The Villas At Robbinsdale
Inspection history, citations, penalties and survey trends for this long-term care facility in Robbinsdale, Minnesota.
- Location
- 3130 Grimes Avenue North, Robbinsdale, Minnesota 55422
- CMS Provider Number
- 245417
- Inspections on file
- 32
- Latest survey
- March 17, 2026
- Citations (last 12 mo.)
- 5 (1 serious)
Citation history
Health deficiencies cited at The Villas At Robbinsdale during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and newly identified elopement risk repeatedly attempted to leave, triggered exit alarms, and expressed a desire to go home, yet the care plan contained only a wander device and general alarm-response directions without specific supervision or individualized interventions. Over the course of an evening, video showed the resident making multiple exit attempts that staff redirected before ultimately leaving through an exit door unobserved and being found by police several blocks away. Agency NAs on duty were not informed which residents were at risk for elopement, and their care sheets did not list elopement risks or related interventions. Additional cognitively impaired residents assessed as elopement risks also had care plans limited to wander devices and general monitoring, with NA care sheets that either omitted elopement risk or lacked preventive interventions, demonstrating a broader failure to translate elopement assessments into clear, supervised care.
Surveyors identified that the facility’s written assessment did not include required elements for staffing recruitment, retention, and contingency planning, despite affecting all 71 residents. The documented assessment omitted a plan to maximize recruitment and retention of direct care staff and did not address how direct care nurse staffing or other care resources would be managed during non-emergency events that could impact resident care. During an interview, the administrator reported having a recruitment plan but confirmed it was not included in the facility assessment and that there was no documented staff retention or non-emergency staffing plan; a requested policy on the facility assessment process was not provided.
The facility failed to verify that an agency nurse aide had an active status on the Minnesota Nursing Assistant Registry before assigning her to a 7.5-hour day shift on a floor caring for multiple residents. The aide reported it was her first shift at the facility, and a registry search later showed her status had been inactive for over a year. The DON stated she relied on the staffing agency to send only registry-listed staff and acknowledged the facility did not verify active status for agency personnel, and the administrator confirmed that their process did not include checking current certification of agency aides. A requested facility policy related to this verification process was not provided.
Soiled linens, including towels and a shower curtain, were observed unbagged in a bin below the laundry chute. A laundry assistant confirmed that some items were sent down the chute without being bagged. Both the environmental director and infection preventionist stated that all soiled linens should be bagged before being sent down the chute to prevent contamination, but no facility policy was provided.
Surveyors identified failures in proper food labeling and dating in community refrigerators, inadequate maintenance of required food temperatures on a steam table, and unsanitary handling of serving dishes during food prep. The Dietary Manager confirmed that these practices did not meet facility policies for food storage, temperature control, and hygiene.
Two residents received meals that were not at safe or appetizing temperatures, with hot foods served below 135°F and milk above 41°F. Both residents and a family member reported that food was cold or warm by the time it was delivered. Staff interviews revealed uncertainty about required food temperatures, and observations confirmed that food was not held or served at appropriate temperatures, potentially affecting all residents on the unit.
A nurse failed to instruct a resident with cognitive impairment and asthma to rinse her mouth after receiving Budesonide via nebulizer, despite facility policy and medication instructions requiring this step to prevent infection. Staff interviews and observations confirmed the resident was able to rinse and spit, and that rinsing after steroid inhalation is standard practice.
A resident with moderate cognitive impairment and a history of falls did not consistently receive all care plan interventions intended to prevent falls. Staff failed to keep the resident's door open as required, and some were unaware of all necessary fall prevention measures. The care plan and documentation were not fully followed, and the facility could not provide a fall policy when requested.
A resident with COPD, asthma, and diabetes did not receive a newly prescribed inhaler because the medication order was not confirmed in the eMAR system, despite the medication being available in the facility. Staff interviews revealed a lack of awareness and follow-through, resulting in the resident missing doses as the order remained in 'Pharmacy Pending Confirmation' status.
A resident refused Lovenox injections on multiple occasions, but the facility failed to notify the medical provider as required. The resident's care plan did not mention anticoagulation therapy, and staff interviews confirmed the oversight in communication and documentation.
A resident with a surgical wound and fistula did not receive the ordered wound care due to the facility's failure to enter hospital discharge orders into the medical record. The care plan lacked necessary interventions for pouch changes and wound dressings, leading to skin irritation and bleeding. Staff interviews revealed that the process for entering hospital orders was not followed, resulting in incomplete wound assessments and care.
A resident with a surgical wound did not receive proper care due to an LPN's failure to perform hand hygiene between glove changes and after handling contaminated items. Despite recent staff education on hand hygiene, the LPN did not follow the facility's policy, which requires handwashing before and after treating wounds and handling waste.
A resident with peripheral vascular disease and diabetes experienced skin breakdown due to the facility's failure to conduct weekly skin inspections and inform the interdisciplinary team. Despite a care plan requiring daily monitoring, the resident returned from a leave of absence with excoriated skin, which was not documented or addressed. The occupational therapist was unaware of the issue, and the director of nursing did not report the excoriation as an open area. The facility's policy for skin assessment and wound management was not followed.
The facility failed to maintain cleanliness and regular maintenance of the fourth-floor dining room ice and water dispenser, which had visible sediment build-up. Despite the maintenance light indicating a need for cleaning, supplies were not ordered until after the observation. Staff continued to use the machine, raising infection control concerns.
A resident, dependent on staff for toileting, experienced a delay in incontinence care, waiting about an hour for assistance after activating their call light. Staff were occupied with other tasks, and the requirement for two staff members to assist contributed to the delay. The facility's policy on resident dignity and timely care was not followed.
A facility failed to reassess a resident's ability to self-administer medications and update their care plan. The resident, with multiple diagnoses including dysphasia, was found with unauthorized medications at their bedside, despite an order against it due to choking risks. Staff interviews revealed a lack of recent assessments and documentation regarding the resident's self-administration of outside medications.
A resident with cognitive impairment and multiple health issues was not adequately monitored for skin conditions and weight changes. Despite having a care plan that required regular skin assessments and weight monitoring, the facility failed to document and assess the resident's numerous skin sores and weight fluctuations. Staff interviews revealed inconsistencies in awareness and documentation of the resident's condition, highlighting a lack of proper monitoring and communication.
A resident with significant hearing loss did not receive timely follow-up for recommended hearing aids due to communication issues between audiology and medical records staff. The resident's care plan lacked documentation of communication needs, and there was a delay in obtaining medical clearance for the hearing aids.
Failure to Provide Adequate Supervision and Individualized Elopement Interventions
Penalty
Summary
The deficiency involves the facility’s failure to ensure an environment free from accident hazards and to provide adequate supervision and individualized, care-planned interventions for residents at risk of elopement. One resident with severe cognitive impairment and a diagnosis of malnutrition was initially assessed on admission as non-wandering and completely dependent for mobility and personal care. However, an elopement assessment completed days later identified this resident as an elopement risk who was able to self-propel a wheelchair, was cognitively impaired, actively exit-seeking, and expressing a desire to go home. The resident’s care plan, initiated after this assessment, included use of a wander device, monitoring the device for proper functioning, and prompt response to door alarms, but it lacked specific supervision measures and individualized interventions tailored to the resident’s escalating exit-seeking behavior. In the days leading up to the elopement, multiple progress notes documented that this resident was wandering up and down the hallway, confused, disoriented, and repeatedly attempting to leave the facility despite staff redirection. On the day of the elopement, documentation indicated the resident was very agitated, wandering into other residents’ rooms, calling the police, stating staff were holding her hostage, and attempting to leave multiple times. Video surveillance from the floor exit area showed the resident making several attempts over the course of the evening to open the stairwell and exit doors, triggering alarms that were reset by staff who redirected her away from the doors. Despite these repeated attempts and clear evidence of escalating exit-seeking, no additional formal interventions beyond the wander device were implemented, and staff did not revise the care plan to include increased supervision or other individualized strategies. Later that evening, the video showed the resident successfully exiting through the floor door without staff present. A police report documented that the resident, who was not dressed for the weather and wearing all black, was later found about five blocks from the facility after knocking on a private residence’s door and asking for help. She was transported to the hospital for evaluation and was discharged in stable condition without injuries. Interviews with staff revealed that agency NAs working that shift were not informed which residents were at risk for elopement and that their care sheets did not identify elopement risks or related interventions. Additional residents assessed as elopement risks also had care plans that included wander devices and general directions to monitor for exit-seeking and answer door alarms, but these plans similarly lacked specific supervision measures and individualized interventions, and NA care sheets did not consistently reflect elopement risk status. The facility’s elopement policy directed staff to establish a process to check bracelet alarm/device batteries according to manufacturer directions, and the user guide for the wander management transmitters required at least weekly testing to verify proper operation. Interviews with nursing and management staff showed inconsistent understanding of responsibilities for testing and ensuring functionality of wander devices, as well as for updating care plans and communicating elopement risk to direct care staff. Some nurses believed only nurse managers or the DON could change care plans, while the DON stated all nurses could make care plan changes. Nurse managers reported that residents at risk for elopement should be noted on NA care sheets, but agency NAs reported they were not alerted to any residents at risk to wander or elope. These documented gaps in assessment translation to care plans, supervision, communication, and device management contributed to the resident’s elopement and the identified deficiency. Three additional residents identified as elopement risks had diagnoses including dementia, moderate to severe cognitive impairment, and conditions such as breast cancer and acute encephalopathy. Their elopement assessments indicated confusion, disorientation, and requests to go home. Their care plans directed use of wander devices, monitoring and documentation of exit-seeking behavior, prompt response to door alarms, and inviting them to activities, but similarly lacked explicit supervision requirements and individualized interventions to prevent elopement. NA care sheets for these residents either did not indicate elopement risk or did not include interventions to prevent elopement. These findings showed that the facility failed to consistently integrate elopement risk assessments into clear, individualized supervision strategies and to communicate those strategies to all staff responsible for resident care.
Removal Plan
- Audited the care plans of residents identified as elopement risks
- Provided education to staff regarding the elopement policy
- Provided education to staff regarding elopement assessments
- Provided education to staff regarding one-to-one supervision
- Provided education to staff regarding safety checks
- Provided education to staff regarding wander device management
- Developed and implemented individualized care plans with interventions including supervision for residents at risk for elopement
Incomplete Facility Assessment for Staffing Recruitment, Retention, and Contingency Planning
Penalty
Summary
The deficiency involves the facility’s failure to conduct and document a comprehensive facility-wide assessment that included all required components related to staffing resources. The facility assessment dated 12/17/25 did not contain a plan to maximize recruitment and retention of direct care staff, despite this being a required element. The assessment also lacked a contingency plan for situations that did not trigger the formal emergency plan but could still affect resident care, such as issues with the availability of direct care nurse staffing or other care resources. During an interview on 3/13/26 at 3:32 p.m., the administrator acknowledged that while a recruitment plan existed, it was not incorporated into the written facility assessment, and further stated that the assessment did not include a staff retention plan or a plan to address direct care staffing needs outside of the emergency plan. A policy governing how the facility assessment should be conducted and documented was requested by surveyors but was not provided. This failure had the potential to affect all 71 residents in the facility, as the incomplete assessment did not fully address how necessary staffing resources would be ensured during routine operations, nights, weekends, or non-emergency events that could impact resident care.
Failure to Verify Active Nurse Aide Registry Status for Agency Staff
Penalty
Summary
The facility failed to ensure that a nurse aide had a current competency evaluation on the Minnesota Nursing Assistant Registry before allowing her to work, affecting 1 of 1 nurse aides reviewed for registry verification and potentially all 71 residents. On 3/12/26 at 11:46 a.m., a nursing assistant (NA-A) reported it was her first shift at the facility, and the facility schedule for that date showed she was assigned to work a 7.5-hour day shift on the third floor, where 26 residents resided, with a total facility census of 71 residents. A Minnesota Nurse Aide Registry search, dated 3/13/26 at 11:45 a.m. and provided by the facility, showed NA-A’s registry status as inactive since 12/7/24. During interviews, the DON stated she trusted the staffing agency to send only staff who were on the registry and acknowledged the facility did not verify active status for agency staff, and the administrator confirmed that their process did not include verifying current certification of agency aides and that she expected only currently certified NAs would be sent. A facility policy related to this process was requested by surveyors but was not provided.
Improper Handling of Soiled Linens in Laundry Process
Penalty
Summary
The facility failed to ensure that soiled facility linens were handled in a manner that prevented potential contamination during the laundry process. During an observation, three towels and a shower curtain were found unbagged and lying in a bin below the laundry chute. The laundry assistant confirmed that some laundry items were sent down the chute without being bagged. The environmental director and infection preventionist both stated that soiled linens should be bagged before being sent down the chute to prevent contamination and potential exposure to infection. The facility was unable to provide a policy regarding the proper handling of soiled linens in relation to the laundry chute.
Deficiencies in Food Labeling, Temperature Control, and Sanitary Practices
Penalty
Summary
The facility failed to ensure proper labeling and dating of food items stored in community refrigerators on two of three floors where residents' personal food was kept. Observations revealed undated and unlabeled containers, including a plastic bag with a Tupperware container, a half-full plastic pitcher with orange liquid, and a container of ice cream dated nearly two months prior. Additionally, an unlabeled and undated container of cooked pasta was found. The Dietary Manager confirmed these items were for resident consumption and acknowledged they should have been labeled and dated according to facility policy. During food service, a dietary aide recorded a chicken temperature of 120°F on the steam table, which was below the required standard. The Dietary Manager verified the temperature and instructed the aide to reheat the chicken, confirming that no residents had been served the underheated food. In the kitchen, another dietary aide was observed prepping fruit without gloves and touching the inside of serving bowls with their thumb, which the Dietary Manager confirmed was not in line with sanitary practices. These actions were inconsistent with the facility's policies on food storage, temperature maintenance, and hygiene during food preparation.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that food was served at a palatable and appetizing temperature for two residents on the second floor. Both residents, one with intact cognition and one with moderate cognitive impairment, reported that their meals were not at appropriate temperatures when delivered to their rooms. One family member also stated that food was usually cold by the time it reached the resident. Observations confirmed that food was plated and placed on a cart, then delivered to the second floor, where the last tray was served with food temperatures below required standards: chicken at 106°F, rice at 119°F, mashed potatoes at 127°F, and milk at 55°F. The surveyor noted that the hot foods were cold or lukewarm, and the milk was warm. Interviews with staff revealed a lack of knowledge regarding proper food holding temperatures. Both a nursing assistant and a dietary aide were unsure of the required temperatures for hot and cold foods. The dietary manager stated that hot foods should be held at a minimum of 135°F and cold foods at 41°F or lower, consistent with the facility's policy, which also identified the danger zone for food temperatures as between 41°F and 135°F. The failure to maintain appropriate food temperatures had the potential to affect all 24 residents on the unit.
Failure to Instruct Resident to Rinse Mouth After Steroid Nebulizer Administration
Penalty
Summary
A deficiency occurred when a registered nurse administered Budesonide inhalation suspension via nebulizer to a resident with cognitive impairment, dementia, anxiety, and asthma, but failed to instruct or assist the resident to rinse her mouth after the medication. The resident's care plan required staff to administer medications as ordered, and the medication's instructions specified that the mouth should be rinsed after inhalation to prevent fungal infections. During the observed medication administration, the nurse placed the nebulizer mask on the resident and returned after the treatment, but did not instruct or assist the resident to rinse her mouth. The nurse later confirmed she had not provided this instruction and was unsure if the resident was able to rinse and spit, despite the resident's demonstrated ability to do so during a subsequent observation with a nursing assistant. Interviews with facility staff, including a licensed practical nurse, pharmacy consultant, and director of nursing, all confirmed the importance of rinsing the mouth after steroid nebulizer use to prevent infections such as thrush. The facility's policy required all medications to be administered in a safe and effective manner. The failure to follow this standard of practice for medication administration resulted in the facility not meeting professional standards of quality for this resident.
Failure to Follow Fall Risk Interventions for High-Risk Resident
Penalty
Summary
Staff failed to consistently implement fall risk interventions for a resident identified as being at high risk for falls. The resident had moderate cognitive impairment, required extensive assistance with activities of daily living, and had a history of falls, as well as diagnoses including diabetes mellitus and depression. The care plan specified several interventions, such as keeping the bed in the lowest position, placing a fall mat next to the bed, keeping the door open when the resident was in the room, posting a 'do not fall' sign, and ensuring the call light was within reach. Additionally, staff were to check on the resident and offer bathroom assistance during specific hours. Despite these interventions, multiple falls occurred over several months, each time prompting additional interventions to be added to the care plan. Observations revealed that the resident was found in bed with the door closed, contrary to the care plan instructions. Interviews with nursing staff indicated a lack of awareness of all required interventions, with some staff only aware of the bed and mat requirements and not the need to keep the door open or other measures. The nursing assistant worksheet lacked comprehensive fall interventions, and the facility was unable to provide a fall policy when requested. The DON confirmed that staff were expected to follow care plans at all times, but this was not consistently done for this resident.
Failure to Administer Ordered COPD Medication Due to System Lapse
Penalty
Summary
The facility failed to implement a system to ensure that medications were available and administered as ordered for a resident with significant medical needs. The resident, who was cognitively intact and dependent on staff for dressing and toileting, had diagnoses including asthma, COPD, and diabetes mellitus. A physician order was placed for Anoro Ellipta, a medication used for COPD, but review of the electronic medication administration record (eMAR) showed that the medication remained in 'Pharmacy Pending Confirmation' status and was not administered as prescribed. The medication was present in the facility, but the order had not been confirmed in the system, resulting in the resident not receiving the medication since it was prescribed. Interviews with facility staff revealed a lack of awareness and follow-through regarding the medication order. The registered nurse acknowledged the medication was in the cart but had not been confirmed or given. The DON was unaware that the medication had not been confirmed or administered, and the consultant pharmacist stated that confirmation should have occurred promptly. The facility's policy required timely and accurate transcription of medication orders, but this was not followed, leading to the deficiency.
Failure to Notify Provider of Medication Refusal
Penalty
Summary
The facility failed to notify the medical provider of a resident's refusal to take Lovenox, a medication used to prevent blood clots following surgery. The resident, who was cognitively intact and had a surgical wound, was prescribed Lovenox to be administered daily. However, the Medication Administration Record (MAR) indicated that the resident refused the medication on multiple occasions, specifically from February 6 to February 8 and from February 11 to February 16. Despite these refusals, there was no documentation that the medical provider was informed, as required by the facility's procedures. Interviews with staff revealed that the registered nurse and the director of nursing acknowledged the oversight, confirming that the provider should have been notified immediately upon the resident's first refusal. The facility's Specific Medication Administration Procedure mandates that persistent medication refusals be documented and communicated to the physician or prescriber. The resident's care plan also lacked any mention of anticoagulation therapy, further highlighting the deficiency in communication and documentation regarding the resident's medication management.
Failure to Provide Ordered Wound Care for Resident
Penalty
Summary
The facility failed to provide wound care as ordered for a resident, identified as R2, who was admitted with a surgical wound and required non-surgical dressings. R2's hospital discharge orders included specific instructions for wound care management, which were not entered into the facility's provider orders upon admission. This oversight resulted in the absence of necessary wound care and pouch changes for R2's fistula, as indicated in the hospital discharge orders. R2's care plan did not reflect the required wound care and pouch changes, and the Skin and Wound Evaluation lacked comprehensive documentation of the wound's condition. The wound provider's progress note highlighted a treatment error, noting that R2 had not been receiving the required dressing changes every six hours, leading to skin irritation and bleeding. Despite the presence of a care plan indicating R2's ability to direct her stoma care, the interventions did not include assistance with pouch changes and wound dressings. Interviews with facility staff, including registered nurses and the director of nursing, revealed that the process for entering hospital orders was not followed correctly, resulting in the omission of R2's wound care orders. The director of nursing acknowledged that the admission wound care orders were not entered into the medical record, and staff did not perform the care as ordered. Additionally, the wound assessment conducted on 2/13/25 was incomplete, failing to assess R2's wound/fistula adequately.
Inadequate Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to conduct appropriate hand hygiene during wound care for a resident who was cognitively intact and had a surgical wound requiring non-surgical dressings. During an observation of the wound care process, an LPN was noted to have washed his hands with soap and water before starting the procedure. However, the LPN did not perform hand hygiene between glove changes while handling a fistula collection bag containing stool, cleaning the resident's legs, and managing wound care supplies. The LPN also failed to perform hand hygiene after touching a receptacle that previously held stool and after leaving the resident's room. The LPN acknowledged during an interview that he did not perform hand hygiene as required, except before starting the wound care. The director of nursing confirmed that staff had been educated on hand hygiene recently and were expected to follow the facility's hand hygiene policy. The facility's handwashing policy indicated that proper handwashing should be performed before and after treating a wound, after cleaning up someone who has used the toilet, and after touching garbage. The policy also required handwashing before donning gloves and after removing them during procedures requiring glove use.
Failure to Monitor and Address Resident's Skin Breakdown
Penalty
Summary
The facility failed to ensure that a resident with peripheral vascular disease and diabetes with neuropathy received appropriate skin care and monitoring, leading to skin breakdown. The resident, who was dependent on staff for mobility and hygiene, had a care plan that required daily skin monitoring and weekly skin inspections. However, the facility did not complete these inspections or inform the interdisciplinary team of the resident's skin breakdown. During a care conference, a family member mentioned a wound, which was not previously noted by therapy staff. The resident returned from a leave of absence with excoriated skin on the thighs, but no further documentation of care for the skin breakdown was provided. Observations and interviews revealed that the resident experienced discomfort from sitting in a wheelchair and had excoriated areas on the buttocks and thighs. The occupational therapist was unaware of the skin breakdown, and the registered nurse noted the excoriation but did not measure it. The director of nursing acknowledged the excoriation but did not report it as an open area. The facility's nurse consultant stated that the director of nursing should have addressed the skin concerns in daily meetings and updated the care plan accordingly. The facility's policy required staff to notify the provider, update the care plan, and involve therapy for skin concerns, which was not followed in this case.
Ice Machine Maintenance Deficiency
Penalty
Summary
The facility failed to maintain cleanliness and regular maintenance of the fourth-floor dining room ice and water dispenser, which was observed to have white, speckled, crust residue on various surfaces. The maintenance director (DOM) acknowledged that the machine's maintenance light had indicated a need for cleaning, but supplies for cleaning and sanitizing were not ordered until after the observation. The DOM, who started working at the facility in March 2024, stated this was the first time they would be cleaning and sanitizing the dispenser. Despite the visible sediment, staff continued to use the machine, and the administrator confirmed the presence of sediment and expected maintenance to address it when triggered by the facility's communication system. The facility's policy required ice machines to be cleaned and sanitized per manufacturer's instructions, which recommended cleaning at least every six months or more frequently based on water mineral content and other factors. The last recorded cleaning of ice machines and bins was on 5/31/24. The administrator noted that the fourth-floor machine had two filters to counter hard water sediment build-up, with one filter dated 3/28/24. The failure to clean and sanitize the machine as required raised infection control concerns, as staff continued to use the machine for resident meal service.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely assistance with incontinence care for a resident, compromising their dignity. The resident, who was cognitively intact and dependent on staff for toileting due to frequent incontinence, reported not being changed since the morning and activated their call light for assistance. A trained medication aide responded but left the room after informing the resident that another staff member would assist them. However, the resident had to wait for approximately an hour before two nursing assistants arrived to change their incontinence brief. Interviews with staff revealed that the delay was due to other staff being occupied with different tasks or on break, and the requirement for two staff members to assist with the resident's care. The registered nurse and director of nursing acknowledged that the call light should remain on until the resident's needs are met and that the delay in care could impact the resident's dignity. The facility's policy emphasizes the importance of upholding residents' rights to dignity and timely care, which was not adhered to in this instance.
Failure to Reassess and Document Self-Administration of Medications
Penalty
Summary
The facility failed to comprehensively reassess a resident's ability to safely self-administer medications, document resident education regarding the risks, and update the care plan accordingly. The resident, who was cognitively intact and had multiple diagnoses including dysphasia, malnutrition, ADHD, depression, and anxiety, was observed to have medications at their bedside. These included guaifenesin, eye drops, ear wax remover, and nystatin powder, which were not authorized for self-administration according to the facility's policy. The resident's medical record lacked additional assessments beyond an initial evaluation that deemed them capable of self-administering certain medications. Despite this, there was an order indicating that medications should not be left in the resident's room due to the risk of choking, as the resident preferred to lie in bed rather than sit upright. Staff interviews revealed that the resident had a history of obtaining medications from outside sources, and there was no recent assessment or documented risk/benefit discussion regarding these outside medications. The facility's policy required a comprehensive assessment by the interdisciplinary team to determine if self-administration was safe and appropriate, with periodic reassessments based on changes in the resident's status. However, the resident had not been recently reassessed, and the care plan was not updated to reflect the medications they could self-administer. The presence of unauthorized medications at the bedside was not addressed by staff, despite being in plain view, leading to concerns about potential interactions and safety risks.
Failure to Monitor Skin Conditions and Weights
Penalty
Summary
The facility failed to comprehensively assess and monitor non-pressure related skin conditions and resident weights for a resident identified as R40. R40, who was cognitively impaired and had a history of alcohol use disorder, depression, cellulitis, and incontinence, was admitted to the hospital with severe dehydration and other symptoms. Upon discharge, R40's care plan included monitoring skin integrity and performing weekly skin inspections, but the facility did not adequately document or assess R40's skin conditions, which included open abrasions and scabs on various parts of the body. Despite the care plan's instructions, the facility's documentation lacked consistent identification and assessment of R40's skin issues. Observations revealed numerous scabs and open sores on R40's body, which were not consistently documented or monitored. Interviews with staff indicated a lack of awareness and documentation regarding R40's skin conditions, with some staff unsure of the status of the sores and others acknowledging the absence of proper documentation and monitoring. Additionally, the facility failed to monitor R40's weight as required, particularly given the resident's use of diuretics and history of weight fluctuations. Although R40's weight was recorded at two points, there was no consistent monitoring or documentation of weight changes, which was crucial due to the resident's medical conditions and medication regimen. The lack of weight monitoring was attributed to agency staff not entering the order for weights, leading to a failure in triggering the necessary monitoring procedures.
Failure to Provide Timely Hearing Aid Follow-Up
Penalty
Summary
The facility failed to ensure that a resident received proper follow-up for recommended hearing assistive devices. The resident, who had intact cognition and diagnoses including Alzheimer's dementia, anxiety, and high blood pressure, was identified as hard of hearing but did not wear hearing aids. An audiology exam revealed significant sensorineural hearing loss in both ears, and hearing aids were recommended. However, the resident's care plan lacked documentation of communication needs, and there was a delay in obtaining medical clearance for the hearing aids. The delay was attributed to communication issues between the audiology staff and the facility's medical records (MR) staff. The MR staff acknowledged missing the notification for medical clearance and stated that the request was only sent to the resident's provider months after the audiology exam. Interviews with staff, including the MR staff, social services, a registered nurse, and the director of nursing, confirmed the breakdown in communication and the lack of timely action on the audiology recommendations. The facility did not provide a policy on appointment follow-up or hearing and communication when requested.
Latest citations in Minnesota
A resident with dry eye syndrome and degenerative eye disease had orders for cyclosporine ophthalmic emulsion and Refresh Tears, both scheduled at the same time. Medication records and direct observation showed a TMA instilled cyclosporine drops in both eyes and immediately followed with Refresh Tears in both eyes without waiting between medications. This practice conflicted with referenced professional guidance recommending several minutes between multiple eye drops and with the medical provider’s recommendation to wait fifteen minutes between the two ophthalmic medications. No facility policy on ophthalmic medication administration was provided when requested.
A resident with severe cognitive impairment, impaired mobility, and high fall risk was care planned to have wheelchair footrests in place at all times, with staff ensuring proper positioning and monitoring for leaning during transport. A NA transported the resident in a manual wheelchair from the shower without the footrests, and while going through the doorway the wheelchair struck the door frame, causing the resident, who was leaning forward, to fall out. The resident sustained a T12 fracture, head injury with concussion, abrasions and contusions, and multiple right-hand lacerations requiring sutures, and the DON confirmed the care plan had not been followed.
A high‑risk, immobile resident with MS and prior heel DTI developed an avoidable unstageable coccygeal pressure ulcer after staff failed to consistently assess and document skin status, did not transfer or timely provide ordered pressure‑relieving mattresses, and did not reliably perform q2h repositioning. The resident was repeatedly left on a bedpan for prolonged periods despite early reports of this issue, and the toileting care plan was not revised to a bedside commode until after the coccygeal wound had significantly worsened. Wound assessments lacked complete measurements and staging, changes in wound size and color were not promptly recognized as deterioration or reported to providers, and recommended interventions from a wound NP (including an air mattress and offloading) were not promptly implemented. As a result, the coccygeal ulcer rapidly progressed to a large, necrotic, malodorous wound requiring hospital transfer and surgical debridement.
A resident with spastic hemiplegia, muscle weakness, and moderate cognitive impairment was observed using bilateral bed grab bars for bed mobility and transfers, but the care plan did not address grab bar or side rail use. Review of the EMR showed no completed bed mobility device or side rail assessment to determine the necessity or safety of the grab bars, and no documentation that risks and benefits were discussed or that informed consent was obtained. An LPN and the ADON stated that a bed mobility device assessment is required before grab bars are installed and confirmed that no such assessment existed for this resident.
A resident with bilateral heel pressure ulcers and multiple comorbidities received wound care during which an RN removed dressings from both heels, cleansed both wounds, and wiped each heel without changing gloves or performing hand hygiene between wounds or after disposing of soiled dressings. This practice conflicted with the facility’s written wound care procedure, which requires glove removal and hand hygiene after dressing removal and after wound cleansing. In interviews, the RN, NP, and DON/IP acknowledged that hand hygiene and glove changes are expected between dirty and clean tasks and between separate wounds to prevent infection.
A resident with MS, neurogenic bladder, mobility limitations, and existing pressure injuries was identified as dependent for toileting hygiene and at risk for pressure ulcers, yet the care plan lacked an individualized toileting/incontinence plan and a defined repositioning schedule. Despite a new coccyx pressure ulcer and documentation that interventions such as increased repositioning and incontinent care were needed, the care plan was not revised for a period of time to reflect these changes. During this time, the resident sometimes fell asleep on a bedpan and remained on it until staff removed it, and staff were not initially informed that the bedpan should no longer be used. The DON later acknowledged that the care plan revisions for turning, repositioning, and toileting were delayed until after the resident’s coccyx ulcer had significantly worsened.
A resident with diabetes, Crohn’s disease, bowel incontinence, and a history of MASD on the right gluteus developed an open, painful lesion on the right gluteal area that was documented over time without complete wound characteristics, clear etiology, or timely provider notification. Wound care orders were written for a stage 3 pressure ulcer on the left buttocks, while staff reported the wound was only on the right side and applied the left‑sided orders to the right gluteal wound in the absence of specific right‑side treatment orders. The DON acknowledged discomfort with staging the wound, lack of early physician notification, and confusion over wound classification, despite a facility policy requiring comprehensive wound assessment, consistent measurement, and provider notification when treatment orders are absent.
A resident with diabetes, chronic leg ulcer, kidney transplant, and a documented gluteal wound was care-planned for Enhanced Barrier Precautions (EBP), with posted instructions requiring gown and gloves for high-contact care such as transfers and wound care. During a telehealth wound assessment, the DON donned a gown and initially performed hand hygiene but then applied gloves without hand hygiene, removed a soiled dressing from the resident’s gluteal area, discarded it, removed gloves, and applied new gloves again without performing hand hygiene between glove changes. On another occasion, during use of a sit-to-stand lift, an NA wore gown and gloves, but the DON handled the lift harness, the resident’s clothing, and assisted with the transfer and repositioning while wearing a gown but no gloves, despite EBP requirements for transfers. The DON stated EBP was only needed for catheter or wound care and not for transfers, contradicting the posted EBP instructions and facility policy.
A resident with severe dementia, psychiatric disorders, and high dependence for ADLs was verbally abused during evening care when a NA, frustrated with the resident’s crying and resistance, loudly ridiculed her as acting like a two-year-old, threatened to hit her back if struck, told her she would be sent to a locked unit, and questioned who would want to care for her when she cried like a baby. Multiple staff witnessed the loud, stern, and intimidating tone and reported it to an LPN, who recognized it as verbal abuse but did not immediately remove the NA from duty or promptly report the allegation per policy, allowing the NA to continue working on the unit. Following this incident, the resident demonstrated increased crying, combativeness, resistance to care, wandering, self-isolation, and refusal of food, fluids, and medications above baseline, with documentation of significant emotional distress and subsequent ED evaluation for aggressive behaviors and poor intake.
A resident with dementia, bilateral above‑knee amputations, vascular disease, and severe protein‑calorie malnutrition developed a wound on an amputation stump that had a dressing dated several days before any documentation or treatment orders appeared in the record. Although bath audits and nursing notes initially reported no skin issues, a later assessment described a full‑thickness stage 4 ulcer/diabetic ulcer on the stump with exposed bone, erythema/edema, slough, and moderate serosanguineous drainage. Nursing staff interviews showed no one could identify who first discovered the wound or applied the initial dressing, and there was no evidence that the wound was assessed, the provider notified, or standing orders implemented when it was first present, despite facility expectations that new wounds be promptly evaluated and reported.
Failure to Follow Professional Standards for Ophthalmic Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice for administering ophthalmic medications to a resident with dry eye syndrome and degenerative eye disease. The resident was cognitively intact, required assistance with ADLs, and had physician orders for cyclosporine ophthalmic emulsion 0.05% one drop in both eyes twice daily and Refresh Tears ophthalmic solution one drop in both eyes four times daily for dry eyes. The administration summary showed that both eye medications were scheduled for the same time and were documented as being given at the same time on multiple dates. During a medication pass observation, a trained medication aide administered the ordered oral medications, then applied gloves and instilled one drop of cyclosporine in each eye, immediately followed by one drop of Refresh Tears in each eye, without any waiting period between the two medications. The surveyors referenced guidance from the American Academy of Allergy, Asthma, and Immunology stating that when more than one eye drop is ordered, three to four minutes should be allowed between drops in the same eye, and five to fifteen minutes should be allowed between different eye medications to prevent dilution. Interviews with the DON, pharmacy consultant, and medical provider confirmed that best practice and the provider’s recommendation were to wait between administration of cyclosporine and Refresh Tears, with the medical provider specifying a fifteen-minute interval. The facility did not provide a policy on ophthalmic medications when requested. The observed practice and documented administration times demonstrated that staff did not follow these professional standards or the medical provider’s recommended interval between the two eye medications.
Failure to Follow Wheelchair Transport Care Plan Leads to Fall With Injuries
Penalty
Summary
The deficiency involves the facility’s failure to implement care-planned fall prevention interventions for a resident at high risk for falls, resulting in a fall with injury. The resident had diagnoses including aphasia, dysphagia, muscle weakness, traumatic brain injury, and impaired mobility, with severe cognitive impairment documented on the MDS and dependence on staff for transfers and wheelchair transport. A care plan addressing wheelchair transport safety and positioning directed staff to ensure the resident was fully positioned and supported in the wheelchair prior to transport, verify footrests were in place prior to transport, and monitor for leaning, sliding, or unsafe positioning. An additional care-planned approach required wheelchair pedals to be on at all times. On the date of the incident, a nursing assistant transported the resident in a manual wheelchair from the shower room to the resident’s room without the foot pedals in place, contrary to the care plan. While being wheeled through the doorway, the wheelchair struck the door frame, causing the chair to stop and the resident, who had begun leaning forward, to fall out of the wheelchair onto the floor. Progress notes and ED documentation identified that the resident sustained a T12 vertebral fracture, a head injury with concussion, an abrasion and contusion to the head, a bruise to the left knee, and multiple lacerations to the right hand requiring sutures. The nursing assistant later acknowledged awareness that the foot pedals should have been on but did not apply them because the transport was only from the shower to the room. The DON confirmed that the resident’s care plan had not been followed when the fall occurred.
Failure to Implement and Update Pressure Ulcer Prevention and Treatment Led to Avoidable Unstageable Coccygeal Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, monitor, and implement individualized pressure ulcer prevention and treatment interventions for multiple high‑risk residents, resulting in an avoidable, unstageable coccygeal pressure ulcer for one resident that required surgical debridement and hospitalization. The resident had primary progressive multiple sclerosis, hereditary spastic paraplegia, obesity, and pre‑existing pressure‑related deep tissue injury to the left heel, and was identified as high risk for pressure ulcers on the Braden Scale due to constant moisture, chairfast status, very limited mobility, inadequate nutrition, and friction/shear risk. Hospital records on readmission documented irritant contact dermatitis of the bilateral gluteal cleft with specific cleansing and barrier cream orders, and facility documentation showed the resident could not reposition in bed or chair and required assist of two and a full‑body mechanical lift for transfers. Despite this, the admission/readmission skin assessment and weekly skin checks lacked measurements and detailed wound characteristics for the heel ulcer and gluteal dermatitis, and the care plan did not include comprehensive, individualized interventions beyond generic repositioning and wound care orders. After a new coccyx pressure ulcer was identified and documented as a stage 2 lesion, the facility failed to promptly and accurately update the care plan and implement recommended pressure‑relieving interventions. The wound nurse practitioner on 3/5 ordered coccyx wound care, an air mattress, pressure offloading, and a dietician consult, but the care plan was not revised and there was no evidence that an air mattress was placed on the bed for nearly two weeks. The environmental services director later confirmed that when the resident was moved to a new room, the gel mattress was not transferred, and the air mattress requested on 3/17 was not actually placed until the following day, despite being marked as completed. During this period, TAR documentation showed gaps in the every‑2‑hour repositioning order, and staff interviews revealed that CNAs were unaware of which residents were on repositioning programs, were not consistently repositioning residents, and had not received recent education on pressure ulcer prevention. The DON and RN case manager acknowledged that the coccyx wound increased in size and changed color between assessments, that the bed lacked the ordered gel mattress, and that the physician was not notified of the wound’s deterioration at that time. The facility also failed to timely modify toileting and incontinence care practices despite knowledge that the resident was being left on a bedpan for extended periods. The DON reported hearing before an IDT meeting that the resident had fallen asleep on a bedpan for an undetermined amount of time, but the care plan was not revised to discontinue bedpan use and implement a bedside commode until after the coccyx wound had significantly worsened. CNAs confirmed that the resident sometimes fell asleep on the bedpan and that they were not informed she should no longer use it until after the sore had worsened. Subsequent wound assessments documented rapid progression of the coccyx wound from a small stage 2 ulcer to a large, malodorous, necrotic wound with eschar, slough, erythema, and purulent drainage, ultimately classified as an unstageable pressure ulcer. The DON, NP, PA, and medical director all indicated that the lack of a pressure‑relieving mattress, failure to adjust pressure‑reducing interventions, and prolonged time on a bedpan likely contributed to the development and deterioration of the resident’s pressure ulcer, which was determined to be avoidable and resulted in hospitalization and surgical debridement. Additional documentation and interviews showed systemic assessment and communication failures related to pressure ulcer management. Weekly skin checks and wound assessments often omitted complete measurements, staging, and wound characteristics, and changes in wound size and appearance were not consistently recognized as deterioration or communicated to providers. The DON acknowledged that a 3/12 assessment showing increased wound size and purple discoloration should have been identified as a deep tissue injury and reported to the physician, but this did not occur. When nursing later documented foul odor, increased pain, and expanding necrotic tissue, telemedicine and PA responses deferred in‑person evaluation and ED transfer despite earlier recommendations that the resident be sent to the ED if an in‑person provider could not assess the wound. The NP ultimately found a large, malodorous, purulent wound with expanding eschar and ordered transfer to the hospital, where imaging and surgical findings confirmed a large necrotic sacral wound requiring extensive debridement. Throughout this sequence, the facility did not consistently follow its own pressure ulcer protocols, did not ensure ordered pressure‑relieving equipment was in place, and did not promptly revise care plans or interventions in response to known risk factors and documented wound changes. The report also notes that other residents reviewed for pressure ulcers were affected by similar failures in monitoring and individualized intervention, though detailed narratives focus primarily on this resident. Staff interviews revealed that CNAs relied on paper care guides that did not clearly identify residents on repositioning programs or at risk for skin breakdown, and that they were unaware of some residents’ special mattress orders or toileting restrictions. The DON and medical director stated that residents at risk for pressure ulcers should have immediate pressure‑relieving interventions and that existing ulcers require ongoing evaluation to prevent deterioration, but the documented practices for this resident did not align with those expectations. These combined actions and inactions—insufficient assessment detail, delayed or missing care plan revisions, failure to implement ordered support surfaces and repositioning, and delayed response to wound deterioration—constituted the deficiency in providing appropriate pressure ulcer care and preventing new ulcers from developing.
Failure to Assess, Care Plan, and Obtain Consent for Bed Grab Bar Use
Penalty
Summary
The deficiency involves the facility’s failure to follow required procedures before installing and using bed grab bars for a resident. The resident had diagnoses including spastic hemiplegia affecting the left side and muscle weakness, and an admission MDS indicating moderate cognitive impairment. During observation, the resident was seen in a power chair with bilateral grab bars on the bed and reported using them to roll in bed and for transfers. The resident’s care plan, dated 1/23/26, documented a need for assistance with bed mobility and independence with transfers but did not mention or address the use of grab bars or side rails. Review of the electronic medical record showed no completed grab bar/side rail or bed mobility device assessment to determine the necessity of the grab bars or whether the resident could safely use them. There was also no evidence that the resident or the resident’s representative had been educated on the risks of having a grab bar on the bed or that informed consent had been obtained. In interviews, an LPN and the ADON both stated that a bed mobility device assessment was required to determine need and safety prior to installing grab bars, and both confirmed that no such assessment was present in the resident’s record.
Failure to Perform Hand Hygiene and Change Gloves During Wound Care
Penalty
Summary
Surveyors observed that a registered nurse (RN) and a nurse practitioner (NP) did not follow the facility’s established infection control practices during wound care for one resident. During a wound treatment, the RN wore gloves while removing the dressing from the resident’s left heel, then removed the dressing from the right heel, sprayed both wounds with wound cleanser, wiped the left heel with gauze, and then used a clean gauze pad to wipe the right heel. The RN did not remove her gloves or perform hand hygiene after disposing of the soiled dressings or between cleaning the left and right heel wounds, contrary to the facility’s written wound care procedure, which requires glove removal and hand hygiene after removing the previous dressing and again after cleaning the wound. The resident’s admission MDS documented diagnoses including multiple rib fractures, heart failure, dementia, anxiety, and the presence of a pressure ulcer, and indicated the resident was cognitively intact and required staff assistance with care and transfers. The resident’s care plan identified pressure ulcers on both heels requiring wound care. In interviews, the RN, NP, and the DON/infection prevention nurse each stated that gloves should be changed when moving from dirty to clean areas and that hand hygiene is expected after glove removal and between wounds to prevent infection, confirming that the observed practice did not align with facility policy or expected infection control standards.
Failure to Timely Revise Care Plan for Toileting and Skin Integrity
Penalty
Summary
The deficiency involves the facility’s failure to timely revise and individualize a resident’s care plan to address toileting and incontinence needs in relation to impaired skin integrity. The resident had diagnoses including primary progressive multiple sclerosis, hereditary spastic paraplegia, obesity, and a pressure-induced deep tissue injury to the left heel. A Significant Change MDS identified the resident as dependent for toileting hygiene, with lower extremity range-of-motion limitations, wheelchair use, dependence for transfers, occasional urinary incontinence, intact cognition, and at risk for pressure ulcers with existing unhealed pressure injuries and MASD. The resident’s skin-focused care plan, revised on various dates, included skin inspections, wound care orders, weekly skin checks, pressure ulcer care to the left heel, nutritional supplements, and a gel mattress, but did not include an individualized toileting or incontinence plan. On a weekly skin check dated 3/3/26, nursing staff identified a new Stage 2 pressure ulcer on the coccyx and contact dermatitis on both gluteal folds. An IDT Final Post Review Follow Up dated 3/10/26 (signed 3/23/26) documented that a new skin issue had occurred and that interventions after the incident included wound care treatment orders, increased repositioning, and increased incontinent care. However, the resident’s care plan from 3/3/26 through 3/16/26 did not show revisions reflecting increased incontinence care or a repositioning schedule, and the care plan was not updated to include these elements until 3/17/26. During this period, the care plan still lacked an individualized toileting plan despite the resident’s identified incontinence and new coccyx pressure ulcer. Progress notes on 3/17/26 documented that the resident’s coccyx wound had declined, with an evaluation describing a deteriorating wound characterized as a Kennedy terminal ulcer/End of Life, staged as a Stage 4 pressure ulcer, in-house acquired, with increased size, exudate, odor, pain, and surrounding erythema. On that same date, the skin focus care plan was revised to include prompt incontinence care and keeping the skin clean and dry, and the elimination focus care plan was revised to address incontinence due to neurogenic bladder with use of a bedside commode offered every 2–3 hours. A nursing assistant reported that when working with the resident, the resident would sometimes fall asleep on the bedpan and forget to ask staff to remove it, and that she was not aware the resident was not supposed to use the bedpan until after the sore had worsened. The DON stated that the resident’s care plan had not been revised earlier to include a turning and repositioning schedule or toileting changes, and that it should have been revised as soon as staff learned the resident was falling asleep on the bedpan, rather than waiting until after the pressure ulcer worsened.
Failure to Assess and Notify Provider for Right Gluteal Wound
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess and appropriately manage a non‑pressure skin issue on a resident’s right gluteal area, and to notify the physician in a timely manner. The resident had diagnoses including diabetes, Crohn’s disease, and a kidney transplant, and the MDS indicated occasional bowel incontinence, no pressure ulcers, and no moisture‑associated skin damage at that time. Earlier documentation identified a resolved MASD to the right gluteus, and a progress note later described a sacral wound with creams applied, noting that sores were still open and painful during application, but without any measurements, wound characteristics, or evidence of physician notification. Subsequent wound assessments documented an open lesion on the right gluteus with specific measurements on multiple dates, but did not identify the wound type or other characteristics, and the record did not show physician notification or treatment orders for the right gluteal lesion. Provider orders in place initially addressed cleansing the buttocks and applying barrier cream, and later included a detailed wound care order for a stage 3 pressure ulcer documented on the left buttocks. However, the resident’s record did not contain a specific treatment order for the right gluteal wound, despite the ongoing documentation of an open lesion in that area. Interviews revealed confusion and inconsistency in wound identification and classification. The DON stated that the right gluteal wound was documented as an open lesion because she did not feel comfortable determining the wound type, and acknowledged that the physician should have been notified when the wound was first identified. The DON was unaware that the NP had documented the wound as being on the left buttocks and as a stage 3 pressure ulcer, while the RN reported that the wound had never been on the left buttocks and that she had been applying the left‑sided wound orders to the right gluteal area because there was no open area on the left. The resident reported a recurring painful area on the right buttocks and chronic stool leakage since prior anal fistula surgery. The facility’s own wound treatment policy required comprehensive assessment of wound etiology and characteristics, consistent measurement and documentation, and provider notification in the absence of treatment orders, which were not followed for this resident’s right gluteal wound. The deficiency centers on the lack of a comprehensive wound assessment for the right gluteal lesion, incomplete documentation of wound characteristics, failure to clearly determine and document the wound etiology, and failure to notify the physician and obtain appropriate treatment orders when the wound was identified and remained open. These actions and inactions resulted in a discrepancy between the documented wound location and type and the actual clinical presentation, as well as a period during which the right gluteal wound had no specific, clearly ordered treatment despite being open and painful.
Failure to Perform Hand Hygiene and Implement Enhanced Barrier Precautions During Wound Care and Transfers
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper hand hygiene during wound care and to consistently implement Enhanced Barrier Precautions (EBP) for a resident requiring such measures. The resident had diagnoses including diabetes, a non-pressure chronic ulcer of the right lower leg, and a kidney transplant, and a wound assessment documented an open lesion on the right gluteal area. The resident’s care plan and a sign posted outside the room specified that EBP, including gown and gloves, were required for high-contact care activities such as dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, catheter care, and wound care. During one observation, the DON performed hand hygiene and donned a gown before entering the resident’s room for a telehealth wound assessment. Inside the room, the DON went into the bathroom, applied gloves without performing hand hygiene, removed the resident’s brief, and removed a foam dressing from the right gluteal area that had stool on one corner. After discarding the soiled dressing, the DON removed gloves and then applied new gloves without performing hand hygiene between glove changes. When questioned, the DON stated that hand hygiene should be done when hands or gloves are visibly soiled and before and after removing or applying gloves, and acknowledged that hand hygiene had not been performed each time gloves were removed and reapplied. In a separate observation, the resident was transferred using a sit-to-stand mechanical lift while EBP requirements were not fully followed. An NA entered the room wearing a gown and gloves with the lift, and the DON applied the lift harness under the resident’s arms and cinched the waist strap, encountering the resident’s clothing, while not wearing gloves. After the transfer to bed, the DON pulled down the resident’s pants and removed the harness while touching the resident’s clothes. Following wound care by a CNP-WOC, the DON again assisted the resident by sitting the resident on the edge of the bed, applying the lift harness, and adjusting the resident’s pants and shirt while wearing a gown but no gloves. The DON stated that EBP was only needed for catheter or wound care and not for transfers, and only upon reading the posted EBP sign acknowledged that EBP was required for all high-contact resident care activities, including transfers.
Failure to Protect Resident From Verbal Abuse and Delay in Removing Alleged Perpetrator
Penalty
Summary
The deficiency involves the facility’s failure to protect a vulnerable resident from mental abuse and to respond appropriately to an allegation of abuse. The resident had severe cognitive impairment, Alzheimer’s disease, dementia, anxiety, depression, psychotic disorder, and significant functional dependence, including frequent incontinence and the need for extensive assistance with ADLs and transfers. Her care plan identified behavioral and mood issues such as wandering, yelling, combative behavior, and calling staff names, with interventions including calm approaches, emotional support, redirection, and monitoring for emotional distress and mood/behavior changes. She was identified as a vulnerable adult, with instructions to monitor for signs of emotional distress and to follow the facility’s abuse reporting policy. On the evening in question, while the resident was crying on the phone with her son and expressing a desire to leave, NA-A and NA-B entered to provide evening care using an EZ stand lift. After the resident ended the phone call, multiple staff reported that NA-A spoke to the resident in a loud, stern, and frustrated tone, telling her to stop crying and that she was acting like a two-year-old. When the resident swatted at NA-A, NA-A stated, “If you hit me, I’m going to hit you back,” and later told the resident she was “in trouble now.” Staff reported that NA-A told the resident she would be sent to a locked unit so she could not get out, and questioned who would want to care for her when she cried like a baby, and that nobody would want to keep working with her. NA-C described NA-A yelling commands such as “HOLD ON!” and “Stop crying! Where would you be if you were not here? Probably lying on the floor,” and felt NA-A was obviously upset and overwhelmed. These statements were made in the presence of the resident while she was already distressed and crying. Following this interaction, the resident exhibited crying, yelling, combativeness, resistance to care, wandering into other residents’ rooms, self-isolation, and refusal of food, fluids, and medications above her prior baseline, as documented in behavior charts, target behavior monitoring, and nursing progress notes. Staff documented that she cried most of the morning, was very restless, difficult to redirect, hit and pinched staff, called staff names, and refused care and meals. She required repeated redirection, 1:1 attention, and non-pharmacological interventions, and was ultimately sent to the ED for evaluation of combativeness and emotional distress, where she was treated for dementia with aggressive behavior and hypoglycemia related to poor intake. The report identifies that the resident’s actual response and the reasonable person concept showed serious psychosocial harm, including increased crying and combative behavior above baseline, fear/anxiety manifested as combativeness, resistance to care and social interaction, and self-isolation. The facility also failed to immediately remove the alleged perpetrator from resident care and to promptly report and investigate the allegation in accordance with its abuse policy. After NA-B and NA-C reported to LPN-A that NA-A had yelled at and threatened the resident, LPN-A acknowledged it as verbal abuse but did not initiate immediate protective measures or timely reporting. LPN-A stated she believed she had 24 hours to report because there was no injury, despite facility policy requiring reporting within two hours. NA-A remained on the unit and continued working until the end of her shift, including after staff had clearly communicated their concerns to LPN-A. TMA and NA staff described uncertainty about their authority to remove NA-A and reliance on the nurse to act, while the DON later informed LPN-A that NA-A should have been removed from the floor to prevent further danger to residents. The Immediate Jeopardy was determined to have begun when NA-A’s derogatory, intimidating, and threatening statements were made and continued while she remained on duty with access to the resident and other vulnerable residents.
Failure to Timely Assess and Treat Newly Discovered Stump Wound
Penalty
Summary
The deficiency involves the facility’s failure to provide timely treatment and care for a newly discovered wound on a resident’s above‑knee amputation stump. The resident was admitted with diagnoses including unspecified dementia with behavioral disturbances, vascular dementia, bilateral above‑knee amputations, vascular disease, reduced mobility, and severe protein‑calorie malnutrition, and had no documented ulcers or skin problems on admission or on the most recent MDS. A weekly bath audit on 3/17/26 documented only non‑tender lymph nodes on the right upper hip and did not identify any open areas. However, when the wound was later assessed, the dressing on the stump was dated 3/16/26, indicating that a wound and dressing existed at that time, even though no corresponding assessment, provider notification, or treatment orders were documented. On 3/23/26, nursing staff documented a new skin issue above the resident’s knee at the amputation site, describing a stage 4 pressure ulcer/injury with full‑thickness skin and tissue loss, exposed bone, erythema/edema, and moderate serosanguineous exudate. The wound measured 1.56 cm by 1.64 cm, with 20–29% granulation tissue and 80% slough. A progress note and skin issues assessment on that date confirmed the wound characteristics and staging, and the NP, after reviewing a picture, determined the wound to be a diabetic ulcer with peripheral vascular disease and severe protein‑calorie malnutrition as contributing factors. On that same date, the NP was notified, antibiotic therapy (doxycycline) was ordered for possible cellulitis, and specific wound care orders were initiated, with documentation on the MAR that these treatments were carried out beginning 3/23/26. Multiple interviews with nursing staff revealed that no one could identify who discovered the wound or who applied the initial dressing dated 3/16/26, and there was no documentation of a wound assessment, provider notification, or interim treatment between 3/16/26 and 3/22/26. Several RNs and LPNs who worked shifts from 3/16/26 through 3/20/26 stated they did not notice a wound on the stump and that, per their usual practice, they would have contacted the provider and initiated treatment if they had found one. One LPN recalled seeing a band‑aid with a date on the stump but could not recall the date, and another LPN stated she did not see the wound because she was not looking for one. The facility’s standing orders required staff to assess all wounds daily, change dressings every three days and as needed, treat with normal saline or non‑cytotoxic cleanser and appropriate dressings, and notify the provider the next business day when a new wound or injury was found. Despite these expectations, the wound identified by the dated dressing on 3/16/26 was not assessed, reported, or treated according to orders and facility policy until 3/23/26.
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