Three Links Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Northfield, Minnesota.
- Location
- 815 Forest Avenue, Northfield, Minnesota 55057
- CMS Provider Number
- 245450
- Inspections on file
- 21
- Latest survey
- September 19, 2025
- Citations (last 12 mo.)
- 19 (1 serious)
Citation history
Health deficiencies cited at Three Links Care Center during CMS and state inspections, most recent first.
A resident with significant mobility and medical needs fell from a full body mechanical lift during a transfer when two nursing assistants failed to properly attach the sling, using different length loops on each side. This error caused the sling to detach, resulting in the resident sustaining a new femur fracture that required hospitalization and surgery.
The facility did not adequately promote or facilitate resident self-determination, resulting in a failure to support resident choice as required. This was due to actions or omissions by staff that did not uphold the resident's right to make decisions about their care or daily activities.
A resident with a recurring pressure ulcer on the right foot was incorrectly coded on the MDS as having a stage two ulcer, despite prior documentation and provider assessment indicating a stage three ulcer in the same location. The MDS coordinator did not identify the previous stage three diagnosis due to incomplete documentation, resulting in inaccurate assessment coding.
Care and assistance were not provided to a resident who was unable to perform activities of daily living independently, resulting in unmet needs for essential daily support.
A resident with a feeding tube, who required enhanced barrier precautions due to infection risk, did not receive proper infection control measures when a registered nurse administered medications and tube feeding without wearing a gown as required. Despite clear facility policy, signage, and staff training on EBP, the nurse only wore gloves, and this lapse was acknowledged during interviews with staff and the infection control nurse.
A resident with COPD and receiving hospice care was not properly re-assessed for safe self-administration of nebulizer medication. Despite being observed falling asleep during treatments, the facility did not ensure consistent supervision or re-evaluation of the resident's ability to self-administer. Nursing staff were aware of the issue but did not inform the nurse manager, leading to a deficiency in following the facility's policy for periodic re-assessment.
A resident's preference for twice-weekly baths was not honored, impacting her quality of life. Despite her care plan indicating a need for two baths weekly due to mobility issues, the schedule was reduced to once weekly without explanation or consent. Nursing staff were unaware of the change, and facility records lacked justification for the alteration.
The facility failed to manage trust account balances for two residents, resulting in amounts exceeding the SSI threshold, risking Medicaid coverage. The accountant was unaware of asset limits and necessary actions, and the administrator did not follow up on the issue. No communication with residents or families about spending down funds was evident.
A resident with osteoarthritis and a pressure injury experienced unmanaged pain due to the facility's failure to develop a comprehensive care plan. Despite assessments indicating the need for pain management, the care plan lacked problem statements, goals, or interventions. Nursing staff confirmed the resident's complaints of pain, but the care plan was not updated to reflect these needs, contrary to the facility's policy.
A facility failed to assess and provide appropriate ROM care for a resident with severe cognitive impairment and a contracture of the left hand after a significant change in condition. Despite being discharged from hospice, the resident was not reassessed for therapy, and the facility's staff missed a request for a therapy screen. Observations showed the resident was awake and engaged, contradicting claims that they were not suitable for exercises. The facility's policy for evaluating residents for restorative services was not followed.
A resident with loose-fitting dentures did not receive timely dental care from the facility, leading to complications such as trouble eating and discomfort. Despite being identified as edentulous with broken or loose-fitting dentures upon admission, the facility failed to offer or provide dental services. Interviews with staff revealed that the resident had declined a specific dental service, but no follow-up or documentation of alternative dental care options was provided, resulting in a deficiency.
A resident with a history of UTIs and an indwelling urinary catheter did not receive proper infection control during personal hygiene and catheter care. A nursing assistant used the same washcloth for multiple areas, including the catheter, without changing gloves or performing hand hygiene. The facility's policy required standard precautions and competency in catheter care, which were not followed.
The facility failed to provide quarterly trust account statements to residents, as required by policy. A resident with intact cognition reported never receiving a statement for their trust account, which was managed by the care center. The accountant responsible admitted that no statements had been mailed out in 2024 due to a recent change in management and banking institutions. The administrator was also unaware of when the last statements had been sent, leading to the deficiency.
Failure to Ensure Safe Mechanical Lift Transfer Results in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when staff failed to ensure safe transfers for a resident using a full body mechanical lift. Two nursing assistants were involved in transferring a resident who was dependent on staff for all transfers and had significant medical conditions, including a recent femur fracture, artificial hip joint, hemiplegia, and hemiparesis. During the transfer, the nursing assistants did not follow the manufacturer's recommendations for the lift and did not properly attach the sling, specifically using different length black loops on each side of the sling, which caused slack and led to the sling detaching from the lift arm. The resident slipped out of the improperly secured sling and fell from an elevated height, striking his head on the ground. The incident resulted in a new fracture of the right femur, requiring hospitalization and surgical intervention. Documentation and interviews confirmed that the nursing assistants were aware that the same length loops should be used but failed to ensure this during the transfer. Additionally, they had not received specific training on the type of sling used for this resident, which had two sets of black loops that could be easily confused. The facility's policies required staff to use appropriate techniques and processes when utilizing mechanical lifts and to conduct root cause analyses following falls. However, the staff involved did not adhere to these protocols, and the lack of specific training on the sling contributed to the incident. The root cause was identified as the use of different length loops, which led to the release of tension and the resident's fall.
Removal Plan
- R1 will be reassessed on return from the hospital for proper sling size and care plan updated.
- Sling and lift used for R1's transfer was removed from use until inspected and found to be free of malfunction.
- NA-A and NA-B had return demonstration competency testing done for safe lifting using the mechanical lift.
- The facility reviewed their policy and procedure for safe mechanical lift transfers and developed a plan to ensure identification via color coding the sling loops to ensure the correct one being used. Policy will be adjusted after mechanical lift representative reviews policy, if needed.
- All residents utilizing similar slings like R1 have had the proper sling to use marked with the colored tape to identify the same loops.
- All residents who utilized the mechanical lifts had slings inspected, care plans reviewed to ensure the proper sling size in the care plan.
- The facility began re-education with return demonstration, to nursing staff on manufacturer's recommendations of using the full body mechanical lift to include checking the straps for tension and using proper sling size according to the care plan and will be having mechanical lift representative provide education to all of the nursing staff.
Failure to Support Resident Self-Determination and Choice
Penalty
Summary
The facility failed to honor the resident's right to self-determination by not promoting and facilitating resident choice. This deficiency was identified based on observations or findings that the facility did not adequately support residents in making their own choices regarding their care or daily life, as required by regulations. Specific actions or omissions by the facility staff led to a lack of support for resident autonomy and decision-making.
Inaccurate MDS Coding for Pressure Ulcer Staging
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was accurately coded for one resident, resulting in the potential for inaccurate federal reimbursement and resident care planning. Specifically, a resident with a history of a stage three pressure ulcer on her right foot between her toes was incorrectly coded as having only a stage two pressure ulcer on the quarterly MDS assessment. Documentation and provider notes indicated that the wound had previously been assessed as a stage three ulcer and had recurred in the same location, but the MDS coordinator was unaware of the prior stage three diagnosis due to the absence of this information in the diagnosis list. As a result, the wound was not coded at its worst stage as required by the CMS Long-Term Care Facility Resident Assessment Instrument User's Manual. Interviews with nursing staff and the MDS coordinator confirmed that the wound was open and unhealed at the time of the assessment, and that the coding error occurred because the prior stage three ulcer was not documented in the diagnosis list. The facility's policy required all interdisciplinary team members to review the current RAI manual and for the MDS coordinator to conduct audits to identify and correct errors, but this process was not followed, leading to the inaccurate MDS coding for the resident.
Failure to Assist Resident with Activities of Daily Living
Penalty
Summary
A deficiency was identified in the facility's provision of care and assistance with activities of daily living (ADLs) for residents who are unable to perform these tasks independently. The report notes that care and assistance were not provided as required for at least one resident who was unable to complete ADLs without help. This failure to provide necessary support directly affected the resident's ability to perform essential daily activities.
Failure to Follow Enhanced Barrier Precautions During Tube Feeding Care
Penalty
Summary
A deficiency occurred when staff failed to follow enhanced barrier precautions (EBP) for a resident with a feeding tube. The resident, who was cognitively intact and had diagnoses including dysphagia following cerebral infarction, pharyngeal dysphagia, diverticulum of esophagus, gastrostomy, anxiety, and gastroesophageal reflux, was on enteral feeding and had specific orders and care plan instructions for EBP. Facility policy and signage on the resident's door required staff to wear gloves and a gown during high-contact care activities, including tube feeding management. During an observed medication and feeding administration, a registered nurse washed her hands and donned gloves but did not wear a gown as required by EBP. The nurse acknowledged forgetting to wear the gown and confirmed the resident was on EBP due to the feeding tube and infection risk. Interviews with other staff and the assistant director of nursing/infection control nurse confirmed the expectation to use gloves and gowns for such care, in line with facility policy and recent staff training. The failure to wear a gown during high-contact care for a resident with an indwelling medical device constituted a breach of the facility's infection prevention and control program.
Failure to Re-assess Safe Self-Administration of Nebulizer Medication
Penalty
Summary
The facility failed to comprehensively re-assess a resident's ability to safely self-administer medication via a nebulizer. The resident, who had intact cognition and was diagnosed with respiratory failure and COPD, was receiving hospice services and had been observed falling asleep during nebulizer treatments. Despite this, the resident's assessments indicated they were able to demonstrate correct administration of medication after staff set-up. However, due to reports of the resident falling asleep during administration, it was determined that the resident was not administering the medication safely, and a nurse was required to observe the treatments. Observations and interviews revealed that the resident frequently fell asleep during nebulizer treatments, causing the nebulizer to fall out of their mouth and their oxygen saturation to lower. The nursing staff, including the LPN and RN, were aware of this issue but did not consistently stay with the resident during treatments due to the high frequency and time required for each session. The nurse manager, responsible for assessing the safety of self-administration, was not informed of the resident's tendency to fall asleep during treatments. The facility's policy required periodic re-assessment of the resident's ability to self-administer medications, but this was not adequately followed, leading to the deficiency.
Failure to Honor Resident's Bathing Preferences
Penalty
Summary
The facility failed to honor a resident's preference for bathing routines, which impacted the resident's quality of life and choice. The resident, identified as R7, expressed frustration during an interview about a reduction in her bathing schedule from twice weekly to once weekly without any explanation. R7's care plan indicated she required extensive assistance with activities of daily living due to weakness and mobility issues, and her bathing routine was initially set for twice a week. However, the care plan was updated to reflect a weekly bath without documented consent or rationale for this change. Interviews with nursing staff revealed that the reduction in R7's bathing schedule was not formally communicated or justified. RN-A confirmed that R7 was supposed to receive two baths weekly, which was also an intervention for her skin issues. The facility's bath schedule and records corroborated the change to a weekly bath, but lacked any evidence of consent or justification for the alteration. The facility's policy on person-centered care planning emphasized the development of care plans consistent with residents' rights and needs, yet no specific policy on choices and bathing preferences was provided upon request.
Failure to Manage Resident Trust Account Balances
Penalty
Summary
The facility failed to manage resident trust account balances exceeding the state-required Supplemental Security Income (SSI) threshold, which is $3,000 for individuals. Two residents, identified as R13 and R42, had trust account balances of $14,648.82 and $12,740.57, respectively, which were not addressed to ensure continued Medicaid coverage. The facility did not take action to reduce these balances, known as a 'spend down,' to prevent potential termination of Medicaid benefits due to exceeding asset limits. Interviews and document reviews revealed that the accountant responsible for managing resident accounts was unaware of the specific asset limits under Minnesota Medicaid law and had not been informed about the necessary actions to address the excess balances. The accountant acknowledged the oversight and mentioned that the transition to a new management company and banking institution might have contributed to the confusion. Additionally, the administrator had not followed up on the issue, and there was no evidence of communication with the residents or their families regarding the need to spend down the funds.
Failure to Develop Comprehensive Pain Management Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident (R7) who was assessed for pain management. R7's quarterly Minimum Data Set (MDS) indicated that the resident had intact cognition, consumed scheduled pain medication, and received non-pharmacological interventions for pain. Despite these assessments, R7's electronic care plan lacked any problem statements, goals, or interventions related to the resident's pain management. Interviews with R7 revealed that they experienced pain in their left leg from a fall and were unsure if the physician or staff were aware of it. The resident's pain assessment identified osteoarthritis and an active pressure injury as potential pain sources, with pain affecting sleep and activities. Interviews with nursing staff confirmed that R7 occasionally complained of pain, particularly during transfers using a mechanical lift. Nursing assistants relied on verbal reports and electronic kardex for communication about interventions. However, the registered nurse managers acknowledged that R7's care plan did not include a pain statement or interventions, which should have been addressed. The facility's Person Centered Care Planning policy required a comprehensive care plan to be developed within seven days of the MDS completion, but this was not adhered to in R7's case.
Failure to Assess and Provide ROM Care for Resident
Penalty
Summary
The facility failed to comprehensively assess and provide appropriate care for a resident, identified as R31, to maintain or improve range of motion (ROM) after a significant change in condition. R31, who has severe cognitive impairment, unspecified dementia, traumatic brain injury, and a contracture of the left hand, was dependent on staff for all activities of daily living (ADLs). Despite being discharged from hospice due to a prognosis of greater than six months, the facility did not reassess R31 for ROM exercises or therapy. Observations showed R31 was awake and engaged during family visits, contradicting the therapy staff's claim that R31 was not appropriate for exercises due to sleeping all the time. The facility's staff, including the therapy director and nurse manager, acknowledged that R31 had not been evaluated for therapy since December 2023, and a request for a therapy screen was missed after R31's discharge from hospice. The facility's policy requires residents to be evaluated for restorative nursing services at least quarterly and with changes in condition, but this was not adhered to in R31's case. The staff task list and nursing assistant Kardex lacked documentation of ROM exercises, indicating a failure to implement a functional maintenance program for R31, despite the family's expressed desire for R31 to participate in ROM exercises.
Failure to Provide Timely Dental Care for Resident with Loose Dentures
Penalty
Summary
The facility failed to provide timely dental services to a resident, identified as R39, who had loose-fitting dentures. R39 was admitted to the care center from an acute care hospital and was noted to have intact cognition and no delusional thinking. Upon admission, R39 was identified as edentulous with broken or loose-fitting dentures. Despite this, the facility did not offer or provide timely dental care to address the issue, which led to complications such as trouble eating and discomfort for the resident. R39 expressed concerns about her loose-fitting dentures during an interview, stating that she was not wearing them due to their poor fit and that it really bothered her. The facility's documentation, including the Ancillary Services Consent and Oral Dental Review, lacked evidence of any dental options being discussed or offered to R39. The resident's care conference summary also failed to address the need for a dental examination, despite the identification of loose-fitting dentures during evaluations on multiple occasions. Interviews with facility staff, including nursing assistants and registered nurse managers, revealed that R39 had declined the Apple Tree Dental service upon admission. However, there was no follow-up or documentation of any dental appointment being discussed or offered after the loose dentures were identified. The facility's Dental Services policy stated that they would provide or obtain dental services to meet residents' needs, but this was not adhered to in R39's case, resulting in a deficiency in providing necessary dental care.
Inadequate Infection Control During Catheter Care
Penalty
Summary
The facility failed to ensure proper infection control practices during personal hygiene and urinary catheter care for a resident diagnosed with heart failure, kidney disease, and respiratory failure. The resident, who had intact cognition, was dependent on staff for toileting hygiene, bed mobility, and transfers, and had a history of urinary tract infections related to an obstruction of the urinary tract. The care plan required assistance with catheter care every morning and night, and the resident had an indwelling urinary catheter with output to be assessed every shift. During an observation, a nursing assistant was seen using the same washcloth for multiple areas of the resident's body, including the catheter area, without changing gloves or performing hand hygiene between tasks. The nursing assistant admitted to using one washcloth for all resident care, including catheter care, and acknowledged not performing hand hygiene or changing gloves between tasks. The director of nursing stated that the nursing assistant should have changed gloves and completed hand hygiene before and after catheter and perineal care. The facility's policy on urinary catheter care and management emphasized maintaining resident safety by following infection control practices, including using standard precautions and demonstrating competency in catheter care. However, these practices were not followed, leading to concerns about the potential for infection.
Failure to Provide Quarterly Trust Account Statements
Penalty
Summary
The facility failed to provide quarterly trust account statements to residents, as required by their policy. This deficiency was identified during a recertification survey when a resident, who had intact cognition, reported never receiving a statement for their trust account, which was managed by the care center. The resident confirmed having a small balance in the account but had not been informed of the exact amount through a statement. The facility's records showed that 27 residents, including this resident, had active trust accounts, but no evidence of statements being provided was available. The accountant responsible for managing the residents' accounts admitted that no statements had been mailed out in 2024, citing a recent change in management and banking institutions as reasons for the oversight. The administrator, who was new to the facility, was also unaware of when the last statements had been sent. The facility's policy, dated April 2020, required that statements be sent quarterly to residents or their authorized representatives, but this had not been adhered to, leading to the deficiency.
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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