The Waterview Woods Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Eveleth, Minnesota.
- Location
- 601 Grant Avenue, Eveleth, Minnesota 55734
- CMS Provider Number
- 245277
- Inspections on file
- 37
- Latest survey
- November 20, 2025
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at The Waterview Woods Llc during CMS and state inspections, most recent first.
A resident's bathroom was left with a missing ceiling tile and a wet, stained towel covering an opening above the toilet for at least a month, with ongoing water leakage and standing water present. Staff confirmed the issue persisted, and the infection preventionist noted increased infection risk due to the wet environment.
A resident with multiple serious diagnoses was prescribed buprenorphine 1mg (half of a 2mg tablet) sublingually three times daily, but was given a whole 2mg tablet on six occasions. Documentation and interviews with nursing staff and the acting DON confirmed the error, which was inconsistent with physician orders and facility policy requiring adherence to the five rights of medication administration.
A resident with heart failure and cognitive impairment fell during a transfer using a ceiling lift with an incorrect sling, resulting in a head laceration. The nursing assistant, unfamiliar with the resident, used a half sling found in the room, leading to the resident slipping out and falling. The facility lacked documentation on the correct sling type and size, contributing to the incident.
A facility failed to include specific sling type and size in care plans for residents requiring mechanical lift transfers, leading to a fall incident. One resident with heart failure and aortic stenosis fell during a transfer due to improper sling use, resulting in a head injury. Staff interviews revealed inconsistencies in sling use guidance, and care plans lacked necessary details, despite slings being correct per manufacturer guidelines.
A resident with a known shellfish allergy was served shrimp, resulting in an allergic reaction and emergency treatment. The deficiency was due to a communication failure in documenting and relaying food allergies to kitchen staff. The resident's allergy was not included on the meal ticket, and the dietary sheet lacked a designated area for allergies, leading to the oversight.
The facility did not maintain 8 hours of continuous RN coverage daily, as required, during the third quarter of 2024. This deficiency was confirmed by the CMS PBJ Staffing Data Report, which identified specific dates lacking the required RN presence. The administrator acknowledged the absence of RN coverage and its importance for resident safety. The facility's scheduling and RN coverage policies were not provided.
The facility failed to provide a substantive snack after dinner, resulting in a 15-hour gap between meals, potentially affecting all residents. Interviews revealed that snacks were not readily offered, and residents had to request them. A resident with Parkinson's and diabetes confirmed the absence of an evening snack pass, and LPNs corroborated the lack of a snack cart. The facility's policy of not exceeding 14 hours between meals without a substantial snack was not followed.
The facility failed to ensure proper PPE use for a resident with enhanced barrier precautions, leading to inadequate infection control. Nursing assistants did not wear full PPE during care, and the facility did not conduct necessary COVID-19 testing or infection surveillance among staff. Additionally, the facility lacked an annual review of infection control policies and did not provide evidence-based criteria for infection identification to nursing staff.
A resident with dementia and impaired cognition, requiring supervision during meals, was found eating unsupervised in bed, contrary to their care plan. The resident was on a mechanical soft diet due to swallowing difficulties and was at risk for choking and aspiration. Staff interviews revealed a lack of awareness about the incident, and the DON confirmed the expectation for supervision was not met.
A facility failed to assess and obtain informed consent for bed rail use for a resident with a hip fracture requiring moderate assistance. The resident's care plan and medical record lacked necessary assessments and consent forms. Staff interviews confirmed the absence of required documentation, and the facility's bed rail use policy was not provided.
Failure to Maintain Safe and Clean Resident Environment Due to Ongoing Water Leak
Penalty
Summary
A deficiency was identified when a resident's bathroom was observed to have a missing ceiling tile directly above the toilet, with a wet, stained towel draped across the opening and free-standing water present on the toilet. The resident, who had intact cognition and diagnoses including hypertension, hyperlipidemia, and renal insufficiency, reported that the ceiling tile had been missing and the towel in place for at least a month due to a leak from the room above. Staff interviews confirmed that the condition had persisted for at least a month, with ongoing water leakage resulting in soaked toilet paper and the need to discard it during cleaning. The maintenance director indicated that the leak above had been repaired, but the towel remained to monitor for further leakage. The infection preventionist acknowledged that the presence of wet towels and standing water increased the risk of infection and illness. The regional director of operations stated that such a situation would typically require the resident to be moved and the area repaired before reoccupancy. No policy for environmental services water leakage was provided upon request.
Failure to Administer Correct Dose of Buprenorphine
Penalty
Summary
A deficiency occurred when a resident with diagnoses including a pathological fracture, malignant neoplasm of the esophagus, and aftercare for joint replacement did not receive the correct dose of buprenorphine as ordered by the physician. The physician's order specified that the resident should receive 1mg (half of a 2mg tablet) sublingually three times a day. However, documentation and medication card review revealed that on six separate occasions, the resident was administered a whole 2mg tablet instead of the prescribed half tablet. The medication card was bubble packed with 2mg tablets, and nursing staff were responsible for splitting the tablets to achieve the correct dose. Interviews with an LPN and the acting DON confirmed that the medication sign-out sheet documented the administration of whole tablets rather than half tablets, contrary to the physician's order and facility policy. The facility's policy required nursing staff to follow the five rights of medication administration and to triple check these rights during the process. The failure to administer the correct dose and to document it accurately led to a significant medication error for the resident.
Improper Sling Use Leads to Resident Fall
Penalty
Summary
The facility failed to properly assess, care plan, and ensure the correct sling was used during transfers for a resident reviewed for mechanical lift transfers. The resident was transferred using a ceiling lift with a reported toileting sling of unknown size, which did not cover the buttocks. During the transfer, the resident slipped out of the sling, resulting in a fall and a laceration to the back of the head. This incident was identified as an immediate jeopardy situation. The resident involved had a primary diagnosis of chronic combined systolic and diastolic heart failure and nonrheumatic aortic stenosis, with moderate cognitive impairment. The incident occurred when a nursing assistant, unfamiliar with the resident, used a half sling found in the resident's room for the transfer. The resident began to flail during the transfer, causing them to slip out of the sling and fall to the ground, hitting their head. Interviews with staff revealed that there was a lack of documentation regarding the specific type and size of sling to be used for the resident. The nursing assistant was instructed to use the ceiling lift due to the resident's weakness in the evenings, but the correct sling type and size were not verified. The facility did not have a formal sling assessment form, and the specific sling type and size were not documented in the resident's medical record.
Deficiency in Care Plan for Sling Use in Transfers
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for residents requiring mechanical lift transfers, specifically neglecting to identify the type and size of sling needed. This deficiency was observed in three residents who were reviewed for mechanical lift use. One resident, admitted with chronic heart failure and aortic stenosis, experienced a fall during a transfer when the resident's upper body slid through the sling, resulting in a head injury. The incident report noted that the correct sling and size were used, but the care plan did not specify the sling type or size. Another resident, dependent on staff for transfers due to conditions such as chronic gout and coronary artery disease, also had a care plan that failed to specify the sling type or size. Similarly, a third resident with diagnoses of seizures and arthritis, who was also dependent on staff for transfers, had a care plan lacking this critical information. Interviews with staff revealed that there was confusion and inconsistency in the use of slings, with some staff relying on care sheets that did not provide adequate guidance on sling specifications. The Director of Nursing and other staff members acknowledged the absence of a formal sling assessment form and the lack of documentation regarding sling type and size in the care plans. Observations confirmed that while the slings in resident rooms were correct according to manufacturer guidelines, the care plans did not reflect this information, leading to potential safety risks during resident transfers.
Failure to Prevent Shellfish Allergy Exposure
Penalty
Summary
The facility failed to ensure that a resident with a known allergy to shellfish was not served shellfish, resulting in an allergic reaction. The resident, identified as R209, was admitted to the facility with a documented allergy to shellfish, as noted in both the admission note and care plan dated 10/9/24. Despite this, on 10/13/24, R209 was served a meal containing shrimp, leading to an allergic reaction that required emergency treatment. The incident was identified as an immediate jeopardy situation due to the severity of the allergic reaction. Interviews and document reviews revealed that the communication process for food allergies was flawed. The health unit coordinator (HUC) was responsible for entering allergy information into the electronic medical record (EMR) and completing a dietary sheet for the kitchen staff. However, R209's shellfish allergy was not included on his meal ticket prior to the incident. The culinary director (CD) was the only staff member with access to the dietary system to verify and add food allergies, which contributed to the oversight. Staff interviews indicated that food allergies should be listed on meal tickets and in the EMR, but this was not consistently checked by all staff members. The root cause of the deficiency was identified as a dietary sheet lacking a designated area for allergies, which led to the failure to communicate R209's shellfish allergy to the kitchen staff. This oversight resulted in the resident being served shrimp, despite having a history of severe allergic reactions to shellfish. The facility's policies and procedures for documenting and communicating food allergies were insufficient, leading to the incident where R209 experienced an allergic reaction and required emergency medical attention.
Removal Plan
- All residents were audited for current food allergies.
- The new admission form was modified to add an area specifically to address resident food allergies.
- Dietary policy related to meal tickets was reviewed.
- Resident allergy documentation was reviewed.
- Staff were educated on the meal ticket handling policy and what to do with new admissions form.
Failure to Maintain Continuous RN Coverage
Penalty
Summary
The facility failed to maintain 8 hours of continuous registered nurse (RN) coverage daily, as required. This deficiency was identified through the Centers for Medicare and Medicaid Services' (CMS) Payroll Based Journal (PBJ) Staffing Data Report for the third quarter of 2024, which showed gaps in RN coverage on multiple dates. Specifically, the facility did not have the required RN coverage on 4/6, 4/7, 4/20, 4/21, 4/27, 4/28, 5/19, 5/25, 5/26, 6/1, 6/2, 6/8, 6/9, and 6/22. During an interview, the administrator confirmed the absence of 8 hours of continuous RN coverage on these dates and acknowledged the importance of having an onsite RN for the safety of the residents. The facility's scheduling policy and RN coverage policy were requested but not provided.
Failure to Provide Substantive Evening Snacks
Penalty
Summary
The facility failed to provide a substantive snack after dinner and before bedtime, resulting in a 15-hour gap between the evening and morning meals, which could potentially affect all residents. Interviews and document reviews revealed that the dietary staff were responsible for restocking snacks, but the nursing staff were tasked with distributing them. However, it was found that there was no evening snack cart, and residents had to request snacks, which were not readily offered by the staff. The kitchen closed at 7 p.m., and the unit fridges, which contained sandwiches, were locked at night, making it difficult for residents to access snacks without staff assistance. A resident with intact cognition and diagnoses of Parkinson's disease and type II diabetes mellitus confirmed the absence of an evening snack pass and the need to request snacks. Interviews with LPNs working both day and evening shifts corroborated the lack of a snack cart and the requirement for residents to ask for snacks. The facility's mealtime document specified that there should not be more than 14 hours between meal services unless a substantial bedtime snack is offered, which was not adhered to, leading to the deficiency.
Inadequate PPE Use and Infection Control Measures
Penalty
Summary
The facility failed to ensure proper utilization of personal protective equipment (PPE) for a resident with enhanced barrier precautions (EBP). The resident, who had severely impaired cognition and was post-colostomy, required staff assistance for various care activities. During an observation, two nursing assistants entered the resident's room for repositioning without wearing the full PPE required for EBP, mistakenly believing that full PPE was only necessary for wound care or COVID-19 cases. Interviews with the nursing staff revealed a lack of understanding and adherence to the EBP requirements, despite the facility's expectations for PPE use during high-contact care. Additionally, the facility did not conduct adequate COVID-19 outbreak testing or infection surveillance among staff members. Despite having two current positive COVID-19 cases among residents, the director of nursing (DON) confirmed that no staff testing had been conducted, relying instead on contact tracing and symptom monitoring. The DON admitted to not performing any surveillance of staff for signs or symptoms of illness and acknowledged the absence of a structured approach to infection surveillance. The facility also failed to annually review its infection control policies and procedures, maintain a current list of reportable communicable diseases, and provide evidence-based surveillance criteria to define infections to nursing staff. The DON indicated that the management company was responsible for policy updates, and there was no form or guide for nurses to use McGreer's criteria for infection identification. Interviews with licensed practical nurses revealed a lack of awareness of any specific criteria or tools to define infections before requesting tests.
Failure to Follow Care Plan for Resident with Choking Risk
Penalty
Summary
The facility failed to adhere to provider orders and care plan interventions for a resident with severely impaired cognition and a diagnosis of dementia. The resident required setup and cleanup assistance with meals and was dependent on others for bed mobility and transfers. According to provider orders, the resident was on a mechanical soft diet due to difficulty swallowing and chewing, and the care plan specified that the resident should eat meals with direct supervision and feeding assistance in the dining room. However, on the observed date, the resident was found lying in bed with the head of the bed elevated only about 30 degrees, slouched down, and with a meal tray on an over-the-bed table. The resident had been eating unsupervised, contrary to the care plan, and was at risk for choking and aspiration. Interviews with staff revealed a lack of awareness and recall regarding the resident's unsupervised meal in bed. A nursing assistant who worked the day shift did not remember the resident eating in bed, and another nearby nursing assistant also had no recollection of the incident. A registered nurse confirmed that the resident was at risk for choking and should not have been eating alone in bed. The director of nursing stated that it was not expected for a known choking risk to be eating in bed unsupervised, highlighting a failure in following the care plan and ensuring the resident's safety.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to comprehensively assess and obtain informed consent prior to the use of bed rails for a resident who was reviewed for bed rail use. The resident, who had intact cognition and a diagnosis of hip fracture, required moderate assistance with rolling and repositioning. The resident's care plan did not include information related to the use of bed rails, and the medical record lacked an assessment for bed rail alternatives, entrapment risk, or informed consent for bed rail use. During an observation, bed rails were noted to be attached to the head of the bed on both sides. Interviews with facility staff revealed that a Bed Mobility Device Evaluation form should have been completed for all residents prior to the placement of bed rails, which includes evaluating the resident's ability to use the rails, interventions utilized before bed rails, and fall and injury risk. However, the registered nurse confirmed that no assessment or consent forms were present in the resident's chart. The director of nursing stated that it was expected for all staff performing assessments to complete a mobility device assessment and obtain consent before placing bed rails, but the facility's bed rail use policy was not provided.
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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