Woodbury Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Woodbury, Minnesota.
- Location
- 7012 Lake Road, Woodbury, Minnesota 55125
- CMS Provider Number
- 245235
- Inspections on file
- 35
- Latest survey
- December 2, 2025
- Citations (last 12 mo.)
- 37 (1 serious)
Citation history
Health deficiencies cited at Woodbury Health Care Center during CMS and state inspections, most recent first.
A resident with chronic kidney disease received an incorrect dosage of Bumex due to a transcription error, resulting in significant weight loss, critical lab values, vomiting, and hospitalization for acute kidney injury. The error occurred because a new HUC, unfamiliar with medical abbreviations, transcribed the order incorrectly, and the required second check by a nurse manager was not completed. Additional medication errors involving two other residents were also identified, highlighting failures in the facility's medication transcription and verification processes.
A resident with a history of end stage renal disease and diarrhea was not placed on contact precautions or included in infection surveillance after a physician ordered a stool sample for C. diff testing. Staff did not notify the infection preventionist, and the room displayed only Enhanced Barrier Precautions instead of contact precautions, contrary to facility policy.
The facility did not obtain food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
A resident with impaired cognition and multiple health conditions had conflicting code status documentation, with the face sheet and physician's orders indicating DNR, while the POLST form indicated both CPR and DNR. Staff interviews revealed reliance on the POLST for code status decisions, but discrepancies led to confusion and the need for clarification. Facility policy required following the physician order and POLST, but the inconsistency in documentation was not resolved at the time of the survey.
A resident with severe cognitive impairment and multiple psychiatric conditions did not receive routine care conferences as required. Facility staff and policy indicated that care conferences should occur quarterly and involve the interdisciplinary team and family, but these were not held after the social worker left. The resident's family was not included in care planning, and the expected review and update of the care plan did not occur.
A deficiency occurred when a resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in care that was not individualized or consistent with regulatory requirements.
A resident with PTSD did not have their trauma history or specific triggers adequately assessed or documented. Staff were unaware of the resident's PTSD diagnosis and potential triggers, and the care plan lacked trigger-specific interventions, despite facility policy requiring this information. The resident reported distress when staff entered without knocking or surprised her, but this was not addressed in her care plan.
A resident with a history of anxiety, depression, and adjustment disorder exhibited repeated disruptive and intimidating behaviors, causing distress among other residents. Despite care plans outlining psychosocial interventions, there was no documented follow-up or support provided to affected residents after a major behavioral outburst that required police involvement. Staff interviews confirmed that no further assessment or support was offered to those impacted by the incident.
A resident with moderate cognitive impairment and physical limitations was found unable to access their call light, which was placed out of reach despite care plan instructions and facility policy. Staff acknowledged the oversight, and interviews confirmed the resident depended on the call light for assistance.
A resident with chronic wounds and a history of MRSA did not receive care in accordance with Enhanced Barrier Precautions (EBP) and hand hygiene protocols. Staff provided incontinence care and transfers without performing hand hygiene or using required PPE such as gowns and masks, despite posted signage. Staff were unaware of the EBP requirements and no PPE cart was available, leading to non-compliance with facility policies designed to prevent infection transmission.
A diabetic resident was admitted to a facility with insulin orders but without blood sugar monitoring instructions, leading to hypoglycemia and hospitalization. Despite standing orders for glucose checks, the facility failed to implement them, and the resident was sent to dialysis without breakfast or blood sugar checks. Staff interviews revealed a lack of communication and adherence to diabetic care protocols.
A resident, requiring substantial assistance due to osteoarthritis and weakness, fell and sustained fractures after being left unsupervised during care. The care plan required two staff members for safety, but this was not followed, leading to the resident's hospitalization for pain management.
The facility failed to maintain resident dignity by labeling clothing visibly and not providing a homelike dining environment. Observations showed name labels on the outside of residents' socks for convenience, which was confirmed by staff. Additionally, meals were served on plastic trays with coverings left on, rather than being placed directly on tables. The assistant director of nursing acknowledged these practices did not align with expectations for dignity and homelike settings.
A resident with intact cognition and multiple diagnoses, including diabetes and hypertension, was found with a half-empty bottle of calcium carbonate tablets at the bedside without a comprehensive assessment for self-administration. The resident's care plan did not address self-administration, and the nurse responsible was unaware of the medication's presence. The facility's policy required an assessment before self-administration, which was not completed.
Two residents at the facility had incomplete and non-person-centered care plans, leading to deficiencies in their care. One resident, admitted with multiple medical conditions, had a care plan with several blank focus areas, while another resident's care plan was generic and lacked personalization. Both the LPN and ADON acknowledged the need for updates to reflect individualized needs, as per the facility's policy on person-centered care plans.
A resident, dependent on staff for bathing, did not consistently receive or have bathing care documented. Despite being scheduled for weekly showers, records showed only one bed bath was documented. The resident expressed dissatisfaction with the lack of bathing, and staff interviews confirmed the absence of consistent documentation. The facility's policy on ADL care was not provided, highlighting a gap in documentation practices.
The facility failed to assess and implement interventions for a proactive bowel management program for a resident with constipation issues and inadequate bed positioning for another resident. Despite concerns expressed by the residents and observations of improper care, the facility lacked comprehensive assessments and documentation of interventions. Staff interviews revealed a lack of awareness and procedural guidance, contributing to the deficiencies.
A resident with Alzheimer's dementia and severe cognitive impairment did not receive prescribed passive range of motion (PROM) exercises or wear a palm protector as recommended. Observations showed the resident's hands were contracted, and staff interviews revealed a lack of awareness about the care plan. The facility's EMR lacked documentation of PROM, and the facility policy on restorative programs was not provided.
A facility failed to clarify urology orders and comprehensively assess a resident's Foley catheter use. The resident was unaware of the catheter's rationale, and the medical record lacked documentation of baseline output and urine characteristics. Staff were unsure of the catheter's purpose, and there was no evidence of order clarification or intermittent catheterization attempts. Interviews revealed confusion over orders and a lack of policy on catheter evaluation.
A facility failed to properly clean a non-invasive ventilation machine for a resident with heart and respiratory failure, as observed by surveyors. The resident's mask showed visible residue, and staff interviews revealed inconsistent cleaning practices. The assistant director of nursing expressed concern about infection risks due to inadequate cleaning, and no cleaning policy was provided.
A facility failed to develop a comprehensive care plan for a resident with PTSD, lacking identification of triggers and interventions. Despite a trauma screening indicating symptoms, no referrals were made, and staff were unaware of the resident's triggers. The care plan and care sheets did not include necessary details, contrary to the facility's policy on person-centered care.
A facility failed to act on consultant pharmacist recommendations for a resident's PRN medications, which included prochlorperazine maleate and lorazepam, both lacking an end date. Despite CMS regulations requiring re-evaluation within 14 days, the facility delayed follow-up until over a month later. The resident had severe cognitive impairment and was on hospice, but hospice is not an exception to the rule. The facility's policies required timely follow-up and clinical rationale for extending PRN orders, which was not followed.
A resident with intact cognition and multiple diagnoses continued to receive nystatin powder for a resolved rash due to a lack of an end date on the medication order. Despite no signs of skin alterations, the medication was administered twice daily. Staff interviews revealed a lack of communication and assessment regarding the resident's skin condition. The facility's medication management policy did not guide staff on when to discontinue medications, leading to the unnecessary continuation of the antifungal treatment.
The facility failed to document resident-specific target behaviors for a resident on antipsychotic medication and did not ensure PRN psychotropic medications were limited to 14 days or had documented rationale for extension. A resident with severe cognitive impairment lacked a care plan for monitoring behaviors related to quetiapine use, while another resident on hospice had a PRN lorazepam order without an end date or justification. The facility's policy required such documentation to ensure medication necessity and effectiveness.
The facility failed to provide quarterly statements of trust fund balances for two residents who reported not receiving them, as well as for 32 other residents with managed trust accounts. Interviews revealed that the responsibility for sending statements was unclear following the resignation of the previous business office manager, and no evidence of statements being sent was found. Additionally, the facility could not provide a policy on personal funds management.
The facility failed to notify residents of trust account balances exceeding the SSI threshold, potentially affecting their medical assistance coverage. Three residents, with varying cognitive impairments, were not informed of their excessive balances, and the facility lacked a policy on managing these accounts. The human resources director and administrator acknowledged the oversight, with the billing office understaffed due to a recent resignation.
Medication Transcription Errors Lead to Resident Harm and Hospitalization
Penalty
Summary
A medication transcription error occurred when a resident with chronic kidney disease, renal insufficiency, and other comorbidities was prescribed Bumex 2 mg by mouth daily for three days. The order was incorrectly transcribed as Bumex 2 mg by mouth three times daily with no stop date, resulting in the resident receiving 36 doses over 12 days instead of the intended 3 doses. This error led to an 18.8-pound weight loss, critical laboratory abnormalities, vomiting, and ultimately hospitalization for acute kidney injury and infection. The error was not identified by staff until after the resident exhibited significant symptoms and laboratory results indicated dehydration and kidney dysfunction. The facility's process for transcribing and verifying medication orders was inadequate. The health unit coordinator (HUC) responsible for transcribing the order was new to the position and lacked a medical background, including knowledge of common medical abbreviations such as QD and TID. The nurse manager, who was supposed to perform a second check of the transcription, failed to do so, allowing the error to persist. Additionally, staff did not recognize the inappropriateness of administering a diuretic in the evening or the resident's significant weight loss, and a scheduled weekly weight was missed during the period of the error. Further review revealed two additional medication transcription errors involving another resident, where antipsychotic and bladder medications were administered at incorrect dosages due to similar transcription mistakes. In these cases, the errors were identified by the facility pharmacy and corrected, but no audits of other recently transcribed orders were conducted at that time. The cumulative failures in order transcription, verification, and monitoring led to significant harm for the affected resident and demonstrated systemic issues in medication management within the facility.
Removal Plan
- Determine the root cause for transcription/medication errors and put in place additional safeguards.
- Review and revise policy and procedures as needed.
- Educate staff on new procedures.
Failure to Implement Transmission-Based Precautions and Infection Surveillance for Suspected C. diff
Penalty
Summary
The facility failed to implement appropriate transmission-based precautions and infection surveillance for a resident who had an active order to collect a stool sample for Clostridioides difficile (C. diff). The resident had a medical history including end stage renal disease, unspecified diarrhea, and gastritis, and was under a physician's order to collect and send a stool sample for C. diff testing with each loose stool. Documentation showed that the resident had a loose stool, prompting the order, but there was no evidence in the progress notes that the resident was placed on contact precautions or that the infection preventionist was notified. The infection surveillance line list did not include the resident, and staff interviews confirmed that the infection preventionist was unaware of the resident's symptoms and pending test. Observations revealed that the resident's room displayed an Enhanced Barrier Precautions (EBP) sign, but not a contact precautions sign as required for suspected C. diff cases. Staff interviews indicated a lack of clarity and adherence to the facility's policies regarding when to implement contact precautions and notify the infection preventionist. The facility's policies directed the infection preventionist to monitor and update infection surveillance and to implement isolation precautions as needed, but these steps were not followed in this case. No specific policy on transmission-based precautions was provided during the review.
Failure to Follow Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Ensure Consistent Documentation of Resident's Resuscitation Wishes
Penalty
Summary
The facility failed to ensure that a resident's wishes regarding resuscitation were accurately and consistently documented across all areas of the medical record. For one resident with moderately impaired cognition and multiple diagnoses, including Ehlers-Danlos Syndrome and COPD, there were discrepancies in the documentation of code status. The resident's face sheet and physician's orders indicated Do Not Resuscitate (DNR), while the Physician's Order for Life Sustaining Treatment (POLST) form indicated both Cardiopulmonary Resuscitation (CPR) and DNR. Interviews with the resident confirmed her wish not to receive life-saving measures. Multiple nursing staff and the director of nursing reported that the POLST is the primary document referenced for code status in the event a resident is found unresponsive. Staff acknowledged that if the POLST contained conflicting instructions, such as both CPR and DNR, they would seek clarification from a nurse manager or compare the POLST to the face sheet in the electronic medical record. Facility policy stated that the physician order status and POLST should be followed in resuscitation situations. The presence of conflicting documentation in the resident's records created confusion among staff regarding the appropriate action to take, and the error was not corrected at the time of the survey.
Failure to Provide Routine Care Conferences and Interdisciplinary Care Plan Review
Penalty
Summary
The facility failed to provide routine care conferences for a resident with severe cognitive impairment and multiple psychiatric diagnoses, including major depressive disorder, Alzheimer's disease, unspecified psychosis, and dementia. Documentation showed that the last care conference was held on 10/7/24, with a subsequent entry on 6/24/25, indicating a significant gap in the expected quarterly schedule. The resident's family member reported that care conferences were initially held quarterly but were discontinued after the social worker left the facility, and no further conferences were offered. The family member expressed a desire to participate in care conferences and contribute to the resident's care plan. Interviews with facility staff, including an LPN manager, the director of social services, and the DON, confirmed that the expectation was to hold care conferences quarterly, annually, upon admission, with changes in condition, or upon request. The interdisciplinary team (IDT), including family, dietary, therapy, social services, nursing, and administration, was expected to be informed and participate. Facility policy also required care conferences to be conducted after admission, quarterly, for discharge planning, changes in condition, or as needed. Despite these policies and expectations, the facility did not provide the required routine care conferences for the resident, resulting in a lack of interdisciplinary review and family participation in the care planning process.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
A deficiency was identified when treatment and care were not provided in accordance with physician orders, as well as the resident's preferences and goals. The report notes a failure to ensure that care was individualized and aligned with the documented directives and wishes of the resident, as required by regulation.
Failure to Assess and Document PTSD Triggers for Resident
Penalty
Summary
The facility failed to adequately assess and document the trauma history and potential triggers for a resident diagnosed with post-traumatic stress disorder (PTSD). The resident's quarterly Minimum Data Set indicated diagnoses of anxiety, depression, and PTSD, and a trauma screening assessment noted a traumatic event and a referral for counseling. However, the assessment did not include details about the traumatic event or identify any specific triggers. The resident's care plan referenced PTSD and included general interventions such as therapy referral, chaplain visits, and consistent staffing, but did not specify any triggers or trigger-specific interventions. Progress notes from an outside provider confirmed ongoing treatment for PTSD and depression. Interviews with the resident revealed that staff often entered the room without knocking, including when the resident was undressed, and that the resident disliked being surprised or approached from behind due to PTSD. The resident was unsure if staff were aware of her PTSD or had discussed it with her. Nursing staff and nursing assistants were not aware of the resident's PTSD diagnosis or any associated triggers, and this information was not present in their task sheets. The Director of Social Services confirmed that trauma assessments should identify triggers and that this information should be included in the care plan, but was unaware of any triggers for this resident. Facility policy required identification of trauma history and triggers, with trigger-specific interventions documented in the care plan, but this was not done for the resident in question.
Failure to Provide Medically-Related Social Services After Disruptive Behavioral Incident
Penalty
Summary
Two residents with cognitive intactness and diagnoses including anxiety, depression, and adjustment disorder experienced psychosocial distress due to disruptive behaviors by one of the residents. The care plans for both residents identified psychosocial well-being issues and included interventions such as encouraging verbalization of feelings, identifying stressors, and providing behavioral health consults. Despite these interventions, the medical record lacked evidence of follow-up after a significant behavioral outburst, which included loud, disruptive, and intimidating behaviors that visibly upset other residents and led to the involvement of police and ambulance staff. Interviews with staff and residents confirmed that the disruptive behaviors caused fear and distress among other residents, and that no follow-up support or assessment was provided to those affected after the incident. The Director of Social Services was aware of the incident through reports but had not followed up with all residents involved to determine if additional support was needed. The facility's own documentation indicated that the social services department was responsible for addressing residents' emotional and psychological needs, but this was not carried out for all affected individuals following the behavioral incident.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
A deficiency occurred when staff failed to ensure that a resident who was dependent on staff for care had their call light within reach and accessible. The resident, who had diagnoses including palliative care, anxiety, depression, and chronic pain syndrome, was moderately cognitively impaired and required substantial to maximum assistance for activities such as toileting, hygiene, dressing, and bed mobility. During an observation, the resident was found lying in bed, unable to reach or locate the call light, and was heard calling for help. The call light was draped over a pillow above the resident's head, out of reach, and the resident's left hand was contracted, making it necessary for the call light to be placed on the right side. Staff present at the time acknowledged that the call light was not within reach and confirmed that it should have been accessible to the resident. Interviews with nursing assistants and an LPN confirmed that the call light was not placed appropriately and that the resident relied on it to request assistance. The nursing assistant admitted to forgetting to reposition the call light after a previous visit. The facility's policy requires that call lights be accessible to all residents, with special accommodations documented in the care plan as needed. The director of nursing stated that it is expected for all dependent residents to have their call lights within reach at all times.
Failure to Implement Enhanced Barrier Precautions and Hand Hygiene for Resident with MRSA and Chronic Wounds
Penalty
Summary
The facility failed to implement and follow Enhanced Barrier Precautions (EBP) and proper hand hygiene protocols for a resident with non-healing wounds and a history of Methicillin Resistant Staphylococcus Aureus (MRSA). The resident's care plan identified the need for EBP due to chronic wounds and MRSA, but did not specify which high-risk activities required EBP or detail the necessary precautions. Observations revealed that staff entered the resident's room without performing hand hygiene, did not use gowns or masks as required, and only donned gloves before providing incontinence care and assisting with transfers. After providing care, staff either failed to perform hand hygiene or changed gloves without cleaning their hands, and then continued to handle the resident and their environment. Signage indicating the need for EBP was posted outside the resident's room, but there was no personal protective equipment (PPE) cart available, and staff were unaware of the requirement to use EBP during personal care activities. Both nursing assistants involved in the care stated they did not know EBP was necessary for the resident and confirmed the absence of a PPE cart. They also described disposing of PPE in the resident's room and admitted to not performing hand hygiene at key points during care. The LPN assigned to the resident confirmed that EBP should be used for all personal care due to the resident's wounds and MRSA history, and the DON stated that facility policy required EBP and hand hygiene for such cases. Facility policies reviewed indicated that EBP should be used for residents with wounds or MDROs during high-contact care activities, and that hand hygiene is required before and after resident contact, between glove changes, and upon entering and exiting rooms. Despite these policies, the observed care did not comply with established protocols, resulting in a failure to reduce the risk of infection transmission for the resident and others.
Failure to Monitor Blood Glucose in Diabetic Resident
Penalty
Summary
The facility failed to accurately assess and implement interventions to prevent hypoglycemia for a diabetic resident, resulting in immediate jeopardy. The resident, who had a history of Type 2 Diabetes Mellitus with diabetic chronic kidney disease and was dependent on renal dialysis, was admitted to the facility with orders for insulin but without orders to check blood sugars. Despite standing orders requiring blood glucose monitoring for diabetic patients upon admission, the facility did not implement these orders or request additional orders to monitor the resident's blood glucose levels. The resident's hospital discharge summary indicated a history of hypoglycemia episodes after starting hemodialysis, and the use of a continuous glucose monitoring system was recommended. However, the facility's progress notes and medication administration records lacked any blood sugar readings from the time of admission until the resident was found unresponsive at a dialysis clinic. The resident was not provided breakfast before being sent to dialysis, and the nurse responsible for the resident was unaware of the resident's diabetic status. Interviews with facility staff revealed a lack of communication and adherence to protocols for diabetic care. The nurse manager and director of nursing stated that blood sugar checks and vital signs should have been conducted before sending the resident to dialysis. The agency nurse assigned to the resident on the morning of the incident did not perform these checks or provide breakfast, citing a lack of information about the resident's condition. The failure to follow standing orders and ensure proper monitoring and nutrition for the diabetic resident led to the resident's hospitalization for hypoglycemia.
Removal Plan
- The facility ensured appropriate blood glucose monitoring was in place.
- Education was provided to all nursing staff on standing orders and when to implement standing orders, specifically to diabetic care.
- Reviewed and educated nursing staff regarding the importance of nutrition for vulnerable residents including those with diabetes or on dialysis.
- Re-educated staff who provide diabetic care to the dialysis residents on these policies and procedures.
- Orientation training package to be provided to all agency staff with competencies test.
Failure to Implement Care Plan Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to implement care plan interventions for a resident, resulting in a fall and subsequent injury. The resident, who was cognitively intact and required substantial assistance with daily activities, was left unsupervised during care, contrary to the care plan that mandated the presence of two staff members. This lapse occurred when a nursing assistant left the resident on her side to fetch barrier cream, leading to the resident falling from the bed and sustaining fractures to her left tibia and fibula. The resident's care plan highlighted her need for assistance due to conditions such as osteoarthritis and generalized weakness. Despite this, the care plan was not adhered to, as one of the nursing assistants left the room, leaving the resident vulnerable. The resident was found on the floor, complaining of pain, and was later hospitalized for pain management and evaluation, confirming the fractures. Interviews with the involved staff revealed that they were aware of the care plan requirements but failed to follow them. The nursing assistant who left the resident alone acknowledged the mistake, and the director of nursing confirmed that the care plan was not followed, which directly led to the resident's fall and injury.
Removal Plan
- Education to the entire staff on care in pairs for residents who received cares in bed and the importance of following the care plan.
- Coaching provided to NA-A and NA-B on the incident and the importance of staying for resident safety.
- Observation of cares to ensure compliance with the care plan.
- Document review of all nursing staff education and coaching provided.
- Nursing staff education on Two Assist and Why it Matters, including topics such as why some NAR sheet tasks say A-2, who decides assistance levels, why assistance levels matter, and what to do if the resident tells the 2nd aide to leave.
Deficiencies in Resident Dignity and Dining Environment
Penalty
Summary
The facility failed to uphold the dignity of residents by improperly labeling clothing and not providing a homelike dining environment. Observations revealed that name labels were placed on the outside of residents' clothing, specifically on socks, making them visible from a distance. This practice was confirmed by the laundry aide and supervisor, who stated it was done for convenience. The assistant director of nursing acknowledged that labeling should be done on the inside of clothing to maintain dignity, and a family member expressed that the labeling would not align with the resident's preferences. In the dining room, the facility did not ensure a homelike environment during meal services. Meals were served on hard plastic trays with disposable coverings left on the trays, rather than being removed and placed directly on the table. This practice was observed across multiple instances, with staff confirming that meals were typically served this way for convenience. The assistant director of nursing stated that meals should be removed from trays to create a more homelike setting, but this was not the practice observed. The report highlights deficiencies in maintaining resident dignity and providing a homelike environment, as evidenced by the improper labeling of clothing and the manner in which meals were served. Despite requests, the facility did not provide policies regarding clothing labeling or dining room practices related to dignity, indicating a lack of formal guidance on these issues.
Failure to Assess Self-Administration of Medication
Penalty
Summary
The facility failed to ensure a comprehensive assessment for self-administration of medications for a resident with medication found at the bedside. The resident, who had intact cognition and was diagnosed with diabetes, a stroke, and hypertension, was dependent on staff for bed mobility, transferring, and toileting. Despite this, the resident had a half-empty bottle of chewable calcium carbonate tablets on the bedside table, which had been there for about a month. The resident stated that the medication was used for heartburn and was taken as needed, although the exact frequency was uncertain. The care plan did not address self-administration of medication, and the Medication Administration Record showed no documented doses of calcium carbonate. During observations and interviews, it was revealed that the registered nurse responsible for the resident's care was unaware of the medication at the bedside and had not conducted an assessment for self-administration. The assistant director of nursing confirmed that no self-administration assessment was found in the resident's medical record. The facility's policy required a medication self-administration assessment to be completed before allowing residents to self-administer medications, but this was not done in this case.
Deficiencies in Person-Centered Care Planning
Penalty
Summary
The facility failed to ensure a comprehensive, person-centered care plan was developed and readily available for two residents, R61 and R199, which led to deficiencies in their care. R61, who was admitted to the care center from an acute care hospital, had multiple medical conditions including fractures, neurogenic bladder, and multiple sclerosis. Despite these conditions, R61's care plan was incomplete, with several focus areas left blank or not completed, such as ADL self-care performance deficit, cognitive loss, and catheter use. The assistant director of nursing (ADON) confirmed that R61's care plan was not updated to reflect individualized needs, which was necessary for guiding staff in providing appropriate care. Similarly, R199's care plan was found to be generic and not person-centered. R199, who was admitted with intact cognition, had a care plan that included vague and non-specific information, lacking personalization such as the resident's name and specific goals. The licensed practical nurse (LPN) and ADON both acknowledged that R199's care plan did not reflect the resident's individual needs and required updating to be more patient-specific. The facility's policy on person-centered care plans, revised in December 2022, emphasizes the importance of individualized care plans that avoid vague or non-specific information. However, the care plans for both R61 and R199 did not adhere to this policy, resulting in deficiencies in the continuity and quality of care provided to these residents.
Failure to Provide and Document Bathing Care for Resident
Penalty
Summary
The facility failed to consistently provide or record bathing care for a resident, identified as R61, who was dependent on staff assistance for bathing. R61, who had intact cognition and was admitted to the care center from an acute care hospital, required substantial assistance with showering and bathing. Despite this, the care plan for R61 lacked specific information on bathing frequency and did not include a goal statement. Observations and interviews revealed that R61 had not received a shower or a thorough bed bath since admission, except for a single recorded bed bath. The resident expressed dissatisfaction with the lack of bathing and had communicated this to the staff. Interviews with nursing staff, including a nursing assistant and a registered nurse, confirmed that R61 was scheduled for a Monday evening shower, but there was no consistent documentation of bathing being offered, provided, or refused. The assistant director of nursing acknowledged the lack of documentation and stated that the expected practice was to record bathing activities weekly or provide a rationale for any omissions. The facility's policy on ADL care, including bathing, was requested but not provided, indicating a gap in policy adherence and documentation practices.
Deficiencies in Bowel Management and Bed Positioning
Penalty
Summary
The facility failed to comprehensively assess and develop interventions for a proactive bowel management program for a resident, identified as R61. Despite being dependent on staff for toilet hygiene and transfers, and consuming multiple medications including opioids, the resident's care plan lacked specific interventions for bowel continence or potential constipation risk. The resident expressed concerns about constipation and was unsure of the bowel management program in place. The medical record lacked evidence of a comprehensive assessment for proactive bowel management needs, despite the resident being hospitalized with constipation issues and having periods of medication refusals. Additionally, the facility failed to assess and implement interventions for proper bed positioning for another resident, identified as R26. The resident, who was non-ambulatory and required substantial assistance with activities of daily living, was observed slouched and leaning to the side in bed, with no comprehensive assessment or interventions documented in the medical record. Despite staff attempts to use a pillow for support, the resident expressed discomfort, and no alternative solutions were documented or implemented. Interviews with staff revealed a lack of awareness and documentation regarding the residents' needs and preferences. The assistant director of nursing acknowledged the absence of a comprehensive assessment for R26's positioning needs and agreed that the resident's preferences should be assessed to ensure safe positioning. The facility's policy on positioning was requested but not provided, indicating a potential gap in procedural guidance.
Failure to Provide ROM Care and Palm Protector
Penalty
Summary
The facility failed to provide appropriate care for a resident, identified as R38, to maintain and/or improve range of motion (ROM) and prevent contractures. R38, who was on hospice with Alzheimer's dementia and had severe cognitive impairment, required substantial assistance with daily activities. Therapy recommendations and discharge instructions indicated that R38 was to wear a palm protector at all times and receive gentle passive range of motion (PROM) exercises. However, the electronic medical record (EMR) for June 2024 showed multiple instances where the palm protector was not applied, and there was no documentation of PROM being performed in the past 30 days. Observations over several days confirmed that R38 was not wearing the palm protector, and her hands were contracted into fists. Interviews with staff revealed a lack of awareness and execution of the care plan, with nursing assistants unaware of the need for a palm protector or PROM. The director of therapy and occupational therapist confirmed that the care instructions were not being followed by the nursing staff. The assistant director of nursing expected staff to adhere to the care plan, but the facility's policy on functional and restorative programs was not provided upon request.
Deficiency in Catheter Management and Order Clarification
Penalty
Summary
The facility failed to ensure proper management and clarification of urology orders for a resident, R20, who was using a Foley catheter. R20's quarterly Minimum Data Set (MDS) indicated that she did not use an indwelling catheter, yet she was observed with a urinary drainage bag attached to her leg. R20 was unaware of the rationale for the catheter's use, which was placed during a urology appointment. The urology referral form included orders for both a Foley catheter and intermittent catheterization, but there was no evidence that these orders were clarified or that intermittent catheterization was attempted. The medical record for R20 lacked comprehensive assessment and documentation regarding the catheter, including baseline output, urine characteristics, and medical rationale for its use. The care plan did not provide specific details about the catheter, such as its size or expected urine characteristics. Nursing staff, including a nursing assistant and a licensed practical nurse, were unaware of the baseline output and relied on reporting changes without having clear guidelines or assessments documented. Interviews with the director of nursing and assistant director of nursing revealed that there was confusion regarding the urology orders, which were not clarified or acted upon. The facility did not have a policy on urology order and catheter evaluation, and there was no recorded assessment to determine baseline characteristics for the catheter. The lack of comprehensive assessment and clarification of orders led to a deficiency in ensuring appropriate catheter care and continuity of care for R20.
Inadequate Cleaning of Non-Invasive Ventilation Machine
Penalty
Summary
The facility failed to ensure proper cleaning of a non-invasive ventilation machine for a resident, leading to potential risks of respiratory infection. The ResMed AirFit F20 Full Face Mask and AirCurve 10 User Guides provided specific cleaning instructions, which were not followed. The resident, who had intact cognition and was diagnosed with heart failure, respiratory failure, and debility, was dependent on staff for various activities and used a non-invasive ventilation machine. Observations revealed a white and yellow substance inside the mask, indicating it had not been cleaned as required. The Treatment/Medication Administration Report (TAR/MAR) documented daily mask cleaning but lacked documentation for cleaning the machine's tubing, water tub, headgear, or exterior. Interviews with nursing staff revealed inconsistencies in cleaning practices. A registered nurse (RN) and a licensed practical nurse (LPN) both acknowledged the machine's unclean state and admitted to not performing thorough cleaning. The assistant director of nursing/infection preventionist (ADON) confirmed that the mask should be washed daily and expressed concern about the risk of respiratory infection due to inadequate cleaning. Despite requests, the facility did not provide a policy regarding the cleaning of non-invasive ventilation machines, highlighting a gap in procedural adherence and documentation.
Deficiency in Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to comprehensively assess and develop a person-centered care plan for a resident with a history of trauma and PTSD. The resident's quarterly Minimum Data Set (MDS) assessment indicated diagnoses of PTSD, adjustment disorder, borderline personality disorder, and depression, with intact cognition. A trauma screening identified the resident's experience of a traumatic event and associated symptoms, but no referrals were made as the resident declined them. The care plan lacked identification of individualized triggers, interventions, measurable objectives, and timeframes for addressing the resident's PTSD. Additionally, the nursing assistant care sheet did not include any information on potential triggers for the resident. Interviews with staff, including nursing assistants, a licensed practical nurse, a social worker, and the assistant director of nursing, revealed a lack of awareness and documentation regarding the resident's triggers and trauma history. Staff relied on care sheets and care plans for information, which did not contain necessary details about the resident's PTSD or potential triggers. The facility's policy on person-centered care plans emphasized the importance of identifying and mitigating triggers to prevent retraumatization, but this was not reflected in the resident's care plan.
Failure to Act on Pharmacist Recommendations for PRN Medications
Penalty
Summary
The facility failed to ensure that consultant pharmacist recommendations were acted upon in a timely manner and that an appropriate rationale was recorded for not implementing these recommendations for a resident reviewed for unnecessary medication use. The resident, who was admitted to the facility with severe cognitive impairment and several medical diagnoses including dementia with agitation, generalized anxiety, and major depressive disorder, was prescribed prochlorperazine maleate and lorazepam without an end date. The consultant pharmacist noted that these PRN psychotropic medications must be re-evaluated within 14 days of initiation according to CMS regulations, and hospice is not an exception to this rule. However, the facility did not follow up on these recommendations until over a month later, during the survey, when the physician discontinued the medication. The consultant pharmacist's monthly medication regimen review indicated that follow-up was expected within 30 days, but the facility did not comply with this timeline. Interviews with the consultant pharmacist and the assistant director of nursing revealed that the facility's process involved sending the medication regimen reviews to the director of nursing, who would then ensure they reached the correct floor for the resident. The nurse manager was responsible for following up on recommendations requiring nurse follow-up, while those requiring physician follow-up were left for the rounding physician. The facility's policies on medication management and mood and behavior programs also stipulated the 14-day limit for PRN orders of psychotropic and antipsychotic medications, requiring a clinical rationale for extensions, which was not adhered to in this case.
Failure to Discontinue Unnecessary Antifungal Medication
Penalty
Summary
The facility failed to ensure the appropriateness of a scheduled antifungal medication for a resident, leading to the administration of an unnecessary drug. The resident, who had intact cognition and was diagnosed with heart failure, respiratory failure, and debility, was receiving nystatin powder for a rash in the groin folds. The medication order, which began on March 26, 2024, did not have an end date, and the resident continued to receive the medication twice daily despite the absence of any skin alterations or rashes as documented in body audits and progress notes from May 2, 2024, to June 27, 2024. Interviews with staff revealed that the nursing assistant and trained medication aide did not observe any redness or rash, and the licensed practical nurse was unaware of any current skin issues, indicating a lack of communication and assessment regarding the resident's skin condition. The assistant director of nursing and infection preventionist acknowledged that nursing staff should have been assessing the resident's skin daily when applying the nystatin powder and updating the provider if the skin was clear of a rash. The facility's medication management policy did not specify when staff should notify a provider to discontinue a medication when the indication was no longer present. The doctor of medicine confirmed that the nystatin powder should not have been continued without an active fungal infection, highlighting a deficiency in medication management and communication within the facility.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to adequately care plan and document resident-specific target behaviors for a resident prescribed scheduled antipsychotic medication. The resident, who had severe cognitive impairment and was dependent on staff for activities of daily living, was prescribed quetiapine fumarate for Alzheimer's dementia with agitation. However, the care plan lacked specific target behaviors related to the use of this medication, and the electronic medical record did not document the behaviors staff should monitor to ensure the medication's effectiveness and necessity. Interviews with the consultant pharmacist and the assistant director of nursing confirmed the expectation that such target behaviors should be documented to track the medication's effectiveness. Additionally, the facility did not ensure that PRN psychotropic medications were limited to 14 days of use or that the practitioner documented a specific order duration and rationale for extending the PRN psychotropic order. A resident with moderately impaired cognition and receiving hospice services had an order for PRN lorazepam without an end date. The medication administration record indicated the use of lorazepam for possible seizure symptoms, but there was no documented rationale or duration for extending the PRN order. The assistant director of nursing acknowledged the issue and noted ongoing problems with hospice providers ordering psychotropic medications without appropriate documentation. The facility's policy on mood and behavior indicated that PRN orders for psychotropic medications should be limited to 14 days unless the attending physician or prescribing practitioner documented their rationale for extending the order and specified a duration. The lack of documentation and adherence to this policy resulted in deficiencies related to unnecessary medication use and inadequate care planning for residents receiving psychotropic medications.
Failure to Provide Quarterly Trust Fund Statements
Penalty
Summary
The facility failed to provide quarterly statements of residents' trust fund balances for two residents who reported not receiving them, as well as for an additional 32 residents with trust accounts managed by the care center. Resident 13, with intact cognition and no delusional thinking, expressed uncertainty about the balance in his account and noted he had not received a statement for many months. Similarly, Resident 75, also with intact cognition, stated he had not received any statements regarding his account balance. A trial balance print-out confirmed that both residents had positive balances, but there was no evidence in their medical records that statements had been mailed or provided within the last quarter. During the recertification survey, the facility was unable to provide evidence of statements being sent on a quarterly basis. Interviews with the human resources director and the administrator revealed that the responsibility for sending statements was unclear following the resignation of the previous business office manager. The administrator acknowledged that statements had likely not been sent since the resignation and that there was no current staff assigned to this task. Additionally, the facility was unable to provide a policy on personal funds management when requested.
Failure to Notify Residents of Excessive Trust Account Balances
Penalty
Summary
The facility failed to notify residents of their trust account balances exceeding the state-required Supplemental Security Income (SSI) threshold of $3,000, which could potentially impact their medical assistance coverage. This deficiency was identified for three residents, each with varying levels of cognitive impairment, who were not informed when their account balances approached or exceeded the threshold. One resident, who managed her own finances, was unaware of the excessive balance, while another resident's family member had to inquire about the balance themselves. A third resident's financial power-of-attorney was also not informed of the high balance, which was significantly higher than previously reported. The facility's human resources director acknowledged that they did not track excessive balances and that the responsibility lay with the billing office, which had been understaffed due to a recent resignation. The administrator confirmed the lack of evidence showing that residents or their representatives were notified of the excessive balances and recognized the importance of such notifications to prevent the state from reclaiming the funds. Despite a request, the facility did not provide a policy on personal trust account management, indicating a lack of formal procedures to address this issue.
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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