The Villas At Richfield
Inspection history, citations, penalties and survey trends for this long-term care facility in Richfield, Minnesota.
- Location
- 7727 Portland Avenue South, Richfield, Minnesota 55423
- CMS Provider Number
- 245492
- Inspections on file
- 30
- Latest survey
- June 26, 2025
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at The Villas At Richfield during CMS and state inspections, most recent first.
A resident with cognitive impairment and risk factors for skin breakdown did not consistently receive care as outlined in the care plan, including the use of barrier cream, heel protectors, floating of heels, and geri-sleeves or long sleeves. Staff were observed not implementing these interventions, and some were unaware of the care plan requirements, resulting in a failure to provide care as ordered.
A resident with cognitive impairment and mental health diagnoses was not provided with preferred music-related activities, nor was she routinely notified or assisted to attend group activities. Staff were unaware of her person-centered goals for activity participation, and the facility's activity calendars lacked music-based options, resulting in unmet individual entertainment needs.
Two residents experienced deficiencies in wound and skin care, including a lack of assessment and documentation for significant bruising and an open area in one resident with multiple risk factors, and failure to implement or clarify a wound care order for another resident after hospitalization. Staff did not consistently document, monitor, or follow provider orders as required by facility policy, and the care provided did not match the prescribed treatments.
A resident with cognitive impairment and limited right hand movement experienced worsening contracture and loss of function, as the facility failed to appropriately assess and address range of motion needs. Despite concerns from the resident's family and staff acknowledgment of the importance of a hand brace, the physical therapy consult did not address the right hand's ROM, and no follow-up was conducted. The resident was observed unable to use silverware, relying on her left hand to eat.
A resident in need of pain management did not receive safe and appropriate pain management services, resulting in a deficiency related to the facility's failure to meet the resident's needs.
A resident with PTSD, depression, and schizophrenia did not receive a comprehensive trauma-informed assessment or individualized care plan. Staff were unaware of the resident's trauma history and specific triggers, and the care plan lacked detailed interventions tailored to the resident's needs, contrary to facility policy.
A deficiency was cited when a resident’s drug regimen included medications that were not clinically indicated or were excessive, without proper justification documented.
Two residents experienced deficiencies in medical record documentation, including lack of assessment and documentation for significant bruising and an open wound, as well as improper administration and recording of diuretic medication despite clear physician orders. Staff interviews confirmed omissions and confusion in documentation practices, and the facility was unable to provide relevant policies when requested.
A resident with a suprapubic catheter was observed with their catheter bag on the floor while in a wheelchair, and staff failed to use the available cover to keep the bag off the floor. This occurred despite the resident's care plan and facility infection control policies requiring proper catheter care and placement to prevent infection.
The facility did not keep its survey results binder in a location that was easily accessible or visible to residents and visitors, as confirmed by interviews and observation. The binder was stored on a high shelf with other materials, and there was no policy in place regarding the posting of survey results.
A resident with moderate cognitive impairment had a bruised and swollen wrist, which was not reported to the State Agency within the required timeframe. Despite the facility's policy requiring such incidents to be reported, staff interviews revealed that the injury was not communicated to the SA, and the administrator was unaware of the situation. The incident highlights a failure in the facility's reporting procedures.
A resident with moderate cognitive impairment had a swollen, bruised, and tender wrist with no known cause, which was not investigated by the facility. Despite the facility's policy requiring investigation of such injuries, the social worker, DON, and administrator confirmed that no investigation took place. The facility's policy mandates reporting and investigating injuries of unknown origin, but this was not followed.
A resident with moderate cognitive impairment and a history of urinary retention was discharged from a facility to an assisted living facility without a necessary catheter. Despite multiple unsuccessful attempts by nurses to reinsert the catheter, the provider was not notified, and the discharge summary lacked critical information about the resident's condition. This failure to communicate and document essential information led to a deficiency in continuity of care.
A resident with moderate cognitive impairment and renal insufficiency was discharged from the hospital with a catheter for urinary retention, but the facility failed to include catheter care in the care plan. When the catheter came out, multiple nurses unsuccessfully attempted reinsertion without notifying the provider, contrary to protocol. The lack of specific catheter orders and failure to notify the provider led to inadequate care.
A facility failed to develop a care plan for a resident with Type 2 diabetes, who required daily insulin injections. Despite physician orders for both long-acting and short-acting insulin, the care plan lacked a focus on diabetic management. Nursing staff noted the resident's high blood glucose levels and acknowledged the absence of a care plan, which should have included interventions for monitoring glucose levels and dietary management. The facility's policy required a comprehensive care plan within 21 days of admission, which was not followed.
The facility failed to properly label, date, and discard food and beverages in the kitchen refrigerators, affecting 87 residents. During a kitchen tour, several items were found without proper dates, including veggie burgers, salad dressings, and thickened milk. The dietary manager confirmed these findings and mentioned a recent water leak as a possible cause for contamination. The registered dietician was unaware of the issue but expected staff to have resolved it. Facility policy requires opened containers to be dated and thickened liquids to be discarded after the use-by date.
A resident with moderate cognitive impairment and various diagnoses was left in a wheelchair with a mechanical lift sling visibly draped over his thighs, which bothered him. Staff interviews confirmed the sling was left in the wheelchair, contrary to the facility's expectations for promoting dignity. The facility's policy emphasized upholding residents' dignity and privacy, which was not followed in this case.
The facility failed to ensure safe medication administration for three residents who had medications left at their bedside without being assessed for self-administration. One resident had unauthorized creams, another self-applied a gel without an order, and a third had opioids left unattended. Staff were unaware of self-administration assessments, and the facility's process for obtaining orders was not followed.
A shared bathroom used by four residents was found with a brown substance on the wall and a sticky floor, which remained uncleaned over consecutive days. The housekeeper responsible had not cleaned the bathroom, relying on staff notifications for cleaning needs. The environmental director and DON expected daily cleaning and immediate response to soiling, as per facility policy, which was not followed.
A facility failed to conduct a timely care conference for a resident with malnutrition, anxiety, and depression, who was at risk for harm due to suicidal thoughts. Despite the requirement for quarterly care conferences, the facility did not document a conference after the resident's quarterly MDS was completed. Interviews revealed that the resident had not attended a care conference for some time, and the facility was behind schedule. The facility also lacked a policy related to care plans or care conferences.
The facility failed to provide adequate assistance with personal hygiene for two residents and dressing for one resident. A resident with intact cognition and medical conditions was observed with long facial hair despite preferring staff assistance. Another resident with memory issues was observed with long facial hair over several days, expressing discomfort. A third resident with severe cognitive impairment was repeatedly seen in a hospital gown with exposed skin, despite having clothing available. The facility's policy to maintain grooming and personal hygiene was not followed.
A facility failed to implement proper PPE practices for a resident under enhanced barrier precautions (EBP). The resident, with severe cognitive impairment and a feeding tube, required EBP during high-contact care activities. An LPN was observed administering medications and performing hygiene care using only gloves, without a gown, contrary to EBP requirements. The DON confirmed the need for EBP, and the facility's policy required gown and glove use, which was not followed, resulting in a deficiency.
A resident with cognitive impairment and mobility dependence was unable to access their call light due to improper placement, as observed during multiple checks. Staff interviews confirmed the oversight, and the facility lacked a call light policy.
Two residents in an LTC facility reported feeling embarrassed due to inadequate personal hygiene care. One resident, dependent on staff for hygiene due to paraplegia, expressed dissatisfaction with infrequent showers and reliance on her boyfriend for assistance. Another resident, with PTSD and depression, felt uncomfortable as her hair was not washed during scheduled care. Staff interviews revealed inconsistencies in care provision and a lack of a dignity policy, contributing to the deficiency.
A resident with quadriplegia and recent hospitalization for shortness of breath was left unattended during a nebulizer treatment in an LTC facility. The LPN administering the treatment left the room and did not return to remove the mask, leaving the resident with the mask on for over two hours. Facility policy required the nurse to stay with the resident during treatment, which was not followed, leading to a deficiency in respiratory care.
Failure to Follow Care Plan for Skin Integrity and Pressure Ulcer Prevention
Penalty
Summary
The facility failed to provide care in accordance with a resident's care plan for non-pressure related skin concerns. The resident had cognitive impairment, required substantial to maximal assistance with most ADLs, and was at risk for pressure ulcers and skin alterations due to incontinence and a history of skin issues. The care plan included interventions such as applying barrier cream after each incontinent episode, encouraging cleansing and drying of skin folds, using heel protectors while in bed, floating heels with pillows, turning and repositioning every two to three hours, and using geri-sleeves or long sleeves to prevent skin tears and bruises. Physician orders also specified the use of geri-sleeves or long sleeves during the day and removal at bedtime. Observations revealed that the resident was not consistently provided with the required interventions. The resident was seen in short sleeves without geri-sleeves on multiple occasions, and her heels were not floated or protected as directed in the care plan. Nursing assistants and a registered nurse confirmed that these interventions were not implemented, and staff were unaware of the need for certain care plan elements, such as heel protectors and arm coverings. Facility leadership confirmed the importance of these interventions and the expectation that staff follow the care plan, but the required care was not provided as documented.
Failure to Provide Resident with Preferred Music Activities
Penalty
Summary
The facility failed to ensure that a resident's preferred activities, specifically music-related entertainment, were available and accessible. The resident, who had cognitive impairment, anxiety, major depressive disorder, and obsessive-compulsive disorder, was dependent on staff for assistance with daily activities and required reminders and support to participate in activities due to her dementia. Despite documented preferences for music, particularly old rhythm and blues, and willingness to try new activities, the activity calendars for several months did not include any music-related activities. Observations showed that the activity director and other staff did not enter the resident's room to notify or assist her to attend group activities, and staff interviews confirmed that the resident was not routinely offered opportunities to participate in activities, nor were her specific preferences for music addressed. Interviews with staff revealed a lack of awareness regarding the resident's person-centered activity goals and interventions, particularly those related to music therapy, as outlined in her care plan. The activity director admitted to not offering music-based activities frequently and not inviting the resident to group activities during observed periods. Additionally, the facility was unable to provide an activity policy when requested. These actions and omissions resulted in the resident's individual entertainment needs and preferences not being met.
Failure to Assess, Monitor, and Document Bruises and Wounds; Failure to Implement Wound Orders
Penalty
Summary
The facility failed to ensure that bruises and non-pressure wounds were adequately assessed, monitored, and documented for two residents. One resident, who had multiple risk factors including cancer, diabetes, obesity, recent surgery, and was on anticoagulant therapy, was observed with significant bilateral bruising on her upper arms and an open area near her left armpit. Despite these findings, there was no documentation or treatment instruction for the open area, nor was there specific assessment or monitoring for the bruising. Multiple skin and wound assessments, daily skilled notes, and care plans lacked detailed information regarding the size, color, or progression of the bruises, and there was no evidence that the bruises were being monitored or that their resolution was tracked. Staff interviews confirmed that the bruises and open area had not been documented or measured as required by facility policy. Additionally, the same resident's care plan and physician orders required daily and weekly skin assessments, monitoring for signs of bleeding, and prompt treatment of skin breaks. However, documentation did not reflect that these interventions were consistently implemented. The facility's policy required notification of the provider, treatment orders, and care plan updates for significant skin alterations such as large or multiple bruises, but these steps were not followed. Staff interviews revealed a lack of clarity and consistency in how bruises and wounds were assessed, documented, and communicated among the care team. A second resident, with severe cognitive impairment and multiple comorbidities, had a physician order for wound care to the scrotum using a specific dimethicone-based cleanser following a recent hospitalization. However, this order was not reflected on the medication or treatment administration records, and staff were unaware of the specific product required, instead using alternative products without the ordered active ingredient. Interviews with nursing staff and review of records confirmed that the wound care order was not implemented or clarified, and the care provided did not match the provider's instructions. The facility's policy required staff to follow and clarify orders as needed, but this was not done in this case.
Failure to Assess and Maintain Range of Motion for Resident with Hand Contracture
Penalty
Summary
A resident with cognitive impairment and limited functional movement in the right hand experienced a decline in range of motion (ROM) and increased contracture, which was not appropriately assessed or addressed by the facility. The resident, who previously could hold silverware and brush her teeth, was observed to be unable to use silverware and instead used her left hand to pick up food. The resident's daughter expressed concern about the worsening contracture, and staff interviews revealed uncertainty about whether a hand brace was in use, despite its importance in maintaining function and preventing further loss of ROM. A physical therapy (PT) consult was ordered several months prior, but the consult only addressed wheelchair positioning and upper body strengthening, not the ROM needs of the right hand. The PT department had not reassessed the resident since that time, and the assistant director of nursing and physician assistant both acknowledged the significance of a brace for the resident's condition. Facility policy indicated that while therapy services are contracted, the facility retains responsibility for resident care and supervision.
Failure to Provide Safe, Appropriate Pain Management
Penalty
Summary
A resident who required pain management services did not receive safe and appropriate pain management. The report identifies a deficiency in the facility's provision of necessary pain management for a resident in need, but does not provide further details regarding the specific actions or omissions that led to this deficiency, nor does it include information about the resident's medical history or condition at the time.
Failure to Provide Individualized Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to comprehensively assess and implement individualized trauma-informed care for a resident diagnosed with post-traumatic stress disorder (PTSD). The resident, who had a history of depression, schizophrenia, and PTSD related to religious persecution, starvation, and violence in Sudan, was not provided with a care plan that identified specific trauma triggers or individualized interventions. The Care Area Assessment Summary for psychosocial well-being was not completed, and the care plan only generically referenced the PTSD diagnosis without detailing the nature of the trauma or strategies to avoid re-traumatization. Interviews with facility staff, including a nursing assistant and a registered nurse, revealed a lack of awareness regarding the resident's PTSD diagnosis, history, and appropriate trauma-informed interventions. The assistant director of nursing confirmed that while the care plan included general interventions such as referrals to psychiatric services and encouragement of trauma-informed care, it did not specify resident-specific details or triggers. Facility policy required that care plans for residents with a history of trauma include goals and interventions to address potential triggers, which was not followed in this case.
Unnecessary Drugs in Resident Drug Regimens
Penalty
Summary
A deficiency was identified regarding the management of residents’ drug regimens. The facility failed to ensure that each resident’s drug regimen was free from unnecessary drugs, as required by regulations. This indicates that at least one resident was prescribed or administered medications that were not clinically indicated or were excessive in dose or duration, without adequate justification documented in the medical record.
Failure to Maintain Complete and Accurate Medical Records for Two Residents
Penalty
Summary
The facility failed to ensure complete and accurate documentation in the medical records for two residents. For one resident with diagnoses including cancer, wound infection, diabetes, and arthritis, there was a lack of documentation and assessment regarding significant bruising and an open area on the upper arms. Despite physician orders requiring daily skilled notes and monitoring for bruising, the medical record did not include specific assessments, measurements, or descriptions of the bruises or the open area. Progress notes, daily skilled notes, and skin and wound evaluation forms repeatedly omitted mention of these issues, and there were no treatment instructions for the open area. Interviews with nursing staff and the DON confirmed that the bruising and open area were not documented as required, and that the facility lacked a policy on complete and accurate documentation. For another resident receiving diuretic therapy for heart failure, the facility failed to accurately document medication administration in accordance with physician orders that required holding the medication if the resident's weight fell below a certain threshold. The medication administration records (MAR) showed that the resident received the diuretic multiple times when their weight was below the specified limit. Interviews with nursing staff and the nurse practitioner confirmed that the medication should have been held and not administered, as the resident's weight had consistently been below the threshold since admission. There was also confusion among staff regarding documentation codes on the MAR, with one LPN incorrectly interpreting staff initials as an indication that medication was not given, when in fact it was. Additionally, the facility did not provide a policy for medication administration when requested, and the DON confirmed that there was no record of non-narcotic medication wastage, despite staff claims that medication was wasted when not administered. The lack of accurate documentation and failure to follow physician orders for medication administration and skin assessments led to incomplete and inaccurate medical records for both residents.
Failure to Maintain Proper Catheter Bag Placement for Infection Control
Penalty
Summary
A deficiency was identified when a resident with a suprapubic catheter was observed with their catheter bag placed on the floor while sitting in a wheelchair. The bag remained on the floor for an extended period and was later hooked onto the wheelchair strap but continued to touch the floor. The nursing assistant confirmed the improper placement and stated that a cover for the catheter bag was available but had not been used at the time, as it was left in the resident's room. The resident had significant medical conditions, including severe cognitive impairment, neurogenic bladder, diabetes, dementia, and was at risk for pressure ulcers. The care plan and physician orders required staff to provide catheter care per policy and ensure infection prevention measures were followed. The facility's Infection Prevention and Control Program directed staff to prevent infection by adhering to proper techniques, but staff failed to ensure the catheter bag was kept off the floor as required.
Survey Results Binder Not Readily Accessible to Residents and Visitors
Penalty
Summary
The facility failed to ensure that its survey results were kept in a location that was readily accessible to all residents and visitors who wished to review them. During interviews, members of the resident council and a resident reported that the survey binder, which should be in the front lobby, was not visible or easily accessible, and one resident noted not having seen it for some time. Observation confirmed that the survey binder was not readily visible or available in the lobby without having to ask for it. The administrator acknowledged that the binder was stored in a basket with other binders on a higher shelf in the lobby, making it not easily accessible. Additionally, the facility did not have a policy regarding the posting of survey results.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident with moderate cognitive impairment, identified as R2, to the State Agency (SA) within the required two-hour timeframe. On 2/19/25, R2 was noted to have a bruised and swollen left wrist with tenderness, but no falls or injuries were reported. The physician's assistant (PA)-A ordered an X-Ray for the wrist, but the progress notes did not document the staff's discovery of the injury. Interviews with various staff members, including a social worker, the director of nursing, registered nurses, and the PA, revealed that the injury was not reported to the SA as required by the facility's policy. The director of nursing and the administrator confirmed that the injury should have been reported to the SA, but it was not. RN-C, who discovered the swollen wrist, informed the PA but did not report it to the SA. The administrator was unaware of the injury until the survey, indicating a breakdown in communication and reporting procedures. The facility's Abuse Prohibition/Vulnerable Adult policy mandates that injuries of unknown origin be reported to the SA, but this protocol was not followed in this instance.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for one resident, identified as R2, who had a swollen, bruised, and tender right wrist with no known related injuries or accidents. R2's Medicare 5-Day Minimum Data Set indicated moderate cognitive impairment. A physician's assistant noted the injury during a discussion about discharge planning, and an X-ray was ordered. However, the social worker, director of nursing, and administrator all confirmed that the injury had not been investigated, despite the facility's policy requiring such incidents to be reported and investigated. The facility's Abuse Prohibition/Vulnerable Adult policy stated that injuries of unknown origin should be reported to the State Agency and investigated, but this was not done in R2's case.
Failure to Ensure Continuity of Care During Resident Discharge
Penalty
Summary
The facility failed to ensure adequate and required information was communicated and documented for a resident's discharge, leading to a deficiency in continuity of care. The resident, who had moderate cognitive impairment, an indwelling catheter, a history of stroke, and renal insufficiency, was discharged to an assisted living facility without a catheter, despite requiring one for urinary retention. The discharge summary lacked an order for the catheter and did not mention the resident's urinary incontinence, bowel incontinence, and mental status. Multiple nurses attempted to reinsert the catheter without success, and the provider was not notified of the issue. The resident's family and staff at the assisted living facility confirmed that the resident arrived without a catheter, which was part of her treatment plan. The facility's discharge planning policy required the identification of resident needs and the development of plans to address them, which was not adhered to in this case.
Failure to Provide Comprehensive Catheter Care and Notify Provider
Penalty
Summary
The facility failed to comprehensively assess and develop a plan of care for a resident with an indwelling catheter. The resident, who had moderate cognitive impairment, a history of stroke, and renal insufficiency, was discharged from the hospital with a catheter due to urinary retention. However, the resident's care plan did not reflect the presence of the catheter, and there were no specific orders regarding the type, size, or maintenance of the catheter. This lack of documentation and planning led to confusion among the nursing staff about the appropriate catheter care. When the resident's catheter came out, multiple nurses attempted to reinsert it without success, and the provider was not notified for further direction. Despite the resident's need for the catheter due to urinary retention, the staff did not follow the expected protocol of notifying the provider or sending the resident to the emergency room. Interviews with the nursing staff and the director of nursing confirmed the absence of a catheter order and the failure to notify the provider when reinsertion attempts were unsuccessful. The facility's discharge planning policy also failed to address the resident's catheter needs adequately.
Failure to Develop Diabetic Management Care Plan
Penalty
Summary
The facility failed to develop a care plan to address diabetic management for a resident diagnosed with Type 2 diabetes, who required insulin injections daily. The resident's quarterly Minimum Data Set indicated cognitive intactness and a need for insulin management, yet the care plan printed on a later date lacked a focus area for diabetic management and corresponding interventions. Physician orders prescribed both long-acting and short-acting insulin, but the care plan did not reflect these orders or include necessary interventions for managing the resident's diabetes. Interviews with nursing staff revealed that the resident's blood glucose levels were higher than recommended, partly due to the resident's preference for double portions of food. Both registered nurses acknowledged the absence of a care plan for diabetic management, which should have included interventions for monitoring blood glucose levels and notifying the provider of high levels. The Director of Nursing confirmed that a comprehensive assessment and corresponding care plan should have been developed upon admission, including interventions related to diabetic management, medication administration, and nutritional services. The facility's care planning policy required a comprehensive individualized care plan to be developed no later than the twenty-first day after admission, but this was not adhered to in the resident's case.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The facility failed to ensure that food and beverages stored in the kitchen refrigerators were properly labeled, dated, and discarded according to professional standards. During a final tour of the kitchen area, several items were found in the kitchen freezer and refrigerator without proper notation of the date they were opened. These items included six veggie burgers in an opened plastic bag, a large plastic container of Asian salad dressing with a black crusty substance around the lid, and a plastic carton of thickened milk with a manufacturer's best by date that had passed. Additionally, large containers of various salad dressings and molasses were found with black crusty particles inside and outside the containers, some without any notation of the date they had been opened. The dietary manager (DM) confirmed these findings and acknowledged that the items should have been discarded. The DM was unsure when the refrigerator was last checked for dated or expired items and mentioned a recent water leak in the kitchen refrigerator as a possible cause for the black substance found on the containers. The registered dietician (RD) was unaware of the undated or undiscarded items but was aware of the water leak and expected staff to have reviewed the refrigerator to ensure the issue was resolved. The facility's policy on food storage indicated that all opened containers should be dated to ensure correct rotation and that thickened liquids should be discarded after the manufacturer's use-by date.
Failure to Promote Resident Dignity with Mechanical Lift Sling
Penalty
Summary
The facility failed to promote dignity for a resident, identified as R13, who was dependent on staff for activities of daily living and required the use of a mechanical lift for transfers. R13 had moderate cognitive impairment and various diagnoses, including moderate intellectual disabilities and Parkinsonism. Observations revealed that R13 was left in a wheelchair with a mechanical lift sling visibly draped over his thighs and hanging out the back of the wheelchair. This was noted to bother R13, as confirmed by both R13 and a resident representative. Interviews with staff, including a nursing assistant and the interim care coordinator LPN, confirmed that the mechanical lift sling was left in the wheelchair, which was against the facility's expectations for promoting dignity. The director of nursing also stated that mechanical lift slings should be removed or hidden to maintain residents' privacy and dignity. The facility's policy on resident rights emphasized upholding the dignity and privacy of all residents, which was not adhered to in this instance.
Failure to Ensure Safe Medication Administration
Penalty
Summary
The facility failed to ensure safe medication administration for three residents who had medications left at their bedside without being assessed as safe to self-administer. Resident R79, who was cognitively intact and receiving hospice services, was observed with antibiotic and pain relief creams at her bedside, which were not ordered or assessed for self-administration. The nursing staff, including a nursing assistant and an LPN, were unaware of any self-administration assessment for R79, and the medications were removed after being discovered. Resident R74, also cognitively intact, was found to have Diclofenac Sodium External Gel in his dresser, which he reported applying independently without a self-administration order or assessment. The EMAR indicated that staff were signing off on the application of the gel, despite the resident self-administering it. Interviews with nursing staff revealed a lack of awareness of any self-administration orders for R74, and the facility's process for obtaining such orders was not followed. Resident R354, who had a history of substance use disorder, was observed with a cup of medications, including oxycodone, on his bedside table. The medications had been left there by an LPN without a self-administration order or assessment. The DON confirmed that the facility's process required a SAM assessment and physician order before allowing residents to self-administer medications. The facility's policy stated that residents could self-administer medications if deemed clinically appropriate and safe by the interdisciplinary team.
Failure to Maintain Cleanliness in Shared Resident Bathroom
Penalty
Summary
The facility failed to maintain a clean and safe environment for four residents sharing a bathroom. Observations on consecutive days revealed a brown substance smeared on the doorframe and wall, and a sticky floor in the shared bathroom. Despite these conditions, the bathroom was not cleaned promptly, as confirmed by the housekeeper responsible for the area. The housekeeper admitted to not cleaning the bathroom on the previous day and stated that the usual practice was to clean based on staff notifications or routine checks. Interviews with the environmental director and the director of nursing highlighted an expectation for daily cleaning and immediate attention to soiled areas. The environmental director conducted daily inspections and expected housekeeping staff to clean resident bathrooms every day and respond quickly to soiling. The director of nursing emphasized the importance of maintaining hygiene and infection control, expecting nursing staff to either clean or notify housekeeping immediately when bathrooms were soiled. The facility's policy on daily cleaning procedures included instructions for spot cleaning visibly soiled walls and mopping floors, which were not adhered to in this instance.
Failure to Conduct Timely Care Conference for Resident
Penalty
Summary
The facility failed to provide a care conference for a resident, identified as R68, to review and revise their care plan with the interdisciplinary team. R68 was cognitively intact and had diagnoses including malnutrition, anxiety, and depression. The resident's care plan, revised on 7/26/24, noted that R68 was a vulnerable adult at risk for harm related to suicidal thoughts and was working with relocation services for housing. Despite the requirement for quarterly care conferences, the facility did not document a care conference after R68's quarterly Minimum Data Set (MDS) was completed. Interviews revealed that R68 had not been offered or attended a care conference for some time and could not recall the last one. The director of social services confirmed that the last care conference for R68 was held on 4/1/24, and acknowledged that the facility was behind schedule for care conferences. The interim administrator confirmed that care conferences should follow the resident's MDS calendar and should have been rescheduled after a hospital visit caused a cancellation. The facility lacked a policy related to care plans or care conferences, as confirmed by the Director of Nursing (DON).
Deficiencies in Personal Hygiene and Dressing Assistance
Penalty
Summary
The facility failed to provide adequate assistance with personal hygiene for two residents and dressing for one resident, as observed during a survey. Resident R30, who had intact cognition and required assistance with personal hygiene due to conditions such as hypertension, renal insufficiency, and diabetes, was observed with long facial hair on multiple occasions. Despite expressing a preference for staff assistance with shaving, R30 had not received help recently, as confirmed by nursing staff who were unsure of the last time R30 was shaved. Resident R12, who had memory problems and poor decision-making skills, was dependent on staff for personal hygiene and dressing. R12 was observed with long facial hair over several days and expressed discomfort with the situation. Staff interviews revealed that R12 could not shave himself and required assistance, yet no recent shaving assistance had been provided, despite R12's ability to communicate his needs. Resident R66, with severe cognitive impairment and non-verbal communication, required total assistance with ADLs. R66 was repeatedly observed in a hospital gown with exposed skin in the dining area, despite having clothing available. A family member expressed concern about R66's state of dress, and staff confirmed that R66 usually wore a hospital gown for comfort and ease of care. The facility's policy indicated that residents unable to perform ADLs should receive necessary services to maintain grooming and personal hygiene, which was not adhered to in these cases.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement appropriate donning and doffing of personal protective equipment (PPE) practices to prevent the spread of infection for a resident observed under enhanced barrier precautions (EBP). The resident, identified as having severe cognitive impairment and multiple diagnoses, including a feeding tube, required extensive assistance for activities of daily living. The care plan for the resident specified the need for EBP, including the use of gowns and gloves during high-contact care activities. However, during an observation, a licensed practical nurse (LPN) was seen administering medications and performing hygiene care for the resident using only gloves, without donning a gown, contrary to the EBP requirements. The LPN confirmed that she only wore gloves when administering medications via the feeding tube and was not aware of the requirement to wear a gown. The director of nursing (DON) confirmed that the resident was on EBP due to the feeding tube and that staff were expected to follow these precautions to prevent infections. The facility's policy, revised earlier in the year, indicated that EBP required targeted gown and glove use during high-contact care activities, and PPE should be available near or outside the resident's room. Despite this policy, the LPN did not adhere to the EBP guidelines, leading to a deficiency in infection control practices.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a call light was accessible for a resident who was cognitively impaired and dependent on staff for activities of daily living and mobility. The resident's care plan did not document the use or placement of the call light. During multiple observations, the resident was unable to reach the call light, which was placed on a pillow on the nightstand table behind him and covered with a blanket. The resident expressed that he could use the call light if it was placed on his legs, but it was not within his reach. Interviews with staff, including a nursing assistant and an LPN, confirmed that the call light was not accessible to the resident. The LPN acknowledged that the call light should have been placed within reach when the resident was put to bed. The Director of Nursing was unaware of the issue but stated that her expectation was for call lights to be within reach at all times. The facility did not have a policy on call lights, which contributed to the deficiency.
Inadequate Personal Hygiene Care for Residents
Penalty
Summary
The facility failed to provide adequate personal hygiene care to two residents, leading to feelings of embarrassment and discomfort. One resident, who had intact cognition and required total assistance with personal hygiene due to paraplegia and other conditions, reported feeling unclean and embarrassed by her appearance. She expressed dissatisfaction with the frequency of her showers, which were scheduled only once a week, and noted that her boyfriend had been relied upon to assist with her hygiene needs. Observations confirmed that her hair appeared oily and uncombed, and she felt her hygiene needs were not being met adequately by the staff. Another resident, also with intact cognition and dependent on staff for personal hygiene, expressed similar concerns. She reported that her hair was not washed during her scheduled shower, leaving her feeling embarrassed and uncomfortable. This resident, who had a history of PTSD, anxiety, and depression, indicated that she found it difficult to ask for help, which compounded her feelings of embarrassment about her appearance. Observations confirmed that her hair appeared oily, and she expressed a desire for assistance in maintaining her personal hygiene. Interviews with staff revealed inconsistencies in the provision of care, with some staff members acknowledging the residents' needs but failing to address them adequately. The facility lacked a dignity policy, and the existing policy on activities of daily living emphasized the importance of person-centered care but was not effectively implemented. Staff interviews highlighted a lack of communication and understanding of the residents' preferences and needs, contributing to the deficiency in care.
Failure to Monitor Resident During Nebulizer Treatment
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, identified as R2, who was left unattended during and after a nebulizer treatment. R2, who was cognitively intact but physically dependent on staff due to conditions such as quadriplegia and a traumatic spinal cord injury, required substantial assistance for daily activities. The resident had been recently hospitalized for shortness of breath and was readmitted to the facility with new orders for nebulizer treatments. On the night of the incident, R2 was left alone with the nebulizer mask on for over two hours, despite being unable to remove it independently due to his physical limitations. The incident occurred when LPN-C administered the nebulizer treatment and left the room, failing to return promptly to remove the mask. R2's roommate eventually alerted a nursing assistant (NA-A) about the situation, who then removed the mask and turned off the machine. Interviews with staff, including LPN-B, LPN-A, and RN-A, confirmed that the standard procedure required the administering nurse to stay with the resident during the treatment to monitor for side effects and changes in respiratory status. The facility's policy also mandated that the nurse remain with the resident unless they were assessed to self-administer the treatment, which R2 was not. The director of nursing (DON) and a pharmacy consultant confirmed that R2 had not been assessed to self-administer the nebulizer treatments, emphasizing the importance of monitoring due to the newness of the treatments for R2. The facility's medication administration procedures outlined the necessity of staying with the resident during nebulizer treatments to ensure safety and effectiveness, which was not adhered to in this case. This oversight in care led to a deficiency in the facility's respiratory care protocol for R2.
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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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