Valley View Manor Hcc
Inspection history, citations, penalties and survey trends for this long-term care facility in Lamberton, Minnesota.
- Location
- 200 East Ninth Avenue, Lamberton, Minnesota 56152
- CMS Provider Number
- 245378
- Inspections on file
- 34
- Latest survey
- November 19, 2025
- Citations (last 12 mo.)
- 11 (1 serious)
Citation history
Health deficiencies cited at Valley View Manor Hcc during CMS and state inspections, most recent first.
A resident with diabetes who required blood glucose monitoring and insulin administration was cared for by nursing staff who had not received training or demonstrated competency in using a continuous glucose monitoring device. Staff were unfamiliar with the device's instructions, and there was no facility policy or process in place to guide its use.
Dietary staff lacked proper training and competency in monitoring dish machine temperatures, resulting in repeated failures to achieve required sanitation levels. Staff were unclear about which gauges to use, did not consistently document or report low temperatures, and competency records were incomplete or missing. The facility's policies for temperature monitoring and reporting were not consistently followed.
The facility failed to ensure dietary staff consistently monitored and documented dish machine temperatures, resulting in repeated failures to reach required sanitizing levels and lack of staff competency documentation. Additionally, a resident using a continuous glucose monitoring device was not assessed for knowledge or competency, and nursing staff had not received training or completed competencies on the device, despite facility expectations for diabetic management and equipment use.
A resident using a continuous blood glucose monitoring device was not assessed for competency or provided guidance on its use, including when to perform manual blood glucose checks. Facility staff had not received training or competency checks on the device, and there was no policy or process in place to ensure proper use and understanding of the device's functions.
A resident with moderate cognitive impairment and multiple medical conditions was prescribed several psychotropic medications without documentation of target behaviors or symptoms, and there was no monitoring for medication side effects. Staff reported the resident experienced hallucinations, but the care plan lacked individualized non-pharmacological interventions and did not address how to respond to these symptoms. The facility's reliance on a standardized care plan library contributed to the absence of personalized interventions.
A resident with documented PTSD, anxiety, and depression did not have PTSD identified on the admission MDS assessment, despite this diagnosis being present in preadmission screening and medical records. The omission was confirmed by the ADON, who noted that the admission MDS had been completed by contracted staff, and that accurate MDS coding is required to ensure appropriate care planning.
A resident with atrial fibrillation and a hip fracture, who was prescribed Eliquis, did not have a care plan that included individualized interventions or monitoring for side effects related to anticoagulant therapy. Nursing staff confirmed the absence of documentation and monitoring measures in the care plan, despite facility policy requiring such details.
A resident with multiple chronic conditions experienced a fall resulting in a fractured ankle, which led to a change in transfer needs from one-person assist to requiring a Hoyer lift with two staff. Despite this significant change, the care plan was not updated to reflect the new transfer requirements, as confirmed by staff interviews and observation.
A resident dependent on staff for all care and receiving hospice services did not have an integrated care plan specifying which services were to be provided by hospice and which by facility staff. The care plan and staff Kardex lacked mention of hospice involvement, and staff interviews revealed inconsistent communication and documentation practices between the facility and hospice provider.
A housekeeping aide did not receive the required second step of the two-step TB skin test at the appropriate interval after hire. Both TSTs were administered on the same day, contrary to guidelines that require the second test 1–3 weeks after the first. The aide was not informed of the need for a second test, and facility documentation did not show proper completion of the TB screening process.
A resident with a history of neuromuscular bladder dysfunction and an indwelling catheter was prescribed ciprofloxacin for a UTI and prostatitis. The facility did not complete or document the required 48-72 hour antibiotic time-out to assess the appropriateness of continued therapy, as outlined in CDC guidelines and facility policy.
A resident with dementia, anxiety, and diabetes, who had previously received multiple pneumococcal vaccines, consented to an additional dose but did not receive it as planned. The vaccine administration was held without notifying the resident's POA or reassessing the resident's suitability for vaccination, contrary to facility policy and CDC recommendations.
A resident with cognitive decline and a history of elopement was inadequately supervised, leading to an elopement incident. The facility failed to update the resident's care plan with specific interventions for supervision, and staff were unclear about supervision responsibilities. Despite the resident's increased risk, the care plan did not reflect necessary precautions, contributing to the resident's unsupervised departure from the facility.
A resident reported an abuse allegation to an LPN, who informed the DON. The DON initially dismissed the claim as a hallucination and delayed reporting it to the administrator and SA. The incident was reported beyond the required two-hour timeframe, violating the facility's policy on immediate reporting of abuse.
The facility failed to implement enhanced barrier precautions (EBP) and ensure proper use of PPE for two residents with wounds and indwelling catheters. Staff inconsistently applied EBP, and the director of nursing was unaware of new requirements. Additionally, the facility did not effectively monitor, track, or trend infections, with incomplete surveillance documentation and no regular review of infection data. The facility's QAPI meeting minutes lacked infection tracking, and the administrator confirmed a lack of infection monitoring.
The facility's acting infection preventionist (IP), also the director of nursing (DON), had not completed specialized training in infection prevention and control, potentially affecting all 21 residents. The DON was assigned as the IP designee after the assistant director of nursing (ADON) resigned abruptly. The facility administrator confirmed the absence of a certified IP and was unable to provide records for two residents' COVID vaccine offerings. A policy related to the IP was requested but not provided.
A medication cart in a common area was left unattended with the electronic health record system open, exposing sensitive resident information. This involved 10 residents with complex medical conditions. Staff interviews revealed expectations to lock screens, but breaches had occurred. The director of nursing and administrator emphasized the importance of safeguarding information.
The facility failed to ensure that four residents were appropriately vaccinated against pneumonia upon admission, as per CDC guidelines. Despite previous vaccinations, there was no documentation that the updated PCV-15 or PCV-20 vaccines were offered or declined. Interviews revealed reliance on a local clinic for routine vaccines, but PCV vaccines were not offered due to in-house standing orders, and consent or declination was not obtained. The facility's policy to assess and document vaccination status was not followed, leading to the deficiency.
The facility failed to offer the COVID-19 vaccine to two residents upon admission, as required by policy. Both residents were cognitively intact and had no record of being offered the vaccine or declining it. The DON could not confirm if the vaccine was administered and lacked declination forms. The facility's policy required education and documentation of vaccine status, overseen by the Infection Preventionist.
The facility failed to ensure appropriate infection control techniques during a meal service, with Cook-A repeatedly using the same gloves to handle various items, including food, utensils, and tray cards, without changing gloves or performing hand hygiene, potentially affecting all 23 residents.
The facility failed to follow CDC infection control guidelines during an Influenza A outbreak, resulting in 9 out of 23 residents being affected. Staff did not use PPE properly, perform adequate hand hygiene, or report illnesses promptly. Observations showed staff entering and exiting isolation rooms without changing masks or using PPE, and symptomatic staff continued to work without testing.
The facility failed to allocate adequate time and resources for the infection preventionist (IP) to manage the infection control program, resulting in an Influenza A outbreak affecting 9 out of 23 residents. The IP, who also served as the ADON, was unable to implement necessary infection control practices due to insufficient time and unclear guidance on required hours.
The facility failed to ensure all dietary staff had adequate training on equipment use, food safety, and sanitation, leading to untrained staff, including a TMA and nursing assistants, working in the kitchen. The dietary manager also neglected proper infection control practices during an Influenza-A outbreak.
The facility failed to ensure residents had access to their personal funds upon request. A resident reported limited access to her money, and staff confirmed that funds could only be accessed during business hours. The administrator believed there was a cash box for after-hours access, but staff were unaware of it and had difficulty locating it. The ADON confirmed that residents only had access to their funds when the administrator or business office manager were present.
The facility failed to provide timely notifications for a resident who experienced multiple falls, resulting in injuries. Despite the facility's policy requiring immediate notification of the DON, medical provider, and family, there was no documentation of such notifications for two of the three falls. The family expressed concerns about the lack of communication during a care conference.
The facility failed to provide adequate OT and PT services for two residents, leading to inconsistent therapy sessions and lack of progress. Despite treatment plans indicating frequent therapy, residents received limited sessions, and there was no evaluation of the therapy's effectiveness. Interviews revealed concerns about the facility's inadequate therapy services and the absence of a full-time PTA.
Failure to Ensure Staff Competency in Use of Continuous Glucose Monitoring Device
Penalty
Summary
The facility failed to ensure that nursing staff were competent in the use of a continuous glucose monitoring device (FreeStyle Libre 3) for a resident with diabetes. The resident required assistance with activities of daily living and had multiple diagnoses, including diabetes, heart failure, respiratory failure, and mental health conditions. The resident's care plan required blood glucose monitoring three times daily and insulin administration based on those readings. Documentation showed the resident's blood glucose levels fluctuated widely, but there was no evidence that staff had received training or demonstrated competency in using the device. Interviews with nursing staff revealed that some had prior experience with similar devices at other facilities but had not received training or completed competency assessments at this facility. Staff were unaware of the location of manufacturer instructions, and the assistant director of nursing confirmed there was no policy or process for the use of the device, nor had any training or competencies been completed. The resident reported relying on staff to interpret her blood sugar readings and was not familiar with when a manual check was needed or how device alarms functioned. The administrator acknowledged that staff should be trained and competent in the use of medical equipment for resident care.
Failure to Ensure Dietary Staff Competency in Dish Machine Temperature Monitoring
Penalty
Summary
The facility failed to ensure that dietary staff were properly trained and competent in monitoring dish machine temperatures to achieve appropriate sanitation. Observations and interviews revealed that staff were unclear about which gauges to use for monitoring wash and rinse cycles, and some staff believed there was no specific temperature requirement. The maintenance director and dietary manager confirmed confusion regarding the correct use of the gauges, and it was found that the right gauge was not functioning as expected, while the left gauge was used for both wash and rinse cycles. The Ecolab data plate and operation manual specified that the wash temperature should be at least 150 degrees Fahrenheit and the rinse temperature at least 180 degrees Fahrenheit, but staff were not consistently following these guidelines. Review of dish machine temperature logs for March, April, and May showed multiple instances where the rinse temperature fell below the required 180 degrees Fahrenheit, and there were several days with missing documentation of temperature monitoring. Staff were instructed to contact the dietary manager if temperatures were not met, but interviews revealed that low rinse temperatures had not been addressed with staff. The dietary manager acknowledged that staff had been trained using an online system and in-person instruction, but admitted that staff did not always follow directions and that she had not previously intervened regarding the low temperatures. Further review of staff training and competency records indicated that dietary aides and cooks lacked documentation of competencies related to monitoring dish machine temperatures, and in some cases, there was no evidence that dietary policies had been read or reviewed. The facility's policy required staff to verify proper temperatures and machine function before use, monitor gauges throughout the cycle, and report any issues to the dietary manager, but these procedures were not consistently followed or documented.
Deficiencies in Dietary Sanitation Monitoring and Blood Glucose Device Competency
Penalty
Summary
The facility failed to ensure proper monitoring and documentation of dish machine temperatures in the dietary department, resulting in repeated instances where the rinse cycle did not reach the required sanitizing temperature of 180 degrees Fahrenheit. Observations and interviews revealed that staff were unclear about which gauges to use for monitoring, and there was confusion regarding the correct temperature requirements. Review of temperature logs for March, April, and May showed multiple days where the rinse temperature fell below the required level, and there were numerous instances of missing documentation. Staff did not consistently follow the policy to notify the dietary manager when temperatures were inadequate, and the dietary manager confirmed that she had not addressed these issues with staff. Additionally, competency documentation for dietary aides and cooks was lacking, with no evidence that staff had been trained or deemed competent in monitoring dish machine temperatures or reviewing relevant policies. In the area of blood glucose monitoring, a resident using a continuous glucose monitoring device (Freestyle Libre 3) was not assessed for knowledge or competency in using the device, including when to perform manual blood glucose checks or how to respond to device alarms. The resident reported that nursing staff relied on her to report her blood sugar readings and provided interventions such as snacks or juice for low readings, but she was not familiar with the device's alarm functions or manual testing procedures. Review of the resident's self-administration assessment showed no evidence of guidance or assessment regarding the use of the device. Manufacturer instructions require users to review all product instructions and complete tutorials, but this was not documented for the resident. Nursing staff, including RNs and the ADON, reported they had not received training or completed competencies on the use of the Freestyle Libre 3 device. Staff were unaware of the location of manufacturer instructions and had not been provided with a policy or process for using the device. The facility's assessment indicated that staff were to be trained and competent in diabetic management and the use of medical equipment, but there was no evidence that this had occurred for the continuous glucose monitoring device. The administrator confirmed the expectation that staff should be trained and competent in the use of any medical equipment used for resident care.
Failure to Assess Resident Competency and Staff Training for Blood Glucose Monitoring Device
Penalty
Summary
The facility failed to determine whether a resident was safe to self-monitor diabetic medication treatment results using a continuous blood glucose monitoring system (FreeStyle Libre 3). Observation and interview revealed that the resident used a sensor and handheld meter to check blood glucose levels and reported the results to nursing staff. The resident was not aware of when a manual blood glucose check would be necessary and was unfamiliar with the device's alarm functions. There was no evidence that the resident had been given guidance or assessed for knowledge on using the monitor or recognizing when to perform a manual check for accuracy. Further review showed that the resident's self-administration of medications assessment did not address the resident's competency with the device or provide any guidance. The assistant director of nursing confirmed that the facility lacked a policy or process for the use of the FreeStyle Libre 3 device and had not provided training or competency checks for nursing staff regarding its operation. Manufacturer instructions for the device require users to review all product instructions and complete tutorials, including understanding symbols that indicate when a manual blood glucose check is needed, but this was not ensured by the facility.
Failure to Identify and Monitor Target Behaviors for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that psychotropic medications prescribed to a resident had clearly identified target behaviors or symptoms, and did not monitor for those behaviors or for adverse effects of the medications. The orders for multiple psychotropic medications, including an antipsychotic and two antidepressants, lacked documentation specifying the symptoms or behaviors they were intended to treat. Additionally, there was no evidence of monitoring for medication side effects, and the care plan did not include individualized non-pharmacological interventions or address the resident's hallucinations and delusional thoughts. Interviews with staff confirmed that while the resident experienced visual and auditory hallucinations, staff responses were limited to reassurance and reporting to nursing, without specific interventions documented in the care plan. The resident involved had a history of moderate cognitive impairment, functional limitations, and multiple medical diagnoses, including a neurological condition, stroke, heart failure, diabetes, and seizure disorder. Despite these complexities, the care plan and medication administration records did not identify target behaviors or symptoms for the psychotropic medications, nor did they outline how staff should respond to the resident's hallucinations. The facility's use of a standardized care plan library further contributed to the lack of individualized interventions, as confirmed by the assistant director of nursing. The facility's policy required comprehensive assessment and documentation of specific conditions for psychotropic medication use, which was not followed in this case.
Failure to Accurately Identify Resident Diagnosis in MDS Assessment
Penalty
Summary
The facility failed to ensure that a resident's status was accurately identified in the Minimum Data Set (MDS) assessment. Specifically, a resident with documented diagnoses of post-traumatic stress disorder (PTSD), anxiety, and depression, as indicated in the Preadmission Screening Results and medical diagnosis list, did not have PTSD identified on the admission MDS assessment. Subsequent quarterly and significant change MDS assessments did include the PTSD diagnosis. The assistant director of nursing confirmed that the admission MDS, completed by contracted staff, lacked the PTSD diagnosis, which would have triggered care planning for PTSD to ensure appropriate support. The Resident Assessment Instrument (RAI) manual requires that MDS submissions be accurate and reflect the resident's actual condition during the look-back period.
Failure to Develop Comprehensive Care Plan for Anticoagulant Therapy
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan addressing anticoagulant therapy and related safety precautions for a resident with atrial fibrillation and a hip fracture. The resident, who was moderately cognitively impaired, was prescribed Eliquis 2.5 mg twice daily for atrial fibrillation. Despite the ongoing use of this anticoagulant, the resident's care plan did not include individualized documentation of pharmacological and non-pharmacological interventions, nor did it address potential side effects or adverse effects associated with the medication. Interviews with nursing staff confirmed that the care plan lacked evidence of monitoring for anticoagulation therapy, such as observing for symptoms like dark stools, bruising, abnormal bleeding, or severe paleness. The assistant director of nursing also acknowledged that the care plan should have included interventions specific to anticoagulant use and its side effects. Review of facility policy indicated that care plans were required to include measurable objectives, timeframes, and ongoing assessments, but these elements were missing in the resident's care plan regarding anticoagulant therapy.
Failure to Update Care Plan After Resident's Change in Condition
Penalty
Summary
The facility failed to revise the care plan for a resident following a significant change in condition. The resident, who had diagnoses including Alzheimer's disease, congestive heart failure, osteoarthritis, and diabetes mellitus, was previously assessed as having intact cognition and required extensive assistance from one staff member for transfers, toileting, and bed mobility. After experiencing increased weakness and falls, the resident was evaluated in the emergency department, where a fractured left ankle was diagnosed and splinted. Upon return to the facility, the resident became non-weight bearing and required the use of a Hoyer mechanical lift with assistance from two staff members for all transfers. Despite this change in the resident's condition and care needs, the care plan was not updated to reflect the new requirement for total assist by two staff using a mechanical lift. Observations and staff interviews confirmed that the resident's transfer method had changed due to the fracture, but the care plan continued to indicate the need for only one staff assist and a walker for ambulation. The assistant director of nursing acknowledged that the care plan had not been revised to address the resident's current needs following the injury.
Failure to Coordinate and Document Hospice Services in Care Plan
Penalty
Summary
The facility failed to develop and implement an integrated care plan that clearly coordinated and delineated the responsibilities of hospice and facility staff for a resident receiving hospice care. The resident, who was dependent on staff for all activities of daily living and had multiple diagnoses including dementia, alcohol dependence, and other chronic conditions, was receiving hospice services. However, the facility's care plan did not mention hospice involvement or specify which services were to be provided by hospice versus the facility. The direct care staff Kardex also lacked any reference to hospice services or coordination with hospice staff for tasks such as bathing. Interviews with facility staff revealed that the electronic medical record system's new care plan library limited the ability to personalize care plans, resulting in the omission of hospice information. The assistant director of nursing acknowledged that hospice was not mentioned in the care plan and that communication with hospice could be inconsistent. The hospice provider reported faxing care plans to the facility and leaving information in a binder, but was unsure how the facility handled this information. Facility policy and the hospice agreement required coordinated care planning, but this was not reflected in the resident's documentation.
Failure to Administer Second TB Test per Protocol for New Employee
Penalty
Summary
The facility failed to ensure that a housekeeping aide received appropriate tuberculosis (TB) testing in accordance with state and federal guidelines. Upon hire, the employee completed a baseline TB symptom screen and received both the first and second tuberculin skin tests (TST) on the same day, with both tests read two days later and found to be negative. However, both the Minnesota Department of Health and CDC guidelines require that if the first TST is negative, the second TST should be administered 1 to 3 weeks after the first, not on the same day. Documentation in the employee's health file indicated that the tests were not spaced appropriately, and there was no evidence that a second TST was completed at the correct interval. Interviews with the housekeeping aide revealed she was not informed that a second TST was required, and the Assistant Director of Nursing (ADON) acknowledged that the TB screening form was filled out incorrectly and that the second TST was not properly documented or administered according to policy. The facility's policy required all employees to be screened and tested for active TB prior to employment, but this process was not followed for the housekeeping aide, resulting in a failure to comply with TB control regulations.
Failure to Complete Timely Antibiotic Review
Penalty
Summary
The facility failed to complete a required review of antibiotic therapy within 48-72 hours for one of three sampled residents. According to CDC guidelines, an antibiotic time-out should be performed within this timeframe to ensure the appropriateness of continued antibiotic use by evaluating the resident's current symptoms and laboratory results. Documentation review showed that the infection control log tracked residents with potential infections and included relevant clinical information. However, for one resident who was prescribed ciprofloxacin for a urinary tract infection and prostatitis, there was no evidence of an initial comprehensive assessment or a completed antibiotic time-out in the medical record. The resident in question had a diagnosis of neuromuscular dysfunction of the bladder and an indwelling catheter, placing them at increased risk for infection. The care plan directed staff to monitor for urinary complaints and manage catheter patency. Despite these risk factors and the initiation of antibiotic therapy, the required review to assess the ongoing need for antibiotics was not documented. The assistant director of nursing confirmed that the antibiotic time-out, which should have been completed and documented in the electronic health record, was missing for this resident.
Failure to Administer and Document Pneumococcal Vaccination per CDC Guidelines
Penalty
Summary
The facility failed to ensure that one resident was properly offered and/or provided updated pneumococcal vaccinations in accordance with CDC recommendations. The resident, who had diagnoses including dementia, anxiety, and diabetes, had a documented history of receiving PCV-7, PPSV23, and PCV-13 vaccines. Despite consenting to receive an additional pneumococcal vaccine, the administration of the vaccine was held without communication to the resident's power of attorney or reassessment of the resident's appropriateness for vaccination. The facility's policy required assessment and administration of the PCV vaccine within 30 days of admission, with documentation of refusals or contraindications, but this process was not followed as required for this resident.
Inadequate Supervision and Elopement Risk Management
Penalty
Summary
The facility failed to comprehensively assess and provide an adequate plan for supervision and appropriate interventions to protect a resident identified as at risk for elopement. The resident, who had intact cognition upon admission, experienced cognitive decline over time, as evidenced by a decrease in their Brief Interview for Mental Status (BIMS) score and observations of forgetfulness and confusion. Despite being identified as a low risk for elopement initially, the resident had a history of elopement or attempted elopement, which was not adequately addressed in their care plan. The resident's care plan and Kardex lacked specific staff interventions to ensure adequate supervision, particularly when the resident was outdoors. The care plan was not updated to reflect the resident's increased risk of elopement and the need for supervision. Interviews with staff revealed that there was confusion and inconsistency regarding the resident's supervision requirements, with some staff believing that the resident's spouse, who was also a resident, could supervise them, despite her own vulnerabilities and inability to effectively prevent elopement. The deficiency was further highlighted by an incident where the resident eloped from the facility, was found by law enforcement, and returned unharmed. The facility's failure to communicate and implement specific interventions for the resident's supervision, as well as the lack of a comprehensive assessment of the resident's cognitive decline and elopement risk, contributed to the incident. The facility's policies on care planning and resident safety were not effectively followed, leading to inadequate supervision and an environment not free from accident hazards.
Delayed Reporting of Abuse Allegation
Penalty
Summary
The facility failed to immediately report an allegation of abuse involving a resident, identified as R1, to the administrator and State Agency (SA). On the night of 6/17/24, R1, who had intact cognition and required staff supervision for certain activities, reported to an LPN that a large woman had grabbed her neck the previous night, causing pain and fear. The LPN notified the Director of Nursing (DON) within an hour of the allegation, but the DON initially dismissed it as a hallucination and did not report it immediately to the administrator or SA. The DON informed the administrator the following morning, and the interdisciplinary team decided to report the incident to the SA. However, the report was not submitted until the evening of 6/18/24, which was beyond the required two-hour timeframe for reporting allegations of abuse. The facility's policy mandates immediate reporting of suspected abuse, defined as within two hours for incidents involving abuse or serious bodily injury. The delay in reporting was a violation of this policy.
Failure to Implement Enhanced Barrier Precautions and Monitor Infections
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) and ensure personal protective equipment (PPE) was used according to EBP indications for two residents with a wound and indwelling catheter. Observations revealed that staff did not consistently use gowns and gloves for high-contact care activities, such as wound care and catheter handling, despite the presence of signs indicating the need for such precautions. Interviews with staff, including nursing assistants and the director of nursing (DON), indicated a lack of understanding and inconsistent application of EBP, with some staff believing that gowns were only necessary when directly handling urine or the catheter. The facility also failed to monitor, track, and trend signs and symptoms of infections effectively. The DON admitted to being unaware of the new requirements for implementing EBP for residents with infections or colonized CDC-targeted multi-drug-resistant organisms (MDROs), wounds, and/or indwelling medical devices. The facility's infection control surveillance documentation was incomplete, with multiple entries under the category of infection marked as unknown, and there was no evidence of regular review or analysis of infection data for trends. Additionally, the facility's Quality Assurance and Assessment (QAA)/Quality Assessment and Performance Improvement (QAPI) meeting minutes lacked a review of infections or a summary of tracking or trending of infections. The DON reported that the previous DON and assistant DON had left the facility, and she was unable to find any surveillance information, indicating a gap in infection control oversight. The administrator confirmed that no one had been monitoring or tracking infections for trends, further highlighting the facility's failure to maintain an effective infection prevention and control program.
Inadequate Infection Preventionist Training
Penalty
Summary
The facility failed to ensure that the acting infection preventionist (IP), who is also the director of nursing (DON), had completed specialized training in infection prevention and control. This deficiency had the potential to affect all 21 residents residing in the facility. During an interview, the DON admitted that she had not completed her IP training and certification, and no other staff in the facility had IP training. She was assigned as the IP designee after the assistant director of nursing (ADON) resigned abruptly. Additionally, the facility administrator confirmed that there was no certified IP at the facility due to the ADON's departure and was unable to provide records for two residents to confirm that COVID vaccines were offered. A review of the facility assessment from July 2023 indicated that the facility previously had a certified IP and conducted monthly infection control meetings. However, a policy related to the IP was requested but not provided by the end of the survey.
Privacy Breach of Resident Medical Information
Penalty
Summary
The facility failed to ensure the privacy of residents' medical information, as observed with a medication cart located in a common area accessible to residents and visitors. The cart was left unattended with the electronic health record system open, displaying sensitive information such as residents' names, pictures, and room numbers. This incident involved 10 residents, including those with complex medical conditions like diabetes, depression, schizophrenia, neurological conditions, and dementia. The medication aide responsible for the cart admitted to forgetting to close the electronic medical record screen, leaving it exposed to unauthorized access. Interviews with staff, including nursing assistants and the director of nursing, revealed that there was an expectation for staff to lock screens to prevent exposure of patient records. However, it was noted that on rare occasions, patient information had been left accessible on the medication cart. The director of nursing and the administrator both emphasized the importance of safeguarding residents' information, aligning with the facility's confidentiality policy. Despite these expectations, the breach in securing resident data was not previously known to the director of nursing.
Failure to Ensure Pneumococcal Vaccination Compliance
Penalty
Summary
The facility failed to ensure that four out of five sampled residents were appropriately vaccinated against pneumonia upon admission, as per the current CDC guidelines. The residents in question were admitted in May 2024, and their vaccination records indicated that they had received previous pneumococcal vaccines, but there was no documentation to support that they had been offered or declined the updated PCV-15 or PCV-20 vaccines upon admission. Specifically, one resident had received PPSV-23 and PCV-13 in the past, another had received Prevnar 13 followed by PPSV-23, and a third had received PCV-13 followed by PPSV-23. The fourth resident's record lacked documentation of any pneumococcal vaccines, and there was no evidence that the PCV-20 or PCV-15 vaccines were offered or administered according to the current guidelines. Interviews with the Director of Nursing (DON) and the administrator revealed that the facility relied on a local clinic to visit residents for routine vaccines, but the PCV vaccines were not offered during these visits due to in-house standing orders. The staff were required to obtain consent or declination of the vaccine for residents, but this was not completed for the new residents identified. The facility's policy from January 2022 stated that they would assess new residents' vaccination status and document refusals, but this was not adhered to, leading to the deficiency.
Failure to Offer COVID-19 Vaccine to Residents
Penalty
Summary
The facility failed to offer the COVID-19 vaccine to two residents, identified as R172 and R173, upon their admission. Both residents were cognitively intact, with R172 having a diagnosis of anemia and R173 having diagnoses of heart disease and high blood pressure. The vaccine history logs for both residents were undated and showed no record of being offered the COVID-19 vaccine or any declination of it. This indicates a lack of documentation and follow-through on the facility's part in offering the vaccine to these residents. During an interview, the Director of Nursing (DON) was unable to confirm whether the facility had administered COVID-19 vaccines to residents, including R172 and R173. The DON speculated that the residents might not have been interested in receiving the vaccine but could not provide any declination forms to support this claim. The facility's policy from December 2021 required that residents be educated about the vaccine and have the option to accept or refuse it, with the Infection Preventionist or a designee responsible for overseeing education, documentation, and vaccine status. The facility's assessment from July 2023 indicated adherence to guidelines from the Minnesota Department of Health and the CDC, which included offering COVID-19 vaccines to residents and employees.
Infection Control Deficiency During Meal Service
Penalty
Summary
The facility failed to ensure appropriate infection control techniques during a meal service, potentially affecting all 23 residents. Observations revealed that Cook-A repeatedly used the same gloves to handle various items, including food, utensils, tray cards, and resident wheelchairs, without changing gloves or performing hand hygiene. Cook-A was seen touching food directly with gloved hands, handling utensils, and serving meals without proper sanitation practices, leading to potential cross-contamination. During the meal service, Cook-A was observed using his gloved hands to support pieces of fish, arrange food on plates, and handle various items such as glasses and tray cards. He also failed to check the temperature of mechanically altered foods adequately and used the same gloves to handle different food items and equipment. Cook-A admitted to not being oriented to the kitchen and relied on his previous experience with a local food service company for his job duties. Interviews with the Dietary Manager (DM) and the Registered Dietitian (RD) revealed that there were expectations for dietary staff to follow infection control practices, including glove changes and hand hygiene. However, Cook-A's training and competency were not reviewed or assessed by the DM. The facility's policy on preventing foodborne illness required all employees handling food to be trained in safe food handling practices and demonstrate competency before working with food, which was not adhered to in this case.
Failure to Implement Infection Control Practices During Influenza A Outbreak
Penalty
Summary
The facility failed to implement infection control practices in accordance with CDC recommendations to prevent and mitigate the spread of Influenza A. This failure included improper utilization of personal protective equipment (PPE), inadequate hand hygiene, allowing ill staff to work, not implementing active symptom screening for residents and staff, and not providing ongoing education to staff during the outbreak. These lapses resulted in an Influenza A outbreak affecting 9 out of 23 residents and potentially exposing the remaining residents, visitors, and staff to the virus. The infection preventionist (IP) admitted to several deficiencies in the facility's infection control program. The IP was unaware of CDC guidelines for active symptom screening and did not maintain an up-to-date illness tracking system for staff. The IP also reported that staff frequently failed to communicate their illnesses, and department managers did not relay information about ill calls. Additionally, the IP noted that staff were not consistently practicing appropriate hand hygiene or using PPE correctly, despite ongoing education and reminders. Observations during the survey revealed multiple instances of staff not adhering to infection control protocols. Staff members were seen entering and exiting rooms of residents on isolation without changing masks or using PPE. One dietary manager continued to work while symptomatic and refused to get tested for Influenza A. Furthermore, several residents on contact and droplet precautions had their room doors open, and staff were observed not performing hand hygiene after interacting with these residents. These actions contributed to the spread of the virus within the facility.
Inadequate Time and Resources for Infection Preventionist
Penalty
Summary
The facility failed to ensure that the infection preventionist (IP) was allocated adequate time and resources to effectively manage the infection prevention and control program. The IP, who also served as the assistant director of nursing (ADON), was not aware of the required hours to be dedicated to infection control activities and had only logged approximately 40 hours since November 2023. The IP's responsibilities included meeting residents' needs, managing wounds, staff education, and orientation, which left insufficient time for infection control tasks. Consequently, the IP did not implement active symptom screening for residents and staff during an Influenza A outbreak, nor did she complete infection control audits or document staff education due to time constraints. The facility's infection prevention program policies and facility assessment did not specify the required time for the IP to perform infection surveillance based on the resident population or during communicable disease outbreaks. During the survey, it was found that the facility failed to implement infection control practices in accordance with CDC recommendations, which included the use of appropriate personal protective equipment (PPE), hand hygiene, preventing ill staff from working, and providing ongoing staff education during the outbreak. This failure resulted in an Influenza A outbreak affecting 9 out of 23 residents, with five residents remaining in isolation. The IP acknowledged that not enough time had been dedicated to infection control, and she was unsure how to balance her other job responsibilities with the necessary infection control activities. The facility's policies and job descriptions did not provide clear guidance on the required time for the IP to effectively manage the infection control program.
Lack of Training and Infection Control in Dietary Department
Penalty
Summary
The facility failed to ensure all staff working in the dietary department had adequate training on the use of equipment, safe temperatures for food safety, and sanitation processes. This deficiency was identified during an entrance conference where the director of nursing (DON) and administrator admitted to staffing issues in the dietary department, leading to multiple staff, including themselves, assisting with meal preparation and cleanup without proper training. The dietary schedule review revealed that a trained medication aide (TMA-A) was frequently scheduled as the evening cook without any specialized orientation or documented training in dietary management or food safety. Observations confirmed that TMA-A and other nursing assistants, who had no training for kitchen duties, were working in the dietary department due to staff shortages. Interviews with various staff, including the assistant dietary manager (ADM) and the dietary manager (DM), corroborated the lack of training and orientation for non-dietary staff assisting in the kitchen. The DM also failed to ensure proper infection control practices, as she was observed coughing and sneezing while working, and had declined to be tested for Influenza-A despite an outbreak in the facility. The registered dietitian (RD) confirmed awareness of the staffing issues and the outbreak, emphasizing the need for proper infection control and training for all staff involved in meal preparation and serving. The facility's policies on influenza prevention and foodborne illness prevention were reviewed, highlighting the requirement for training and competency in safe food handling practices, which were not adhered to in this case.
Failure to Ensure Resident Access to Personal Funds
Penalty
Summary
The facility failed to ensure residents had access to their personal funds upon request. A resident reported that she could only access her money when the administration or business office was open, and not on weekends or holidays. Interviews with staff confirmed that residents had to go to the administrator or business office manager during business hours to access their funds. The administrator believed there was a cash box with $30 in the medication room for after-hours access, but staff were unaware of its existence and had difficulty locating it. Eventually, the cash box was found with $45, but the staff did not know how to access it. The assistant director of nursing (ADON) confirmed that residents only had access to their funds when the administrator or business office manager were present. The ADON was also unaware of any money in the medication room for resident use or how to access it. The facility's policy stated that resident requests for access to their funds should be honored as soon as possible, but no later than the same day for amounts less than $100 ($50 for Medicaid residents) and within three banking days for larger amounts.
Failure to Provide Timely Notifications for Resident Falls
Penalty
Summary
The facility failed to provide timely notifications for a resident who experienced multiple falls. The resident, who had diagnoses including dementia, malnutrition, and a history of falls, experienced three documented falls in March. On 3/11/24, the resident was found on the floor with a large lump and laceration on the back of her head, and minor injuries on her hand, forearm, and ankle. The family was notified of this incident. However, on 3/20/24, the resident fell again while walking in the hall with a gait belt, resulting in a cut on her knee. There was no documentation of notification to the Director of Nursing (DON) for this incident. On 3/21/24, the resident was found on the floor with a large hematoma on her forehead and a skin tear on her elbow, but there was no documentation of notification to the responsible party or family members. During a care conference on 3/27/24, the family expressed concerns about the lack of notification, especially regarding the fall on 3/21/24. The DON confirmed that the facility's policy required timely notification of the DON, medical provider, and family following an incident. The DON acknowledged that the family should have been notified immediately after the assessment of the fall on 3/21/24 to determine if the resident needed to be sent to the Emergency Department. The facility's Falls-Clinical Protocol also required documentation of the fall, assessment data, interventions, and notifications, which was not followed in these instances.
Inadequate Rehabilitative Services for Residents
Penalty
Summary
The facility failed to provide adequate and specialized rehabilitative services of occupational therapy (OT) and physical therapy (PT) according to the individualized needs of two residents, R2 and R10. R2, who had diagnoses including bilateral osteoarthritis, sepsis, and a pressure wound, was admitted with orders for OT and PT. Despite the treatment plan indicating a frequency of three to five times per week for OT and daily sessions for PT, R2 received inconsistent therapy sessions, with OT provided only seven times and PT only twice over an 18-day period. The lack of consistent therapy sessions did not meet the ordered treatment plan, and there was no evaluation of the goal status or effectiveness of the limited therapy provided. R10, who had a stroke and weakness on one side of his body, was also admitted with orders for OT and PT. The treatment plan for PT indicated a frequency of one to five times per week, but R10 only completed three PT sessions over a 23-day period. The PT notes did not include the duration of the visits or an evaluation of the goal status and effectiveness of the therapy provided. The inconsistency in therapy sessions and the lack of a full-time physical therapist assistant (PTA) contributed to the deficiency in providing adequate rehabilitative services. Interviews with the Director of Nursing (DON) and the physical therapist (PT)-A revealed that the facility did not have adequate therapy services in place, leading to concerns about residents' potential decline in mobility and strength. The facility had switched therapy companies and was actively working on hiring additional therapy staff. However, the lack of consistent therapy services and the absence of a full-time PTA negatively impacted the residents' progress and the quality of care provided.
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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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