The Villas At St Paul
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Paul, Minnesota.
- Location
- 445 Galtier Avenue, Saint Paul, Minnesota 55103
- CMS Provider Number
- 245340
- Inspections on file
- 27
- Latest survey
- April 3, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at The Villas At St Paul during CMS and state inspections, most recent first.
Surveyors identified deficiencies in food storage and labeling, with multiple undated and expired food items found in both kitchen and resident refrigerators, improper storage of chemical buckets near food, and ice packs stored with food. Staff interviews revealed confusion over responsibility for monitoring and discarding expired items, and dishwashing procedures were inadequate, with blank temperature logs and staff lacking training on required sanitization temperatures.
A resident with latent TB was not tracked on the infection line listing despite being prescribed antibiotics, and two residents on contact isolation for MRSA did not have consistent enforcement of transmission-based precautions. Staff entered the room without required PPE, and there was confusion among staff about when PPE was necessary, despite clear signage and care plan instructions.
A resident with cognitive impairment and multiple diagnoses was observed wearing TED stockings incorrectly, with the stockings rolled down and causing skin indentations and redness. Although the resident preferred to apply the stockings independently, nursing staff acknowledged their responsibility to ensure proper application, which was not documented in the care plan. Facility policy on TED stocking use was not provided when requested.
Several residents with cognitive and physical impairments did not receive necessary assistance with oral hygiene, as required by their care plans. Observations showed unopened or missing oral care supplies, and residents reported not being helped with oral care. Staff interviews revealed confusion about oral care procedures and inconsistent provision of services, despite facility policy requiring support for activities of daily living.
Several residents, including those with cognitive and physical impairments, did not have water or other fluids readily available outside of meal and medication times. Observations and interviews showed that residents often lacked access to drinks in their rooms and sometimes relied on staff or visitors to obtain water, despite care plans and facility policy requiring regular hydration support.
Staff with facial hair prepared food without wearing beard nets due to a supply shortage, despite knowing the requirement and facility policy mandating beard restraints to prevent hair contamination. The issue was observed and confirmed by staff interviews, and the administrator noted that the supply issue should have been communicated.
A nursing assistant delayed responding to a resident's call light and instructed the resident to use it only for emergencies, resulting in the resident's needs not being addressed promptly. Other staff were unaware of this practice, which was inconsistent with facility policy and expectations regarding timely response to resident requests.
A facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing their medical and personal needs. One resident's care plan lacked focus on incontinence and dental care, another's was incomplete regarding fall risk and pain management, and the third's did not address skin integrity or communication needs. Staff interviews highlighted a lack of detailed and updated care plans, increasing the risk of neglect.
A resident developed an avoidable stage II pressure ulcer due to the facility's failure to reassess pressure ulcer risk and update the care plan. Despite being at moderate risk, the resident's care plan lacked specific interventions for pressure ulcer prevention. Staff interviews revealed a lack of awareness and documentation regarding the resident's condition and necessary interventions. The facility's policy required a pressure ulcer risk assessment and preventative measures, which were not adequately implemented.
The facility failed to verify the nurse aide registration for an agency nursing assistant before allowing him to work with residents. The staffing coordinator was unable to confirm the registration due to a last-minute shift request and reliance on an agency portal system. The director of human resources and the administrator expected the staffing coordinator to handle agency paperwork, but the confirmation of the aide's registration was received only after he had already worked with residents.
A resident with a fungal skin infection did not receive prescribed Nystatin powder due to a transcription error, leading to a lack of treatment for several days. The medication order was not confirmed and revised until days later, resulting in the resident's condition deteriorating. Staff interviews revealed a lack of awareness and communication regarding the missed applications, and facility policies were not followed.
A resident reported that staff placed a pillow over her roommate's mouth to silence her during morning care. Despite being informed, an LPN and a nursing assistant did not report the allegations to management. The resident allegedly abused denied the incident when questioned. The Director of Nursing was unaware of the allegations until informed by the surveyor, and the facility did not provide a policy on abuse reporting.
A resident with intact cognition and specific bathing preferences did not receive showers as per their preference, leading to neglect in personal hygiene. The facility failed to assess and document the resident's preferences in the MDS, resulting in inconsistent bathing schedules and lack of proper care. Staff interviews revealed confusion and inconsistency in following the bath schedule, and the facility lacked a policy on preferences.
Two residents were not provided adequate privacy during personal care due to malfunctioning privacy curtains. Despite the doors being shut, the curtains were not pulled, leaving the residents exposed when staff entered the rooms. The nursing assistant acknowledged the issue and had requested repairs, but they were not completed. The DON confirmed the expectation for privacy, but the facility's privacy policy was not provided.
A resident dependent on staff for daily living and receiving nutrition via a feeding tube had dried enteral feeding liquid on the support legs of their tube feeding pump pole. Despite multiple observations over several days, the substance remained uncleaned. Nursing staff acknowledged their responsibility to clean the equipment, but the facility lacked a specific cleaning policy for tube feeding pump poles.
A facility failed to complete a comprehensive assessment and implement a resident's preferences for bathing. The resident, who had intact cognition and required assistance for bathing, did not receive showers as preferred and had inconsistent documentation of bathing schedules. Staff interviews revealed that the MDS section for preferences was not consistently completed, and the resident's care plan lacked specific information on bathing preferences.
A resident with mobility issues and a prosthetic leg was not provided with the restorative nursing program (RNP) as planned after discharge from physical therapy. Despite the care plan's directive for daily ambulation assistance, the resident reported not using the prosthetic due to pain and had not walked for weeks. Staff interviews revealed inconsistencies in the RNP's implementation, with some staff unaware of the resident's ambulation status and others noting refusal to wear the prosthetic. The facility lacked a formal RNP policy.
A resident with severe cognitive impairment and a history of falls did not receive consistent fall prevention interventions, such as a floor mat, as outlined in their care plan. Despite being at high risk for falls, the facility failed to maintain necessary safety measures, leading to multiple falls. Observations and staff interviews revealed a lack of adherence to the care plan and inadequate communication, contributing to the deficiency in providing a safe environment.
A facility failed to monitor and assess a resident's respiratory status, leading to improper oxygen use and lack of medication administration. The resident, with COPD and impaired cognition, had no documented interventions for oxygen use in their care plan. Observations showed the resident's nasal cannula was often misplaced, and no respiratory assessments were conducted. Staff interviews revealed confusion about oxygen orders and the use of PRN inhalers, with no specific guidelines provided for respiratory assessments.
A resident with a history of stroke and diabetes, dependent on tube feeding, did not receive care in accordance with enhanced barrier precautions (EBP). An LPN was observed performing tube feeding care without wearing a gown, despite EBP signage and facility policy requiring PPE for high contact care. The LPN was misinformed about the necessity of EBP, contrary to the facility's policy and the director of nursing's guidance.
A resident with multiple pressure ulcers did not have wound care orders properly documented in the EMR, leading to a lack of continuity in care. Despite having a care plan, it lacked specific directions for dressing changes. Observations showed that dressing changes were not documented, and the director of nursing confirmed the absence of orders in the EMR, indicating a breakdown in communication and documentation processes.
Deficiencies in Food Storage, Labeling, and Dishwashing Procedures
Penalty
Summary
Surveyors observed multiple deficiencies in food storage, labeling, and handling within the facility. In the main kitchen, a stand-up freezer contained a pan of beef roast with loose plastic wrap and visible ice crystals, and a refrigerator held cut pineapple and turkey lunch meat without dates, as well as sour cream past its best-by date. The dry storage area had empty chemical buckets with residual contents and holes in the lids stored on the floor. Staff interviews confirmed that open food items should be dated and expired items discarded, and acknowledged that chemical buckets should not be stored near food. On resident care floors, refrigerators and freezers contained several unlabeled and undated food items, including milk, sandwiches with visible mold, thawed frozen meals, bread past its best-by date, and take-out containers. Ice packs were stored alongside food, contrary to staff expectations. Staff interviews revealed uncertainty about responsibility for monitoring and cleaning resident refrigerators, with some believing it was the kitchen staff's duty, while others were unsure or thought it might be activities or housekeeping. The DON confirmed that all food should be labeled with the resident's name and date, and that expired or open items should be discarded after three days. Dishwashing procedures were also found deficient. The dishwasher temperature log was blank, and dietary aides were unaware of the required wash and rinse temperatures or proper monitoring procedures. Observed wash and rinse cycles did not consistently reach the temperatures indicated on posted signage. Staff reported a lack of formal training on dishwashing temperatures, and the Corporate Dietary Director acknowledged that only some staff had received education on this process. Facility policy required labeling and dating of resident food and proper disposal after three days, but a food storage policy was not provided when requested.
Failure to Track Latent TB and Enforce Contact Precautions for Residents on Isolation
Penalty
Summary
The facility failed to properly identify and track a potential infection for a resident diagnosed with latent tuberculosis (TB). The resident, who had cognitive impairment and chronic lymphocytic leukemia, was prescribed rifampin for latent TB, but this diagnosis and antibiotic use were not documented on the facility's Monthly Line Listing Infection Report. The infection preventionist confirmed that the resident was not included in the infection tracking system and was unaware of the need to monitor this case. Additionally, the facility did not ensure that transmission-based precautions were consistently implemented for two residents on contact isolation for MRSA. Observations revealed that staff, including nursing assistants, an LPN, and a social services staff member, entered the shared room of these residents without donning the required personal protective equipment (PPE), despite clear signage on the door instructing staff to wear gowns and gloves. Staff interviews indicated confusion about when PPE was necessary, with some believing it was only required for direct care and not for other interactions such as delivering meal trays or asking questions. The care plans for the residents on contact precautions directed staff to follow enhanced barrier precautions and to don and doff PPE as indicated. However, the observed practices did not align with these instructions or with CDC recommendations, which require PPE for all interactions that may involve contact with the resident or their environment. The facility's infection prevention and control policy also required the use of surveillance tools to recognize infections and the implementation of appropriate isolation precautions, which was not consistently followed.
Failure to Ensure Proper Application of Compression Stockings
Penalty
Summary
The facility failed to ensure that a resident's compression stockings (TED stockings) were applied correctly, as required by physician orders and the resident's care needs. The resident, who had moderately impaired cognition and diagnoses including spondylosis with myelopathy, muscle weakness, and dementia, was noted to be independent with activities of daily living but had a physician's order for TED stockings to be worn during the day and removed at night. Observations on multiple occasions revealed that the resident's TED stockings were rolled down to the ankles, with excess material hanging off the toes, causing indentations and a red area on the right ankle. The resident stated he put on his own TED stockings, but staff were responsible for ensuring they were applied correctly. Interviews with nursing staff and the director of nursing confirmed that, even when a resident prefers to apply their own TED stockings, it is the responsibility of nurses and nursing assistants to ensure the stockings are worn correctly and according to orders. The resident's care plan did not include any information about the use of TED stockings or the resident's preferences regarding them. Additionally, a facility policy regarding the use of TED stockings for edema was requested but not provided.
Failure to Provide Oral Hygiene Assistance for Dependent Residents
Penalty
Summary
The facility failed to provide necessary oral hygiene services for five out of six residents reviewed for activities of daily living. Multiple residents with cognitive impairments and significant medical conditions, such as severe mental impairment, alcoholic cirrhosis, failure to thrive, schizophrenia, and autistic disorder, were observed to lack assistance with oral care. Observations and interviews revealed that oral care supplies were often unopened or missing from residents' rooms, and residents reported not receiving assistance with oral hygiene. Staff interviews indicated uncertainty regarding the use of oral care supplies and the frequency of oral care, with some staff unfamiliar with residents' needs or care plans. Care plans for these residents indicated a need for assistance with personal hygiene, including oral care, but this assistance was not consistently provided. Residents dependent on staff for oral hygiene either did not receive help or only received it sporadically, and some were unaware of how to use the provided supplies. The facility's policy required staff to maintain residents' abilities in activities of daily living, including oral hygiene, but this standard was not met for the residents reviewed.
Failure to Provide Adequate Hydration Consistent with Resident Needs
Penalty
Summary
The facility failed to provide drinks, including water, consistent with the needs and preferences of five out of six residents reviewed for hydration. Multiple residents with varying degrees of cognitive and physical impairment did not have water or other fluids readily available in their rooms outside of meal and medication times. Observations and interviews revealed that residents often relied on staff or visitors to obtain water, and some expressed a desire for water throughout the day. In several cases, residents were dependent on staff for assistance with drinking, but water was not present or accessible in their rooms. One resident's friend provided water during a visit, and another resident reported only receiving fluids with meals and medications. Staff interviews indicated uncertainty about hydration protocols, and one nursing assistant noted the lack of reusable water mugs on the floor, with staff using small disposable cups instead. The care plans and physician orders for these residents included specific instructions for hydration, such as offering fluids between meals and monitoring for signs of dehydration. Despite these directives, observations showed that water was not consistently available, and staff were not always aware of or following hydration protocols. The DON stated that water should be readily available and that staff were expected to check rooms, but this was not observed in practice. Facility policy required maintaining adequate hydration for all residents, but the observed practices did not align with this policy.
Failure to Ensure Beard Nets Worn by Food Preparation Staff
Penalty
Summary
The facility failed to follow infection control guidelines by not ensuring that staff with facial hair wore beard nets while preparing food in the kitchen. During an observation, a cook with a full beard was seen working in the kitchen without a beard net and confirmed that he had prepared food on multiple days without one because the facility was out of beard nets. The cook acknowledged awareness of the requirement to wear a beard net to prevent hair from contaminating food. A dietary aide reported that the kitchen manager was not present because she had left to purchase beard covers. The administrator stated that staff were expected to wear beard covers and should have communicated the supply shortage so that arrangements could be made to obtain more. Facility policy required the use of hair nets and beard restraints to prevent hair from contacting exposed food and clean equipment.
Neglect Due to Delayed Call Light Response and Staff Discouragement
Penalty
Summary
A nursing assistant (NA) failed to respond promptly to a resident's call light and instructed the resident to limit the use of the call light to emergencies only. The resident, who had recently been admitted and was alert and oriented, used the call light frequently for various needs, including personal care, water, pain medication, and wound care. The NA admitted to intentionally delaying responses, sometimes waiting up to ten minutes before checking on the resident, and prioritized other residents' needs over this resident. The NA also communicated to the resident that unless it was an emergency, he should not use the call light as often, citing the resident's confusion and frequent requests as justification. Other staff, including registered nurses and the administrator, were unaware of the NA's actions and stated that such behavior was unacceptable and not in line with facility expectations. The facility's policy defined neglect as the failure to provide necessary goods and services to avoid physical harm, mental anguish, or emotional distress. The incident was identified as neglect, as the resident's needs were not addressed in a timely manner, and the resident was discouraged from seeking assistance through the call light system.
Deficient Care Planning for Residents
Penalty
Summary
The facility failed to ensure comprehensive, person-centered care plans were developed and adjusted as needed for three residents, leading to deficiencies in care planning. Resident 1's care plan lacked focus areas for bowel and bladder incontinence and dental care, despite these issues being identified in the Minimum Data Set (MDS) and Care Area Assessments (CAAs). The resident required substantial assistance for toileting and oral hygiene, experienced occasional bladder incontinence, and was free of natural teeth, yet these needs were not adequately addressed in the care plan. Resident 2's care plan was incomplete, with several focus areas left blank or not completed, including fall risk, alteration in mobility, and self-care deficit. The resident had a history of falls, used high-risk medications, and experienced frequent pain impacting daily activities. Despite these concerns, the care plan lacked specifics and did not address pain management, toileting, or high-risk medication usage. The care plan also failed to reflect the discontinuation of occupational and physical therapy, which were initially included as interventions. Resident 3's care plan was similarly deficient, with several focus areas left blank or not completed, such as alteration in skin integrity, self-care deficit, and alteration in communication. The resident was severely cognitively impaired, required physical assistance, and had multiple medical conditions, including diabetes and a pressure ulcer. Despite these needs, the care plan did not address the resident's right arm pain, activities, or high-risk medication usage. Interviews with staff revealed a lack of comprehensive care planning, with expectations for detailed and updated care plans not being met, increasing the risk of neglect and unmet needs.
Failure to Reassess and Update Care Plan for Pressure Ulcer Risk
Penalty
Summary
The facility failed to comprehensively reassess the pressure ulcer risk and adjust the care plan for a resident who developed an avoidable stage II pressure ulcer on the coccyx. The resident, who was admitted from an acute care hospital, was severely cognitively impaired and required physical assistance with care and mobility. The resident was at risk for pressure ulcers due to total bowel and bladder incontinence, diabetes, aphasia, cerebrovascular accident, dementia, hemiplegia, and seizure disorder. Despite being assessed as at moderate risk for pressure ulcers, the resident was initially free of pressure ulcers upon admission. The resident's care plan included interventions such as using an incontinent product, repositioning every two hours, and routine skin care. However, after the pressure ulcer was identified, the facility did not comprehensively reassess the resident's pressure ulcer risk or update the care plan to reflect the new condition. The care plan lacked specific interventions related to the pressure ulcer, and the nursing staff did not document a comprehensive assessment of the pressure ulcer risk after its discovery. Interviews with staff revealed a lack of awareness and documentation regarding the resident's pressure ulcer and the necessary interventions to prevent further skin breakdown. The facility's policy required a pressure ulcer risk assessment and appropriate preventative measures, such as mobility and repositioning plans, to be implemented. However, the resident's care plan did not include individualized interventions for pressure ulcer prevention, and the staff did not update the care plan or resident care lists after the ulcer was identified. The Director of Nursing acknowledged that the pressure ulcer was avoidable and that the resident's care plan should have included specific interventions to prevent skin breakdown.
Failure to Verify Nurse Aide Registration for Agency Staff
Penalty
Summary
The facility failed to verify the nurse aide registration for an agency nursing assistant (NA-A) before allowing him to work directly with residents. This oversight occurred on NA-A's first shift at the facility, where he provided care to residents, including hygiene, dressing, feeding, and mechanical lift transfers. The staffing coordinator (SC) acknowledged that the shift request for NA-A was last minute, which prevented her from verifying his registration before he began working. The SC relied on an agency electronic portal system to request and verify licensure or nurse aide registration, but due to the specific agency's process, this information was not immediately available. The director of human resources (DHR) stated that she only managed paperwork for facility staff, not agency staff, and expected the SC to handle agency paperwork. The administrator expected both DHR and SC to ensure agency staff met all requirements, including licensure verification, to maintain resident safety. The SC eventually received confirmation of NA-A's active nurse aide registration via email from the agency on the same day, but this was after NA-A had already worked with residents. The facility did not maintain agency staff employee files, as they accessed information through the agency's portal.
Failure to Transcribe and Administer Medication for Fungal Infection
Penalty
Summary
The facility failed to ensure that a medicated powder for a fungal skin infection was transcribed and applied according to provider orders for a resident with skin breakdown. The resident was assessed by a nurse practitioner for moisture-associated skin damage and a rash, and an order was made for Nystatin powder to be applied to specific areas three times a day. However, the order was not transcribed correctly, and the medication was not administered as scheduled, leading to a lack of treatment for several days. The resident's Medication Administration Record (MAR) showed that the Nystatin order was scheduled to start the day after it was ordered, but there were multiple instances where the medication was not administered. The order was not confirmed and revised until several days later, which resulted in the medication not being applied until then. The resident's condition deteriorated during this period, with the rash spreading and requiring more aggressive treatment. Interviews with staff revealed a lack of awareness and communication regarding the missed medication applications. The Director of Nursing and the administrator were unaware of the issue until it was brought to their attention, and the Health Information Assistant and Licensed Practical Nurse involved in the order process could not recall details about the order. The facility's Medication Error Procedure and Medication and Treatment Orders policy were not followed, contributing to the deficiency.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to immediately report allegations of physical abuse to the State Agency within the required two-hour timeframe. A resident, R3, reported that during morning care, staff placed a pillow over her roommate R2's mouth to stop her from screaming. R3 had previously witnessed a similar incident but did not report it because another staff member intervened. On the day of the incident, R3 informed both an LPN and a nursing assistant about her concerns, but neither reported the allegations to management. R2, the resident allegedly abused, was unable to complete a mental status assessment and was dependent on staff for daily activities. Despite R3's report, R2 denied any abuse when questioned by the LPN. The LPN, who spoke Hmong, did not report the allegations because R2 denied them. The nursing assistant also failed to report, assuming the LPN would handle it. The Director of Nursing was unaware of the allegations until informed by the surveyor. The facility did not provide a policy on abuse reporting when requested.
Failure to Honor Resident's Bathing Preferences
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not providing bathing preferences for a resident, identified as R74. The resident's admission Minimum Data Set (MDS) indicated that an interview for preferences, including bathing preferences, should have been conducted, but it was not assessed. The resident was dependent on staff for showering and bathing, and the care plan indicated a weekly bath schedule. However, the care sheet lacked information on when or what type of bath the resident would receive. The resident's medication administration record and treatment administration record showed a bath was to be given within 24 hours of admission and then follow a bath day schedule, but documentation was inconsistent. Interviews and observations revealed that the resident had not received a shower since admission and had only received sponge baths twice. The resident expressed dissatisfaction with the lack of showers and had visible signs of neglect, such as an odor and long, dirty fingernails. Staff interviews indicated that the resident had a bath schedule, but there was confusion and inconsistency in following it. The resident preferred to sleep in and did not like to get up early, which was not accommodated in the bath schedule. The facility's staff, including the director of social services, nursing assistants, and therapists, acknowledged the resident's preferences but failed to document refusals or adjust the care plan accordingly. The director of reimbursement and registered nurse involved in completing the MDS admitted that section F, which includes resident preferences, was not consistently completed. The director of nursing confirmed the importance of knowing resident preferences and updating care plans accordingly but acknowledged the MDS was not completed. The facility lacked a policy regarding preferences, contributing to the oversight in honoring the resident's bathing preferences.
Failure to Maintain Resident Privacy During Personal Care
Penalty
Summary
The facility failed to maintain privacy for two residents during personal care activities. Resident R42, who is cognitively impaired and dependent on staff for various activities of daily living, was observed receiving care with the door shut but the privacy curtain not pulled. This left R42 exposed when an unidentified staff member entered the room, despite the resident being undressed and facing the wall. Similarly, Resident R64, who is cognitively intact but always incontinent and dependent on staff for personal hygiene, was also observed receiving care without the privacy curtain pulled. This resulted in R64's private areas being exposed when several staff members entered the room. The nursing assistant (NA-A) involved in the care of both residents acknowledged that the privacy curtains in the rooms were stuck and not functioning properly, which prevented them from being used to ensure privacy. NA-A had submitted a work order for the repair of the curtains, but the issue had not been resolved at the time of the observations. The Director of Nursing (DON) confirmed that it was the facility's expectation for staff to provide privacy for residents during personal care by using the curtains. However, the facility's resident privacy policy was not provided upon request.
Failure to Maintain Cleanliness of Tube Feeding Equipment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for a resident who was dependent on staff for all activities of daily living and had a feeding tube through which they received more than 50% of their nutrition. The resident had a history of traumatic brain injury, hemiparesis, and aphasia. Observations revealed that the support legs of the tube feeding pump pole had a dried brown substance, identified as enteral feeding liquid, adhered to them. This substance was noted on multiple occasions over several days, indicating a lack of timely cleaning by the nursing staff. Interviews with the nursing staff, including a registered nurse and the nurse manager, confirmed that the pole was dirty and should have been cleaned. The staff acknowledged that it was their responsibility to clean the equipment once a spill was identified. Despite this, the dried substance remained on the pole for several days. The director of nursing also confirmed that the expectation was for nursing staff to clean equipment immediately if it was dirty. However, the facility was unable to provide a cleaning policy regarding tube feeding pump poles when requested.
Failure to Complete Comprehensive Assessment and Implement Resident Preferences
Penalty
Summary
The facility failed to ensure a comprehensive assessment was developed, completed, and implemented for a resident, identified as R74, upon admission and periodically as required. The resident's Minimum Data Set (MDS) indicated intact cognition and dependency on staff for showering and bathing. However, the MDS lacked an assessment of the resident's preferences for bathing, as required under Section F of the Resident Assessment Instrument (RAI) manual. The resident's care plan and care sheet also lacked specific information regarding the type and timing of baths. Interviews and observations revealed that the resident had not received a shower since admission and had only been given sponge baths twice. The resident expressed dissatisfaction with the lack of showers and had an odor and untrimmed fingernails. Staff interviews indicated that the resident had a bath schedule, but documentation of baths or refusals was inconsistent or missing. The resident's preferences for bathing were not incorporated into the care plan, and the MDS section F was not consistently completed. The facility's staff, including the Director of Reimbursement, Registered Nurse, and Licensed Practical Nurse, acknowledged the importance of completing the MDS and incorporating resident preferences into the care plan. However, they admitted that section F of the MDS was not consistently completed, and there was a lack of documentation regarding the resident's bathing schedule and preferences. The Director of Nursing confirmed the absence of a policy regarding the MDS and emphasized the importance of knowing resident preferences.
Failure to Implement Restorative Nursing Program for Resident with Mobility Issues
Penalty
Summary
The facility failed to ensure that a restorative nursing program (RNP) was completed for a resident with mobility issues. The resident, who has a history of peripheral vascular disease, muscle weakness, difficulty in walking, and an acquired absence of the right leg above the knee, was discharged from physical therapy with a plan to continue ambulation through an RNP. Despite the care plan directing staff to assist the resident in ambulating daily with a prosthetic leg, the resident reported not using the prosthetic due to pain and had not walked for four weeks. Interviews with staff revealed inconsistencies in the implementation of the RNP, with some staff unaware of the resident's ambulation status and others noting the resident's refusal to wear the prosthetic. The resident's treatment administration record (TAR) indicated that the RNP order was being completed, but an interdisciplinary team (IDT) note later identified the resident as not appropriate for the program due to refusal to participate, citing pain with the prosthetic fitting. Despite this, the resident expressed a desire to walk and was able to ambulate with assistance after the IDT meeting. The facility's director of nursing stated that staff should follow orders and document refusals appropriately, but there was no restorative nursing program policy provided upon request, indicating a lack of formal guidance for staff.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement adequate interventions to prevent falls for a resident with a history of repeated falls. The resident, identified as R19, had severe cognitive impairment and required extensive assistance for mobility and toileting. Despite being at high risk for falls due to impaired mobility, unsteady gait, and a history of seizures, the facility did not consistently implement or maintain necessary safety interventions, such as a floor mat next to the bed, as outlined in the resident's care plan. R19 experienced multiple falls, including one on 6/12/24, where the resident was found on the floor next to the bed. The interdisciplinary team (IDT) reviewed the incident and added a floor mat as an intervention. However, subsequent observations revealed that the floor mat was not consistently in place, and staff were not following the care plan. On 6/24/24, R19 was observed trying to get out of bed without a floor mat present, despite the care plan indicating its necessity. Interviews with staff, including a licensed practical nurse manager and the director of nursing, revealed a lack of communication and adherence to the care plan. The facility's policy on fall prevention and management was not effectively implemented, as evidenced by the lack of consistent interventions and documentation. The resident's fall risk evaluations and risk management reports highlighted the need for interventions, yet these were not adequately addressed. The failure to maintain the floor mat and ensure staff followed the care plan contributed to the resident's continued risk of falls, demonstrating a deficiency in providing a safe environment for the resident.
Failure to Monitor and Assess Respiratory Status
Penalty
Summary
The facility failed to ensure ongoing monitoring and assessment of a resident's respiratory status and did not provide respiratory medications as indicated. The resident, identified as R50, had a significant change in their Minimum Data Set (MDS) indicating severely impaired cognition and a diagnosis of chronic obstructive pulmonary disease (COPD). Despite the resident's care plan identifying a potential for respiratory distress, it lacked specific interventions for oxygen use. The resident's physician orders included an albuterol inhaler for wheezing or shortness of breath, but the Medication Administration Record (MAR) showed no administration of the inhaler. Observations and interviews revealed that the resident's oxygen use was not properly documented or monitored. On multiple occasions, the resident was found with the nasal cannula improperly placed or on the floor, and there was no respiratory assessment conducted before or after oxygen therapy. The resident's oxygen saturations and respiratory rate had not been checked since a previous date, and there was no order for oxygen use in the electronic medical record, despite a verbal order being given earlier in the month. Staff interviews indicated a lack of awareness and adherence to proper procedures for oxygen use and respiratory assessments. Nursing staff were unsure about the necessity of orders for oxygen use and the appropriateness of using the PRN inhaler for shortness of breath. The facility's standing house orders lacked specific guidelines for respiratory assessments with oxygen use, and a policy for respiratory assessments was not provided upon request.
Failure to Follow Enhanced Barrier Precautions During Tube Feeding
Penalty
Summary
The facility failed to ensure staff utilized enhanced barrier precautions (EBP) for a resident during tube feeding care. The resident, who had a history of stroke, aphasia, diabetes, malnutrition, and was dependent on tube feeding for nutrition, was observed receiving care without the proper use of personal protective equipment (PPE) as required by EBP. The resident's care plan and active orders specified the need for EBP, including the use of gloves and gowns during high contact care activities such as tube feeding. During an observation, an LPN was seen entering the resident's room, wearing gloves but not a gown, and performing tube feeding care, which included handling the feeding tube and associated equipment. Despite the EBP signage on the door and the facility's policy requiring gowns and gloves for residents with indwelling medical devices, the LPN did not adhere to these precautions. The LPN later stated she was informed by an unidentified person that EBP was not necessary for tube feeding care, contradicting the facility's policy and the director of nursing's statement that PPE should be worn in accordance with EBP for device care.
Failure to Document Wound Care Orders
Penalty
Summary
The facility failed to ensure that the wound care provider's treatment orders were properly transcribed into the medical record for a resident with multiple pressure ulcers. The resident, who had severely impaired cognition and required total assistance for bed mobility and transfers, was at risk for developing pressure injuries. Despite having a care plan in place, the plan lacked specific directions for wound care dressing changes. The wound care provider's orders for the resident's left gluteus pressure ulcer were not documented in the electronic medical record (EMR) or the medication and treatment administration records, leading to a lack of continuity in care. Observations revealed that the dressing changes for the left gluteus pressure ulcer were not being documented as ordered. During wound care rounds, it was discovered that the dressing was wet with drainage, prompting a change in the wound care orders. However, these orders were not entered into the EMR, as expected by the nurse practitioner. The director of nursing confirmed the absence of these orders in the EMR, highlighting a breakdown in communication and documentation processes. The facility's policy required that treatment orders be updated in the care plan, which was not adhered to in this case.
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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