered insulin to a resident approximately two hours after the blood sugar check without confirming the resident's breakfast intake status or rechecking the blood sugar. Another resident received insulin late because the LPN was too busy to follow up on the resident's breakfast status, leading to insulin being administered two hours after the blood sugar check without confirming food intake or rechecking blood sugar levels. Additionally, a resident's morning insulin was omitted entirely due to the LPN's inability to administer it on time and lack of communication with the provider or unit manager about the omission. The LPN documented the administered insulin for the next scheduled timeframe to avoid giving a double dose, but this resulted in the resident missing a dose of insulin. The report also highlights that the LPN was responsible for 25 residents and was the only nurse on the unit, which contributed to the delays and omissions in insulin administration. The facility's policies and expectations for timely medication administration were not followed, and there was a lack of communication with providers and supervisors about the delays and omissions. The report includes interviews with staff and the DON, who expressed concerns about the timeliness of insulin administration and the lack of provider updates, emphasizing the potential risks of hypo/hyperglycemia due to the observed deficiencies.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
