Walker Methodist Westwood Ridge Ii
Inspection history, citations, penalties and survey trends for this long-term care facility in West Saint Paul, Minnesota.
- Location
- 61 Thompson Avenue West, West Saint Paul, Minnesota 55118
- CMS Provider Number
- 245618
- Inspections on file
- 24
- Latest survey
- April 15, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Walker Methodist Westwood Ridge Ii during CMS and state inspections, most recent first.
The facility failed to ensure proper PPE use for a resident on enhanced barrier precautions, as nursing assistants did not wear gowns during high-contact care activities. Additionally, the facility lacked a comprehensive Infection Prevention and Control Program, with no current surveillance of infections or tracking of antibiotic use. The director of nursing confirmed these deficiencies.
The facility failed to implement an effective antibiotic stewardship program, as the DON, acting as the infection preventionist, admitted to not tracking antibiotic use or conducting antibiotic time-outs. The facility's policy required detailed documentation of antibiotic regimens, but these protocols were not being followed, leading to a deficiency.
The facility's acting infection preventionist, the DON, had not completed specialized training in infection prevention and control, as required by the facility's policy. The DON confirmed she was responsible for the infection control program but was not enrolled in any training, and no other staff had the necessary specialized training.
The facility failed to protect resident information privacy by leaving care sheets and computer screens with sensitive data unattended and in public view. This included residents' names, diagnoses, and other personal details. Staff acknowledged the oversight, which violated the facility's privacy policy.
The facility failed to offer pneumococcal and influenza vaccinations to several residents as recommended by the CDC. Five residents were not offered the PCV20 or PCV21 vaccines despite eligibility, and one resident was not offered the influenza vaccine. Documentation lacked evidence of shared clinical decision-making or education regarding these vaccines. Interviews with staff confirmed that immunizations are typically offered upon admission, but records did not reflect this for the affected residents.
A resident in hospice care with intact cognition expressed a preference for showers over bed baths, but the facility failed to assess and document this preference. The care plan and other documentation lacked evidence of the resident's choice, and staff were unaware of the preference. The director of nursing confirmed that preferences should be assessed and documented, but this was not done for the resident.
The facility failed to provide timely Medicare coverage notices to three residents, resulting in delayed or missing Skilled Nursing Facility Advanced Beneficiary Notices (SNFABN) and Notices of Medicare Non-Coverage (NOMNOC). This left residents without necessary information about their coverage and potential financial liabilities, contrary to the facility's policy.
A facility failed to provide a resident with a copy of their baseline care plan upon admission, as required by policy. The resident, who was cognitively intact, confirmed not receiving the care plan and expressed a desire to have it. Interviews with staff revealed that the facility's practice was to provide the care plan only upon discharge, contrary to the policy that required providing a written summary by the completion of the comprehensive care plan.
A resident's care plan was found to be inadequate, lacking specific goals and interventions for critical areas such as communication, urinary incontinence, and falls. The plan also failed to incorporate the resident's personal preferences, such as using the bathroom over an incontinent pad and preferring showers to bed baths. Additionally, there was a lack of coordination with hospice services and no discharge planning, despite the resident's uncertain future living arrangements. Staff interviews revealed reliance on incomplete care sheets and Kardexes, leading to insufficient personalized care.
A resident admitted with multiple health conditions did not have a care conference conducted within the required timeframe. Despite the facility's usual practice of holding care conferences within a week of admission, no conference was held for this resident, who was on private pay and hospice care. Staff interviews confirmed the absence of a care conference, and the facility lacked a policy on the timing of such conferences.
A facility failed to coordinate effectively with a contracted hospice organization for a resident receiving hospice services. The resident's care plan and documentation lacked essential information about hospice visits and services, and staff interviews revealed a lack of awareness about the hospice schedule. The hospice binder was missing critical details, and a facility policy on coordination was not provided.
A facility failed to reassess and justify the continued use of an indwelling catheter for a resident with severe cognitive impairment and urine retention, despite recommendations for its removal. Additionally, a cognitively intact resident expressed a preference for using the toilet for bowel movements, but was not offered a toilet or bed pan, and had not been transferred out of bed for at least a week. The facility's policies on catheter management and incontinence were not adhered to, leading to significant deficiencies in care.
A resident with moderate cognitive impairment and multiple diagnoses was prescribed psychotropic medications but was not continuously monitored for side effects as required. Staff interviews revealed that monitoring should occur every shift without an end date, but documentation showed it ceased prematurely. A policy on monitoring was requested but not provided.
A resident with dementia and depression was prescribed trazodone for sleep without clear parameters, leading to two doses being administered within a short time frame. This oversight resulted in the resident experiencing a fall and a fracture. Interviews with staff confirmed the lack of clear medication parameters, and the DON acknowledged the need for adherence to prescribed orders to prevent overdose and reduce fall risk.
A resident with a full code status was found unresponsive and not breathing, but CPR was not initiated promptly by the nursing staff. The resident, who had a complex medical history and recent hospitalization, was discovered by an RN in a lifeless state, yet there was a delay in verifying the code status and starting resuscitation efforts. This deficiency resulted in the resident's death and highlighted inconsistencies in staff actions and statements.
A resident recovering from bladder surgery pulled out their indwelling catheter, but the facility failed to notify the physician in a timely manner. The nurse delayed contacting the on-call provider for several hours, despite the resident's history of bladder surgery and bleeding issues. The nurse received an order to reinsert the catheter but did not follow up when the resident refused the procedure. The facility's policy required timely notification of acute changes, which was not adhered to, contributing to the resident's unresponsive state and subsequent death.
A resident with a full resuscitation order experienced a delay in CPR initiation, leading to a failure to immediately report suspected neglect to the state agency. The incident involved inconsistencies in staff statements and a delayed submission of the incident report, which was filed 20 hours after the neglect was suspected.
A resident recovering from bladder surgery pulled out their catheter, and the facility failed to contact the provider timely or follow orders to replace the catheter or send the resident to the ER. The resident had a history of bladder cancer and anemia, and the facility did not conduct necessary assessments or monitoring, leading to a lack of timely intervention.
Failure in PPE Use and Infection Control Program
Penalty
Summary
The facility failed to ensure proper personal protective equipment (PPE) use for a resident on enhanced barrier precautions (EBP). During an observation, two nursing assistants entered the resident's room without donning gowns, despite a sign indicating the need for gowns and gloves during high-contact care activities. The resident, who was dependent on staff for bathing, toileting, and dressing, had a Foley catheter in place. The nursing assistants provided care, including a partial bed bath and brief change, without wearing gowns. Interviews with the nursing assistants and the resident's family member confirmed the lack of gown use, and the director of nursing acknowledged the importance of PPE in preventing infection spread. The facility also failed to maintain a comprehensive Infection Prevention and Control Program (IPCP). The infection control program lacked specific surveillance and analysis data, and the director of nursing, acting as the infection preventionist, confirmed the absence of current surveillance of infections, resident symptoms, or tracking of antibiotic use. There were no audits of staff adherence to PPE use or handwashing, and no tracking of antibiotic use to ensure proper follow-up. The facility's policy indicated that ongoing surveillance for healthcare-associated infections should be conducted, but this was not being implemented.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program, which is crucial for preventing antibiotic resistance and the spread of infectious diseases. During an interview, the Director of Nursing (DON), who was also acting as the facility's infection preventionist, admitted that the facility was not tracking antibiotic use among residents. This included a lack of monitoring for prophylactic antibiotics and the absence of antibiotic time-outs, which are necessary to evaluate the continued need for antibiotics. The DON was unaware of any ongoing antibiotic time-outs, indicating a significant gap in the facility's infection control practices. The facility's policy on Antibiotic Stewardship, revised in January 2025, outlined the need for a designated Registered Nurse as the Infection Preventionist, who should be certified in Infection Prevention and Control. The policy also required a system to monitor antibiotic use, including detailed documentation of resident antibiotic regimens on a surveillance tracking form. This form should include information such as the resident's name, medical record number, unit and room number, date symptoms appeared, name of the antibiotic, start date, pathogen identified, site of infection, date of culture, stop date, and total days of therapy. However, these protocols were not being followed, as confirmed by the DON, leading to the deficiency noted in the report.
Infection Preventionist Lacks Specialized Training
Penalty
Summary
The facility failed to ensure that the acting infection preventionist, who is the Director of Nursing (DON), had completed specialized training in infection prevention and control. This deficiency was identified during an interview and document review, where the DON confirmed that she was responsible for overseeing the infection control program but had not completed any specialized training in this area. Furthermore, the DON was not currently enrolled in any specialized training nor had any scheduled. It was also verified that no other staff members in the facility had specialized training in infection prevention and control. The facility's policy, revised in January 2025, requires the infection preventionist to be qualified by education, training, experience, or certification and to have completed specialized training in infection prevention and control.
Failure to Protect Resident Information Privacy
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of residents' personal and medical information. During an observation, a medication cart in the 400 hallway was left unattended with a care sheet in public view. This care sheet contained sensitive information about five residents, including their full names, diagnoses, special programs, alertness, transfer and ambulation status, continence, diet, precautions, skin conditions, and other notes. Multiple residents were observed passing by the unattended cart, exposing their private information. A registered nurse acknowledged that such information should be kept out of public view. In another instance, a clipboard with a care sheet was left on the edge of a unit desk, visible to residents and family members. This sheet also contained detailed information about five residents. A registered nurse later picked up the clipboard. Additionally, a medication cart was left unattended with a computer screen displaying a resident's medication orders and a care sheet in view. A licensed practical nurse admitted to leaving the screen open and confirmed the care sheet contained resident information. The facility's policy requires maintaining the privacy and security of protected health information, which was not adhered to in these instances.
Failure to Offer Pneumococcal and Influenza Vaccinations
Penalty
Summary
The facility failed to ensure that five out of six residents reviewed for immunizations were offered or provided the pneumococcal vaccination series as recommended by the CDC. Specifically, residents were not offered the PCV20 or PCV21 vaccines despite being eligible, as it had been more than five years since their last pneumococcal dose. The records for these residents lacked evidence of shared clinical decision-making with a physician regarding these vaccines, and there was no documentation of the residents being offered or receiving the vaccines or any related education. Additionally, one resident was not offered or provided the influenza vaccination as recommended by the CDC. This resident's records also lacked evidence of being offered or receiving any pneumococcal doses or education. The facility's documentation did not reflect that the resident was provided education, offered, or received an annual influenza immunization. Interviews with facility staff, including an LPN and the DON, confirmed that immunizations are typically offered upon admission and documented in progress notes or the resident's hard chart. However, the DON verified that the records for the residents in question lacked evidence of being offered or receiving the necessary vaccinations until after the survey entrance, indicating a lapse in following the facility's policies and CDC recommendations.
Failure to Honor Resident's Bathing Preferences
Penalty
Summary
The facility failed to honor and assess a resident's bathing preferences, specifically for Resident R5, who was under hospice care. R5, who had intact cognition, expressed a preference for showers over bed baths, but this preference was not documented or honored by the facility. Since admission, R5 had only been out of bed once and had not been offered a shower, which he preferred. The care plan and other documentation, such as the Kardex and care sheets, lacked any mention of R5's preference for a shower, indicating a failure to assess and document his choices. Interviews with various staff members, including nursing assistants and registered nurses, revealed a lack of awareness and documentation regarding R5's bathing preferences. Nursing assistants relied on care sheets and Kardex for resident information, but these documents did not reflect R5's preference for showers. Staff members, including NA-C and NA-D, confirmed that R5 had not been assisted with a shower and were unaware of his preference. The registered nurse and licensed practical nurse coordinator acknowledged that resident preferences should be assessed and documented in the care plan, but this was not done for R5. The director of nursing verified that resident preferences should be assessed and included in the care plan, but this was not the case for R5. The facility's failure to assess and document R5's preference for showers over bed baths represents a deficiency in promoting and facilitating resident self-determination. Additionally, the facility was unable to provide a policy on resident choices when requested, further highlighting the lack of adherence to resident rights and preferences.
Failure to Provide Timely Medicare Coverage Notices
Penalty
Summary
The facility failed to provide necessary Medicare and Medicaid coverage notices to residents upon the termination of Medicare A coverage. Specifically, three residents did not receive the required Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) and/or Notice of Medicare Non-Coverage (NOMNOC) in a timely manner. For one resident, the NOMNOC was received, but the SNFABN was delayed until after the private pay costs had started. Another resident received the NOMNOC but did not receive the SNFABN at all, and a third resident did not receive either notice. This lack of timely notification left residents without the necessary information regarding their coverage and potential financial liabilities. The facility's policy, revised in January 2025, mandates informing residents about available services and charges, including those not covered by Medicare/Medicaid, at admission and periodically during their stay. However, the facility did not adhere to this policy, as evidenced by the missing or delayed notices. The administrator confirmed these deficiencies and acknowledged that retraining was necessary to address the issue, as some processes were not being completed as required.
Failure to Provide Baseline Care Plan to Resident
Penalty
Summary
The facility failed to provide a copy of the baseline care plan to a resident, identified as R26, who was admitted on 12/10/24 and was cognitively intact. The resident's Care Conference Summary, dated 12/22/24, indicated that copies of the care plan were not applicable, and during an interview on 1/22/25, the resident confirmed not receiving a copy of her care plan, expressing a desire to have one. Interviews with social services and nursing staff revealed that the facility's process was to start the baseline care plan upon admission but only provide a copy to residents or their representatives upon discharge. This practice was confirmed by the nurse coordinator and director of nursing, despite the facility's policy stating that a written summary of the baseline care plan should be provided by the completion of the comprehensive care plan.
Inadequate Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and maintain a comprehensive care plan for a resident, identified as R5, which resulted in inadequate care provision. R5's admission Minimum Data Set (MDS) indicated that the resident required maximum assistance for various activities of daily living (ADLs) and had several medical diagnoses, including acute kidney failure, diabetes, and congestive heart failure. Despite these needs, the care plan lacked specific goals and interventions for several critical areas, such as communication, urinary incontinence, falls, and psychotropic drug use. Additionally, the care plan did not address R5's cognitive abilities, behavioral symptoms, or specific needs related to mobility and safety. The care plan also failed to incorporate R5's personal preferences and specific care requirements. Interviews with nursing assistants revealed that R5 had not been offered a bed pan or the use of the bathroom, despite expressing a preference for using the bathroom over an incontinent pad. Furthermore, R5 preferred showers to bed baths, but this preference was not reflected in the care plan. The care plan also lacked coordination with hospice services, which were part of R5's care, and did not include any discharge planning, despite R5's uncertainty about future living arrangements. Staff interviews highlighted a lack of awareness and adherence to R5's care preferences and needs. Nursing assistants and registered nurses indicated that they relied on care sheets and Kardexes for resident information, but these documents did not contain the necessary details to provide comprehensive and personalized care for R5. The facility's policy required that comprehensive care plans include all necessary services to maintain the resident's well-being, but R5's care plan did not meet these standards, resulting in a deficiency in care provision.
Failure to Conduct Timely Care Conference for Resident
Penalty
Summary
The facility failed to conduct a care conference for a resident (R5) within the required timeframe following admission. R5 was admitted with multiple diagnoses, including heart failure, hypertension, diabetes, depression, obstructive sleep apnea, ischemic cardiomyopathy, and chronic kidney disease. Despite the resident's complex medical needs and the requirement to develop a complete care plan within seven days of the comprehensive assessment, there was no evidence of a care conference being conducted or planned for R5 from the time of admission on 12/31/24 to 1/23/25. Interviews with the resident and staff confirmed the absence of a care conference, and the resident expressed uncertainty about their future care plan and living arrangements. The LPN coordinator and social worker acknowledged that care conferences are typically held within a week or so after admission, involving therapy, nursing, social work, family, and the resident. However, they confirmed that no care conference had been conducted for R5, who was admitted on private pay and hospice care. The social worker indicated there was no policy mandating a specific timeframe for care conferences, and the director of nursing was unsure of any such requirement. The facility did not provide a policy on care conference timing when requested, highlighting a lack of adherence to regulatory expectations for timely care planning.
Lack of Coordination with Hospice Services
Penalty
Summary
The facility failed to ensure effective collaboration with a contracted hospice organization, affecting a resident receiving hospice services. The resident, who was cognitively intact and required maximum assistance for various activities of daily living, had multiple diagnoses including acute kidney failure, anemia, atrial fibrillation, and chronic kidney disease. Despite being under hospice care, the resident's hospice chart lacked a calendar of planned visits and a copy of the hospice care plan. Additionally, there was no coordination documented between hospice staff and facility staff, particularly from hospice nursing assistants. The resident's care plan and order summary report were missing critical information such as the hospice provider's name, contact information, services provided, and frequency of visits. The Medication Administration Record also lacked evidence of hospice provider details. Progress notes indicated some communication with hospice regarding the resident's condition, but they did not document the frequency of hospice visits or the services provided. The Kardex and care sheet also failed to reflect the resident's hospice services accurately. Interviews with facility staff, including nursing assistants and registered nurses, revealed a lack of awareness regarding the hospice schedule and services provided to the resident. The hospice binder, intended for coordination of care, was missing essential information such as a calendar of visits, notes from nursing assistants, and the hospice plan of care. The director of nursing confirmed the expectation of coordinated care between the facility and hospice, but the documentation did not support this coordination. A facility policy on coordination with providers was requested but not received.
Deficiencies in Catheter Management and Bowel Continence Care
Penalty
Summary
The facility failed to comprehensively reassess and justify the continued use of an indwelling catheter for a resident with severe cognitive impairment and urine retention due to Parkinson's Disease. Despite recommendations from a urology consult and physician progress notes to discontinue the Foley catheter and resume intermittent straight catheterization, the catheter remained in place. Interviews with facility staff revealed uncertainty about the ongoing plan for the resident's catheter, and the facility's policy indicated that residents should be assessed for catheter removal as soon as possible unless clinically necessary. Another deficiency involved a resident who was cognitively intact and expressed a preference to use the toilet for bowel movements rather than an incontinent pad. The resident's care plan indicated they were dependent on staff for toileting and encouraged the use of the toilet. However, interviews with nursing assistants revealed that the resident had not been offered the use of a toilet or bed pan and had not been transferred out of bed for at least a week. The facility's policy on incontinence emphasized the importance of implementing interventions to promote continence, but there was no evidence of a toileting program being attempted for this resident. The facility's failure to develop a comprehensive plan of care for residents with indwelling catheters and to provide services to maintain bowel continence for a resident who was continent of bowel highlights significant deficiencies in the care provided. The lack of adherence to facility policies and the absence of a clear plan for catheter management and toileting programs contributed to these deficiencies.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to ensure proper monitoring for side effects in a resident prescribed psychotropic medications. The resident, identified as R283, had moderate cognitive impairment and was diagnosed with pneumonia, heart failure, and malnutrition, among other conditions. The resident was prescribed trazadone for insomnia and buspirone for anxiety. According to the Medication Administration Record, monitoring for psychotropic side effects was initiated but only continued until a specified date, contrary to the facility's practice of continuous monitoring. Interviews with staff, including an LPN and the Director of Nursing, revealed that the facility's protocol was to monitor residents for side effects of psychotropic medications continuously, every shift, without an end date. However, the documentation did not reflect this practice, as monitoring was not conducted beyond a certain date. Additionally, a facility policy on monitoring psychotropic side effects was requested but not provided, indicating a lack of formalized procedures or documentation to ensure compliance with monitoring requirements.
Failure to Ensure Proper Parameters for PRN Antipsychotic Medication
Penalty
Summary
The facility failed to ensure proper parameters for the administration of a PRN antipsychotic medication for a resident diagnosed with dementia with behavioral disturbance and depression. The resident, who required substantial assistance with daily activities and had fluctuating behaviors, was prescribed trazodone for sleep without clear parameters for its use. The medication order lacked documentation specifying that trazodone should only be used once in 24 hours, and there was no stop date included. This oversight led to the resident receiving two doses within a short time frame, which was not in accordance with the intended prescription. The incident was highlighted when the resident experienced an unwitnessed fall, resulting in a fracture, after receiving trazodone. Interviews with facility staff, including an LPN and the clinical pharmacist, confirmed the lack of clear parameters for the medication's administration. The Director of Nursing acknowledged that the trazodone order should have been followed as prescribed, with parameters in place to prevent overdose and reduce the risk of falls. The facility's medication management policy emphasized the need for clear medication orders and documentation, which was not adhered to in this case.
Failure to Initiate Timely CPR for Resident with Full Code Status
Penalty
Summary
The facility failed to provide basic life support, including CPR, in accordance with the resident's wishes and physician orders for full code status. This deficiency involved a resident who was found not breathing and without a pulse, yet CPR was not initiated in a timely manner. The resident, who had a full resuscitation order, was found by RN-A at 12:30 a.m. in a lifeless state, but no immediate action was taken to resuscitate her, resulting in her death. The resident had a complex medical history, including a neoplasm of the bladder, heart failure, and a history of venous thrombosis and embolism. She had recently been hospitalized for vaginal bleeding and had undergone several medical procedures, including the placement of an inferior vena cava filter. Despite these conditions, her Provider Orders for Life-Sustaining Treatment (POLST) indicated a full code status, requiring attempts at resuscitation, including CPR and advanced airway interventions. On the night of the incident, there was a significant delay in initiating CPR. RN-A, who discovered the resident unresponsive, did not immediately verify the code status or begin resuscitation efforts. Instead, there was confusion and a lack of urgency in responding to the resident's condition. The timeline of events was inconsistent, and staff statements varied, leading to an inconclusive investigation by the facility. The delay in initiating CPR and the failure to follow the resident's advance directives contributed to the immediate jeopardy situation and the resident's death.
Failure to Timely Notify Physician After Catheter Removal
Penalty
Summary
The facility failed to notify the physician in a timely manner for a resident who was recovering from bladder surgery and had pulled out their indwelling catheter. The resident had specific orders to contact the physician with any change in condition, which were not followed. The resident's medical history included a neoplasm of the bladder, acute post-hemorrhagic anemia, heart failure, and diabetes mellitus, among other conditions. The resident had a Foley catheter due to a bladder tumor diagnosis, and the care plan directed staff to monitor and report any signs of urinary tract infection or changes in condition. On the evening of the incident, the resident pulled out their indwelling catheter, causing some bleeding. The nurse on duty, RN-A, delayed contacting the on-call provider for several hours, despite the resident's history of bladder surgery and bleeding issues. When the nurse finally contacted the provider, the information provided was insufficient, and the provider was not made aware of the resident's full medical history and the duration the catheter had been out. The nurse received an order to reinsert the catheter but did not follow up with the provider when the resident refused the procedure. The facility's director of nursing and administrator both indicated that the nurse should have contacted the provider immediately and followed the orders due to the resident's medical history. The facility's policy required physicians to be notified of acute changes in a resident's condition as soon as possible, which was not adhered to in this case. The lack of timely communication and documentation contributed to the deficiency, ultimately leading to the resident's unresponsive state and subsequent death.
Delayed CPR and Reporting of Neglect
Penalty
Summary
The facility failed to immediately report to the state agency when a Provider Orders for Life-Sustaining Treatment (POLST) and cardiopulmonary resuscitation (CPR) were not initiated timely, as per the resident's wishes. The incident involved a resident with multiple medical conditions, including neoplasm of the bladder, heart failure, and diabetes mellitus. The resident's POLST indicated a full resuscitation order, but there was a delay in initiating CPR when the resident was found unresponsive. The incident occurred when nursing staff noted the resident had cessation of pulse and respirations. However, the timeline of events from nurse progress notes was inconclusive as to when CPR was initiated. A registered nurse was suspended pending further investigation, and the facility's findings were inconclusive due to inconsistencies with staff statements and the inability to establish and verify the timeline of events. The resident's primary nurse resigned immediately following the incident. The facility's incident report was submitted to the state agency 20 hours and 44 minutes after the facility suspected neglect. Interviews with staff revealed discrepancies in the timeline and actions taken, with one nurse alleging that CPR was delayed by 35 minutes. The facility's policy requires immediate reporting of suspected neglect, but the report was delayed until after staff statements were gathered and reviewed.
Failure to Provide Timely Care for Post-Surgery Resident
Penalty
Summary
The facility failed to provide necessary care and services for a resident recovering from bladder surgery. The resident, who had a history of bladder cancer, anemia, and recent surgery, pulled out their indwelling catheter, and the facility did not contact the provider in a timely manner. The provider's orders to replace the catheter or send the resident to the emergency department were not followed, and ongoing assessment and monitoring for bladder retention, bleeding, or change of condition were not completed. The resident's medical history included a neoplasm of the bladder, acute post-hemorrhagic anemia, and a recent surgery that involved partial removal of a bladder tumor. The resident was admitted to the facility with an indwelling catheter, which was crucial to prevent bladder rupture due to the thin bladder walls and history of bleeding. Despite the critical nature of the resident's condition, the facility staff delayed contacting the provider after the catheter was pulled out and failed to follow the provider's orders for re-insertion or emergency transfer. Interviews with facility staff revealed that the nurse responsible for the resident's care was overwhelmed with other tasks and did not prioritize the resident's urgent needs. The nurse did not document assessments or communicate effectively with the provider about the resident's condition, leading to a lack of timely intervention. The facility's director of nursing and administrator acknowledged the failure to follow protocol and the lack of critical thinking in addressing the resident's care needs.
Latest citations in Minnesota
A resident with dry eye syndrome and degenerative eye disease had orders for cyclosporine ophthalmic emulsion and Refresh Tears, both scheduled at the same time. Medication records and direct observation showed a TMA instilled cyclosporine drops in both eyes and immediately followed with Refresh Tears in both eyes without waiting between medications. This practice conflicted with referenced professional guidance recommending several minutes between multiple eye drops and with the medical provider’s recommendation to wait fifteen minutes between the two ophthalmic medications. No facility policy on ophthalmic medication administration was provided when requested.
A resident with severe cognitive impairment, impaired mobility, and high fall risk was care planned to have wheelchair footrests in place at all times, with staff ensuring proper positioning and monitoring for leaning during transport. A NA transported the resident in a manual wheelchair from the shower without the footrests, and while going through the doorway the wheelchair struck the door frame, causing the resident, who was leaning forward, to fall out. The resident sustained a T12 fracture, head injury with concussion, abrasions and contusions, and multiple right-hand lacerations requiring sutures, and the DON confirmed the care plan had not been followed.
A high‑risk, immobile resident with MS and prior heel DTI developed an avoidable unstageable coccygeal pressure ulcer after staff failed to consistently assess and document skin status, did not transfer or timely provide ordered pressure‑relieving mattresses, and did not reliably perform q2h repositioning. The resident was repeatedly left on a bedpan for prolonged periods despite early reports of this issue, and the toileting care plan was not revised to a bedside commode until after the coccygeal wound had significantly worsened. Wound assessments lacked complete measurements and staging, changes in wound size and color were not promptly recognized as deterioration or reported to providers, and recommended interventions from a wound NP (including an air mattress and offloading) were not promptly implemented. As a result, the coccygeal ulcer rapidly progressed to a large, necrotic, malodorous wound requiring hospital transfer and surgical debridement.
A resident with spastic hemiplegia, muscle weakness, and moderate cognitive impairment was observed using bilateral bed grab bars for bed mobility and transfers, but the care plan did not address grab bar or side rail use. Review of the EMR showed no completed bed mobility device or side rail assessment to determine the necessity or safety of the grab bars, and no documentation that risks and benefits were discussed or that informed consent was obtained. An LPN and the ADON stated that a bed mobility device assessment is required before grab bars are installed and confirmed that no such assessment existed for this resident.
A resident with bilateral heel pressure ulcers and multiple comorbidities received wound care during which an RN removed dressings from both heels, cleansed both wounds, and wiped each heel without changing gloves or performing hand hygiene between wounds or after disposing of soiled dressings. This practice conflicted with the facility’s written wound care procedure, which requires glove removal and hand hygiene after dressing removal and after wound cleansing. In interviews, the RN, NP, and DON/IP acknowledged that hand hygiene and glove changes are expected between dirty and clean tasks and between separate wounds to prevent infection.
A resident with MS, neurogenic bladder, mobility limitations, and existing pressure injuries was identified as dependent for toileting hygiene and at risk for pressure ulcers, yet the care plan lacked an individualized toileting/incontinence plan and a defined repositioning schedule. Despite a new coccyx pressure ulcer and documentation that interventions such as increased repositioning and incontinent care were needed, the care plan was not revised for a period of time to reflect these changes. During this time, the resident sometimes fell asleep on a bedpan and remained on it until staff removed it, and staff were not initially informed that the bedpan should no longer be used. The DON later acknowledged that the care plan revisions for turning, repositioning, and toileting were delayed until after the resident’s coccyx ulcer had significantly worsened.
A resident with diabetes, Crohn’s disease, bowel incontinence, and a history of MASD on the right gluteus developed an open, painful lesion on the right gluteal area that was documented over time without complete wound characteristics, clear etiology, or timely provider notification. Wound care orders were written for a stage 3 pressure ulcer on the left buttocks, while staff reported the wound was only on the right side and applied the left‑sided orders to the right gluteal wound in the absence of specific right‑side treatment orders. The DON acknowledged discomfort with staging the wound, lack of early physician notification, and confusion over wound classification, despite a facility policy requiring comprehensive wound assessment, consistent measurement, and provider notification when treatment orders are absent.
A resident with diabetes, chronic leg ulcer, kidney transplant, and a documented gluteal wound was care-planned for Enhanced Barrier Precautions (EBP), with posted instructions requiring gown and gloves for high-contact care such as transfers and wound care. During a telehealth wound assessment, the DON donned a gown and initially performed hand hygiene but then applied gloves without hand hygiene, removed a soiled dressing from the resident’s gluteal area, discarded it, removed gloves, and applied new gloves again without performing hand hygiene between glove changes. On another occasion, during use of a sit-to-stand lift, an NA wore gown and gloves, but the DON handled the lift harness, the resident’s clothing, and assisted with the transfer and repositioning while wearing a gown but no gloves, despite EBP requirements for transfers. The DON stated EBP was only needed for catheter or wound care and not for transfers, contradicting the posted EBP instructions and facility policy.
A resident with severe dementia, psychiatric disorders, and high dependence for ADLs was verbally abused during evening care when a NA, frustrated with the resident’s crying and resistance, loudly ridiculed her as acting like a two-year-old, threatened to hit her back if struck, told her she would be sent to a locked unit, and questioned who would want to care for her when she cried like a baby. Multiple staff witnessed the loud, stern, and intimidating tone and reported it to an LPN, who recognized it as verbal abuse but did not immediately remove the NA from duty or promptly report the allegation per policy, allowing the NA to continue working on the unit. Following this incident, the resident demonstrated increased crying, combativeness, resistance to care, wandering, self-isolation, and refusal of food, fluids, and medications above baseline, with documentation of significant emotional distress and subsequent ED evaluation for aggressive behaviors and poor intake.
A resident with dementia, bilateral above‑knee amputations, vascular disease, and severe protein‑calorie malnutrition developed a wound on an amputation stump that had a dressing dated several days before any documentation or treatment orders appeared in the record. Although bath audits and nursing notes initially reported no skin issues, a later assessment described a full‑thickness stage 4 ulcer/diabetic ulcer on the stump with exposed bone, erythema/edema, slough, and moderate serosanguineous drainage. Nursing staff interviews showed no one could identify who first discovered the wound or applied the initial dressing, and there was no evidence that the wound was assessed, the provider notified, or standing orders implemented when it was first present, despite facility expectations that new wounds be promptly evaluated and reported.
Failure to Follow Professional Standards for Ophthalmic Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice for administering ophthalmic medications to a resident with dry eye syndrome and degenerative eye disease. The resident was cognitively intact, required assistance with ADLs, and had physician orders for cyclosporine ophthalmic emulsion 0.05% one drop in both eyes twice daily and Refresh Tears ophthalmic solution one drop in both eyes four times daily for dry eyes. The administration summary showed that both eye medications were scheduled for the same time and were documented as being given at the same time on multiple dates. During a medication pass observation, a trained medication aide administered the ordered oral medications, then applied gloves and instilled one drop of cyclosporine in each eye, immediately followed by one drop of Refresh Tears in each eye, without any waiting period between the two medications. The surveyors referenced guidance from the American Academy of Allergy, Asthma, and Immunology stating that when more than one eye drop is ordered, three to four minutes should be allowed between drops in the same eye, and five to fifteen minutes should be allowed between different eye medications to prevent dilution. Interviews with the DON, pharmacy consultant, and medical provider confirmed that best practice and the provider’s recommendation were to wait between administration of cyclosporine and Refresh Tears, with the medical provider specifying a fifteen-minute interval. The facility did not provide a policy on ophthalmic medications when requested. The observed practice and documented administration times demonstrated that staff did not follow these professional standards or the medical provider’s recommended interval between the two eye medications.
Failure to Follow Wheelchair Transport Care Plan Leads to Fall With Injuries
Penalty
Summary
The deficiency involves the facility’s failure to implement care-planned fall prevention interventions for a resident at high risk for falls, resulting in a fall with injury. The resident had diagnoses including aphasia, dysphagia, muscle weakness, traumatic brain injury, and impaired mobility, with severe cognitive impairment documented on the MDS and dependence on staff for transfers and wheelchair transport. A care plan addressing wheelchair transport safety and positioning directed staff to ensure the resident was fully positioned and supported in the wheelchair prior to transport, verify footrests were in place prior to transport, and monitor for leaning, sliding, or unsafe positioning. An additional care-planned approach required wheelchair pedals to be on at all times. On the date of the incident, a nursing assistant transported the resident in a manual wheelchair from the shower room to the resident’s room without the foot pedals in place, contrary to the care plan. While being wheeled through the doorway, the wheelchair struck the door frame, causing the chair to stop and the resident, who had begun leaning forward, to fall out of the wheelchair onto the floor. Progress notes and ED documentation identified that the resident sustained a T12 vertebral fracture, a head injury with concussion, an abrasion and contusion to the head, a bruise to the left knee, and multiple lacerations to the right hand requiring sutures. The nursing assistant later acknowledged awareness that the foot pedals should have been on but did not apply them because the transport was only from the shower to the room. The DON confirmed that the resident’s care plan had not been followed when the fall occurred.
Failure to Implement and Update Pressure Ulcer Prevention and Treatment Led to Avoidable Unstageable Coccygeal Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, monitor, and implement individualized pressure ulcer prevention and treatment interventions for multiple high‑risk residents, resulting in an avoidable, unstageable coccygeal pressure ulcer for one resident that required surgical debridement and hospitalization. The resident had primary progressive multiple sclerosis, hereditary spastic paraplegia, obesity, and pre‑existing pressure‑related deep tissue injury to the left heel, and was identified as high risk for pressure ulcers on the Braden Scale due to constant moisture, chairfast status, very limited mobility, inadequate nutrition, and friction/shear risk. Hospital records on readmission documented irritant contact dermatitis of the bilateral gluteal cleft with specific cleansing and barrier cream orders, and facility documentation showed the resident could not reposition in bed or chair and required assist of two and a full‑body mechanical lift for transfers. Despite this, the admission/readmission skin assessment and weekly skin checks lacked measurements and detailed wound characteristics for the heel ulcer and gluteal dermatitis, and the care plan did not include comprehensive, individualized interventions beyond generic repositioning and wound care orders. After a new coccyx pressure ulcer was identified and documented as a stage 2 lesion, the facility failed to promptly and accurately update the care plan and implement recommended pressure‑relieving interventions. The wound nurse practitioner on 3/5 ordered coccyx wound care, an air mattress, pressure offloading, and a dietician consult, but the care plan was not revised and there was no evidence that an air mattress was placed on the bed for nearly two weeks. The environmental services director later confirmed that when the resident was moved to a new room, the gel mattress was not transferred, and the air mattress requested on 3/17 was not actually placed until the following day, despite being marked as completed. During this period, TAR documentation showed gaps in the every‑2‑hour repositioning order, and staff interviews revealed that CNAs were unaware of which residents were on repositioning programs, were not consistently repositioning residents, and had not received recent education on pressure ulcer prevention. The DON and RN case manager acknowledged that the coccyx wound increased in size and changed color between assessments, that the bed lacked the ordered gel mattress, and that the physician was not notified of the wound’s deterioration at that time. The facility also failed to timely modify toileting and incontinence care practices despite knowledge that the resident was being left on a bedpan for extended periods. The DON reported hearing before an IDT meeting that the resident had fallen asleep on a bedpan for an undetermined amount of time, but the care plan was not revised to discontinue bedpan use and implement a bedside commode until after the coccyx wound had significantly worsened. CNAs confirmed that the resident sometimes fell asleep on the bedpan and that they were not informed she should no longer use it until after the sore had worsened. Subsequent wound assessments documented rapid progression of the coccyx wound from a small stage 2 ulcer to a large, malodorous, necrotic wound with eschar, slough, erythema, and purulent drainage, ultimately classified as an unstageable pressure ulcer. The DON, NP, PA, and medical director all indicated that the lack of a pressure‑relieving mattress, failure to adjust pressure‑reducing interventions, and prolonged time on a bedpan likely contributed to the development and deterioration of the resident’s pressure ulcer, which was determined to be avoidable and resulted in hospitalization and surgical debridement. Additional documentation and interviews showed systemic assessment and communication failures related to pressure ulcer management. Weekly skin checks and wound assessments often omitted complete measurements, staging, and wound characteristics, and changes in wound size and appearance were not consistently recognized as deterioration or communicated to providers. The DON acknowledged that a 3/12 assessment showing increased wound size and purple discoloration should have been identified as a deep tissue injury and reported to the physician, but this did not occur. When nursing later documented foul odor, increased pain, and expanding necrotic tissue, telemedicine and PA responses deferred in‑person evaluation and ED transfer despite earlier recommendations that the resident be sent to the ED if an in‑person provider could not assess the wound. The NP ultimately found a large, malodorous, purulent wound with expanding eschar and ordered transfer to the hospital, where imaging and surgical findings confirmed a large necrotic sacral wound requiring extensive debridement. Throughout this sequence, the facility did not consistently follow its own pressure ulcer protocols, did not ensure ordered pressure‑relieving equipment was in place, and did not promptly revise care plans or interventions in response to known risk factors and documented wound changes. The report also notes that other residents reviewed for pressure ulcers were affected by similar failures in monitoring and individualized intervention, though detailed narratives focus primarily on this resident. Staff interviews revealed that CNAs relied on paper care guides that did not clearly identify residents on repositioning programs or at risk for skin breakdown, and that they were unaware of some residents’ special mattress orders or toileting restrictions. The DON and medical director stated that residents at risk for pressure ulcers should have immediate pressure‑relieving interventions and that existing ulcers require ongoing evaluation to prevent deterioration, but the documented practices for this resident did not align with those expectations. These combined actions and inactions—insufficient assessment detail, delayed or missing care plan revisions, failure to implement ordered support surfaces and repositioning, and delayed response to wound deterioration—constituted the deficiency in providing appropriate pressure ulcer care and preventing new ulcers from developing.
Failure to Assess, Care Plan, and Obtain Consent for Bed Grab Bar Use
Penalty
Summary
The deficiency involves the facility’s failure to follow required procedures before installing and using bed grab bars for a resident. The resident had diagnoses including spastic hemiplegia affecting the left side and muscle weakness, and an admission MDS indicating moderate cognitive impairment. During observation, the resident was seen in a power chair with bilateral grab bars on the bed and reported using them to roll in bed and for transfers. The resident’s care plan, dated 1/23/26, documented a need for assistance with bed mobility and independence with transfers but did not mention or address the use of grab bars or side rails. Review of the electronic medical record showed no completed grab bar/side rail or bed mobility device assessment to determine the necessity of the grab bars or whether the resident could safely use them. There was also no evidence that the resident or the resident’s representative had been educated on the risks of having a grab bar on the bed or that informed consent had been obtained. In interviews, an LPN and the ADON both stated that a bed mobility device assessment was required to determine need and safety prior to installing grab bars, and both confirmed that no such assessment was present in the resident’s record.
Failure to Perform Hand Hygiene and Change Gloves During Wound Care
Penalty
Summary
Surveyors observed that a registered nurse (RN) and a nurse practitioner (NP) did not follow the facility’s established infection control practices during wound care for one resident. During a wound treatment, the RN wore gloves while removing the dressing from the resident’s left heel, then removed the dressing from the right heel, sprayed both wounds with wound cleanser, wiped the left heel with gauze, and then used a clean gauze pad to wipe the right heel. The RN did not remove her gloves or perform hand hygiene after disposing of the soiled dressings or between cleaning the left and right heel wounds, contrary to the facility’s written wound care procedure, which requires glove removal and hand hygiene after removing the previous dressing and again after cleaning the wound. The resident’s admission MDS documented diagnoses including multiple rib fractures, heart failure, dementia, anxiety, and the presence of a pressure ulcer, and indicated the resident was cognitively intact and required staff assistance with care and transfers. The resident’s care plan identified pressure ulcers on both heels requiring wound care. In interviews, the RN, NP, and the DON/infection prevention nurse each stated that gloves should be changed when moving from dirty to clean areas and that hand hygiene is expected after glove removal and between wounds to prevent infection, confirming that the observed practice did not align with facility policy or expected infection control standards.
Failure to Timely Revise Care Plan for Toileting and Skin Integrity
Penalty
Summary
The deficiency involves the facility’s failure to timely revise and individualize a resident’s care plan to address toileting and incontinence needs in relation to impaired skin integrity. The resident had diagnoses including primary progressive multiple sclerosis, hereditary spastic paraplegia, obesity, and a pressure-induced deep tissue injury to the left heel. A Significant Change MDS identified the resident as dependent for toileting hygiene, with lower extremity range-of-motion limitations, wheelchair use, dependence for transfers, occasional urinary incontinence, intact cognition, and at risk for pressure ulcers with existing unhealed pressure injuries and MASD. The resident’s skin-focused care plan, revised on various dates, included skin inspections, wound care orders, weekly skin checks, pressure ulcer care to the left heel, nutritional supplements, and a gel mattress, but did not include an individualized toileting or incontinence plan. On a weekly skin check dated 3/3/26, nursing staff identified a new Stage 2 pressure ulcer on the coccyx and contact dermatitis on both gluteal folds. An IDT Final Post Review Follow Up dated 3/10/26 (signed 3/23/26) documented that a new skin issue had occurred and that interventions after the incident included wound care treatment orders, increased repositioning, and increased incontinent care. However, the resident’s care plan from 3/3/26 through 3/16/26 did not show revisions reflecting increased incontinence care or a repositioning schedule, and the care plan was not updated to include these elements until 3/17/26. During this period, the care plan still lacked an individualized toileting plan despite the resident’s identified incontinence and new coccyx pressure ulcer. Progress notes on 3/17/26 documented that the resident’s coccyx wound had declined, with an evaluation describing a deteriorating wound characterized as a Kennedy terminal ulcer/End of Life, staged as a Stage 4 pressure ulcer, in-house acquired, with increased size, exudate, odor, pain, and surrounding erythema. On that same date, the skin focus care plan was revised to include prompt incontinence care and keeping the skin clean and dry, and the elimination focus care plan was revised to address incontinence due to neurogenic bladder with use of a bedside commode offered every 2–3 hours. A nursing assistant reported that when working with the resident, the resident would sometimes fall asleep on the bedpan and forget to ask staff to remove it, and that she was not aware the resident was not supposed to use the bedpan until after the sore had worsened. The DON stated that the resident’s care plan had not been revised earlier to include a turning and repositioning schedule or toileting changes, and that it should have been revised as soon as staff learned the resident was falling asleep on the bedpan, rather than waiting until after the pressure ulcer worsened.
Failure to Assess and Notify Provider for Right Gluteal Wound
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess and appropriately manage a non‑pressure skin issue on a resident’s right gluteal area, and to notify the physician in a timely manner. The resident had diagnoses including diabetes, Crohn’s disease, and a kidney transplant, and the MDS indicated occasional bowel incontinence, no pressure ulcers, and no moisture‑associated skin damage at that time. Earlier documentation identified a resolved MASD to the right gluteus, and a progress note later described a sacral wound with creams applied, noting that sores were still open and painful during application, but without any measurements, wound characteristics, or evidence of physician notification. Subsequent wound assessments documented an open lesion on the right gluteus with specific measurements on multiple dates, but did not identify the wound type or other characteristics, and the record did not show physician notification or treatment orders for the right gluteal lesion. Provider orders in place initially addressed cleansing the buttocks and applying barrier cream, and later included a detailed wound care order for a stage 3 pressure ulcer documented on the left buttocks. However, the resident’s record did not contain a specific treatment order for the right gluteal wound, despite the ongoing documentation of an open lesion in that area. Interviews revealed confusion and inconsistency in wound identification and classification. The DON stated that the right gluteal wound was documented as an open lesion because she did not feel comfortable determining the wound type, and acknowledged that the physician should have been notified when the wound was first identified. The DON was unaware that the NP had documented the wound as being on the left buttocks and as a stage 3 pressure ulcer, while the RN reported that the wound had never been on the left buttocks and that she had been applying the left‑sided wound orders to the right gluteal area because there was no open area on the left. The resident reported a recurring painful area on the right buttocks and chronic stool leakage since prior anal fistula surgery. The facility’s own wound treatment policy required comprehensive assessment of wound etiology and characteristics, consistent measurement and documentation, and provider notification in the absence of treatment orders, which were not followed for this resident’s right gluteal wound. The deficiency centers on the lack of a comprehensive wound assessment for the right gluteal lesion, incomplete documentation of wound characteristics, failure to clearly determine and document the wound etiology, and failure to notify the physician and obtain appropriate treatment orders when the wound was identified and remained open. These actions and inactions resulted in a discrepancy between the documented wound location and type and the actual clinical presentation, as well as a period during which the right gluteal wound had no specific, clearly ordered treatment despite being open and painful.
Failure to Perform Hand Hygiene and Implement Enhanced Barrier Precautions During Wound Care and Transfers
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper hand hygiene during wound care and to consistently implement Enhanced Barrier Precautions (EBP) for a resident requiring such measures. The resident had diagnoses including diabetes, a non-pressure chronic ulcer of the right lower leg, and a kidney transplant, and a wound assessment documented an open lesion on the right gluteal area. The resident’s care plan and a sign posted outside the room specified that EBP, including gown and gloves, were required for high-contact care activities such as dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, catheter care, and wound care. During one observation, the DON performed hand hygiene and donned a gown before entering the resident’s room for a telehealth wound assessment. Inside the room, the DON went into the bathroom, applied gloves without performing hand hygiene, removed the resident’s brief, and removed a foam dressing from the right gluteal area that had stool on one corner. After discarding the soiled dressing, the DON removed gloves and then applied new gloves without performing hand hygiene between glove changes. When questioned, the DON stated that hand hygiene should be done when hands or gloves are visibly soiled and before and after removing or applying gloves, and acknowledged that hand hygiene had not been performed each time gloves were removed and reapplied. In a separate observation, the resident was transferred using a sit-to-stand mechanical lift while EBP requirements were not fully followed. An NA entered the room wearing a gown and gloves with the lift, and the DON applied the lift harness under the resident’s arms and cinched the waist strap, encountering the resident’s clothing, while not wearing gloves. After the transfer to bed, the DON pulled down the resident’s pants and removed the harness while touching the resident’s clothes. Following wound care by a CNP-WOC, the DON again assisted the resident by sitting the resident on the edge of the bed, applying the lift harness, and adjusting the resident’s pants and shirt while wearing a gown but no gloves. The DON stated that EBP was only needed for catheter or wound care and not for transfers, and only upon reading the posted EBP sign acknowledged that EBP was required for all high-contact resident care activities, including transfers.
Failure to Protect Resident From Verbal Abuse and Delay in Removing Alleged Perpetrator
Penalty
Summary
The deficiency involves the facility’s failure to protect a vulnerable resident from mental abuse and to respond appropriately to an allegation of abuse. The resident had severe cognitive impairment, Alzheimer’s disease, dementia, anxiety, depression, psychotic disorder, and significant functional dependence, including frequent incontinence and the need for extensive assistance with ADLs and transfers. Her care plan identified behavioral and mood issues such as wandering, yelling, combative behavior, and calling staff names, with interventions including calm approaches, emotional support, redirection, and monitoring for emotional distress and mood/behavior changes. She was identified as a vulnerable adult, with instructions to monitor for signs of emotional distress and to follow the facility’s abuse reporting policy. On the evening in question, while the resident was crying on the phone with her son and expressing a desire to leave, NA-A and NA-B entered to provide evening care using an EZ stand lift. After the resident ended the phone call, multiple staff reported that NA-A spoke to the resident in a loud, stern, and frustrated tone, telling her to stop crying and that she was acting like a two-year-old. When the resident swatted at NA-A, NA-A stated, “If you hit me, I’m going to hit you back,” and later told the resident she was “in trouble now.” Staff reported that NA-A told the resident she would be sent to a locked unit so she could not get out, and questioned who would want to care for her when she cried like a baby, and that nobody would want to keep working with her. NA-C described NA-A yelling commands such as “HOLD ON!” and “Stop crying! Where would you be if you were not here? Probably lying on the floor,” and felt NA-A was obviously upset and overwhelmed. These statements were made in the presence of the resident while she was already distressed and crying. Following this interaction, the resident exhibited crying, yelling, combativeness, resistance to care, wandering into other residents’ rooms, self-isolation, and refusal of food, fluids, and medications above her prior baseline, as documented in behavior charts, target behavior monitoring, and nursing progress notes. Staff documented that she cried most of the morning, was very restless, difficult to redirect, hit and pinched staff, called staff names, and refused care and meals. She required repeated redirection, 1:1 attention, and non-pharmacological interventions, and was ultimately sent to the ED for evaluation of combativeness and emotional distress, where she was treated for dementia with aggressive behavior and hypoglycemia related to poor intake. The report identifies that the resident’s actual response and the reasonable person concept showed serious psychosocial harm, including increased crying and combative behavior above baseline, fear/anxiety manifested as combativeness, resistance to care and social interaction, and self-isolation. The facility also failed to immediately remove the alleged perpetrator from resident care and to promptly report and investigate the allegation in accordance with its abuse policy. After NA-B and NA-C reported to LPN-A that NA-A had yelled at and threatened the resident, LPN-A acknowledged it as verbal abuse but did not initiate immediate protective measures or timely reporting. LPN-A stated she believed she had 24 hours to report because there was no injury, despite facility policy requiring reporting within two hours. NA-A remained on the unit and continued working until the end of her shift, including after staff had clearly communicated their concerns to LPN-A. TMA and NA staff described uncertainty about their authority to remove NA-A and reliance on the nurse to act, while the DON later informed LPN-A that NA-A should have been removed from the floor to prevent further danger to residents. The Immediate Jeopardy was determined to have begun when NA-A’s derogatory, intimidating, and threatening statements were made and continued while she remained on duty with access to the resident and other vulnerable residents.
Failure to Timely Assess and Treat Newly Discovered Stump Wound
Penalty
Summary
The deficiency involves the facility’s failure to provide timely treatment and care for a newly discovered wound on a resident’s above‑knee amputation stump. The resident was admitted with diagnoses including unspecified dementia with behavioral disturbances, vascular dementia, bilateral above‑knee amputations, vascular disease, reduced mobility, and severe protein‑calorie malnutrition, and had no documented ulcers or skin problems on admission or on the most recent MDS. A weekly bath audit on 3/17/26 documented only non‑tender lymph nodes on the right upper hip and did not identify any open areas. However, when the wound was later assessed, the dressing on the stump was dated 3/16/26, indicating that a wound and dressing existed at that time, even though no corresponding assessment, provider notification, or treatment orders were documented. On 3/23/26, nursing staff documented a new skin issue above the resident’s knee at the amputation site, describing a stage 4 pressure ulcer/injury with full‑thickness skin and tissue loss, exposed bone, erythema/edema, and moderate serosanguineous exudate. The wound measured 1.56 cm by 1.64 cm, with 20–29% granulation tissue and 80% slough. A progress note and skin issues assessment on that date confirmed the wound characteristics and staging, and the NP, after reviewing a picture, determined the wound to be a diabetic ulcer with peripheral vascular disease and severe protein‑calorie malnutrition as contributing factors. On that same date, the NP was notified, antibiotic therapy (doxycycline) was ordered for possible cellulitis, and specific wound care orders were initiated, with documentation on the MAR that these treatments were carried out beginning 3/23/26. Multiple interviews with nursing staff revealed that no one could identify who discovered the wound or who applied the initial dressing dated 3/16/26, and there was no documentation of a wound assessment, provider notification, or interim treatment between 3/16/26 and 3/22/26. Several RNs and LPNs who worked shifts from 3/16/26 through 3/20/26 stated they did not notice a wound on the stump and that, per their usual practice, they would have contacted the provider and initiated treatment if they had found one. One LPN recalled seeing a band‑aid with a date on the stump but could not recall the date, and another LPN stated she did not see the wound because she was not looking for one. The facility’s standing orders required staff to assess all wounds daily, change dressings every three days and as needed, treat with normal saline or non‑cytotoxic cleanser and appropriate dressings, and notify the provider the next business day when a new wound or injury was found. Despite these expectations, the wound identified by the dated dressing on 3/16/26 was not assessed, reported, or treated according to orders and facility policy until 3/23/26.
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