The Villas At The Park
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Louis Park, Minnesota.
- Location
- 4415 West 36 1/2 Street, Saint Louis Park, Minnesota 55416
- CMS Provider Number
- 245083
- Inspections on file
- 24
- Latest survey
- November 20, 2025
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at The Villas At The Park during CMS and state inspections, most recent first.
Two residents at a facility developed worsening pressure ulcers due to inadequate assessment and intervention. One resident's deep tissue injuries progressed to unstageable pressure injuries due to lack of repositioning and heel protection. Another resident's stage two ulcer worsened due to insufficient nutritional support and intervention. The facility failed to implement necessary preventive measures, leading to deterioration in both residents' conditions.
A resident with hemiplegia did not receive the ordered hand splint program due to discomfort and lack of follow-up by the facility. The care plan required a splint to prevent contractures, but the resident reported pain, and the program was not consistently implemented. Staff were unaware of the program, and documentation lacked evidence of refusal or rationale for discontinuation. Observations showed the resident's hand was contracted, and there was no policy provided for assistive devices.
A resident with a history of falls did not receive necessary fall prevention interventions, such as non-slip tape, despite being identified as at risk. The care plan and care guide lacked specific fall prevention measures, and staff interviews confirmed the oversight. Observations showed that planned interventions were not implemented, leading to a fall incident.
A resident with pressure injuries and an indwelling catheter did not receive proper infection control measures during wound and catheter care. Staff failed to use enhanced barrier precautions (EBP) and did not follow the facility's catheter care policy, which included using a barrier and alcohol wipes. The facility's policies were not fully implemented, leading to deficiencies in infection control practices.
A facility failed to regularly inspect bed rails, leading to a deficiency. A resident with Alzheimer's and mobility issues had a loose bed rail missing a lock, despite having a physician's order for grab bars. Staff interviews revealed inconsistent inspection practices, and the facility lacked documentation of regular checks. This oversight resulted in the deficiency as the facility did not ensure the safety and maintenance of bed rails.
A resident with intact cognition and multiple respiratory conditions was observed with an Advair inhaler at their bedside without a proper self-administration assessment or physician's order. The facility's policy required a completed assessment and order for self-administration, which were not in place for the Advair inhaler. Staff interviews confirmed the lack of documentation and awareness regarding the resident's ability to self-administer this medication.
A resident with severe cognitive impairment and a history of hallucinations was found to have restricted movement due to pillows placed under the fitted sheet of their bed, blocking the egress section of a perimeter mattress. This intervention was not documented in the care plan, and staff were unaware of its use as a fall prevention measure. Interviews revealed that the use of pillows was not a recognized intervention, and the facility's policy lacked guidance on ensuring interventions were not restraints.
The facility failed to implement physician orders for compression stockings for two residents with edema. One resident, with heart failure and brain neoplasm, was often without stockings due to lack of documentation and staff confusion. Another resident, with chronic venous insufficiency, also lacked proper documentation and was not wearing compression socks as required. Staff interviews revealed a lack of awareness and adherence to orders, highlighting a deficiency in care practices.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to comprehensively assess and implement pressure ulcer interventions for two residents identified at risk for pressure ulcers, resulting in actual harm. One resident, referred to as R30, developed two deep tissue injuries that worsened to unstageable pressure injuries on the heels after admission. The facility did not include necessary interventions such as floating heels or a turning and repositioning schedule in the care plan. Despite being at high risk due to limited mobility and other comorbidities, R30 was not repositioned according to the care plan, and the facility failed to accurately assess the resident's sensory perception issues, which contributed to the development of pressure ulcers. Another resident, referred to as R33, developed a stage two pressure ulcer that worsened to an unstageable pressure ulcer. The facility failed to accurately stage the pressure ulcer and did not assess the resident's nutritional needs or implement provider-ordered nutritional interventions to aid in healing. R33 was at risk for pressure ulcers due to extensive assistance needed for bed mobility and incontinence, yet the care plan lacked specific interventions such as a wedge cushion in the bed. The resident experienced weight loss, and the facility did not provide nutritional supplements despite the resident's poor appetite and risk for pressure ulcers. The facility's inaction and lack of appropriate interventions led to the deterioration of the residents' conditions. Observations revealed that staff did not consistently reposition R30 as required, and the resident was not compliant with wearing protective boots, which was not adequately addressed by the facility. The facility's failure to implement timely and effective pressure ulcer prevention measures, such as floating heels and ensuring proper nutrition, resulted in the worsening of pressure ulcers for both residents.
Failure to Implement Hand Splint Program for Resident
Penalty
Summary
The facility failed to implement an occupational therapy (OT) ordered hand splint program for a resident, identified as R14, who was reviewed for positioning and mobility. R14 had a history of hemiplegia affecting the right dominant side and required extensive assistance for bed mobility. The care plan indicated the need for a splint to prevent contractures and manage pain, but the resident reported discomfort with the splint, leading to its non-use. Despite modifications to the splint by OT, the resident continued to experience pain, and the splint program was not consistently followed. The facility's documentation lacked evidence of the resident's refusal of the splint program and did not provide a rationale for discontinuing the splint order. Interviews with staff revealed a lack of awareness and follow-up regarding the splint program. The resident's care conferences and progress notes did not address the splint or contracture issues, and there was no documentation of discussions with the resident about the risks of not wearing the splint or options for reassessment with therapy. Observations showed the resident's right hand was contracted in a fist position, and there was an unpleasant odor, indicating potential skin issues. The facility's policy on maintaining abilities in activities of daily living was not adhered to, as the necessary care and services to prevent the resident's decline were not provided. The facility did not provide a policy on assistive devices or splint programs when requested.
Failure to Implement Fall Interventions for a Resident
Penalty
Summary
The facility failed to implement fall interventions for a resident, identified as R40, who had a history of falls. R40's care plan indicated that the resident was at risk for falls due to osteoarthritis and required various interventions, including physical therapy, a low bed, and a clutter-free room. However, the care plan lacked specific interventions such as applying non-slip tape to the resident's room, which was noted as necessary after a fall incident. Despite the care plan's instructions, the care guide also lacked information on fall prevention interventions. R40 experienced a fall on October 3, 2024, when the resident was found on the floor after attempting to go to the bathroom independently. The interdisciplinary team reviewed the fall and planned to implement interventions such as gripper socks and non-slip tape upon the resident's return from the hospital. However, observations on subsequent days revealed that the non-slip tape was not applied to R40's room, indicating a failure to follow through with the planned interventions. Interviews with staff, including a nursing assistant and a registered nurse, confirmed that R40 was allowed to walk independently in the room and that the intervention for non-slip tape was documented but not implemented. The director of nursing acknowledged the oversight and noted that universal fall precautions were in place, but the specific intervention of non-slip tape was not executed. The facility's policy on fall prevention and management emphasized the importance of implementing fall prevention interventions, which was not adhered to in this case.
Infection Control Deficiencies in Wound and Catheter Care
Penalty
Summary
The facility failed to ensure staff utilized enhanced barrier precautions (EBP) during wound care and did not follow current standards of infection control practice for catheter care for a resident identified as R30. R30 had intact cognition, stress incontinence, neurogenic bladder, two unstageable pressure injuries, and an indwelling catheter. The care plan for R30 included EBP for the foley catheter but lacked EBP for wound care. During an observation, registered nurses entered R30's room without donning the required personal protective equipment (PPE) for wound care, which was only corrected after a surveyor's intervention. Additionally, the facility did not adhere to proper infection control measures during catheter care. A nursing assistant was observed emptying a urinary catheter drainage bag without placing a barrier on the floor or using an alcohol wipe to clean the drainage outlet, as required by the facility's policy. The care plan for R30 included monitoring for signs and symptoms of urinary tract infection (UTI) but did not specify infection control measures during the emptying of the catheter. The facility's policies on EBP and indwelling catheter care were not fully implemented, as evidenced by the lack of PPE use during wound care and the absence of a barrier and alcohol wipe use during catheter care. Interviews with staff, including the director of nursing, confirmed the expectations for PPE use and infection control practices, which were not met during the observed incidents.
Failure to Conduct Regular Bed Rail Inspections
Penalty
Summary
The facility failed to conduct regular inspections of hospital bed rails as part of a maintenance program, leading to a deficiency. A resident, identified as R204, who had intact cognition and required assistance with bed mobility, was observed using a bed rail that was not securely attached to the bed frame. Despite having a physician's order for bilateral grab bars to aid in bed mobility, the left bed rail was found to be loose and missing a lock during multiple observations. Nursing staff and maintenance personnel were interviewed, revealing inconsistencies in the inspection and maintenance of bed rails. While some staff claimed that bed rails were checked frequently, others admitted that they might not check all residents' bed rails regularly. The maintenance director stated that bed rails were checked daily, but he had not been informed of any issues with R204's bed rail. The administrator expected maintenance to check bed rails during rounds, but a policy or log documenting regular inspections was not provided. The only documentation available was a maintenance log indicating a bed rail inspection on a date prior to the installation of R204's bed rail. This lack of documentation and inconsistent practices contributed to the deficiency, as the facility did not ensure the safety and proper maintenance of bed rails for residents who required them.
Failure to Ensure Proper Self-Administration Assessment and Physician's Order
Penalty
Summary
The facility failed to ensure a self-administration assessment (SAM) and a physician's order were completed for a resident to safely self-administer their medication. The resident, who had intact cognition and multiple cardiorespiratory conditions, was observed with an Advair diskus inhaler at their bedside. Despite having a physician's order to self-administer a nebulizer after nursing setup, there was no order or assessment for the resident to self-administer the Advair inhaler. The resident's Self Administration of Medication Evaluation form indicated they were capable of self-administering inhalation medication, specifically the nebulizer, but did not include the Advair inhaler. Several checkboxes on the form were left unmarked, indicating incomplete assessment of the resident's ability to self-administer medications. Observations over several days confirmed the presence of the Advair inhaler at the resident's bedside, and staff interviews revealed a lack of awareness and documentation regarding the resident's ability to self-administer this medication. Interviews with facility staff, including a trained medication aide and licensed practical nurses, confirmed that there was no physician's order for the resident to self-administer the Advair inhaler. The facility's policy required a completed SAM and physician's order for self-administration, which were not in place for the Advair inhaler. The director of nursing verified that the SAM evaluation form did not include the Advair inhaler, and the facility's policy on self-administration of medications emphasized the need for a comprehensive assessment and documentation in the medical record and care plan.
Improper Use of Physical Restraints on a Resident
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, as observed when multiple pillows were placed under the fitted sheet of the resident's bed, blocking the egress section of a perimeter mattress. This setup restricted the resident's movement and was not easily removable by the resident, who was identified as having severely impaired cognition and a history of hallucinations and delusions. The resident, who had a traumatic brain injury and anxiety, required extensive assistance for bed mobility and transfers and was at risk for falls. The resident's care plan and associated documentation did not include the use of pillows as a fall intervention, and there was no evidence of a thorough assessment or interdisciplinary team involvement regarding the use of such restraints. Nursing staff and the resident's guardian were unaware of the pillows being part of the care plan, and the facility's policy on fall prevention lacked guidance on ensuring interventions were not restraints. Observations revealed that the resident attempted to crawl out of bed but was impeded by the pillows, which were placed under the fitted sheet by nursing assistants. Interviews with staff, including registered nurses and the director of nursing, indicated that the use of pillows was not a recognized intervention and could potentially increase the risk of injury or behavioral issues. The physical therapist also noted that the pillows were not a realistic intervention and could hinder mobility. The facility's failure to properly assess and document the use of pillows as a restraint led to the deficiency, as it restricted the resident's freedom of movement without appropriate justification or documentation.
Failure to Implement Compression Stocking Orders for Residents with Edema
Penalty
Summary
The facility failed to implement physician orders for compression stockings for two residents, R40 and R45, who were reviewed for edema. R40 had a medical history including heart failure and brain neoplasm, and required compression stockings as per physician orders to manage lower extremity edema. However, the care plan and nursing assistant care guide lacked documentation of this requirement. Observations revealed that R40 was often without compression stockings, and interviews with staff indicated confusion about who was responsible for applying them. The registered nurse acknowledged that R40 was unable to put on the stockings independently and that the nursing assistants should have been applying them. Similarly, R45, who had chronic venous insufficiency, also required compression socks as per physician orders. However, the facility's records, including the Medical Administration Record and Treatment Administration Record, lacked documentation of the use or refusal of compression socks. Observations showed that R45 was not wearing compression socks, and interviews revealed that staff were unaware of the orders or the location of the socks. The registered nurse and licensed practical nurse confirmed the need for compression socks but noted they were not listed in the care plan or electronic medical record. The director of nursing stated that staff were expected to follow physician orders and document them accordingly, but this was not done for either resident. The facility did not provide a specific policy on edema management, but their policy on Activities of Daily Living indicated that necessary care and services should be provided to maintain or improve residents' abilities. The lack of adherence to physician orders for compression stockings for both residents highlights a deficiency in the facility's care practices.
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 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 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 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 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 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 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 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 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 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 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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