Wabasso Restorative Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Wabasso, Minnesota.
- Location
- 660 Maple Street, Wabasso, Minnesota 56293
- CMS Provider Number
- 245400
- Inspections on file
- 41
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at Wabasso Restorative Care Center during CMS and state inspections, most recent first.
A resident with DM, peripheral neuropathy, malnutrition, and anxiety, who was independent with ambulation and eating, sustained a significant partial-thickness burn to the right thigh and groin after hot water from a plastic thermal mug spilled when the lid popped off during lunch. The resident reported severe pain, difficulty removing clothing, and a delay before a nurse arrived, while an NA described a large, very red area with a forming blister. Initial nursing documentation noted only redness and use of Vaseline, with later notes identifying a blistered burn and subsequent debridement, and a hospital wound consult later measuring the wound at 15 x 26 x 0.1 cm. Staff interviews revealed that residents had not been assessed for hot liquid safety before the incident, the resident’s care plan lacked hot liquid precautions at the time, and dietary staff acknowledged serving very hot water, with one report that reheated water had been temped at 138°F despite an existing hot liquid safety policy requiring assessment and individualized interventions.
A resident with diabetes, peripheral neuropathy, malnutrition, and anxiety, who was cognitively intact and independent with a walker, spilled hot water on the upper thigh, resulting first in redness and then in a large blistered area requiring wound care and later hospital debridement. Facility documentation showed physician and provider orders for topical treatment and dressings, but the DON and administrator acknowledged that, although they were notified soon after the incident, they did not consider the injury significant at first and did not report the allegation of neglect or serious bodily injury to the State Agency within the required 2-hour timeframe, contrary to the facility’s Abuse, Neglect, and Exploitation Policy.
A resident with severe cognitive impairment and high care needs was physically abused by another resident, who pulled her hair, struck her head, and pushed her wheelchair. The victim reported the incident to several staff and a family member, who contacted law enforcement after being unable to reach the facility. Staff interviews confirmed the abuse was reported, but there was a delay in administrative response and awareness. The aggressor had a history of behavioral issues and recent medication changes. The facility failed to prevent and promptly address the abuse, leading the victim to leave due to fear for her safety.
A resident with severe cognitive impairment reported being physically assaulted by another resident, and although nursing staff were informed immediately and internal monitoring was initiated, the facility did not report the allegation to the State Agency within the required timeframe. The incident was reported to law enforcement by the resident's family before the facility submitted the required report.
A resident with cognitive impairment was unable to locate survey results, and review of the facility's survey binder revealed missing recertification surveys, complaint investigations, and plans of correction. Staff confirmed that not all required documents were available, and no policy for posting survey results was provided, limiting access to important information for all residents, families, and staff.
Staff did not promptly inform a resident, the resident's doctor, and a family member about important events such as injury, decline, or room changes, as required. This lapse in communication was identified during the survey.
The facility did not honor a resident's right to voice grievances without discrimination or reprisal and failed to establish or follow a grievance policy or make prompt efforts to resolve grievances.
A resident with mental health diagnoses did not receive morning medications as preferred because staff failed to wake her, leading to behavioral escalation. The care plan did not reflect her established preferences for wake-up and medication times, and staff were unaware of these needs until after the incident.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a failure to meet individualized care requirements.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
A resident with PTSD and cognitive impairment experienced ongoing unwanted sexual advances and explicit notes from another resident, leading to psychosocial harm. Despite multiple reports from residents and staff, the facility did not conduct a comprehensive assessment, update care plans, or implement effective supervision and interventions to ensure safety, resulting in continued distress and a lack of protection for the affected resident.
A resident with severe cognitive impairment and mental health issues, along with several other female residents, reported ongoing sexual harassment, inappropriate advances, and theft by another resident. Despite being aware of these allegations and conducting internal investigations, facility staff did not report the incidents to the State Agency within the required timeframe, failing to follow policy and protect residents.
A resident with severe cognitive impairment and mental health diagnoses reported ongoing sexual harassment and inappropriate advances from another resident, including unwanted letters and verbal behaviors. Multiple residents expressed feeling unsafe, but the facility did not conduct a thorough investigation, failed to document interviews or protective actions, and did not prevent further incidents, despite repeated complaints and its own policy requiring immediate response.
A resident with complex behavioral and mental health needs was transferred to another facility without being given adequate notice, the right to appeal, or the opportunity to remain during the appeal process. The transfer was conducted rapidly, with the resident not signing a discharge agreement, not being allowed to discuss the move with an advocate, and experiencing emotional distress after the move. The facility did not follow its own policies regarding resident rights and discharge procedures.
Two residents with PTSD did not receive trauma-informed care when one was repeatedly harassed and sexually approached by another, despite both having documented trauma histories. The facility failed to update care plans, assess psychosocial harm, or implement effective monitoring and interventions, resulting in ongoing distress and unaddressed triggers for both individuals.
A resident with severe cognitive impairment and psychiatric conditions did not have required physician documentation for routine visits over a 60-90 day period. Although the physician saw the resident and signed orders, no note was entered in the medical record, contrary to facility policy.
Two residents with significant behavioral health needs, including PTSD and cognitive impairment, were not provided with comprehensive assessments or individualized, person-centered interventions. One resident experienced ongoing harassment and triggering of trauma symptoms by another resident, with insufficient safety measures or supportive services implemented. The facility did not follow its trauma-informed care policy or provide evidence of effective behavioral health planning.
The facility did not adequately identify or document the specific care and practices needed for residents with PTSD in its facility-wide assessment, and failed to maintain the required full-time Social Services Designee (SSD) position, instead splitting the SSD's time between two locations. This resulted in insufficient social services support for residents with behavioral health needs, including those with PTSD.
A resident with a history of substance abuse left the facility and was found intoxicated at a bar. The facility lacked protocols to monitor or prevent substance abuse, and the resident's care plan was not updated following the incident. Staff were unaware of how to handle the situation, and there was no documentation of vital signs or assessments upon the resident's return.
A resident with congestive heart failure experienced significant weight gain and symptoms such as shortness of breath and chest pain, but the facility failed to monitor and report these changes to the physician. Despite hospital discharge orders for daily weight monitoring, the facility did not adhere to these instructions, leading to the resident's hospitalization for CHF exacerbation and a heart attack.
The facility failed to provide accurate Ombudsman contact information to residents, as observed during a resident council meeting. Five residents were unaware of how to contact the Ombudsman, and the posted information was outdated. Interviews confirmed the inaccuracy, despite previous requests for updates. The facility's assessment and admission packet indicated residents should be informed of their rights and provided with accurate contact information, which was not effectively implemented.
The facility failed to provide necessary physical therapy (PT) services to residents due to the absence of PT staff since August 2024, affecting residents who required these services. Despite having physician orders for PT, residents did not receive the necessary therapy. Additionally, the facility's staffing plan was not adhered to, particularly on weekends, where the number of staff scheduled was less than required. The administrator acknowledged the need to update the facility assessment to reflect the actual services provided.
The facility failed to adequately explain the binding arbitration agreement to 16 residents, leading to a lack of understanding and awareness of their right to refuse signing. Interviews revealed that many residents did not recall receiving an explanation or understanding the agreement, with some feeling pressured to sign without full comprehension. This deficiency affected the residents' rights to make informed decisions about their care and legal options.
A facility failed to implement enhanced barrier precautions for a resident with surgical wounds and a PICC line, as required by CDC guidelines. Observations showed no signage on the resident's door, and staff did not wear gowns during dressing changes. Additionally, the facility's infection control surveillance was inadequate, with critical sections left blank, making it impossible to determine if precautions were implemented timely. The DON, new to her role, admitted to being unsure about necessary precautions, and oversight from a sister facility's IP was minimal.
Two residents in a facility expressed fear of retaliation from staff, feeling intimidated and unable to voice concerns. One resident, admitted with multiple health issues, felt the social services designee was unapproachable and feared being expelled. Another resident, with chronic pain and other conditions, believed the facility misrepresented its services and was denied access to a doctor. During a resident council meeting, several residents shared similar fears. The facility's policy on reporting concerns lacked specific avenues for addressing fears of retaliation from management.
The facility failed to securely store lighters for residents who smoked, leading to potential fire hazards. Residents were observed keeping lighters and cigarettes in unsecured locations, contrary to the facility's policy. Staff reported challenges in enforcing the policy, as residents often kept lighters in their possession. The facility's smoking policy did not explicitly address the secure storage of lighters, contributing to inconsistent enforcement and increased fire risk.
A facility failed to ensure nursing staff were competent in identifying and responding to an emergent change in condition for a resident with congestive heart failure, leading to a delay in emergency medical evaluation. The resident experienced significant weight gain, shortness of breath, and chest pain, but staff did not notify the physician or send the resident to the emergency department. Interviews revealed a lack of timely updates to the physician and insufficient staff training on recognizing changes in condition.
The facility failed to maintain adequate staffing levels on weekends as per their assessment, with only one licensed nurse on the day shift for 12 out of 26 weekend days. The administrator was unaware of the staffing requirements and questioned the accuracy of data submitted to CMS.
A resident with intact cognition and a history of stroke, heart failure, renal insufficiency, and diabetes mellitus reported missing personal items to the Social Service Director (SSD). Despite the report, the SSD did not recall the grievance, and no documentation was found in the facility's grievance log. The facility also failed to provide a grievance policy, indicating a lack of follow-up and documentation.
A facility failed to ensure a resident could communicate with their county care coordinator (CC), resulting in multiple unsuccessful contact attempts by the CC. The social services designee (SSD) instructed the CC to direct communication needs to her, but the CC faced difficulties reaching the SSD and the resident was not informed of the calls. Interviews revealed no directive to forward calls to the SSD, and residents could take calls privately. The resident was unaware of the CC's attempts, indicating a communication breakdown.
A facility failed to accurately code the MDS for a resident with a non-pressure chronic ulcer and other medical conditions. Despite medical records confirming the presence of a skin ulcer, the MDS did not reflect this, leading to discrepancies in the resident's care documentation. Interviews revealed that the resident was aware of ongoing wound care, but staff were not consistent in coding practices, and the DON was unaware of the MDS coding process.
The facility failed to revise care plans for two residents, leading to deficiencies in their care. One resident's care plan lacked monitoring for behaviors associated with anti-anxiety medication and did not address potential adverse reactions or signs of increased depression. Another resident's care plan did not include daily weight monitoring as ordered, resulting in significant weight gain and hospital readmission with congestive heart failure.
The facility failed to assess and document target behaviors and non-pharmacological interventions for residents on psychotropic medications. One resident with severe cognitive impairment and worsening behaviors lacked a care plan with specific target behaviors. Another resident's care plan did not include non-pharmacological interventions for anxiety and depression. A third resident's care plan failed to document target behaviors or side effects of medications. The DON acknowledged these deficiencies, which were not in line with the facility's psychotropic medication policy.
The facility failed to label two opened vials of Tuberculin (TB) PPD solution with an open date, as required by the manufacturer's guidelines. The vials were found in the medication room refrigerator without an open date, despite being dispensed on a specific date. An LPN confirmed the absence of an open date, and the DON expected medications to be dated and initialed upon opening. A policy on medication labeling and storage was not provided.
A resident with intact cognition and multiple health conditions, including stroke and diabetes, repeatedly requested a dental appointment due to missing molars. Despite oral assessments documenting these requests, the facility failed to schedule the necessary dental services. The Social Service Director did not recall the request and missed an email notification from the RN responsible for oral assessments.
Two residents at the facility did not receive physician-ordered physical therapy (PT) services due to the unavailability of PT providers. One resident, admitted to regain strength and return to independent living, did not receive PT after August 2024. Another resident, with moderate cognitive impairment and requiring assistance with daily activities, also did not receive PT as ordered. The facility lacked a plan to provide PT services in the interim, and no policy on skilled therapy services was available.
The facility failed to ensure the DON, also serving as the IP, had the necessary training and oversight for effective infection control management. The DON was new to the role and had not completed required training, leading to incomplete documentation and analysis of infection control measures. Surveillance records showed gaps in isolation and precaution documentation for residents with infections, including COVID-19, resulting in deficiencies in infection control practices.
A resident with a history of aggressive behavior physically abused two other residents in the smoking area of an LTC facility. Despite a care plan requiring supervision, the resident was not adequately monitored, leading to repeated incidents of aggression. Staff and other residents expressed concerns about the resident's behavior, highlighting a failure in the facility's abuse prevention measures.
A resident with a history of unsafe smoking behavior was frequently observed smoking without supervision, despite being deemed unsafe to smoke independently. The facility's failure to enforce its smoking policy and provide necessary supervision led to multiple incidents, including resident-to-resident altercations. Staff acknowledged challenges in monitoring the resident, who was able to access cigarettes and lighters against facility policy.
The facility failed to report an allegation of abuse to the State Agency (SA) for a resident with moderate cognitive impairment who required staff assistance with daily activities. Despite being notified by the county sheriff's department, the facility's staff believed that since the allegation had already been reported by an outside facility, they did not need to report it to the SA again. This failure to report the allegation as required by federal regulations constitutes a deficiency.
The facility failed to analyze and evaluate identified PIP concerns within their QAPI program. Meeting minutes lacked documentation on data analysis, intervention modifications, and decisions on project continuation. The executive director and DON acknowledged these deficiencies during an interview.
The facility failed to ensure that all licensed nursing staff were appropriately trained and competent to administer insulin. An LPN administered insulin without priming the pen, and the DON confirmed no insulin competencies had been completed. Additionally, there were no drug books or manufacturer's directions available for reference.
The facility failed to provide mandatory training on its specific QAPI Program to all staff. Interviews revealed a lack of awareness and understanding of the facility's QAPI goals and elements, with staff either not receiving any QAPI training or only receiving generalized training through Relias. The executive director of operations acknowledged the issue, and the review of training records showed outdated or missing QAPI training for several staff members.
The facility failed to ensure that four out of nine staff members received the required initial and annual training on Alzheimer's disease or related disorders, ADLs, problem-solving with challenging behaviors, and communication skills. The training records for the DON, an LPN, and two NAs were incomplete, leading to deficiencies in staff preparedness.
A facility failed to ensure a resident appropriately disposed of cigarette butts, posing a risk to other residents. Despite being aware of the designated receptacle, the resident stored used cigarette butts in her jacket pocket and discarded them in her room's trash bin. Staff were aware of the issue but did not effectively enforce the smoking policy.
A resident with moderate cognitive impairment and respiratory issues was observed multiple times with incorrect oxygen settings, contrary to physician orders. Staff confirmed the discrepancy and adjusted the oxygen setting, but the facility failed to ensure proper adherence to oxygen administration policies.
A facility failed to ensure an insulin pen was appropriately primed before administration for a resident. An LPN administered a Lantus injection without priming the pen, and the DON confirmed no insulin competencies had been completed with licensed nurses. Additionally, there were no drug books or manufacturer's directions available for reference.
Failure to Assess and Protect Resident From Hot Liquid Burn
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from avoidable accidents related to hot liquids and to have an effective system to assess residents’ safety with hot liquids. A cognitively intact resident with diagnoses including diabetes, peripheral neuropathy, malnutrition, and anxiety was independently ambulatory with a walker and independent with eating. The resident’s care plan initially identified independence with eating, and only after the incident was a revision made to specify that staff should ensure the lid was on and secure for hot liquids. At the time of the incident, there was no documented individualized assessment or care plan intervention addressing the resident’s ability to safely handle hot liquids despite her peripheral neuropathy and other comorbidities. On the day of the incident, the resident was having lunch when hot water from a plastic thermal mug spilled onto her upper right thigh. The resident later reported that the lid was not sitting correctly on the mug and popped off, causing hot water to splash onto her hand, startling her and leading her to jerk, which caused the remaining hot water to spill onto her right thigh. She stated that the hot water soaked through her sweatpants and into her incontinent brief, burning most of the top of her right thigh and the right groin fold. The resident reported experiencing horrible pain and stated it took 20–30 minutes for a nurse to come while she struggled to remove her clothing. A nursing assistant confirmed being notified by dietary staff that the resident had spilled hot water, immediately taking her back to her room, and then leaving to find the charge nurse, describing the resident’s leg as a large, very red area with a forming blister and noting the resident’s significant pain and frustration. Clinical documentation following the incident showed that the initial nursing note described visible redness to the upper thigh, with education provided to the resident to be careful with hot liquids and to ask for help. The physician ordered Vaseline and pain medication. The following day, documentation identified a reddened area with a blister approximately five inches by three inches, and orders were obtained for Xeroform and dressings. A subsequent wound note documented a partial thickness burn acquired in the facility, but the measurements recorded were later verified as incorrect. The resident’s primary care provider’s visit note from the day after the incident did not mention the thigh burn, describing the skin as warm and dry with no rashes or lesions on exposed skin. Later documentation identified the burn as a stage 2 burn site requiring debridement and daily wound care. A hospital wound care consult subsequently measured the burn at 15 x 26 x 0.1 cm and described it as a partial thickness burn that was blistered, fragile, bleeding, and erythematous. Staff interviews revealed that prior to this incident, the facility had not been conducting hot water assessments on residents, and there was inconsistency in staff accounts regarding the existence and implementation of a hot liquid policy and temperature monitoring at the time the resident was burned. Additional staff interviews highlighted issues related to hot liquid temperatures and supervision. The dining specialist stated that all hot water and coffee were served from the kitchen and that the water was too hot, noting that on the day of the interview the temperature was being turned down. She reported being on duty when the resident was burned but did not know who provided the hot water, and she assumed, based on the severity of the burn, that the water had been way too hot. The certified dietary manager reported that a dietary staff member reheated the water in the microwave and stated that the water was reportedly 138°F when checked, with staff expected to log temperatures. The facility’s hot liquid safety policy, implemented prior to the incident, required assessment of all residents for their ability to handle containers and consume hot liquids, with individualized interventions on the care plan, and described the time–temperature relationship for serious burns, including that at 133°F a third-degree burn could occur in 15 seconds and at 140°F in 5 seconds. Despite this policy, interviews and documentation showed that residents had not been systematically assessed for hot liquid safety and that the resident involved in the incident did not have appropriate hot liquid precautions in place at the time of the burn.
Failure to Timely Report Significant Burn Injury as Alleged Neglect
Penalty
Summary
The facility failed to immediately report an allegation of neglect involving a resident who sustained a significant burn injury from hot liquid. The resident, who had intact cognition, ambulated independently with a walker, and was independent with eating, had diagnoses including diabetes, peripheral neuropathy, malnutrition, and anxiety. Progress notes documented that the resident spilled hot water on the right upper thigh, resulting in visible redness, and was educated to be careful with hot liquids and to ask for help when needed. A physician ordered Vaseline to the affected area and pain medication. The following day, documentation showed a reddened area with a blister approximately five inches by three inches, and the provider ordered Xeroform dressings, ABD pad, Kerlix, and added the resident to wound rounds. Despite these findings and the development of a large blistered area, the facility did not report the incident to the State Agency within the required two-hour timeframe for events involving alleged abuse or resulting in serious bodily injury, as required by its Abuse, Neglect, and Exploitation Policy. A later hospital wound care consult identified a partial thickness burn on the resident’s right thigh measuring 15 x 26 x 0.1 cm, described as blistered, fragile, bleeding, and erythematous, and requiring chemical and mechanical debridement. The DON stated she was notified of the burn on the date of occurrence but did not consider it significant until several days later and confirmed the burn was not reported to the State Agency. The administrator also confirmed that although staff notified him immediately after the incident, it was not reported to the State Agency, and there was no evidence the facility assessed residents for mitigation of hazards related to hot liquids prior to this event.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A resident with severe cognitive impairment and significant physical care needs was subjected to physical abuse by another resident. The incident occurred in the facility's smoking area, where the aggressor pulled the victim's hair, struck her in the back of the head, and pushed her wheelchair into a fence. The victim immediately experienced pain and reported the incident to several nursing staff, though she could not recall exactly whom she told. The victim also contacted a family member, expressing fear for her safety, especially after the aggressor threatened her the following day. The family member attempted to reach the facility but, unable to get a response, contacted the Sheriff's department to conduct a welfare check. Multiple staff interviews confirmed that the victim reported the abuse shortly after it occurred, with several nursing assistants recalling the resident's complaints of being hit and having her hair pulled. The aggressor admitted to grabbing the victim by the hair and shaking her during a verbal altercation. Documentation showed that the victim had a pain level of ten and required medication for her symptoms. The aggressor had a history of behavioral issues, including previous verbal altercations and threats, and had recently experienced a medication change that increased his discomfort and irritability. Despite the victim's immediate reports to staff, there was a delay in administrative awareness and response. The charge nurse on duty did not recall the incident, and the director of nursing was not informed until the following day. The facility's policy required protections against abuse, but the events indicate a failure to prevent and promptly address resident-to-resident physical abuse, resulting in the victim's decision to leave the facility against medical advice due to ongoing fear and lack of perceived safety.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse in a timely manner to the State Agency (SA) as required by policy. An incident occurred in which one resident, who had severe cognitive impairment and required substantial assistance with activities of daily living, reported that another resident pulled her hair, struck her in the back of the head, and pushed her wheelchair while outside in the smoking area. The incident was reported by the affected resident to nursing staff immediately after it happened, and the nursing assistant informed both the assistant director of nursing and the charge nurse. The residents involved were placed on 15-minute checks following the report. Despite the immediate internal notification, the facility did not submit the Facility Reported Incident (FRI) to the SA until approximately 25.5 hours after the event, exceeding the required reporting timeframe of no later than 2 hours for allegations involving abuse. The administrator confirmed that the FRI was submitted late, as she was not aware of the full details of the incident until the following day. Additionally, law enforcement was contacted by the resident's family member, and a welfare check was conducted prior to the FRI being submitted to the SA. Facility policy required immediate reporting of all alleged violations to the administrator, state agency, and other authorities within specified timeframes, which was not followed in this case.
Failure to Provide Complete and Accessible Survey Results
Penalty
Summary
The facility failed to ensure that survey results, including recertification surveys, complaint investigations, and facility plans of correction, were readily available for review by residents, family, visitors, and staff. During interviews and document review, it was found that a resident with moderately impaired cognition expressed a desire to view the results of state agency surveys but was unable to locate them. Upon inspection, the binder labeled as containing facility survey results was found behind other documents and was missing several required survey reports and plans of correction. Specifically, recertification surveys from certain dates and multiple complaint investigations, as well as associated plans of correction, were not present in the binder. Further interviews with facility staff confirmed that the survey results are considered public knowledge and should be accessible, but the binder did not contain all required documents. The administrator acknowledged difficulty in maintaining the availability of these documents, stating that they often go missing. No facility policy regarding the posting of survey results was provided when requested. This deficiency had the potential to affect all residents, family members, visitors, and staff by limiting access to important regulatory information.
Failure to Immediately Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors during the review of facility practices and records. The deficiency centers on the facility's failure to ensure that all required parties were promptly informed when significant events impacting the resident occurred, as mandated by regulations.
Failure to Honor Resident Grievance Rights
Penalty
Summary
The facility failed to honor the resident's right to voice grievances without discrimination or reprisal. The facility did not establish or follow a grievance policy and did not make prompt efforts to resolve grievances as required. This deficiency was identified based on the facility's actions and inactions regarding the handling of resident grievances.
Failure to Update Care Plan for Medication Administration Preferences
Penalty
Summary
The facility failed to revise and update the care plan for a resident with anxiety disorder, borderline personality disorder, and delusional disorder, who exhibited new behaviors when her medications were not administered according to her preferences. The resident, who typically wakes up around 9:00 to 9:30 a.m. but sometimes sleeps later, relies on staff to wake her for morning medications. On the day of the incident, staff attempted to administer her medications but did not wake her, resulting in the medications being marked as not given. When the resident later requested her medications, she became visibly upset, raising her voice, pacing, and repeatedly returning to the medication cart. The situation was only resolved after the clinical registered nurse consultant contacted the on-call physician and obtained an order to administer the medications outside the usual time frame. Review of the resident's care plan revealed it did not address her preferences for wake-up times or being woken for medication administration, despite staff and the resident confirming this was her usual routine. Interviews with staff indicated a lack of awareness and documentation regarding the resident's preferences, and the care plan was not updated to reflect these needs until after the incident occurred. The facility's policy requires a comprehensive, person-centered care plan based on the resident's assessment and preferences, which was not followed in this case.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with established directives or the expressed wishes and objectives of the resident, resulting in noncompliance with required standards for individualized care.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated.
Failure to Prevent and Assess Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to ensure adequate supervision and a comprehensive assessment to prevent resident-to-resident sexual abuse. A resident with a history of PTSD and cognitive impairment reported receiving unwanted, sexually explicit notes and advances from another resident over a period of months. Multiple residents expressed feeling unsafe due to the behaviors of the resident delivering the notes, and several staff members, including the DON and social worker, were made aware of the situation through direct reports, grievances, and resident council meetings. Despite these reports, the facility did not complete a comprehensive assessment of the affected resident for psychosocial harm, nor did it implement effective interventions or monitoring systems to ensure her safety and well-being. The affected resident had a documented history of childhood sexual abuse, PTSD, anxiety, depression, and cognitive impairment. Her care plan identified a need for a safe environment and support for coping with trauma, but interventions were limited to general reassurances and reminders, without specific measures to address the ongoing harassment. The resident repeatedly reported feeling unsafe, experiencing increased PTSD symptoms, and having trouble sleeping due to the unwanted attention and fear of further abuse. Other residents and staff corroborated the ongoing nature of the harassment, including the delivery of sexually explicit notes and unwanted advances in unsupervised areas such as the smoking area. The facility's response to the reports was inadequate, as staff primarily addressed the issue by speaking to the resident delivering the notes and advising the affected resident to avoid him. There was no evidence of a thorough assessment of the affected resident's psychosocial harm, no clear documentation of interventions to ensure her safety, and no updates to the care plan of the resident exhibiting the inappropriate behaviors. The facility also failed to monitor or restrict interactions effectively, and did not promptly report the abuse to the State Agency as required. The lack of comprehensive assessment, supervision, and timely intervention resulted in ongoing psychosocial harm to the affected resident and a failure to protect her and others from further abuse.
Failure to Timely Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to timely report multiple allegations of abuse, neglect, and theft involving a resident with severe cognitive impairment and a history of mental health issues. Over a period of several weeks, the resident and other female residents reported feeling unsafe due to another resident's sexually inappropriate behavior, harassment, and theft. Specific incidents included unwanted letters, verbal advances, and being followed to common areas, as well as reports of items being stolen. Despite these ongoing concerns, the facility did not report the allegations to the State Agency within the required timeframe. Documentation and interviews revealed that staff, including the DON and social services, were aware of the inappropriate behaviors and the residents' discomfort. The DON acknowledged receiving complaints and conducting internal investigations but chose not to report the incidents, citing a belief that the resident involved was capable of consenting to the interactions. However, there was no clear determination of the resident's capacity to consent, and the facility's own assessments indicated the resident was at risk for abuse due to cognitive impairment and other vulnerabilities. The facility's policy required immediate reporting of all alleged violations, including abuse and neglect, to the administrator, state agency, and other authorities. Despite this, the allegations were not reported until well after the incidents occurred, and some staff members were unaware of all the events. The delay in reporting and lack of timely action failed to provide the required protections for the residents involved.
Failure to Investigate and Protect Residents After Sexual Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate and protect residents following allegations of sexual abuse and harassment involving a resident with severe cognitive impairment and a history of mental health issues. Multiple reports were made by female residents, including one who reported feeling unsafe due to another resident's sexually inappropriate behavior, unwanted advances, and persistent letter writing. Despite these reports, the facility did not provide documentation of a comprehensive investigation, nor did it demonstrate that effective measures were taken to prevent further abuse or address the concerns raised by the residents. Documentation shows that the resident with severe cognitive impairment, along with other female residents, repeatedly expressed discomfort and fear regarding the behavior of another resident, who had a documented history of verbal and behavioral symptoms. The facility's response included minimal actions such as speaking to the alleged perpetrator and providing education, but there was no evidence of a thorough investigation, interviews, or protective interventions. The affected resident continued to receive inappropriate letters even after submitting a grievance, and staff interviews revealed a lack of documentation and uncertainty about the steps taken to ensure resident safety. The facility's own policy requires immediate and thorough investigation of abuse allegations, including interviews, documentation, and protective measures for residents. However, the facility was unable to provide requested investigation records, timelines, or evidence of actions taken to protect residents from further harm. Reports from staff, social services, and law enforcement indicated ongoing issues with harassment and a lack of effective response, further highlighting the facility's failure to meet its investigative and protective obligations.
Failure to Provide Resident Rights and Proper Discharge Process During Transfer
Penalty
Summary
The facility failed to ensure that a resident was provided with appropriate choices and rights during a transfer/discharge process. The resident, who had a history of emotional lability, alcohol use, cognitive communication deficits, depression, anxiety disorder, and osteonecrosis, was identified as having moderately impaired cognition and required staff assistance for mobility and daily activities. The care plan noted ineffective coping, a history of trauma, and a preference for female caregivers. The resident also exhibited behavioral issues, including negative statements, isolation, and anxiety, and was on 15-minute safety checks due to recent incidents involving other residents. Despite these complex needs, the facility did not provide the resident with adequate notice or options regarding the transfer. The discharge notice was completed on the same day as the transfer, and the resident was moved to a sister facility within a short timeframe, reportedly without being given the opportunity to discuss the decision with an advocate or to appeal the transfer. The Ombudsman was not notified until several days after the transfer, and the resident did not sign a discharge agreement. Interviews revealed that the resident felt rushed, was not allowed to process the discharge, and experienced emotional distress following the move. The facility's own policies require that residents be given notice, the right to appeal, and the opportunity to remain during the appeal process, none of which were followed in this case. Staff interviews indicated confusion about who initiated the discharge and whether the interdisciplinary team had discussed the transfer. The resident expressed a desire to return to the original facility and reported feeling isolated and depressed at the new location. The transfer was described as sudden, with the resident's belongings hastily packed and some personal items discarded. The facility did not document that the resident's mental health and substance use history were considered in the decision-making process, nor did they ensure the resident was prepared for a safe and supported transition.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to implement trauma-informed care for two residents diagnosed with post-traumatic stress disorder (PTSD). One resident had a history of childhood molestation and was identified as having severe cognitive impairment, depression, anxiety, and PTSD. Despite documentation of her trauma history and potential triggers, her care plan was not updated to address current PTSD-related symptoms or triggers. When this resident reported feeling unsafe due to harassment and sexual advances from another resident, the facility's response was limited to offering an alternative smoking area and notifying law enforcement, without comprehensive assessment or ongoing monitoring for psychosocial harm or exacerbation of PTSD symptoms. The second resident, also with a history of childhood sexual abuse and other mental health diagnoses, exhibited behaviors such as writing sexual notes and following female residents, including the first resident, to unsupervised areas. Although his care plan noted a preference for female caregivers and a history of trauma, it did not address his sexual behaviors toward others or include updated interventions. Reports from multiple residents about his inappropriate behavior were met with education for the resident, but there was no evidence of behavior management, supervision, or monitoring to mitigate the risk of re-triggering PTSD in other residents. Interviews with the affected resident and her family revealed ongoing distress, including increased PTSD symptoms, trouble sleeping, and feelings of being unsafe, despite repeated reports to staff. The facility's trauma-informed care policy required identification of triggers, individualized interventions, and ongoing evaluation with resident and family input, but these steps were not followed. The lack of comprehensive assessment, care plan updates, and effective interventions contributed to the deficiency in providing trauma-informed care.
Lack of Physician Documentation for Routine Visits
Penalty
Summary
The facility failed to ensure that a resident with severe cognitive impairment and multiple psychiatric diagnoses had proper physician documentation for routine visits as required by facility policy. The resident's medical record showed physician visits occurred on several dates, but there was a lack of documentation for routine 60-90 day visits between two specific dates. During an interview, the DON confirmed that the physician had seen the resident and signed orders but did not document a note for the visit, and the physician could not recall the reason for this omission. The facility's policy requires residents to be seen by a physician within 30 days of admission, every 30 days for the first 90 days, and at least every 60 days thereafter, with documentation of these visits in the medical record.
Failure to Provide Comprehensive Behavioral Health Assessment and Person-Centered Planning
Penalty
Summary
The facility failed to implement comprehensive assessment and person-centered planning to ensure that the individualized behavioral health needs of two residents were met. One resident, with diagnoses including alcoholic encephalopathy, PTSD, anxiety, depression, and a history of childhood trauma, was admitted under a court commitment order and required multiple therapies and substance abuse treatment. Despite documented cognitive impairment and a history of trauma, the care plan lacked evidence that the facility identified the resident's responses to stressors or utilized person-centered interventions developed by the interdisciplinary team (IDT). The care plan was not reviewed or revised when interventions were ineffective or when the resident experienced a change in condition related to ongoing abuse. The resident reported feeling unsafe due to harassment and inappropriate sexual advances from another resident, including receiving disturbing notes and being followed in unsupervised areas. These incidents triggered the resident's PTSD symptoms, leading to increased anxiety, sleep disturbances, and emotional distress. The facility's records did not indicate that a comprehensive assessment was completed to determine psychosocial harm, nor were there clear interventions or monitoring systems implemented to ensure the resident's safety or provide supportive services. Family members also expressed concerns about the lack of follow-through on safety plans and the ongoing nature of the harassment. The second resident involved had a history of emotional lability, alcohol use, depression, and anxiety, and was reported by multiple female residents for inappropriate behavior, including writing notes and following them. Staff responses included educating the resident and checking on the affected resident during smoking breaks, but there was no evidence of a comprehensive behavioral health assessment or effective interventions. The facility's trauma-informed care policy outlined the need for individualized interventions and ongoing evaluation, but there was no documentation that these practices were followed in these cases. The facility did not provide additional policies related to behavioral health services.
Failure to Identify PTSD Care Needs and Maintain Social Services Staffing
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment (FA) that accurately identified the specific care and practices necessary to meet the needs of residents with post-traumatic stress disorder (PTSD). The assessment did not sufficiently address the requirements for managing PTSD, despite the presence of residents with this diagnosis or history. The FA was intended to use evidence-based, data-driven methods to evaluate the care needs of the resident population, including behavioral health and psychiatric conditions, but did not specify the interventions or resources required for PTSD care. Additionally, the facility did not maintain the identified number of staff required to provide social services, as the Social Services Designee (SSD) position was split between two facilities, resulting in only part-time coverage at each location. The administrator believed the SSD's time at the facility was sufficient, but the documented staffing plan called for one full-time SSD. This staffing shortfall had the potential to affect all residents with behavioral health needs, including those with PTSD, as the facility did not ensure adequate social services support as outlined in their own assessment and policy.
Failure to Monitor and Prevent Substance Abuse in Resident
Penalty
Summary
The facility failed to adequately assess and monitor a resident with a known history of substance use/abuse, leading to a deficiency in preventing and managing substance abuse incidents. The resident, who was wheelchair-bound and had a history of opioid, cocaine, and other stimulant abuse, left the facility and was later found intoxicated at a bar. Despite being aware of the resident's condition, the facility staff did not have protocols in place to monitor or prevent substance abuse, nor did they update the resident's care plan following the incident. Upon returning to the facility, the resident was found to be intoxicated and asleep, but there was no documentation of vital signs being taken or assessments performed to monitor the resident's condition. Interviews with staff revealed a lack of awareness and protocols for handling residents under the influence of alcohol or drugs. The charge nurse on duty was not informed of the resident's departure from the facility, and there was no clear guidance on how long to monitor the resident or what interventions to implement. The facility's existing care plan for the resident did not include specific interventions to prevent substance abuse or monitor for signs of intoxication. The facility's policy on safety for residents with substance use disorder did not address specific interventions for potential or actual substance abuse, highlighting a gap in the facility's preparedness to handle such situations. This lack of assessment, monitoring, and protocol contributed to the deficiency identified in the report.
Failure to Monitor and Report CHF Symptoms
Penalty
Summary
The facility failed to identify a significant change in condition and provide timely medical intervention for a resident with congestive heart failure (CHF), resulting in actual harm. The resident, who had a history of CHF, hypertension, diabetes, and coronary artery disease, experienced a significant weight gain of 61.8 pounds over a period of approximately five weeks. Despite the hospital discharge orders to monitor daily weights and report significant weight changes, the facility did not adhere to these instructions, and the resident's weight gain was not reported to the physician in a timely manner. The resident's medical records indicated multiple instances of shortness of breath, chest pain, and edema, yet there was a lack of documentation showing that the physician was notified of these symptoms or the significant weight gain. The facility's staff failed to follow the hospital's discharge orders and the medical director's modified orders for daily weights, which were only followed for one week. The resident continued to gain weight, and despite complaints of shortness of breath and chest pain, the facility did not seek immediate medical evaluation or treatment. Interviews with facility staff, including the RN, physician, and director of nursing, revealed that the facility did not have adequate procedures or training in place to recognize and act on changes in a resident's condition. The facility lacked a policy on identifying and responding to changes in condition, and there was no evidence of training for the majority of the nursing staff on this issue. The resident was eventually admitted to the hospital with CHF exacerbation and a heart attack, where she was treated with IV diuretics, resulting in a 20-pound weight loss before being discharged back to the facility.
Failure to Provide Accurate Ombudsman Contact Information
Penalty
Summary
The facility failed to provide accurate and accessible information regarding Ombudsman services to residents, as observed during a resident council group meeting. Five residents attending the meeting were unaware of how to contact the Ombudsman, and there was no mention of this information in the resident council minutes from June to November 2024. Although Ombudsman contact information was posted near the main entrance, it was outdated and incorrect, listing a former employee who no longer represented the facility. Interviews with the Ombudsman, the administrator, and the social service designee confirmed the inaccuracy of the posted information. The Ombudsman had previously requested updates to her contact details, but these were not made. The facility's August 2024 assessment and admission packet indicated that residents should be informed of their rights and provided with accurate contact information for relevant agencies, including the Ombudsman. However, this was not effectively implemented, leading to a deficiency in ensuring residents' rights to access advocacy services.
Deficiency in Physical Therapy Services and Staffing
Penalty
Summary
The facility failed to implement a comprehensive facility-wide assessment to ensure adequate resources and staffing were available to meet the needs of residents, particularly in the area of physical therapy (PT) services. The report highlights that the facility did not have PT services available from the end of August 2024, affecting residents who required these services. Despite having physician orders for PT, residents R20 and R37 did not receive the necessary therapy due to the absence of PT staff. Interviews with staff, including the Speech Therapist, Director of Nursing, and Registered Nurse, confirmed the lack of PT services and the absence of a plan to address this gap. Resident R37, who had intact cognition and was independent with activities of daily living, was dependent on staff for emotional, intellectual, physical, and social needs due to physical limitations. Despite having orders for PT, the facility did not provide these services, which were crucial for his mobility and strengthening. Similarly, Resident R20, who had moderate cognitive impairment and required substantial assistance with daily activities, was not seen by a physical therapist despite having orders for PT and OT evaluations and treatments. The facility's failure to provide PT services as ordered had the potential to affect all 32 residents. Additionally, the facility's staffing plan was not adhered to, particularly on weekends, where the number of staff scheduled was less than required. The facility assessment identified the need for two licensed nurses on the day shift, but this was not implemented. The administrator acknowledged the discrepancy in the staffing plan and the need to update the facility assessment to reflect the actual services provided. The lack of PT services and inadequate staffing were significant deficiencies identified in the report.
Failure to Explain Arbitration Agreement
Penalty
Summary
The facility failed to ensure that the binding arbitration agreement was fully explained to 16 out of 32 residents and/or their representatives, leading to a lack of understanding and awareness of their right to refuse signing the agreement. The social service designee (SSD) was responsible for explaining the arbitration agreement during the admission process, but interviews with residents revealed that many did not recall receiving an explanation or understanding the agreement. Some residents, such as R148 and R10, reported not being aware of signing any agreement, while others, like R32, did not remember any discussion about the arbitration agreement. During a resident council meeting, several residents expressed that they were unaware of signing an arbitration agreement upon admission and did not understand what it entailed. The SSD had informed residents that the arbitration agreement was not a precondition for admission, but failed to ensure that residents comprehended the implications of signing the agreement. This lack of communication and understanding was further highlighted by R37, who initially claimed to understand the agreement but later admitted to feeling intimidated and unaware of what he had signed. The report also noted that some residents, such as R40, felt pressured to sign the documents without fully understanding them, fearing retaliation from staff. The SSD's failure to adequately explain the arbitration agreement and ensure residents' comprehension resulted in a significant deficiency, affecting the residents' rights to make informed decisions about their care and legal options.
Failure to Implement Enhanced Barrier Precautions and Inadequate Infection Surveillance
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for a resident with surgical wounds and a PICC line, as required by CDC guidelines. The resident, who was a new admission, had undergone multiple surgeries due to frostbite, resulting in amputations and the placement of an orthopedic pin. Despite the care plan identifying the need for EBP, observations revealed that there was no signage on the resident's door to indicate these precautions, and staff did not wear gowns during dressing changes. Interviews with staff confirmed the lack of awareness and implementation of EBP, with reliance on door signage that was absent. Additionally, the facility's infection control surveillance was inadequate, failing to monitor infections through to resolution over a three-month period. The Director of Nursing (DON), who was new to her role as both DON and Infection Preventionist (IP), admitted to being unsure about the necessary transmission-based precautions and acknowledged gaps in the surveillance process. Critical sections of the surveillance records, such as isolation status and resolution dates, were often left blank, making it impossible to determine if precautions were implemented timely or at all. The facility's infection surveillance policy required comprehensive tracking and analysis of infection-related data, but this was not effectively carried out. The DON had limited time to devote to infection control, and oversight from a sister facility's IP was minimal due to their absence. The administrator recognized the need for extensive oversight and improvement in the surveillance tracking system to prevent the potential spread of infection.
Fear of Retaliation Among Residents
Penalty
Summary
The facility failed to implement policies to ensure residents could voice concerns without fear of retaliation. Two residents, identified as R37 and R40, expressed fear of being retaliated against by facility staff. R37, who was admitted following an acute hospitalization for various diagnoses including metabolic encephalopathy and alcohol abuse, reported feeling intimidated by the social services designee (SSD) and feared being kicked out of the facility. He admitted to lying about understanding an arbitration agreement due to this fear. R37 also felt that the SSD was unapproachable and dismissive when he sought assistance with his concerns about housing and employment. R40, who was admitted with conditions such as vertebrogenic low back pain and sheltered homelessness, also reported fear of retaliation. She believed that the facility would expel residents who raised concerns, yet did not address issues with problematic residents. R40 felt that the facility misrepresented the services they could provide and was denied a request to see the MD by the DON. The facility administrator, when interviewed, stated that retaliation did not occur and expected concerns to be reported to her, although she was unaware of any such issues. Additionally, during a resident council meeting, several residents expressed discomfort in voicing concerns to the SSD due to fear of retaliation. The facility's Abuse, Neglect, and Exploitation policy outlined procedures for reporting concerns without fear of retaliation but lacked specific avenues for addressing fears of retaliation from management. The admission packet provided information on residents' rights and procedures for filing complaints without fear of reprisal, but the residents did not feel comfortable utilizing these resources.
Failure to Securely Store Lighters for Smoking Residents
Penalty
Summary
The facility failed to ensure that lighters were stored securely away from residents, leading to potential fire hazards for several residents who smoked. Observations and interviews revealed that residents were keeping their smoking materials, including lighters, in their rooms or on their person, contrary to the facility's policy. The policy required lighters to be stored at the nurse's station, but staff reported difficulty in enforcing this rule as residents often purchased additional lighters and kept them in their possession. Several residents, including those with cognitive impairments and various medical conditions, were observed keeping lighters and cigarettes in unsecured locations such as unlocked drawers or bedside tables. Despite the facility having an automatic wall-mounted lighter in the designated smoking area, residents continued to use personal lighters. Interviews with staff and residents indicated a lack of consistent enforcement of the smoking materials policy, with some residents never being asked to turn in their lighters. The facility's smoking policy outlined safety measures for the designated smoking area but did not explicitly mention the secure storage of lighters. Staff interviews highlighted challenges in managing residents' compliance with the policy, as they were unable to search residents' rooms or forcibly take lighters from them. This lack of enforcement and secure storage of lighters posed a risk of fire hazards within the facility.
Failure to Identify and Respond to Emergent Change in Condition
Penalty
Summary
The facility failed to ensure that five out of six nursing staff were competent in identifying an emergent change in condition and the need for hospital transfer for emergency medical evaluation for a resident with a history of congestive heart failure, hypertension, diabetes mellitus, and coronary artery disease. The resident experienced significant weight gain, shortness of breath, and chest pain, which are indicative of a potential heart attack or acute heart failure. Despite these symptoms, the staff did not follow the facility's assessment or develop policies and procedures to ensure staff had demonstrated competencies to perform care for residents. The resident's care plan required staff to monitor for signs and symptoms of congestive heart failure and report any significant changes, such as weight gain or shortness of breath. However, the facility did not complete the hospital discharge order to obtain a baseline weight, and the resident experienced a weight gain of 61.8 pounds since re-admission. Multiple nursing progress notes documented the resident's complaints of shortness of breath, chest pain, and significant weight gain, yet there was no indication that the physician or discharging hospital was notified, or that the resident was sent to the emergency department for further evaluation and treatment. Interviews with the facility's medical director, attending physician, and director of nursing revealed that the facility did not update the physician with the resident's weight changes in a timely manner. The facility lacked a policy on identifying and acting on a change in condition, and there was no professional reference for nursing staff to utilize. Only one of the five licensed nurses on staff had received training on recognizing and communicating resident changes in condition. The facility's failure to ensure staff competency and adherence to care plans resulted in a delay in emergency medical evaluation and treatment for the resident.
Inadequate Weekend Staffing Levels
Penalty
Summary
The facility failed to ensure adequate staffing levels on weekends as determined by their facility assessment. The Payroll Based Journal (PBJ) Report for quarter 3 identified excessively low weekend staffing, which triggered a deficiency. The facility assessment indicated that the day shift required two licensed nurses and three direct care staff, while the night shift required one licensed nurse and two direct care staff. However, a review of working schedules and timecards revealed that for 12 out of 26 weekend days, the day shift was staffed with only one licensed nurse, contrary to the facility's assessment requirements. Interviews with the administrator revealed a lack of awareness regarding the facility assessment's staffing requirements. The administrator reported that the low weekend staffing was attributed to the census and that the facility no longer cut hours since COVID. Despite the administrator's expectation for staffing to align with the facility assessment, she was unaware that the assessment required two licensed nurses on the day shift. The administrator also expressed uncertainty about the accuracy of the data submitted to CMS, as she believed there was a discrepancy in the reported staffing levels. The facility's policy required the submission of complete and accurate staffing information to CMS, verified by the administrator, HR director, and director of nursing, but this was not adhered to, leading to the deficiency.
Failure to Address Resident Grievance
Penalty
Summary
The facility failed to address a verbal grievance reported by a resident, identified as R5, who had intact cognition and a medical history including stroke, heart failure, renal insufficiency, and diabetes mellitus. R5 reported to the Social Service Director (SSD) that his gel pens, a key to his locked drawer, and a stylist were missing. Despite R5's report, the SSD did not recall the grievance and no documentation was found in the facility's grievance log from May to November 2024. Additionally, the facility did not provide a grievance policy by the end of the survey, indicating a failure to follow up on the resident's complaint and to maintain proper grievance documentation.
Failure to Facilitate Resident Communication with Care Coordinator
Penalty
Summary
The facility failed to ensure that a resident was provided with communication access to their county care coordinator (CC) and did not discourage or obstruct these communications. The CC made multiple attempts to contact the resident, R18, without success. On one occasion, the CC left contact information with an unidentified charge nurse, but the resident was not informed of the call. The social services designee (SSD) instructed the CC to direct all communication needs to her, citing the nurses' busy schedules. Despite this, the CC experienced difficulty reaching the SSD and was unable to contact R18, leading to a personal visit to the facility. During this visit, R18 reported not receiving any messages from the CC, indicating a breakdown in communication. Interviews with facility staff, including a trained medication aid (TMA) and a licensed practical nurse (LPN), revealed that there was no directive to forward calls to the SSD, and residents could take calls in a private room. The SSD confirmed that residents had the right to receive phone calls and that calls could be forwarded to her if necessary. However, the CC's repeated attempts to contact R18 were unsuccessful, and the resident was unaware of the attempts made to reach him. This situation suggests a failure in the facility's communication process, preventing the resident from accessing necessary services.
Inaccurate MDS Coding for Resident with Wounds
Penalty
Summary
The facility failed to ensure the accurate coding of the Minimum Data Set (MDS) for a resident, identified as R26, who was reviewed for wounds. R26 was admitted in September 2023 with medical conditions including an abscess on the buttocks, a non-pressure chronic ulcer with fat layer exposed, protein-calorie malnutrition, and end-stage renal disease. Despite these conditions, the MDS completed on 9/21/24 did not mention the non-pressure skin ulcer, although it noted the application of a nonsurgical dressing. Subsequent medical records, including a history and physical on 9/29/23 and a wound care progress note on 10/09/24, confirmed the presence of a left buttock abscess and a skin ulcer with fat layer exposed, respectively. Interviews conducted with the resident and staff revealed discrepancies in the MDS coding process. The resident was aware of daily wound dressing changes but was unsure why the wound had not healed over nine months. A registered nurse confirmed the presence of a non-pressure ulcer and acknowledged that the wound was previously coded under surgical wounds in the MDS. The Director of Nursing was unaware of the MDS coding process, and the MDS Coordinator's job description emphasized the need for accurate assessments and compliance with regulations. The facility's MDS 3.0 Completion policy required accurate assessment and identification of care needs, which was not adhered to in this case.
Failure to Revise Care Plans for Two Residents
Penalty
Summary
The facility failed to revise the care plans for two residents, R33 and R40, leading to deficiencies in their care. For R40, the care plan did not include target behaviors to be monitored despite her receiving anti-anxiety medication. Additionally, the care plan failed to identify potential adverse reactions to the antidepressant medication and did not address signs of increased depression or suicidal ideation, despite R40's history of suicidal thoughts. R40's medical conditions included vertebrogenic low back pain, muscle spasm, and a history of substance abuse, and she required both medication and non-medication interventions for pain management. For R33, the facility did not follow hospital discharge orders to obtain a baseline weight the morning after discharge and failed to conduct daily weight monitoring as required. The care plan did not include instructions for daily weights or when to report significant weight changes to the physician. This oversight resulted in a 60-pound weight gain over a month, leading to R33's readmission to the hospital with congestive heart failure and other complications. The facility delayed adding the physician's order for daily weights to the administration record, and the care plan was not updated to reflect these critical monitoring requirements.
Failure to Document Target Behaviors and Non-Pharmacological Interventions
Penalty
Summary
The facility failed to comprehensively assess and identify target behaviors and non-pharmacological interventions for residents receiving psychotropic medications. For one resident, identified as R8, the Minimum Data Set (MDS) assessment indicated severely impaired cognition and worsening behaviors, including hallucinations and intrusiveness. Despite being on multiple psychotropic medications, R8's care plan lacked specific target behaviors to monitor, and there was no mention of non-pharmacological interventions. The Director of Nursing (DON) acknowledged these deficiencies during an interview. Another resident, R246, was diagnosed with anxiety and major depressive disorder and was on antidepressant and anti-anxiety medications. The care plan for R246 did not specify non-pharmacological interventions, and the DON agreed that these should have been included upon admission. The care plan was updated only after surveyors pointed out the deficiencies. For resident R42, who had anxiety, depression, and PTSD, the care plan failed to identify specific target behaviors or side effects of the prescribed medications. Interviews with staff revealed a lack of documentation on target behaviors and side effects in the care plan. The DON was unaware of the side effects related to psychotropic medication use and planned to collaborate with the nursing team to address this issue. The facility's psychotropic medication policy required documentation of residents' responses to medications, including symptoms and therapeutic goals, which was not adhered to in these cases.
Failure to Label Opened PPD Vials
Penalty
Summary
The facility failed to ensure that two opened vials of Tuberculin (TB) purified protein derivative (PPD) solution were labeled according to the manufacturer's guidelines with an open date. During an observation, two open vials of PPD solution were found in the medication room refrigerator, with the pharmacy-labeled bag dated as dispensed on 9/28/24. However, neither vial was dated to indicate when they had been opened. The pharmacy list indicated that the solution was good for 30 days from the date opened. An LPN confirmed that medications were supposed to be dated when opened and acknowledged the absence of an open date on the vials. The DON stated that her expectation was for medications to be dated and initialed on the date of opening. A policy on medication labeling and storage was requested but not provided by the time of exit.
Failure to Provide Scheduled Dental Services
Penalty
Summary
The facility failed to provide scheduled routine dental services upon request for a resident, identified as R5. R5's quarterly Minimum Data Set (MDS) assessment indicated that his cognition was intact, and he had diagnoses of stroke, heart failure, renal insufficiency, and diabetes mellitus. During interviews conducted on two separate occasions, R5 reported that he had requested a dental appointment when he was first admitted to the facility, as he was missing all his molars and believed he would benefit from a partial denture. Observations confirmed that R5 was missing all but one upper molar. Additionally, oral assessments conducted on three different dates by RN-A documented R5's requests for a dental appointment. RN-A, who conducted the oral assessments, stated that she always asks residents if they would like a dental appointment and communicates their requests to the Social Service Director (SSD) either verbally or via email. An email dated June 4, 2024, from RN-A to the SSD confirmed that R5 had requested a dental appointment, noting that he had several cavities but no pain or difficulty chewing at the time. However, the SSD claimed she did not recall R5's request and acknowledged that she must have missed the email notification. This oversight resulted in the facility's failure to arrange the necessary dental services for R5.
Failure to Provide Physical Therapy Services
Penalty
Summary
The facility failed to provide physician-ordered physical therapy (PT) services for two residents, R20 and R37, due to the unavailability of PT services. R37, who had intact cognition and was independent with activities of daily living, was admitted to the facility following hospitalization with the goal of regaining strength and returning to independent living. Despite having orders for PT services, R37 did not receive PT after the end of August 2024, as the facility no longer had PT services available. Interviews with staff, including the director of nursing and the administrator, confirmed that PT services were not provided due to the lack of a PT provider. R20, who had moderate cognitive impairment and required substantial assistance with daily activities, was also affected by the lack of PT services. R20 had medical diagnoses including an artificial knee joint and osteoporosis, and was supposed to receive PT and occupational therapy (OT) as per physician orders. However, the facility could not provide documented evidence that R20 had been seen by a physical therapist. Interviews with the occupational therapist and the administrator revealed that the facility had been without a PT provider since the end of August 2024, and there was no interim plan to ensure PT services were provided. The facility's failure to provide PT services was further highlighted by the absence of a policy on the provision of skilled therapy services, which was requested but not provided by the end of the survey. The facility's August 2024 assessment indicated that it would provide ancillary services, including PT, but the lack of a PT provider and the absence of a plan to address this gap resulted in the deficiency noted in the report.
Inadequate Infection Control Management Due to Lack of Training and Oversight
Penalty
Summary
The facility failed to ensure that the Director of Nursing (DON), who also served as the Infection Preventionist (IP), had the appropriate training and oversight to manage the infection control program effectively. The DON was new to her role and had only been in the position for approximately two weeks. She had not yet completed the necessary training course and was unsure about the types of transmission-based precautions (TBP) needed. The surveillance records from August 2024 through November 2024 showed several critical sections, such as isolation status, were left blank, making it impossible to determine if TBP had been implemented timely or at all. The DON had limited time to devote to infection control and was relying on assistance from a staff member at a sister facility, who was unavailable due to vacation and minimal prior interaction. The infection control surveillance records revealed significant gaps in documentation and analysis. Of the 45 entries reviewed, only one healthcare-acquired infection (HAI) and one isolation were recorded. Specific cases, such as a resident with Clostridium Difficile and others with resistant bacteria strains, lacked documentation on precautions and resolution of symptoms. Additionally, 33 residents were identified with COVID-19 or upper respiratory infections, but there was no indication of TBP implementation or analysis to prevent further outbreaks. The facility's infection surveillance policy required ongoing data collection and analysis, but these processes were not adequately followed, leading to deficiencies in infection control management.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, specifically in the case of resident-to-resident abuse involving three residents. On two separate occasions, one resident physically abused two other residents. The first incident involved the resident hitting another resident in the ankle with a rock, and the second incident involved the resident punching another resident in the face. These incidents occurred in the designated smoking area, where the resident was not adequately supervised by staff, despite having a care plan that required supervision due to a history of aggressive behavior. The resident involved in the abuse had a history of moderate cognitive impairment and was known to have aggressive tendencies, as noted in their care plan. Despite this, the facility failed to implement effective measures to prevent further incidents. The resident was able to access cigarettes and a lighter, despite a doctor's order prohibiting smoking for health and safety reasons. The resident's behavior was not adequately monitored, and staff were not consistently present to supervise the resident in the smoking area, leading to repeated incidents of aggression. Interviews with other residents and staff revealed that the resident's aggressive behavior was well-known, and there was a general sense of fear and discomfort among other residents when the resident was present in the smoking area. Staff interviews indicated that the facility's attempts to supervise the resident were inconsistent and ineffective, with staff acknowledging that they were unable to consistently monitor the resident's activities. The facility's policy on abuse prevention was not effectively enforced, leading to a failure to protect residents from harm.
Inadequate Supervision of Resident Smoking
Penalty
Summary
The facility failed to provide adequate supervision and safety interventions for a resident identified as R1, who was deemed unsafe to smoke by her physician. Despite the care plan indicating that R1 required 1:1 staff supervision when outside in the smoking area, multiple observations and interviews revealed that R1 was frequently smoking without supervision. R1 had a history of smoking-related incidents, including burning clothing and smoking in bed, and was observed falling asleep with a lit cigarette. The facility's policy required that residents who are unsafe to smoke should have their smoking materials maintained by nursing staff, but R1 was found with cigarettes and a lighter in her possession. Interviews with staff and other residents indicated that R1 was able to access cigarettes and lighters despite the facility's policy against it. R1 was observed smoking outside without staff supervision on multiple occasions, and other residents reported incidents of R1 attempting to steal cigarettes and lighters. The facility's staff, including nursing assistants and the director of nursing, acknowledged the difficulty in supervising R1 due to her quick movements and the inability to always catch her when she went outside to smoke. The facility's failure to implement the necessary supervision and safety measures resulted in several incidents of resident-to-resident altercations involving R1. Other residents reported being physically assaulted by R1 in the smoking area, and staff interviews confirmed that R1 was not consistently monitored as required by her care plan. The facility's policies on smoking safety were not effectively enforced, leading to ongoing safety risks for R1 and other residents.
Failure to Report Allegation of Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency (SA) for a resident who was reviewed for allegations of neglect. A Vulnerable Adult Maltreatment Report was submitted to the SA by an undisclosed person, alleging that the resident was sexually and physically abused in the facility. The resident had moderate cognitive impairment and required staff assistance with eating, toileting, and transferring. The facility's Incident Report Log identified the alleged abuse and noted that a MAARC report was filed against them. The facility's investigative note indicated that the social service designee (SSD) was notified by the county sheriff's department of the allegation, and the director of nursing and administrator were informed. However, the SSD, director of nursing, and administrator all believed that since the allegation had already been reported by an outside facility, they did not need to report it to the SA again. Instead, they initiated an internal investigation of the abuse allegation. During interviews, the SSD, director of nursing, and administrator all confirmed that they were aware of the allegation but did not report it to the SA, believing it was unnecessary due to the prior report by an outside facility. The facility's policy on abuse, neglect, exploitation, and misappropriation prevention, last revised in April 2021, indicated that the facility was required to investigate and report any allegations within the timeframes required by federal requirements. The failure to report the allegation to the SA as required by federal regulations constitutes a deficiency in the facility's handling of the abuse allegation.
Lack of Analysis and Evaluation in QAPI Program
Penalty
Summary
The facility failed to provide evidence of analysis and evaluation of identified Performance Improvement Project (PIP) concerns within their Quality Assurance Performance Improvement (QAPI) program. Specifically, the QAPI meeting minutes from 9/28/23 lacked identification and analysis of the Mantoux PIP project, which aimed to ensure new admissions completed a Mantoux Skin Test correctly. Additionally, the meeting minutes did not identify any new high-risk or problem-prone areas. The QAPI meeting minutes from 3/28/24 revealed four ongoing PIP projects, including call light response times, fall reduction, Relias training completion, and grievance reduction. However, none of these projects included documentation on data analysis, intervention modifications, or decisions on whether the projects should continue. During an interview on 4/24/24, the executive director of operations acknowledged the lack of data analysis and intervention modifications for the PIP projects. The director of nursing (DON) confirmed that all department heads were responsible for daily rounds but could not provide specific details on who was completing the fall rounds. The executive director also admitted that the Relias training project lacked analysis and that the grievance PIP project was not appropriately chosen. The facility's QAPI policy, dated 1/1/24, stated that the committee should meet quarterly to evaluate activities, identify issues, and develop corrective plans, but this was not adequately followed as per the findings in the report.
Failure to Ensure Competency in Insulin Administration
Penalty
Summary
The facility failed to ensure that all licensed nursing staff were appropriately trained and deemed competent to administer insulin. During an observation and interview, an LPN administered insulin to a resident without priming the insulin pen with 2 units of insulin prior to dialing up the ordered dose. The LPN expressed surprise at forgetting to prime the pen. The resident's Medication Administration Record indicated they were receiving multiple doses of Novolog and Lantus insulin daily for diabetes management. The manufacturer's instructions for the Lantus Solostar pen clearly state that the pen should be primed with 2 units of insulin before administering the dose, a step that was missed by the LPN during the observed administration. The Director of Nursing (DON) confirmed that staff should be priming insulin pens and admitted that no insulin competencies had been completed with licensed nurses. Additionally, there were no drug books or manufacturer's directions available for nurses to reference at the nurses' station, medication room, or medication cart, although the DON had requested a new drug book from the executive director of operations. The executive director of operations stated that they would expect the DON to ensure licensed nurses were competent with insulin administration. No policy related to insulin administration was provided by the end of the survey.
Failure to Provide Mandatory QAPI Training to All Staff
Penalty
Summary
The facility failed to provide mandatory training on its specific Quality Assurance Performance Improvement (QAPI) Program to all staff. Interviews with various staff members, including a nursing assistant, maintenance supervisor, director of nursing, social service director, trained medication aide, dietary aide, and dietary manager, revealed a lack of awareness and understanding of the facility's specific QAPI goals and elements. The staff reported either not receiving any QAPI training or only receiving generalized QAPI training through Relias, which did not cover the facility-specific details. The director of nursing and other staff members were unable to identify specific QAPI projects or performance improvement projects (PIPs) currently being worked on by the facility. The executive director of operations acknowledged that while staff were trained on the elements of the facility's QAPI program, they were quick to forget what they had learned. The review of the Relias training records showed that several staff members had outdated or no QAPI training listed. Additionally, the facility's August 2022 In-Service Training policy indicated that staff were required to complete training on the elements and goals of the QAPI program, which was not being adhered to. This lack of proper training and awareness among staff led to the deficiency in the facility's QAPI program implementation.
Deficiency in Staff Training on Alzheimer's and Related Disorders
Penalty
Summary
The facility failed to ensure that four out of nine staff members received the required initial and annual training on Alzheimer's disease or related disorders, assistance with activities of daily living (ADL), problem-solving with challenging behaviors, and communication skills. Specifically, the Director of Nursing (DON) did not complete training on Alzheimer's disease and related disorders upon hire. Licensed Practical Nurse (LPN)-A did not complete training on communication needs upon hire. Nursing Assistant (NA)-A did not complete annual training on ADLs, and NA-C did not complete annual training on Alzheimer's disease and related disorders. The facility's Resident Admission Packet and In-Service Training policy indicated that staff should receive training on understanding the Alzheimer's disease process, behaviors, assisting with ADLs, and communication skills. However, the policy lacked specific identification of required training on Alzheimer's disease or related disorders, assistance with ADLs, communication needs, and problem-solving with challenging behaviors. This discrepancy led to the identified deficiencies in staff training records.
Failure to Ensure Proper Disposal of Cigarette Butts
Penalty
Summary
The facility failed to ensure that a resident appropriately disposed of cigarette butts after smoking, which had the potential to affect other residents who also smoked. During an interview, the resident stated that she stored used cigarette butts in her jacket pocket and discarded them in the trash bin in her room, despite being aware of the designated receptacle outside. Observations confirmed that the resident continued this practice, and the facility had signs posted instructing residents to dispose of cigarette butts in the proper receptacle. The resident's smoking review assessment indicated she had a visual deficit and understood the smoking policy, but her Minimum Data Assessment did not identify her use of tobacco products. The care plan aimed to prevent injury from unsafe smoking practices and included educating the resident on smoking locations and times. Interviews with staff revealed that the facility had signs posted to inform residents about proper cigarette disposal, but the nursing assistant was not fully aware of the resident's practices. The Director of Nursing acknowledged finding cigarette butts in the resident's room and stated that the resident had been educated on the facility's smoking policy in the past. However, the Director was unaware that the resident continued to store used cigarette butts in her pocket. The facility's smoking policy required a designated smoking area with ashtrays for proper disposal, but this was not effectively enforced for the resident in question.
Failure to Administer Oxygen Per Physician Orders
Penalty
Summary
The facility failed to ensure that a resident's oxygen was administered per physician orders. The resident, who had moderate cognitive impairment and a diagnosis of pneumonia, anxiety, depression, and respiratory failure, was observed multiple times with her oxygen set at 4 liters, contrary to the physician's order of 2 liters at rest and 5 liters with activities. Despite being observed asleep, watching television, and eating a meal, the oxygen setting remained incorrect. Both a nursing assistant and a licensed practical nurse confirmed the discrepancy and adjusted the oxygen setting accordingly. The Director of Nursing stated that staff are expected to follow physician orders related to oxygen use and that interventions should be in place to prevent contamination of oxygen tubing. However, there were no orders to titrate the oxygen between the baseline 2 liters and the maximum 5 liters. The facility's policy on oxygen administration requires that oxygen be administered as prescribed by the physician, following professional standards of practice. The failure to adhere to these orders was identified during the survey, highlighting a deficiency in the facility's respiratory care practices.
Failure to Prime Insulin Pen Before Administration
Penalty
Summary
The facility failed to ensure an insulin pen was appropriately primed prior to administration for a resident. During an observation and interview, an LPN administered a Lantus injection to a resident without priming the insulin pen with 2 units of insulin as required. The LPN acknowledged forgetting to prime the pen. The resident's Medication Administration Record indicated multiple daily doses of Novolog and Lantus for diabetes management. The Lantus pen instructions clearly state the need to perform a safety test by priming with 2 units of insulin before administration, which was not followed in this instance. The Director of Nursing (DON) confirmed that staff should prime insulin pens before administration and admitted that no insulin competencies had been completed with licensed nurses. Additionally, there were no drug books or manufacturer's directions available for nurses to reference at the nurses' station, medication room, or medication cart. The Executive Director of Operations expected the DON to ensure licensed nurses were competent with insulin administration. There was no policy related to insulin administration in place at the facility.
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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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