Thief River Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Thief River Falls, Minnesota.
- Location
- 2001 Eastwood Drive, Thief River Falls, Minnesota 56701
- CMS Provider Number
- 245252
- Inspections on file
- 33
- Latest survey
- April 1, 2026
- Citations (last 12 mo.)
- 12 (1 serious)
Citation history
Health deficiencies cited at Thief River Care Center during CMS and state inspections, most recent first.
A resident with Alzheimer's disease and a history of exit-seeking behavior eloped from the facility during severe winter weather after staff failed to recognize and communicate recent exit-seeking behaviors, did not update the care plan or elopement risk assessment, and discontinued the use of a wander guard. The resident was found outside in a wheelchair, inadequately dressed, after being last seen in a common area. Documentation and communication lapses among staff contributed to the lack of supervision and failure to prevent the incident.
A resident with severe cognitive impairment and a history of falls was not assisted with toileting as per their care plan, leading to a fall and hip fracture. Despite expressing the need to use the bathroom, staff did not assist the resident, who attempted to self-transfer and fell. The facility's documentation lacked evidence of regular checks and assistance, and there were no audits to ensure compliance with care plan interventions.
The facility failed to maintain the required 180-degree rinse temperature in the dishwasher, compromising dish sanitization. Staff were inadequately trained on temperature monitoring, relying only on front gauges. Maintenance was not informed of the issue, and corrective actions were not consistently followed, leading to repeated instances of insufficient sanitization.
The facility failed to expand COVID-19 testing and contact tracing after positive cases were identified, contrary to CDC guidelines. Despite staff and residents potentially intermingling across units, broad-based testing was not conducted. Additionally, a resident with severe cognitive impairment and medical devices did not receive proper enhanced barrier precautions during care, as staff failed to wear appropriate PPE.
The facility failed to serve meals at safe and palatable temperatures, affecting five residents. Meals were served from an open cart, resulting in food temperatures significantly below the required 135 degrees. The issue was attributed to inadequate warming of the steam table and improper use of the plate warmer function.
A facility failed to assess a resident's electric scooter for mobility, despite the resident being cognitively intact and having discussed the scooter with staff. The care plan did not include the scooter, and no assessment or referral was documented. Social services staff believed an assessment was done, but physical therapy confirmed no referral was received. An undated note about a scooter evaluation was not communicated to nursing staff, and no policy on following up resident requests was provided.
The facility failed to update care plans for two residents, one requiring a new transfer status after a hip fracture and another needing a revised repositioning schedule due to a new skin issue. Despite changes in care needs, the care plans were not updated, leading to inconsistencies in care delivery.
A resident with severe cognitive impairment and incontinence was not provided timely toileting assistance as per her care plan, which required check and change every two hours due to impaired skin integrity. Observations showed the resident was not offered toileting from morning until late morning, resulting in soiled briefs and a scabbed area on her buttocks. Staff interviews revealed a lack of awareness and adherence to the updated care plan.
A resident experienced a significant weight gain and dependent edema, which the facility failed to assess or address. Despite a 13.79% weight increase and visible swelling in the resident's lower extremities, the care plan did not include interventions for these issues. Family concerns about the lack of leg elevation were noted, and although the facility notified the provider, no response or new interventions were documented. The facility's weight monitoring policy was not followed, leading to this deficiency.
A resident with severe cognitive impairment and at risk for pressure ulcers was not repositioned as required by their care plan, leading to the development of a new skin issue. Despite an updated care plan mandating repositioning every two hours, the resident remained in the same position for nearly four hours. Staff interviews revealed a lack of adherence to the repositioning schedule, and the facility's policy to establish individualized repositioning schedules was not effectively implemented.
A resident with a history of epilepsy experienced a seizure after receiving partial doses of Lamotrigine due to a medication administration error at the facility. The resident, who had been seizure-free since 2017, was prescribed Lamotrigine, Keppra, and Zonisamide. However, staff failed to administer the full dose of Lamotrigine on three occasions, leading to a breakthrough seizure and emergency department intervention. The error was attributed to confusion in the medication administration process and was not promptly identified or reported.
A facility failed to honor a resident's rights by removing his shoes to slow his movement, despite his severe cognitive impairment and need for assistance. The resident, diagnosed with Alzheimer's and dementia, was upset by the removal, and his family member confirmed he had to attend an appointment in the rain without shoes. Staff interviews revealed the shoes were taken to limit his mobility due to wandering, but there was no evidence of behaviors justifying this action. Facility policy allows residents to retain personal possessions unless it infringes on others' rights or safety.
A resident with Alzheimer's, dementia, anxiety, and depression, known for inappropriate behavior, was left unsupervised in the dining room and engaged in sexual contact with another female resident diagnosed with Hemiplegia, schizoaffective disorder, depression, anxiety, and aphasia. The incident, witnessed by a nursing assistant, highlighted a lapse in supervision protocols. Despite non-pharmacological interventions and antipsychotic medications, the resident's inappropriate behavior persisted, leading to the incident. Staff acknowledged the need for increased supervision, but the initial plan to have the resident be the first and last in the dining room was ineffective.
The facility failed to report an incident of resident-to-resident sexual abuse to law enforcement. A resident with Alzheimer's and dementia was observed rubbing the genital area of another resident with hemiplegia and schizoaffective disorder. The Director of Nursing admitted the incident was not reported and was unaware of the requirement to do so, violating the facility's policy on reporting suspected crimes.
The facility failed to report an allegation of sexual assault to the state agency for a cognitively impaired resident who accused a male nursing assistant of rape. Despite the resident's history of delusional behavior and false accusations, the facility's staff did not follow the required protocol to report the allegations immediately.
The facility failed to investigate a sexual assault allegation made by a cognitively impaired resident with a history of hallucinations and delusions. Despite the facility's policy requiring thorough investigations, no evidence of an investigation was found, and key staff were either not involved or unaware of the process.
Failure to Prevent Elopement of Cognitively Impaired Resident During Hazardous Weather
Penalty
Summary
A deficiency occurred when a resident with a history of Alzheimer's disease, dementia, and paranoid personality disorder was not provided adequate supervision and was able to elope from the facility during hazardous winter weather. The resident had a documented history of exit-seeking behavior, impaired cognition, and poor safety awareness, and had previously required a wander guard device. However, the wander guard was discontinued after staff determined there were no recent exit-seeking behaviors, and the elopement risk was removed from the care plan. Despite this, the resident continued to display confusion, impulsivity, and had triggers related to the holiday season that were not adequately considered in risk assessments or care planning. On the day of the incident, the resident was last seen by staff in the facility's common area and was later found outside in a wheelchair, inadequately dressed for the severe weather conditions. The resident had expressed a desire to leave and was looking for his truck the evening prior, but this information was not effectively communicated between shifts. Staff interviews revealed that the resident required supervision due to his cognitive deficits and that staff were expected to check on him every two to three hours, but closer monitoring was not implemented despite recent exit-seeking behaviors. Documentation and communication failures contributed to the deficiency. The resident's care plan and elopement risk assessments did not reflect his ongoing risk factors, including his history of elopement, cognitive impairment, and seasonal behavioral triggers. Staff were unaware of the resident's increased risk and did not implement appropriate interventions or monitoring. The lack of timely reassessment and failure to update the care plan after the resident expressed exit-seeking behavior directly led to the resident's unsupervised exit during dangerous weather conditions.
Removal Plan
- A complete head to toe health assessment was completed for R1 upon return to facility
- R1's provider was updated
- An elopement assessment with past and recent risk for elopement was included
- A wander guard was placed on R1's wheelchair
- Reviewed and revised R1's care plan to ensure it included details related to holiday challenges, staff communication, behavioral tracking, and interventions for exit seeking
- Elopement assessment practices were reviewed and revised to best determine resident elopement risk, including consideration of history, mental health, seasonal challenges, and medication changes
- Nursing staff completing elopement assessments were retrained on recognizing and responding to exit seeking behavior
- All staff were trained on R1's care plan changes and facility policy changes
- Facility education document 'Critical Safety Alert: Elopement Prevention & Emergency Protocol' with mandatory interventions and communication requirements was issued
Failure to Assist Resident with Toileting Leads to Fall and Injury
Penalty
Summary
The facility failed to ensure a dependent resident was toileted per request, resulting in actual harm when the resident fell while attempting to self-transfer to the toilet, leading to a hip fracture. The resident, who had severe cognitive impairment and was dependent on staff for toileting, had a history of falls since admission. Despite being care planned for frequent toileting assistance, the resident was not adequately supervised or assisted when expressing the need to use the bathroom. On the day of the incident, the resident expressed a need to use the bathroom after being toileted thirty minutes prior. An activities aide informed nursing assistants of the resident's request, but they did not assist the resident as they were busy with meal service. The resident, unable to wait, attempted to go to the bathroom independently and was later found on the floor with a hip fracture. The care plan directed staff to anticipate and meet the resident's needs, including toileting every two hours and before and after meals, but documentation showed these interventions were not consistently followed. Interviews with staff and family members revealed that the resident was anxious about having accidents and would often attempt to toilet herself. The facility's documentation lacked evidence of regular checks and assistance as per the care plan, and there were no audits to ensure compliance with the care plan interventions. The facility's fall prevention policy required a comprehensive assessment and intervention plan for residents with multiple falls, but it appears this was not effectively implemented for the resident in question.
Dishwasher Temperature Deficiency
Penalty
Summary
The facility failed to ensure that the final rinse temperature of the dishwasher reached the required 180 degrees Fahrenheit to properly sanitize dishes. This deficiency was observed during a kitchen tour where a dietary aide ran plate covers through the dishwasher multiple times, with the rinse temperature only reaching 180 degrees on the third attempt. The temperature logs for January and December showed multiple instances where the rinse temperature was recorded below the required 180 degrees, indicating a recurring issue. Interviews with staff revealed a lack of proper communication and training regarding the dishwasher's operation and temperature monitoring. The dietary aide and cook were unaware of alternative methods to check the dishwasher's temperature, relying solely on the front gauges. Maintenance staff were not informed of the dishwasher's issues, and the repair technician did not provide training on accurate temperature measurement methods. This lack of communication and training contributed to the failure to maintain proper sanitization standards. The facility's policy required a minimum rinse temperature of 180 degrees for sanitization, and staff were expected to take corrective actions if this was not achieved. However, the staff did not consistently follow these procedures, as evidenced by the dietary aide's admission of not knowing what else to do when the rinse temperature was insufficient. The director of dietary services acknowledged the need for staff training in this area, highlighting the deficiency in ensuring proper dish sanitization.
Failure to Expand COVID-19 Testing and Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to expand COVID-19 testing and contact tracing of staff and residents on other units after residents tested positive for COVID-19, as per CDC guidelines. Initially, a nursing assistant (NA-E) developed symptoms and tested positive for COVID-19 after working on the Evergreen unit. Following this, four residents on the same unit also tested positive. Despite these cases, the facility did not extend testing to other units or conduct broad-based testing of all staff and residents, even though staff and residents from different units could potentially intermingle during shifts and activities. The facility's COVID-19 outbreak document indicated that high-risk staff and residents on the Evergreen unit were tested, but other staff and residents who might have been exposed were not included in the testing protocol. The Director of Nursing acknowledged that the facility should have tested the entire facility once additional cases were identified, as staff worked across different units, increasing the risk of spreading the virus. The facility's policy required broad testing if close exposure could not be determined, but this was not implemented. Additionally, the facility failed to implement enhanced barrier precautions (EBP) for a resident with severely impaired cognition and multiple medical devices. During an observation, a nursing assistant did not wear a gown while providing high-contact care, which included peri care and transferring the resident, despite the presence of a PPE cart and signage indicating the need for EBP. The infection preventionist confirmed that staff were educated on EBP and should have worn the appropriate PPE during such care activities.
Failure to Serve Meals at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to ensure that food was served at warm, palatable temperatures for five residents who received meal trays that were out of the acceptable temperature range. On a specific date, a resident with intact cognition and independent eating abilities reported that meals served in their room were almost always cold, regardless of the meal time. Observations during the supper meal service on the Blueberry unit revealed that residents were served meals from an open metal cart, and the food temperatures were significantly below the required 135 degrees, with a hot dog measuring 99.5 degrees and tater tots at 94 degrees. The cook acknowledged that the food was cold and attributed the issue to the dietary aide not allowing the steam table to warm up adequately before meal service and not using the plate warmer function. The Director of Nursing confirmed that the food temperatures were unacceptable and unappetizing. The Director of Dietary Services noted that the use of an open tray cart could contribute to the food cooling off quickly, and reiterated that food is not safe if the temperature drops below 135 degrees. The facility's policy on General Food Preparation and Handling requires all meats to be heated to a safe minimum internal temperature, with hot holding temperatures maintained at 135 degrees.
Failure to Assess Resident's Electric Scooter for Mobility
Penalty
Summary
The facility failed to complete an assessment for a resident's electric scooter, which was intended to increase the resident's mobility. The resident, who was cognitively intact and independent with bed mobility, had a care plan that did not include the use of an electric scooter, despite the resident having one at home and discussing it with the staff. The resident's care plan only mentioned the use of a walker and wheelchair for mobility and required assistance for transfers and walking. The resident's care conference notes and medical records lacked any mention or assessment of the electric scooter. The resident's electric scooter was brought to the facility by the resident's son, but no follow-up was conducted by the staff. Social services staff believed the resident was assessed by occupational therapy and deemed not strong enough to use the scooter, but there was no documentation to support this. The physical therapy assistant confirmed that no referral for scooter assessment was received. An undated note by social services staff mentioned a scooter evaluation but was not communicated to the nursing staff. The facility did not provide a policy regarding follow-up on resident requests.
Failure to Update Care Plans for Transfer and Repositioning Needs
Penalty
Summary
The facility failed to update the care plan for a resident with a new transfer status following a fall that resulted in a hip fracture. The resident, who had severe cognitive impairment, was initially dependent on staff for toileting transfer and was weight-bearing as tolerated. However, after the fall, the resident became non-weight bearing and required a Hoyer lift for transfers. Despite this change, the care plan was not updated to reflect the new transfer needs, leading to inconsistencies in the care provided. Nursing assistants reported using the Hoyer lift, but the care plan did not accurately reflect this requirement, which was acknowledged by the Director of Nursing. Additionally, the facility failed to update the care plan for another resident who developed a new skin issue. This resident, also with severe cognitive impairment, required substantial assistance with turning and repositioning and was at risk for pressure ulcers. Although the resident's care plan initially indicated repositioning every three hours, a new skin issue necessitated repositioning every two hours. While this change was communicated to the nursing staff and assistants, it was not updated in the care plan, leading to potential inconsistencies in care delivery. The facility's policy required that care plans be updated to reflect immediate health and safety concerns, which was not adhered to in these cases.
Failure to Provide Timely Toileting Assistance
Penalty
Summary
The facility failed to provide timely assistance with toileting and incontinence care for a resident with severe cognitive impairment and dependency on staff for activities of daily living. The resident, who was incontinent of bowel and bladder, was observed from 7:18 a.m. to 11:13 a.m. without being offered toileting assistance, despite being involved in various activities and remaining in her wheelchair. The resident's care plan required toileting and incontinence care every three hours and as needed, but this was not adhered to during the observation period. Interviews with nursing assistants revealed a lack of awareness and adherence to the updated care plan, which required check and change every two hours due to a new area of impaired skin integrity. The nursing assistant assigned to the resident was unsure of the last time the resident was checked or offered toileting assistance, and it was noted that the resident had a small amount of feces and urine in her brief, along with a scabbed area on her buttocks. The facility's policy on urinary incontinence care was not followed, as confirmed by the director of nursing, who stated that staff were expected to adhere to the care plan to prevent incontinence-related complications.
Failure to Address Significant Weight Gain and Edema in Resident
Penalty
Summary
The facility failed to identify and address a significant weight gain and dependent edema in a resident, R55, who was admitted with intact cognition and required assistance with activities of daily living. R55's medical record showed a weight increase from 203 lbs at admission to 231 lbs over a period of approximately two months, indicating a 13.79% gain. Despite this significant weight gain, the facility did not conduct a comprehensive assessment or implement interventions to address the edema or weight gain. The care plan for R55 did not include issues related to intact skin, weight, or edema, and there was no evidence in the medical record that the weight gains were assessed or that interventions were implemented. Observations and interviews revealed that R55 had significant swelling in both lower extremities, which was not adequately addressed by the facility. Family members expressed concerns about the lack of attempts to have R55 lie down or elevate his legs to reduce swelling. Although the facility notified R55's provider about the edema and requested compression wraps, there was no response, and no new interventions were attempted. The facility's weight monitoring program policy required that medically significant weight gains be assessed and tracked, but this was not done for R55. Staff interviews indicated a lack of documentation and follow-up on the resident's weight gain and edema, contributing to the deficiency.
Failure to Reposition Resident Leads to Pressure Ulcer Development
Penalty
Summary
The facility failed to provide timely repositioning for a resident (R8) who was at risk for pressure ulcers. R8 had severe cognitive impairment and required substantial assistance with turning and repositioning. Despite being identified as at moderate risk for developing pressure ulcers, R8's care plan initially required repositioning every three hours, which was later updated to every two hours after a new skin issue was identified. Observations on a specific day revealed that R8 was not repositioned for nearly four hours while seated in a wheelchair, contrary to the updated care plan. Interviews with staff indicated a lack of adherence to the updated repositioning schedule. A nursing assistant assigned to R8 was unaware of when the last repositioning occurred and admitted to not repositioning R8 after breakfast. The director of nursing confirmed that staff were expected to follow the care plan, which included timely repositioning. The facility's policy aimed to establish individualized repositioning schedules based on skin assessments, but this was not effectively implemented for R8, leading to the development of a new skin issue.
Medication Administration Error Leads to Resident Seizure
Penalty
Summary
The facility failed to ensure that physician orders for an anticonvulsant medication were administered correctly for a resident with a seizure disorder. The resident, who had a history of epilepsy and had been seizure-free since 2017, was prescribed Lamotrigine, Keppra, and Zonisamide to manage his condition. However, due to a medication administration error, the resident received partial doses of Lamotrigine on three separate days, which led to a breakthrough seizure. The resident was subsequently transported to the emergency department for medical intervention. The medication error occurred because the nursing staff did not follow the correct procedure for administering the resident's Lamotrigine. The medication was provided in three separate punch cards, and staff failed to administer the full dose as ordered. Specifically, 200 mg of Lamotrigine was omitted on three occasions, resulting in the resident receiving only 250 mg instead of the prescribed 450 mg. This error was not immediately identified, and the resident experienced a seizure, which was likely due to the inadequate dosing. Interviews with facility staff revealed that the medication administration process was confusing, leading to the error. The staff did not consistently start at the correct position on the medication punch cards, and the sequence of administration was disrupted. This oversight was compounded by the fact that the error was not promptly reported or addressed, resulting in harm to the resident. The facility's failure to adhere to the prescribed medication regimen and ensure accurate administration of anticonvulsant drugs directly contributed to the resident's seizure.
Facility Failed to Honor Resident's Rights by Removing Shoes
Penalty
Summary
The facility failed to honor a resident's rights by removing his shoes to slow his movement within the facility. The resident, who had diagnoses including Alzheimer's, dementia, anxiety, and depression, was identified as having severe cognitive impairment and required assistance with transfers but could self-propel short distances in his wheelchair. The facility's action to take away his shoes was documented in a report log, and during an observation, the resident's family member confirmed that the shoes were taken to limit his mobility, which upset the resident. The family member also reported that the resident had to attend a dental appointment in the rain without shoes, as the facility refused to provide them. Interviews with facility staff, including a registered nurse and a nursing assistant, revealed that the shoes were removed to slow the resident down due to his wandering behavior. The director of nursing mentioned that the shoes were taken because the resident had behaviors such as kicking staff when agitated, although there was no evidence in the medical record to support this claim. The facility's policy on resident rights indicated that residents should be allowed to retain personal possessions, including clothing, unless it infringes on the rights or safety of others. However, the facility did not provide evidence that the resident's behavior posed such a risk.
Inadequate Supervision Leads to Resident-to-Resident Sexual Abuse Incident
Penalty
Summary
The facility failed to ensure adequate supervision to prevent resident-to-resident sexual abuse when a resident (R1) with a history of inappropriate behavior was found engaging in sexual contact with another female resident (R2) in the dining room. R1, diagnosed with Alzheimer's, dementia, anxiety, and depression, had a documented history of inappropriate actions and touching female residents. Despite being identified as needing assistance with transfer and self-propelled in his wheelchair, R1 was left unsupervised in the dining room, where he engaged in inappropriate behavior with R2, who had a diagnosis of Hemiplegia, schizoaffective disorder, depression, anxiety, and aphasia. The incident of sexual abuse was witnessed by a nursing assistant, highlighting the lack of supervision at the time. The facility's failure to adequately supervise R1 to prevent resident-to-resident sexual abuse resulted in an immediate jeopardy situation for R2, who expressed feeling uncomfortable and scared during the incident. The investigation revealed that R1 had a pattern of inappropriate behavior towards female residents, leading to the implementation of non-pharmacological interventions and eventually the addition of antipsychotic medications. Despite these interventions, R1 was still able to engage in sexual abuse towards R2 in the dining room, indicating a lapse in supervision protocols. The facility's response to the incident included changes in R1's seating arrangements, increased supervision during meals and activities, and ongoing monitoring to prevent further incidents. Multiple staff members acknowledged the need for increased supervision of R1 following the incident, with interventions such as hourly checks, changing R1's seating arrangements, and ensuring staff members were present during R1's time in common areas. The facility's initial plan to have R1 be the first and last resident in the dining room for supervision was deemed ineffective as staff left him unsupervised, leading to the resident-to-resident sexual abuse incident. The lack of a 24-hour supervision plan for R1 raised concerns about the facility's ability to prevent future incidents of abuse.
Failure to Report Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to report an incident of resident-to-resident sexual abuse to law enforcement. Resident 1, who has Alzheimer's, dementia, anxiety, and depression, was observed by a nursing assistant rubbing the genital area of Resident 2 in the dining room. Resident 2, who has hemiplegia, schizoaffective disorder, depression, anxiety, and aphasia, expressed discomfort and fear during the incident. The Director of Nursing admitted that the incident was not reported to law enforcement and was unaware of the requirement to do so. Resident 1's service plan had previously noted inappropriate actions and touching of female residents, indicating a history of such behavior. Despite this, no immediate action was taken to report the incident to the appropriate authorities. The facility's policy on reporting reasonable suspicion of a crime was not followed, as it mandates reporting to the Minnesota Adult Abuse Reporting Center and the state agency. This oversight led to a failure in ensuring the safety and well-being of the residents involved.
Failure to Report Allegation of Sexual Assault
Penalty
Summary
The facility failed to report an allegation of sexual assault to the state agency for a resident who alleged she had been raped at the facility. The resident, who had diagnoses including Parkinsonism, Alzheimer's disease, and dementia, exhibited severe cognitive impairment and displayed physical and verbal behaviors, hallucinations, and delusions. Despite these behaviors, the facility's care plan noted that the resident had a history of making false accusations about staff. On multiple occasions, the resident accused a male nursing assistant of raping her, but these allegations were not substantiated. The facility's progress notes documented these accusations, but the allegations were not reported to the state agency as required by the facility's maltreatment reporting guidelines. Interviews with facility staff, including the social services designee, director of nursing, and registered nurses, revealed that they were aware of the resident's accusations but did not report them to the state agency. The director of nursing and registered nurses acknowledged the resident's cognitive impairments and history of delusional behavior but did not take the necessary steps to report the allegations. The facility's administrator also confirmed that the allegations had not been reported and stated that she was unaware of the rape allegations. The facility's policy required immediate reporting of any suspected maltreatment, including abuse, neglect, exploitation, or misappropriation of resident property, but this protocol was not followed in this case.
Failure to Investigate Allegation of Sexual Assault
Penalty
Summary
The facility failed to thoroughly investigate an allegation of sexual assault made by a resident (R4) who had severe cognitive impairment and a history of hallucinations and delusions. R4's care plan indicated that she exhibited auditory hallucinations and had a history of making false accusations about staff. Despite R4's severe cognitive impairment and history of delusional behavior, the facility did not conduct a thorough investigation into her allegations of rape. The Director of Nursing (DON) admitted that no evidence of an investigation was available because they did not believe the rape had occurred. Additionally, the social services designee (SSD) and the administrator were not involved in or aware of the investigation process, respectively. The facility's policy on maltreatment reporting required staff to begin an investigation of alleged maltreatment, including resident and staff interviews, observations, and medical record reviews. However, this protocol was not followed in R4's case. The DON stated that a registered nurse (RN) had spoken with R4 and determined that the rape had not occurred, but there was no documentation or evidence to support that an investigation had been completed. This lack of a thorough investigation is a clear violation of the facility's maltreatment reporting guidelines and demonstrates a failure to respond appropriately to serious allegations made by a resident with severe cognitive impairments.
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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