Tweeten Lutheran Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Spring Grove, Minnesota.
- Location
- 125 5th Avenue Southeast, Spring Grove, Minnesota 55974
- CMS Provider Number
- 245429
- Inspections on file
- 25
- Latest survey
- April 2, 2026
- Citations (last 12 mo.)
- 23 (1 serious)
Citation history
Health deficiencies cited at Tweeten Lutheran Health Care Center during CMS and state inspections, most recent first.
A resident with dementia and Parkinson's Disease was not properly monitored or assessed for pressure ulcer risk, and interventions such as heel boots and offloading were delayed or inconsistently documented. Wound assessments were incomplete, lacking key details and timely updates, and weekly comprehensive assessments by an RN were not consistently performed, contrary to facility policy.
A resident with cognitive impairment and a history of wandering was able to exit the facility in extremely cold weather after activating an exit alarm, with staff failing to immediately retrieve her despite visual confirmation. Additionally, another resident experienced multiple falls without comprehensive root cause analysis or timely updates to care plans and interventions. Staff interviews indicated insufficient training and inconsistent implementation of safety protocols.
The facility did not ensure an RN was on duty for at least eight consecutive hours in a 24-hour period, as required. Although posted staffing information indicated RN coverage, the actual schedule showed only LPNs were present, and the DON confirmed the absence of RN coverage. The facility's staffing policy did not specify the need for eight consecutive hours of RN coverage, potentially affecting all residents.
The facility did not immediately investigate suspicious bruises of unknown origin found on two residents, as required by its abuse prohibition policy. One resident with cognitive and physical impairments was found with a breast bruise, and another with multiple medical conditions had a bruise near the rectum. In both cases, there was no documentation of how the injuries occurred or evidence of staff interviews, and the DON confirmed that investigations should have been initiated but were not.
Two residents with significant medical conditions were found with bruises of unknown origin in suspicious locations. In both cases, the LPN who discovered the injuries did not immediately notify the administrator or DON, and reporting to the State Agency was delayed or not completed, contrary to facility policy requiring prompt reporting of potential abuse.
A resident with severe cognitive impairment and a history of falls was admitted and experienced two additional falls. The baseline care plan did not identify the resident's fall risk or include updated interventions from fall investigations, despite new measures being identified after each incident. The DON confirmed the care plan was incomplete and not updated as required.
Two residents experienced multiple falls and pressure ulcer events, but their care plans were not promptly updated to include new interventions identified during investigations and IDT reviews. Despite specific recommendations such as increased assistance, safety checks, and offloading devices, these were not consistently added to the care plans. Staff interviews revealed confusion about responsibility for care plan updates, contributing to the deficiency.
A resident with cognitive impairment and a history of wandering did not receive ordered occupational therapy evaluation, treatment, or cognitive testing due to a breakdown in communication and follow-up between nursing and therapy staff. The order was transcribed but not relayed to the therapy department, resulting in the services not being provided as directed.
The facility posted inaccurate nurse staffing information by listing an RN for a day shift when, in fact, an LPN worked that shift. The DON discovered the error after verifying the nurse's license, resulting in a staff posting that did not reflect the actual personnel on duty. This inaccuracy had the potential to affect all residents in the facility.
The facility failed to ensure proper hand hygiene practices among staff, affecting multiple residents. Nursing assistants and an LPN were observed not performing hand hygiene before and after resident contact, between glove changes, and after touching potentially contaminated surfaces. Additionally, the facility lacked an infection surveillance system, with no tracking of infections since July 2024, contrary to the facility's Infection Prevention and Control Plan.
The facility failed to maintain a clean and sanitized kitchen environment, potentially leading to cross-contamination or foodborne illness. During inspections, several kitchen items were found unclean with crusted food and debris. The dietary manager confirmed the issues and stated that all staff are trained on proper cleaning procedures, but the presence of dirty items indicates a failure to adhere to these procedures.
A facility failed to complete a Level II PASARR for a resident with mental disorders, including schizoaffective and bipolar disorders. Despite the resident's need for psychiatric care and psychotropic medications, the facility did not request the necessary screening, as confirmed by staff interviews and the facility's policy requirements.
The facility did not document that three staff members, including two LPNs and a housekeeper, were offered or educated about the COVID-19 vaccine. Interviews revealed a lack of awareness and documentation regarding vaccine offers and education, despite the facility's policy requiring such actions.
A resident with congestive heart failure and hypernatremia experienced harm due to the facility's failure to conduct a comprehensive nutritional assessment and monitor for dehydration. Despite being on diuretics and a pureed diet with thickened liquids, the resident's fluid intake was inadequately monitored, leading to multiple hospitalizations for severe health issues. Staff interviews revealed a lack of awareness and systems to monitor fluid intake, and facility policies on dehydration were not effectively implemented.
A facility failed to create a comprehensive care plan for a resident with acute respiratory failure with hypoxia. The care plan lacked specific goals and interventions for respiratory assessment and monitoring, despite the resident's recent hospitalization for severe hypotension and respiratory failure. Staff interviews confirmed the absence of necessary interventions in the care plan.
A resident with intact cognition and diagnoses of hypernatremia and hyperosmolality experienced frequent loose stools while receiving scheduled bowel medications, including docusate sodium. Despite documentation of large, loose stools and staff reports, the facility continued administering the medication without proper evaluation. Interviews revealed that bowel medications were not consistently held, and the provider was not notified promptly, contrary to the facility's bowel management policy.
A resident with Alzheimer's and psychotic disorder reported an incident of physical abuse by staff, which was not reported to the administration or State Agency within the required timeframe. The resident felt unsafe during the incident but has since felt secure. The facility's policy mandates immediate reporting of abuse allegations, which was not adhered to in this case.
A resident with Alzheimer's and other conditions reported an incident of physical abuse by two staff members, which was not thoroughly investigated by the facility. The investigation lacked interviews with all relevant parties and did not implement protective measures, contrary to the facility's policy.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a stage 3 pressure ulcer, as required by their care plan. Observations showed no signage or PPE available, and staff were unaware of EBP requirements. Interviews confirmed that EBP was not implemented for any residents, despite the facility's policy outlining the need for staff training and PPE availability.
Failure to Monitor and Manage Pressure Ulcers
Penalty
Summary
A resident with diagnoses of dementia and Parkinson's Disease was not properly monitored or assessed for pressure ulcer risk, despite being identified as at risk for pressure injuries and requiring maximum assistance for mobility. The resident's care plan included interventions such as an air mattress, skin inspections, and heel protectors, but documentation showed inconsistencies and delays in implementing these interventions. For example, heel boots were not added to the care plan until eight days after a left heel wound was identified, and there was no documentation of offloading measures prior to the appearance of redness on the heel. Wound assessments for the resident were incomplete and lacked comprehensive details such as wound characteristics, pain, drainage, and surrounding skin condition. Several wound management reports failed to include necessary information or to document the use of pressure-relieving interventions. Additionally, weekly comprehensive wound assessments by a registered nurse were not consistently performed or documented, and the care plan was not promptly updated to reflect new or worsening wounds. Interviews with nursing staff and the DON confirmed that comprehensive wound assessments were not being reviewed to ensure wounds were not worsening and that appropriate treatments were being used. The facility's own policy required weekly head-to-toe skin inspections and comprehensive wound assessments for residents with wounds, but these procedures were not followed, resulting in delayed identification and management of pressure ulcers for the resident.
Failure to Prevent Elopement and Inadequate Fall Risk Management
Penalty
Summary
The facility failed to immediately respond to an elopement incident involving a resident with mild cognitive impairment, chronic kidney disease, and a history of wandering. The resident, identified as an elopement risk and equipped with an exit alarm bracelet, was able to leave the facility without appropriate clothing for extremely cold weather. When the exit alarm sounded, staff initially searched the wrong area and did not immediately pursue the resident outside, despite visual confirmation of her location. The resident was eventually found by a staff member approximately 15 minutes later, outside and exposed to cold temperatures, with red face and very cold hands. Additionally, the facility did not conduct comprehensive investigations or root cause analyses for multiple falls experienced by another resident with cognitive impairment and impaired mobility. The fall investigations often lacked thorough assessments of contributing factors such as toileting needs, call light placement, and footwear. Interventions were inconsistently implemented or documented, and care plans were not promptly or adequately revised to address the identified risks and causal factors for repeated falls. Staff interviews revealed gaps in training and understanding of elopement prevention and response protocols. Documentation and care planning for fall prevention were incomplete, with delays in updating interventions and a lack of comprehensive analysis following each incident. The facility's policies required individualized interventions and ongoing evaluation, but these were not consistently followed, resulting in repeated deficiencies in accident prevention and resident supervision.
Failure to Provide Required RN Coverage for Eight Consecutive Hours
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for a minimum of eight consecutive hours within a 24-hour period on one day during the review period. Specifically, on 12/13/25, posted nurse staffing information indicated that an RN was scheduled for the day shift, but the actual daily schedule showed only licensed practical nurses (LPNs) were present, with no RN coverage documented for that 24-hour period. During an interview, the director of nursing (DON) confirmed that there was no RN coverage on that date, despite the posted information. Review of the facility's Nurse Staffing Hours policy revealed that while it required posting of total and actual hours worked by nursing staff, it did not specify the requirement for RN coverage for eight consecutive hours in a 24-hour period. This deficiency had the potential to affect all thirty-six residents residing in the facility.
Failure to Immediately Investigate Injuries of Unknown Source
Penalty
Summary
The facility failed to immediately investigate injuries of unknown source in accordance with its abuse prohibition policy for two residents. One resident with Alzheimer's and Parkinson's disease, who was dependent for transfers and had moderate cognitive impairment, was found with a bruise of unknown origin on the right breast. There was no documentation in the resident's record or incident reports regarding how or when the bruise occurred, nor evidence that staff interviews were conducted. Another resident with heart failure, diabetes mellitus, and atrial fibrillation, who was dependent with toileting hygiene and transfers and had intact cognition, was found with a dark bruise near the rectum. The resident attributed the bruise to a recent bowel movement and denied abuse or pain, but again, there was no further information or staff interviews documented in the records or incident reports. During an interview, the DON confirmed that bruises found on the breast or anal region are considered suspicious for abuse and should trigger an immediate investigation, which did not occur in these cases. The facility's policy requires that all reports of abuse, including injuries of unknown source, be promptly and thoroughly investigated, with results documented. The policy specifically lists bruising in areas such as the inner thigh, chest, face, and breast, or bruises of unusual size or in atypical locations, as requiring immediate investigation to rule out abuse. Despite these requirements, investigations were not initiated for either resident after their injuries were discovered.
Failure to Timely Report and Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to immediately report injuries of unknown origin to the administrator and did not notify the State Agency (SA) within the required reporting guidelines for two residents. One resident with Alzheimer's and Parkinson's disease, who was dependent for transfers and had moderate cognitive impairment, was found to have a bruise on the right breast of unknown origin. The LPN who discovered the bruise believed it was caused by a sit-to-stand lift and, since the resident denied abuse, did not report the injury to the administrator immediately, instead sending an email notification several hours later. The bruise was not investigated or reported to the SA as required. Another resident, with diagnoses including heart failure, diabetes mellitus, and atrial fibrillation, and who was dependent with toileting and transfers, was found to have a dark bruise near the anal region. The LPN who identified the bruise did not notify the DON or administrator immediately, as the resident believed the bruise was from a bowel movement and denied abuse. Notification to administration was delayed and sent via email at a later time. The facility's policy required that allegations involving abuse be reported no later than two hours after the allegation is made, but this protocol was not followed in either case.
Failure to Update Baseline Care Plan After Resident Falls
Penalty
Summary
The facility failed to ensure that a baseline care plan for falls was continuously evaluated and updated to reflect interventions identified as a result of fall investigations for a resident with neurocognitive disorder with Lewy bodies and polyneuropathy. Upon admission, the resident was noted to have severe cognitive impairment, a history of falls, and required supervision for transfers. The initial baseline care plan did not identify the resident's level of fall risk or include appropriate fall prevention interventions. Following two witnessed falls in the dining area, additional interventions such as one-to-one supervision, increased staff assistance, and specific instructions for transfers and ambulation were identified during fall investigations. Despite these incidents and the identification of new interventions, the baseline care plan was not updated to reflect the changes. The DON confirmed that although the resident was recognized as high fall risk at admission and a baseline care plan was created, it did not specify the risk level or include the necessary interventions to mitigate future falls. The facility's policy requires that a baseline care plan be developed and implemented within 48 hours of admission to address health and safety concerns, but this was not followed in the resident's case.
Failure to Timely Revise Care Plans After Falls and Pressure Ulcer Events
Penalty
Summary
The facility failed to revise and update care plans in a timely manner for two residents who were reviewed for falls and pressure ulcers. For one resident with diagnoses of malignant neoplasm of the lung and brain, and moderate cognitive impairment, multiple falls occurred over a period of time. Each fall investigation identified specific interventions such as increased assistance during transfers, regular toileting intervals, use of call lights, 15- or 30-minute safety checks, and environmental modifications like fall mats and visible signs. However, these interventions were not consistently or promptly incorporated into the resident's care plan following each incident, despite being identified as necessary in fall investigations and interdisciplinary team (IDT) reviews. Additionally, another resident with dementia and Parkinson's Disease, who was at risk for pressure ulcers and had existing skin breakdown, did not have their care plan updated to reflect new interventions after a skin integrity event. The event identified the need for offloading heels with pillows and boots, but these interventions were not added to the care plan. The care plan also lacked clarity regarding the measurement units for wounds and did not specify all required interventions for pressure ulcer prevention and management. Interviews with facility staff revealed a lack of clarity and accountability regarding who is responsible for updating care plans after new interventions are discussed or implemented. Both nursing and administrative staff indicated they were either unaware of their responsibilities or had not received training on revising care plans, resulting in delays and omissions in care plan updates. The facility's own policy requires timely care plan revisions when there are changes in condition or interventions, but this was not followed in the cases reviewed.
Failure to Implement Physician Orders for Occupational Therapy and Cognitive Testing
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a physician's order for occupational therapy evaluation, treatment, and cognitive testing was implemented according to professional standards for one resident. The resident had diagnoses including mild cognitive impairment, chronic kidney disease, and a history of breast cancer, and was noted to have daily wandering behaviors and moderate cognitive impairment. The physician assistant issued an order for occupational therapy and cognitive testing, with instructions for therapy to provide the results to the provider. Despite the order being transcribed and placed in the therapy box by the registered nurse case manager, it was not communicated to the therapy director or followed up on by nursing staff. Interviews revealed that the occupational therapy department had not received the order, and the director of nursing confirmed that the order was not communicated as required. The physician assistant stated that her expectation was for orders to be processed promptly and communicated to the appropriate staff. A policy for following physician orders was requested but not provided.
Inaccurate Nurse Staffing Posting
Penalty
Summary
The facility failed to ensure the accuracy of its daily nurse staffing posting on 12/13/25. The posted information indicated that a registered nurse (RN) worked the day shift, but a review of the nursing schedule and subsequent verification by the director of nursing (DON) revealed that an LPN actually worked that shift. The DON initially believed the scheduled nurse was an RN, but upon checking the license, discovered the error, resulting in an inaccurate staff posting. The facility's policy requires accurate posting of the names, hours, and roles of nursing staff for each shift, but this was not followed on the date in question. This discrepancy had the potential to affect all 36 residents in the facility.
Inadequate Hand Hygiene and Lack of Infection Surveillance
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were implemented by staff, affecting six residents observed for handwashing/hand hygiene. Nursing assistants and an LPN were observed not performing hand hygiene before and after resident contact, between glove changes, and after touching potentially contaminated surfaces. For instance, a nursing assistant assisted multiple residents with meals without washing hands between interactions, and another did not perform hand hygiene after transferring residents. An LPN was seen touching her face with gloved hands and then proceeded to care for a resident without washing hands. These actions were contrary to the facility's stated expectations for hand hygiene. Additionally, the facility lacked a system for infection surveillance to identify possible communicable diseases or infections. The Director of Nursing admitted that no infection surveillance had been conducted since July 2024, and the medical director expressed concern over this oversight. The facility's Infection Prevention and Control Plan required an infection control surveillance system, but this was not being implemented, leaving the facility without a mechanism to track and respond to infections among residents and staff.
Failure to Maintain Clean and Sanitized Kitchen Environment
Penalty
Summary
The facility failed to maintain a clean and sanitized kitchen environment, which could potentially lead to cross-contamination or foodborne illness affecting all residents, staff, and visitors. During an initial tour of the kitchen, several large pans, mixing bowls, and containers were found to be unclean with dry crusted food on them. The dietary manager acknowledged the dirty items and removed them from the storage area. Additionally, several dirty utensils were found in storage drawers. A follow-up observation revealed more dirty kitchen items, including large pans with dried food and a baking pan with paper debris, which were confirmed by a cook to be dirty and in need of cleaning. The dietary manager explained the facility's sanitary policy and confirmed that the dishwasher was functioning properly. The manager acknowledged the unclean items found during the initial tour and stated that they were discussed with the staff and removed for cleaning. The facility employs about 10 kitchen staff, some of whom are new, and all are trained on proper cleaning and sanitization procedures. The facility's policy requires all kitchen items to be cleaned, rinsed, and sanitized after each use, with staff expected to inspect items for cleanliness before storage. Despite this policy, the presence of dirty kitchen items indicates a failure to adhere to these procedures, potentially leading to foodborne illness.
Failure to Complete PASARR Level II Screening for Resident with Mental Disorder
Penalty
Summary
The facility failed to ensure a Level II Pre-admission Screening and Resident Review (PASARR) was completed or clarified for a resident with a mental disorder. The resident, who was admitted with diagnoses including schizoaffective disorder, bipolar disorder, narcissistic personality disorder, and anxiety, was on a medication regimen that included psychotropic medications. Despite these conditions, the facility did not initiate a request for a PASARR Level II screening, which was necessary due to the resident's mental health concerns and extended stay. Interviews with facility staff, including the social services worker and the director of nursing, revealed a lack of awareness and action regarding the resident's PASARR status. The social services worker acknowledged the need for a Level II assessment, and the director of nursing was unaware of the resident's PASARR status and the missed psychiatric appointments. The facility's policy required a Level I PASARR prior to admission and a referral for a Level II screening if necessary, but this process was not followed, leading to the deficiency.
Failure to Document COVID-19 Vaccine Education and Offer
Penalty
Summary
The facility failed to maintain documentation that staff were offered or provided education regarding the benefits and potential risks associated with COVID-19 vaccination for three staff members, including two Licensed Practical Nurses (LPN-A and LPN-B) and a housekeeper (HSK-A). During interviews, the Human Resources Director stated there was no documentation of the COVID-19 vaccine being offered or education provided to these staff members. The Director of Nursing was unaware if employees were offered the COVID-19 vaccine, and the Medical Director expected the facility to ensure staff were educated on the risks and benefits and offered the vaccine. The facility's policy, dated November 2024, required that each staff member be offered the vaccine and provided education, with documentation maintained, but this was not followed.
Failure to Monitor and Address Dehydration Risk
Penalty
Summary
The facility failed to ensure a comprehensive nutritional assessment and monitoring for signs of dehydration for a resident, leading to harm. The resident, who had intact cognition and diagnoses including congestive heart failure and hypernatremia, was on diuretics and required a regular diet. However, the nutritional assessment did not account for the resident's diuretic use or specify daily fluid needs. The resident's fluid intake was consistently low, and there was no comprehensive assessment or care plan addressing the risk of dehydration. The resident experienced multiple hospitalizations due to severe health issues, including profound hypernatremia and hypovolemia, which were attributed to poor oral intake and inadequate fluid monitoring. Despite being on a pureed diet with thickened liquids, the resident's fluid intake was not adequately monitored, and the care plan did not include interventions to prevent dehydration. Interviews with staff revealed a lack of awareness and systems in place to monitor fluid intake and dehydration risk. The facility's policies on dehydration and nutrition interventions were not effectively implemented, as evidenced by the resident's low fluid intake and frequent loose stools, which increased the risk of dehydration. The registered dietician admitted to not comprehensively assessing the resident's fluid needs, and the interim director of nursing acknowledged the absence of a monitoring system for fluid intake. The physician assistant highlighted the need for close monitoring of residents with low fluid intake and chronic loose stools to prevent dehydration and related complications.
Failure to Develop Comprehensive Care Plan for Respiratory Condition
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident diagnosed with acute respiratory failure with hypoxia. Upon review, it was found that the resident's care plan, spanning from October 8 to November 13, did not include a respiratory plan of care with specific goals and individualized interventions to manage the resident's respiratory condition. The resident had been hospitalized for severe hypotension and acute respiratory failure with hypoxia due to a choking/aspiration event and was discharged with new dietary orders. Despite these significant health issues, the care plan lacked interventions for respiratory assessment and monitoring. Interviews with facility staff, including an LPN and the interim director of nursing, confirmed that the resident's care plan did not address the necessary interventions for the resident's respiratory condition. A physician assistant also stated that a resident with such a diagnosis should have a care plan with person-centered interventions, including a full respiratory assessment twice a day and monitoring for changes. The facility's policy on care planning emphasized the need for comprehensive, person-centered care plans with measurable objectives and timetables, which were not reflected in the resident's care plan.
Failure to Monitor and Evaluate Necessity of Bowel Medications
Penalty
Summary
The facility failed to adequately monitor and evaluate the necessity of bowel medications for a resident, leading to the administration of unnecessary drugs. The resident, who had intact cognition and was diagnosed with hypernatremia and hyperosmolality, was frequently incontinent of bowel and received scheduled bowel medications, including docusate sodium, Citrucel, and Miralax. Despite having loose stools throughout her stay, the facility continued to administer these medications without proper evaluation of their necessity. The resident's bowel movements were consistently documented as large and loose, with frequent episodes of incontinence. Despite these observations, the medication administration record indicated that docusate sodium was given twice daily, except on a few occasions due to hospitalization or loose stools. Progress notes highlighted that the resident experienced loose stools and stomach upset, yet bowel medications were not consistently held, and the provider was not notified promptly. Interviews with nursing staff revealed that the resident's loose stools were reported to nurses, but bowel medications were still administered. The interim director of nursing confirmed that the docusate sodium was unnecessary and should have been given only as needed. The facility's bowel management policy emphasized the importance of assessing individual needs and holding medications in cases of diarrhea, but these guidelines were not followed, resulting in the continued administration of unnecessary bowel medications.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of staff-to-resident physical abuse to the administration and State Agency (SA) within the required timeframe. A resident, who was admitted with diagnoses including Alzheimer's disease and psychotic disorder, reported an incident where two staff members allegedly attempted to force her into bed against her usual routine, causing her distress and bruising on her arms. The resident reported feeling unsafe during the incident but has since felt secure as the staff involved have not been seen again. The incident was not reported to the administration or the SA immediately, as required by the facility's policy. The social worker and former Director of Nursing (DON) were aware of the allegation but did not report it to the administrator or the SA within the mandated two-hour window. The administrator was only informed of the incident several days later, highlighting a failure in the facility's abuse reporting protocol. The facility's policy clearly states that all allegations of abuse must be reported immediately, but this protocol was not followed in this case.
Inadequate Investigation of Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of staff-to-resident physical abuse involving a resident with Alzheimer's disease, auditory hallucinations, and a psychotic disorder. The resident, who required partial to moderate assistance with daily activities, reported an incident where two staff members allegedly attempted to force her into bed against her usual routine, resulting in her feeling disrespected and sustaining bruises on her arms. The resident identified the staff involved as two black females and mentioned that two white female staff intervened after she called for help. The facility's investigation was inadequate as it only included interviews with the resident and two staff members who typically worked the evening shift. It did not involve interviews with other residents, additional staff fitting the description of the alleged perpetrators, or the staff who intervened. Furthermore, the investigation did not identify or implement any protective interventions to ensure the safety of the resident or others. The facility's policy on abuse prevention and investigation was not followed, as it requires a comprehensive investigation process, including interviews with all relevant parties and a thorough documentation of findings. The social worker and administrator acknowledged the shortcomings in the investigation, noting that it should have been more thorough to ensure resident safety.
Failure to Implement Enhanced Barrier Precautions for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a stage 3 pressure ulcer, which is an infection control intervention designed to reduce the transmission of multidrug-resistant organisms. The resident's care plan identified the need for EBP due to wounds, requiring the use of gowns and gloves during high-contact resident care activities. However, observations revealed that there was no signage indicating EBP on the resident's door, and no personal protective equipment (PPE) was available outside the room. Nursing assistants were observed transferring the resident without using gowns or gloves, and they were unaware of the requirement to use EBP for residents with wounds. Interviews with staff, including a licensed practical nurse (LPN) and a registered nurse (RN), confirmed that EBP was not being implemented for any residents in the facility. The LPN verified the absence of signage and PPE carts, while the RN mentioned that the previous infection preventionist was aware of the EBP regulation but did not implement it. The interim director of nursing (IDON) also indicated a lack of awareness regarding the regulation and confirmed that EBP had not been implemented during her tenure. The facility's policy on Enhanced Barrier Precautions, dated November 2023, outlined the requirements for implementing EBP, including staff training, availability of PPE, and proper signage. Despite this policy, the facility did not adhere to these guidelines, resulting in a failure to protect residents from potential infection risks associated with wounds and indwelling medical devices. The lack of implementation and awareness among staff contributed to the deficiency in infection control practices.
Latest citations in Minnesota
A resident with dry eye syndrome and degenerative eye disease had orders for cyclosporine ophthalmic emulsion and Refresh Tears, both scheduled at the same time. Medication records and direct observation showed a TMA instilled cyclosporine drops in both eyes and immediately followed with Refresh Tears in both eyes without waiting between medications. This practice conflicted with referenced professional guidance recommending several minutes between multiple eye drops and with the medical provider’s recommendation to wait fifteen minutes between the two ophthalmic medications. No facility policy on ophthalmic medication administration was provided when requested.
A resident with severe cognitive impairment, impaired mobility, and high fall risk was care planned to have wheelchair footrests in place at all times, with staff ensuring proper positioning and monitoring for leaning during transport. A NA transported the resident in a manual wheelchair from the shower without the footrests, and while going through the doorway the wheelchair struck the door frame, causing the resident, who was leaning forward, to fall out. The resident sustained a T12 fracture, head injury with concussion, abrasions and contusions, and multiple right-hand lacerations requiring sutures, and the DON confirmed the care plan had not been followed.
A high‑risk, immobile resident with MS and prior heel DTI developed an avoidable unstageable coccygeal pressure ulcer after staff failed to consistently assess and document skin status, did not transfer or timely provide ordered pressure‑relieving mattresses, and did not reliably perform q2h repositioning. The resident was repeatedly left on a bedpan for prolonged periods despite early reports of this issue, and the toileting care plan was not revised to a bedside commode until after the coccygeal wound had significantly worsened. Wound assessments lacked complete measurements and staging, changes in wound size and color were not promptly recognized as deterioration or reported to providers, and recommended interventions from a wound NP (including an air mattress and offloading) were not promptly implemented. As a result, the coccygeal ulcer rapidly progressed to a large, necrotic, malodorous wound requiring hospital transfer and surgical debridement.
A resident with 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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