Victory Health & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Minneapolis, Minnesota.
- Location
- 512 49th Avenue North, Minneapolis, Minnesota 55430
- CMS Provider Number
- 245544
- Inspections on file
- 50
- Latest survey
- January 15, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Victory Health & Rehabilitation Center during CMS and state inspections, most recent first.
A resident was hospitalized after a safety incident and later discharged from the facility without the emergency family contacts being notified. Documentation did not show any communication with the family about the resident's hospitalization or discharge, and interviews confirmed that family members were unaware of these events until they visited the facility in person.
A resident was transferred to the ED due to safety concerns, but neither the resident nor their family received a written notice of transfer or information about the facility's bed hold policy. The EMR lacked documentation of these notifications, and staff interviews confirmed that only verbal notice was typically provided, with no written policy in place or uploaded to the record.
A resident with asthma and intact cognition was found keeping and using an albuterol inhaler at their bedside without staff knowledge or a documented assessment for self-administration. Although there was a provider order for the inhaler, no assessment or care plan interventions for self-administration were completed, contrary to facility policy. Staff confirmed that proper procedures for assessing and documenting self-administration were not followed.
A resident with severe cognitive impairment and psychiatric diagnoses was found without access to a call light, contrary to her care plan and facility policy. The call light was discovered on the floor under the bed, and staff interviews confirmed that call lights should be within reach to allow residents to request assistance.
A resident with severe cognitive impairment and multiple psychiatric diagnoses received ECT twice weekly, but staff failed to monitor and document temperature and IV site condition as required by care plan and discharge instructions. Nursing staff and the DON confirmed that only behaviors and certain symptoms were monitored, omitting temperature and IV site checks after ECT sessions, despite provider and policy expectations.
An allegation of abuse involving two residents in a physical altercation, resulting in injury, was not reported to the State Agency within the required two-hour timeframe. Staff interviews revealed confusion about reporting procedures, and the incident was only reported several days later, contrary to facility policy.
A medication cart was left unlocked and unattended for about 30 minutes in a hallway, during which time multiple staff and residents passed by, and a resident touched items on the cart. The responsible LPN confirmed the cart should have been locked, and facility leadership reiterated that locking medication carts is required by policy.
A resident with severe cognitive and physical impairments was left to struggle with meals without assistance, violating dignity standards. Observations showed the resident attempting to eat independently in bed and later being assisted while seated alone in the dining room by untrained staff. Facility policies on meal assistance and dignity were not adhered to.
A resident with severe cognitive and physical impairments, including a history of stroke and right-sided hemiplegia, was found to have an inaccessible call light on multiple occasions. Despite the care plan's instructions to keep the call light within reach to prevent falls, it was repeatedly observed in a drawer out of reach. The resident struggled to eat without assistance, and staff confirmed the call light should have been accessible, indicating a failure to meet the resident's needs.
A resident with multiple medical conditions, including diabetes, repeatedly requested the exclusion of orange juice from their breakfast tray, but the facility failed to honor this preference. Despite the facility's policy to assess and implement individual food preferences, the resident continued to receive orange juice, contrary to their requests. The Food Service Director acknowledged that residents should receive their preferred choices within their dietary orders.
A resident with severe cognitive and physical impairments was not provided with the appropriate therapeutic diet and meal supervision, nor was the resident transferred safely according to their care plan. Observations showed the resident was left unsupervised during meals with inappropriate food items and was transferred using a pivot method instead of the required Hoyer lift. Staff interviews confirmed misunderstandings of the resident's needs, and facility policies on meal assistance and safe transfers were not followed.
A resident with a complex medical history experienced significant unplanned weight loss due to the facility's failure to provide necessary meal assistance and prescribed nutritional supplements. Observations showed the resident often left meals untouched without encouragement or setup assistance. Staff interviews revealed a lack of awareness and documentation regarding the resident's nutritional supplement, and the resident's weight was not adequately monitored, violating the facility's weight assessment policy.
A facility failed to include an end date for a PRN psychotropic medication order for a resident with moderate cognitive impairment and receiving hospice care. The resident was prescribed Lorazepam for anxiety without a stop date, contrary to facility policy requiring a 14-day limit unless justified by the provider. Interviews with staff confirmed the oversight and highlighted the need for documented rationale and specified duration for extended use.
A resident with severe cognitive and physical impairments, including dysphagia, was left to eat without assistance and later helped by an untrained social services director. The facility's policy did not ensure only qualified staff assisted residents with meals, leading to a deficiency in care.
The facility failed to properly sanitize dishware due to inadequate water temperatures in their low-temperature chemical sanitizing dishwasher. Despite using chlorine test strips to measure sanitizer concentration, the water temperature consistently fell below the required 120 F. Staff confusion and lack of proper training contributed to the deficiency, and the issue was not addressed by maintenance or reported to the service company.
The facility failed to coordinate appointments for two residents, leading to missed medical visits. One resident with glioblastoma missed neurosurgery and oncology appointments due to poor communication, while another with eye issues experienced delays in specialist care. Additionally, a resident with liver failure was not monitored for edema despite significant weight gain, and medications were improperly administered through a feeding tube without proper orders.
The facility failed to provide individualized non-pharmacological interventions in the care plans for two residents on psychotropic medications. One resident, with cognitive impairments and mental health diagnoses, expressed distress without receiving tailored interventions. Staff interviews revealed a lack of awareness of specific interventions, and the DON confirmed the absence of individualized care plans, contrary to facility policy.
The facility failed to provide individualized non-pharmacological interventions for two residents on psychotropic medications. One resident, with cognitive impairment and a history of depression and anxiety, expressed distress without specific interventions in place. Staff addressed the resident's distress uniformly, lacking individualized strategies. Another resident, dependent on staff for daily activities and on antipsychotic medication, also lacked non-pharmacological interventions in their care plan, contrary to facility policy.
A facility failed to ensure proper hand hygiene and Enhanced Barrier Precautions (EBP) for residents requiring such measures. A nursing assistant did not change gloves or perform hand hygiene after catheter care, and an LPN did not use gown and gloves for a resident with a dialysis line, mistakenly believing EBP was for the roommate. Interviews confirmed the facility's expectations for infection control, highlighting lapses in adherence to policies.
Failure to Notify Family of Resident Hospitalization and Discharge
Penalty
Summary
The facility failed to communicate with a resident's emergency family contacts regarding significant events, including the resident's hospitalization and subsequent discharge. The resident was admitted to the facility and later sent to the emergency department due to safety concerns after being found unredirectable and walking towards traffic. Documentation in the electronic medical record did not show any evidence that the facility informed the resident's family about the safety incident, the hospitalization, or the discharge from the facility. Interviews with the resident's emergency contacts revealed that they were not notified of the resident's hospitalization or discharge. One family member only learned of the hospitalization after visiting the facility and being told by staff that the resident had been taken to the hospital by paramedics. The family also reported difficulty obtaining information from the facility and was not informed about the resident's discharge until they visited in person. The facility administrator and social worker confirmed that there was no documentation of communication with the family regarding these events, and the facility was unable to provide a discharge policy.
Failure to Provide Written Transfer Notice and Bed Hold Policy Upon Hospitalization
Penalty
Summary
The facility failed to provide a written notice of transfer and information regarding the bed hold policy to a resident and/or their family when the resident was hospitalized. The resident's electronic medical record showed an admission and subsequent discharge after being sent to the emergency department due to being unredirectable and walking towards traffic, which posed a safety concern. Documentation in the EMR did not show that the resident or their family received a written notice of transfer or information about the facility's bed hold policy at the time of hospitalization. During interviews, the resident's emergency contact confirmed not being informed or receiving any written notice or bed hold information, and the facility social worker stated that only verbal notice was typically given and documented in a progress note, with no awareness of a specific written notice policy. The facility administrator confirmed that a written notice and bed hold policy should have been uploaded to the EMR but were not present for this resident. No bed hold or written notice of transfer policy was provided for review.
Failure to Assess and Document Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a self-administration of medications assessment was completed for a resident who was observed with medication at their bedside. The resident, who had intact cognition and diagnoses including morbid obesity and asthma, was found to have an albuterol inhaler at their bedside, which they used as needed without notifying staff. The resident's most recent self-administration assessment indicated they did not wish to self-administer medications, and their care plan did not address self-administration. However, the resident kept and used the inhaler independently several times a week. Staff interviews confirmed that when a medication is found in a resident's room, it should be removed and an assessment should be completed to determine if self-administration is safe, followed by obtaining a provider order if appropriate. In this case, although there was a provider order for the inhaler, there was no order or documented assessment for self-administration, nor was it addressed in the care plan. The facility's policy requires an interdisciplinary assessment and documentation in the medical record and care plan if self-administration is deemed safe and appropriate, which was not followed in this instance.
Failure to Ensure Call Light Accessibility for Resident with Cognitive Impairment
Penalty
Summary
The facility failed to accommodate the needs of a resident with severe cognitive impairment and multiple psychiatric diagnoses by not ensuring the resident's call light was within reach, as required by the care plan and facility policy. During observation, the resident was found lying in bed without a call button accessible, and stated she did not have one, relying instead on waving or calling out to staff for assistance. Further inspection revealed the call light was on the floor under the bed, and both an LPN and a nursing assistant confirmed that staff are expected to ensure call lights are within reach before leaving a resident's room. The director of nursing also affirmed the importance of call light accessibility for resident communication. Facility policy directs staff to make call lights accessible from the bed, toilet, shower, and floor.
Failure to Monitor Temperature and IV Site After ECT
Penalty
Summary
The facility failed to monitor temperature and intravenous (IV) access site for a resident following electroconvulsive therapy (ECT) as required by the resident's care plan and discharge instructions. The resident, who had severe cognitive impairment and diagnoses including schizoaffective disorder, bipolar type, and catatonic schizophrenia, received ECT twice weekly. The care plan and ECT discharge instructions specified monitoring for extreme headache, nausea, vomiting, confusion, temperature greater than 100.5°F, and signs of IV site complications such as redness, swelling, drainage, or pain lasting more than 24 hours. However, the physician orders transcribed into the resident's record did not include monitoring for temperature or IV site complications after ECT, and the treatment administration record (TAR) and nurse's notes lacked documentation of these assessments on multiple occasions when ECT was administered. Interviews with nursing staff and the director of nursing confirmed that special monitoring was documented in the TAR according to provider orders, which in this case did not include temperature or IV site monitoring after ECT. The medical director stated that nurses should follow patient instructions for monitoring after ECT, including checking temperature and IV site. Despite this, the resident's temperature was only checked once during the relevant period, and there was no documentation of IV site monitoring after any of the ECT sessions. The facility's policy required the interdisciplinary team to document improvements or worsening in behavior, mood, and function, but the required monitoring for post-ECT complications was not completed or documented as ordered.
Failure to Timely Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to ensure that an allegation of potential abuse involving two residents engaged in a physical altercation was reported to the State Agency (SA) immediately, but no later than two hours as required. The incident involved a verbal altercation escalating to one resident allegedly striking another in the face, resulting in injuries including a dislocated jaw and chest wall contusion. Documentation showed that both residents were cognitively intact, with one having a recent history of verbal behaviors. The incident occurred late in the evening, but the report to the SA was not submitted until several days later. Interviews with staff revealed confusion and lack of awareness regarding the correct abuse reporting procedures. One LPN reported the incident only to the DON, not to the administrator or the SA, while another LPN was unaware of how to report to the SA and referenced unclear instructions. The DON and administrator both acknowledged that abuse allegations should be reported to the SA within two hours, but this protocol was not followed due to staff not being properly informed and the incident occurring over a weekend. The facility's policy required immediate reporting of alleged abuse, but this was not adhered to in this case.
Unattended and Unlocked Medication Cart
Penalty
Summary
A medication cart located outside the dining room on the [NAME] Hall was observed to be unlocked and unattended for approximately 30 minutes. During this period, thirteen staff members and eleven residents passed by the cart, and one resident touched items on top of it. The responsible LPN confirmed she had left the cart unattended and acknowledged that it should have been locked to prevent unauthorized access. Additional interviews with another LPN, the director of nursing, and the administrator confirmed that facility policy and standard practice require medication carts to be locked when unattended. The facility's Medication Labeling and Storage policy also specifies that medications and biologicals must be stored in locked compartments accessible only to authorized personnel.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience for a resident with severe cognitive impairment and physical limitations due to a stroke. The resident required substantial assistance with meals and was on a mechanically altered diet. During an observation, the resident was left in bed with a breakfast tray and struggled to eat independently, using his left hand to eat sausage and attempting to open a water bottle with his teeth. No staff were present to assist, and a nursing assistant entered the room briefly but did not acknowledge or assist the resident. Later, the resident was observed in the dining room, seated alone in a wheelchair, while the social services director stood next to him to assist with lunch. The director admitted to not having received feeding assistance training and was unaware that standing while assisting was undignified. Interviews with staff, including a licensed practical nurse and the director of nursing, confirmed that staff should sit next to residents when assisting with meals to ensure a dignified experience. The facility's policies emphasized the importance of checking food consistency and positioning a chair next to the resident for assistance, which were not followed in this instance.
Inaccessible Call Light for Resident with Severe Impairments
Penalty
Summary
The facility failed to ensure that a call light was accessible for a resident with severe cognitive impairment and physical limitations. The resident, who had a history of stroke, aphasia, and right-sided hemiplegia, required substantial assistance with most activities of daily living. The care plan for the resident indicated that the call light should be within reach to prevent falls. However, during multiple observations, the call light was found inside the top drawer of the nightstand, out of the resident's reach. On several occasions, the resident was observed in bed with meals in front of him, struggling to eat without assistance and attempting to open a water bottle with his teeth. No staff were present to assist, and the call light remained inaccessible. Interviews with a nursing assistant and the director of nursing confirmed that the call light should have been within reach, as per the facility's policy on answering call lights. The deficiency was identified through these observations and interviews, highlighting a failure to accommodate the resident's needs and preferences as outlined in their care plan.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor and implement the food preferences of a resident, identified as R24, who was reviewed for choices. R24 has multiple medical diagnoses, including multiple sclerosis, type II diabetes mellitus with hyperglycemia, major depressive disorder, and adjustment disorder. The resident's clinical physician orders specified a diabetic diet with regular texture and thin liquids consistency. However, during an observation, it was noted that the breakfast tray provided to R24 included items that the resident had specifically requested to be excluded, such as orange juice. Despite R24's repeated requests to exclude orange juice from the breakfast tray, it continued to be provided every morning. The Food Service Director confirmed that the dietary aide is responsible for verifying the resident menu slip and stated that residents should receive their preferred choices as long as they align with the ordered diet. The facility's policy on resident food preferences, dated July 2017, indicated that individual food preferences should be assessed upon admission and staff should interview residents to determine their preferences. However, this policy was not effectively implemented in R24's case, leading to the deficiency.
Failure to Provide Adequate Supervision and Safe Transfers
Penalty
Summary
The facility failed to provide appropriate therapeutic diet and meal supervision for a resident with severe cognitive impairment and physical disabilities. The resident, who had a history of stroke, aphasia, dysphagia, and right-sided hemiplegia, required a mechanically altered diet and substantial assistance with eating. Observations revealed that the resident was left unsupervised during meals, struggling to manage food items that were not appropriately prepared for his dietary needs, such as whole waffles and an unpeeled hard-boiled egg. Staff failed to check for food pocketing, and the resident was observed attempting to open a water bottle with his teeth, indicating a lack of adequate supervision. The facility also failed to ensure safe transfer methods for the resident, who was assessed to require a Hoyer lift for transfers due to his physical limitations. Despite this, staff were observed using a pivot transfer method without the necessary equipment, contrary to the resident's care plan and therapy recommendations. Interviews with staff revealed a misunderstanding of the resident's transfer needs, with some staff incorrectly believing that the resident did not require a lift or transfer belt. Interviews with various staff members, including the director of rehabilitation services, licensed practical nurse, and director of nursing, confirmed that the resident should have been supervised during meals and transferred using a Hoyer lift. The facility's policies on assisting impaired residents with meals and safe lifting and moving of residents were not followed, contributing to the deficiencies observed. The lack of adherence to these policies resulted in inadequate care and supervision for the resident, as evidenced by the observations and staff interviews.
Failure to Prevent Weight Loss in Resident
Penalty
Summary
The facility failed to comprehensively assess and implement interventions to prevent weight loss for a resident with significant unplanned weight loss. The resident, who had a complex medical history including vascular dementia, dysphagia, and Crohn's disease, was not provided with the necessary assistance for meals and did not receive a prescribed nutritional supplement. Observations revealed that the resident was often left in bed with meals untouched, and there was no encouragement or setup assistance provided by the staff. The resident's care plan indicated a need for setup assistance with meals, yet this was not consistently provided. The dietary notes highlighted the resident's potential nutritional problems and the need for dietary supplements, but these were not administered as ordered. Interviews with staff revealed a lack of awareness and documentation regarding the resident's nutritional supplement, and the resident's weight was not adequately monitored or flagged for significant weight loss. The facility's policy on weight assessment and intervention was not followed, as the resident's weights were not recorded in the weight chart, and there was no evaluation or intervention noted in the care plan. The failure to implement the prescribed nutritional interventions and monitor the resident's weight contributed to the resident's continued weight loss, highlighting a deficiency in the facility's care practices.
Failure to Include End Date for PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a PRN psychotropic medication order for a resident included an end date. The resident, who had moderate cognitive impairment and was diagnosed with lung cancer and depression, was receiving hospice care and had been prescribed Lorazepam for anxiety. The provider's order for Lorazepam, dated 12/13/24, specified a dosage of 0.25 milliliters every 4 hours as needed but did not include a stop date. This oversight was confirmed during an interview with an LPN, who acknowledged that the order should have been limited to 14 days unless otherwise justified by the provider. Further interviews with the Director of Nursing (DON) and the consultant pharmacist revealed that the facility's policy required all PRN psychotropic medications to have a stop date of 14 days unless extended with provider justification. The DON noted that hospice providers typically wrote orders for 90 days, but this was not reflected in the resident's order. The consultant pharmacist reiterated that even if the medication was not an antipsychotic, an end date was still necessary. The facility's policy on antipsychotic medication use, revised in 7/2022, also directed that PRN psychotropic medications needed beyond 14 days must include a documented rationale and specified duration in the order.
Unqualified Staff Assisting Resident with Dysphagia
Penalty
Summary
The facility failed to ensure that residents with difficulty swallowing were assisted with meals only by qualified individuals. A resident with severe cognitive impairment, upper and lower extremity impairment, and a history of stroke, aphasia, dysphagia, and right-sided hemiplegia required substantial assistance with meals and a mechanically altered diet. Despite these needs, the resident was observed struggling to eat independently without staff assistance, and later, was assisted by a social services director who was not trained as a feeding assistant. The facility's policy did not specify that only qualified staff should assist residents with meals, and the social services director admitted to helping the resident without having received any feeding assistance training. Interviews with staff, including a licensed practical nurse and the director of nursing, confirmed that only trained individuals should assist residents with meals, especially those on a dysphagia diet. The speech therapist also emphasized the need for supervision and assistance for the resident during meals, highlighting the facility's failure to adhere to these requirements.
Inadequate Dishware Sanitization Due to Low Water Temperature
Penalty
Summary
The facility failed to ensure proper sanitization of dishware used for meal preparation and resident service due to inadequate wash and rinse temperatures in their low-temperature chemical sanitizing commercial dishwasher. The dietary manager and dietary aide demonstrated the use of the dishwasher, which was identified as an Ecolab ES2000, and used chlorine test strips to measure the chemical sanitizer concentration. The concentration was found to be within the acceptable range of 100-200 ppm, but the water temperature was consistently below the required 120 F, reaching only between 112 F and 118 F during various observations. The dietary aide expressed confusion about the water temperature requirements and incorrectly recorded the temperature as 150 F on the log, despite the actual readings being lower. The dietary manager acknowledged the issue but stated that the dishwasher used chemicals to sanitize, implying that the water temperature was not a concern. However, the dishwasher service representative later confirmed that the machine required a minimum water temperature of 120 F during the wash and rinse cycles for proper sanitization. The facility's maintenance staff and administrator were unaware of the inadequate temperature issue, and the service company had not been contacted to address it. The administrator assumed the chemical sanitizer was effective based on the test strip results, but the lack of a user manual and proper training for staff contributed to the deficiency. The facility's policies lacked specific information on water temperature requirements during chemical sanitation, further compounding the issue.
Deficiencies in Appointment Coordination, Edema Monitoring, and Medication Administration
Penalty
Summary
The facility failed to ensure proper coordination of scheduled and follow-up appointments for two residents who required services from outside medical providers. One resident with cognitive impairment and diagnoses of glioblastoma and schizophrenia missed multiple neurosurgery and oncology appointments due to a lack of communication and coordination between the facility and the outside providers. The Health Unit Coordinator (HUC) was responsible for coordinating these appointments but was unaware of the missed appointments until later. Another resident, who had a history of retinal detachment and cataract surgery, experienced a delay in scheduling a follow-up eye specialist appointment, which was attributed to a communication gap within the facility. The facility also failed to monitor a resident with liver failure and ascites for edema. Despite the resident's significant weight gain over a short period, there was no indication in the medical records that the resident required monitoring for edema. The resident expressed concerns about swelling, but the staff did not document or implement interventions to address the edema. The registered nurse acknowledged the lack of monitoring and attributed the weight gain to the resident's dietary habits, despite the resident's history of edema-related issues. Additionally, the facility did not adhere to standard practices for administering medications through a feeding tube for a resident with multiple diagnoses, including stroke and hypertension. The registered nurse administered a mixture of crushed and liquid medications without an order to cocktail them, which is against the facility's expectations. The Director of Nursing stated that each medication should be administered separately with a flush of water in between, and an order should be present if medications are to be combined.
Lack of Individualized Care Plans for Residents on Psychotropic Medications
Penalty
Summary
The facility failed to include individualized non-pharmacological interventions in the comprehensive care plan for two residents, leading to a deficiency in managing unnecessary medications. One resident, who was moderately cognitively impaired and diagnosed with dementia, depression, and a psychotic disorder, was on routine antidepressant and antipsychotic medications. Despite the resident's significant change in condition, the care plan lacked specific interventions tailored to their mental health needs, such as non-pharmacological approaches to manage behavior. Observations and interviews revealed that the resident expressed distress and negative emotions, yet staff interventions were not individualized. During an observation, the resident was heard crying and expressing negative feelings, but staff only placed them in bed without addressing the underlying issues. Interviews with various staff members, including a registered nurse, a trained medication aide, and a licensed practical nurse, indicated a lack of awareness and implementation of resident-specific interventions for mental health concerns. The Director of Nursing confirmed that the care plan did not contain individualized interventions for the resident's depression and anxiety. The facility's policy on antipsychotic medication use emphasized the need for behavioral interventions to be attempted and included in the care plan, which was not adhered to in this case. This oversight highlights the importance of tailoring care plans to meet the specific needs of residents, particularly those with mental health issues.
Lack of Individualized Non-Pharmacological Interventions for Residents
Penalty
Summary
The facility failed to identify individualized non-pharmacological interventions for two residents, R1 and R27, who were reviewed for unnecessary medications. R1, who was moderately cognitively impaired with diagnoses of dementia, depression, and psychotic disorder, was on multiple psychotropic medications. Despite having a care plan that included various interventions for anxiety and mood problems, there was no evidence of non-pharmacological, resident-specific interventions. Observations revealed that R1 expressed distress and negative emotions, yet staff did not have specific interventions to address these behaviors, relying instead on general approaches. Interviews with staff, including a registered nurse, a trained medication aide, a licensed practical nurse, and a nursing assistant, indicated a lack of awareness and implementation of resident-specific interventions for R1. The staff addressed R1's distress in a uniform manner, without individualized strategies, and the director of nursing confirmed the absence of specific interventions in R1's care plan. This lack of individualized care planning was evident despite R1's history of suicidal ideation and anxiety, highlighting a deficiency in the facility's approach to managing R1's mental health needs. Similarly, R27, who had moderately impaired cognition and was dependent on staff for all activities of daily living, was receiving antipsychotic medication for mood disorder. R27's care plan included monitoring for side effects and effectiveness of medications but lacked non-pharmacological, resident-specific interventions. The facility's policy on antipsychotic medication use emphasized the need for behavioral interventions to be attempted and included in the care plan, yet this was not reflected in R27's care plan, indicating a systemic issue in the facility's management of psychotropic medication use and care planning.
Infection Control Deficiencies in Hand Hygiene and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed during personal and catheter care for a resident with moderately impaired cognition and an indwelling catheter. During an observation, a nursing assistant did not change gloves or perform hand hygiene after completing catheter and perineal care before touching various surfaces and items in the resident's room. The nursing assistant acknowledged the lapse in protocol during an interview, despite being aware of the correct procedures. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) for a resident with a dialysis port, as required by the facility's policy. An LPN was observed assisting the resident with various tasks, including removing a shirt and transferring the resident, without donning the necessary gown and gloves. The LPN mistakenly believed the EBP sign on the door was for the resident's roommate, not the resident with the dialysis line. Interviews with the infection preventionist, RN, and interim Director of Nursing confirmed the expectations for hand hygiene and EBP usage. The facility's policy required gown and gloves for high-contact care activities for residents with indwelling medical devices. The interim DON acknowledged that the resident with the dialysis line should have been on EBP, indicating a lapse in adherence to the facility's infection control policies.
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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