Woodlyn Heights Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Inver Grove Heights, Minnesota.
- Location
- 2060 Upper 55th Street East, Inver Grove Heights, Minnesota 55077
- CMS Provider Number
- 245320
- Inspections on file
- 37
- Latest survey
- December 31, 2025
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Woodlyn Heights Healthcare Center during CMS and state inspections, most recent first.
The facility failed to serve meals at a warm and palatable temperature, impacting residents' quality of life and nutritional intake. Observations showed that meal trays were not maintained at the expected temperature, with pancakes and oatmeal served cooler than required. Residents expressed dissatisfaction with the food temperature and quality, and the facility's In-Room Dining policy was not followed.
The facility failed to monitor and remove expired food from storage, risking foodborne illness. During a tour, the DD found opened bags of sliced ham and turkey without proper date marking, and an expired bag of turkey. The DD admitted to not expecting staff to date quickly used deli meat and was unable to explain the process for ensuring thawed food was safe. The facility's policy required date marking on high-risk foods.
The facility failed to consistently implement enhanced barrier precautions (EBP) for three residents, leading to potential infection risks. A staff member assisted a resident with an indwelling catheter without wearing a gown, despite EBP signage. Another resident with a PICC line for MRSA treatment was attended by a nurse who did not follow EBP guidelines. Additionally, staff did not use gowns or gloves for a resident with a pressure ulcer, misunderstanding the necessity of EBP. These lapses highlight a failure to adhere to CDC guidelines for infection control.
A facility failed to manage constipation for a resident on narcotics, inadequately addressed a resident's Darier's disease by not providing necessary supplies and consistent care, and neglected to manage a PICC line for a resident on IV antibiotics, lacking orders and documentation for dressing changes and infection monitoring.
A resident's POLST indicating DNR status conflicted with the EMR showing 'Full Code' in a facility. The resident confirmed their DNR preference, but staff acknowledged the inconsistency, which posed a risk of unwanted resuscitation. The facility's policy required matching documentation, but lacked guidance on ensuring consistency.
A resident was observed receiving peri-care with the window blinds open, exposing them to the outside parking lot. The staff member providing care did not close the blinds, which was later acknowledged as an oversight. The resident expressed a preference for the blinds to be closed during care. The DON confirmed that staff are trained to ensure privacy, but recent audits on privacy had not been conducted.
A resident's motorized wheelchair was found to be dirty, with dust, food particles, and stains, indicating a failure to maintain a clean and safe environment. Staff interviews revealed confusion over cleaning responsibilities, and the resident expressed dissatisfaction with the unclean state of the wheelchair. The facility lacked a policy on wheelchair cleaning, and the DON acknowledged the potential infection control and dignity issues.
A resident with multiple medical conditions, including diabetes, did not receive proper nail care from staff, despite being dependent on them for personal care. Observations showed the resident's nails were long and dirty, and staff failed to trim them despite requests. The facility's protocol required weekly nail trimming, especially for diabetic residents, but this was not adhered to.
The facility failed to reassess and document the participation of two residents in their ROM programs. One resident received ROM exercises only four times in 28 days, with refusals and lack of documentation noted. Another resident refused exercises 12 times in 30 days, with similar documentation issues. Staff were often too busy to perform exercises, and refusals were not communicated to the nurse manager. The facility lacked a policy on ROM, contributing to the deficiency.
A resident with intact cognition and multiple medical conditions attempted to order alcohol via a mobile delivery service, but the facility failed to assess and develop interventions to ensure safety. Staff were unaware of the behavior, and the care plan lacked necessary monitoring or interventions. The facility's policy on alcohol consumption was not provided.
A resident experienced significant weight gain in less than 10 months, but the facility failed to assess and implement interventions for weight management. Despite the resident's desire to lose weight and reports of unhealthy eating habits, the care plan and EMR lacked recommendations or education. Staff interviews revealed a lack of awareness and communication regarding the resident's weight management needs.
A facility failed to attempt a gradual dose reduction (GDR) or document a clinical rationale for not doing so for a resident on psychotropic medications. The resident, with anxiety and depression, was prescribed aripiprazole and duloxetine. Despite the pharmacist's recommendation to switch to a less stimulating antidepressant, the prescriber declined the GDR, citing the resident's refusal and ongoing psychiatric care. The director of nursing confirmed no GDR was attempted since admission.
The facility did not ensure adequate surety bond coverage for resident personal fund accounts, affecting 20 residents with positive balances totaling $27,953.42. The existing bond covered only up to $25,000, as acknowledged by the administrator, who noted that the corporate office managed the bond. No updated bond evidence was provided, despite the facility's policy requiring sufficient coverage.
The facility lacked a qualified therapeutic recreation director (TRD) to oversee the activities program, as the current TRD had no prior healthcare recreation experience and had not completed the required certification. A resident expressed dissatisfaction with the lack of weekend activities, leading to boredom. The TRD had not been recording residents' attendance at activities, and the facility's job description did not specify the need for state-approved certification, as required.
The facility did not accurately post nurse staffing information, failing to display the total number and actual hours worked by LPNs separately. Instead, LPN hours were incorrectly included in RN staffing hours due to a computer program error. The staffing coordinator confirmed the issue, and no policy on posting nurse staffing information was provided.
The facility failed to reconcile narcotic and controlled substances on two medication carts as per policy, with numerous unsigned spaces on count records indicating incomplete shift counts. This affected six residents with active orders for controlled substances, raising concerns about medication security amid a possible drug diversion incident.
A resident with multiple diagnoses, including COPD and bronchiectasis, was admitted to a facility with orders for respiratory chest physiotherapy, which was not provided. The resident also received oxygen therapy without a physician's order. Interviews and records indicated a lack of consistent treatment, contributing to the resident's death from severe sepsis and pneumonia.
The facility failed to maintain a homelike environment for two residents due to another resident playing loud music, which disturbed their ability to hear their own music or television. Despite the facility's aim to manage noise levels, the DON was unaware of any complaints, and no policy for a homelike environment was provided.
A resident with complex medical needs, including dialysis and respiratory concerns, did not have a comprehensive care plan addressing these issues. Interviews with staff revealed a lack of coordination in care planning, and the facility's policy on person-centered care was not followed, leading to significant omissions in the resident's care plan.
A resident with multiple health issues, including a gastrostomy-jejunostomy, was not properly monitored for hydration status by the facility staff, leading to severe dehydration and hospitalization. The facility's staff, including the DON and dietitian, failed to communicate and assess the resident's hydration needs, and no policy on hydration assessment was provided.
A resident with end-stage renal disease and dependence on dialysis did not receive the required pre-and-post dialysis assessments at a facility. Despite orders for regular monitoring, only three assessments were completed. Interviews with staff revealed a lack of consistent monitoring and absence of a formal policy, contributing to the deficiency.
A resident with a complex medical history, including sepsis and COPD, required pre-and-post dialysis assessments, which were not consistently documented by the facility. Vital signs were inaccurately recorded, and staff interviews revealed a lack of awareness regarding the resident's respiratory status and condition. This deficiency highlights lapses in documentation and monitoring of the resident's health needs.
The facility failed to ensure a neutral and fair arbitration process by not allowing residents or their representatives to agree on the selection of a neutral arbitrator and a convenient venue. Interviews revealed that residents were unaware of the implications of signing the arbitration agreement, and staff acknowledged the importance of neutrality but had no input or training on the agreement's contents.
The facility failed to disinfect community use glucometers between patient use and did not keep a wound vac machine off the floor, posing significant infection control issues. Staff acknowledged the importance of these practices but did not adhere to them, contrary to the facility's policies and guidelines.
The facility failed to assess and supervise two residents for self-administration of medications. One resident was self-administering creams without a SAM assessment, while another resident with cognitive impairment was found self-administering oral medications and using a nebulizer unsupervised, despite being deemed inappropriate for SAM.
The facility failed to ensure Level II PASARRs were conducted, documented, and retained for two residents with significant mental health diagnoses. Despite initial screenings indicating the need for further evaluation, the facility did not follow up with the lead agency, and the medical records clerk admitted to giving up on the process. The administrator confirmed the expectation for staff to complete PASARRs but did not ensure this was done.
The facility failed to implement proper infection control techniques during wound care for two residents and did not comprehensively assess, monitor, or provide necessary care for a resident with an intrathecal baclofen pump. Staff used uncleaned medical equipment and surfaces, and were unaware of the baclofen pump's existence and required monitoring.
A resident with moderate cognitive impairment and multiple diagnoses was not assisted with her bilateral hearing aids, despite care plans indicating their necessity. Staff were unaware of the hearing aids' location and had not been helping the resident with them, leading to potential communication and isolation issues.
The facility failed to ensure appropriate administration of oxygen and CPAP therapy for a resident with COPD and obstructive sleep apnea. The resident received oxygen at a higher rate than prescribed without proper documentation or notification to the NP. Additionally, the facility did not follow up on the resident's need for a new CPAP machine, despite recommendations from the hospital and the resident's request for information.
A resident with severe cognitive impairment and on psychotropic medications did not receive appropriate side effect monitoring, orthostatic blood pressure checks, or non-pharmacological interventions. The care plan and MAR lacked documentation of these essential monitoring activities, as confirmed by the nurse manager and director of nursing.
A resident did not receive prescribed medications for hypertension and high cholesterol for 30 days. The facility's medical orders and Medication Administration Record lacked documentation of these medications, and interviews confirmed the oversight. The facility's policy on medication management was requested but not provided.
A resident with heart failure, diabetes, and depression required dental extractions due to pain and fractured teeth. Despite a recommendation from a dentist, the facility failed to schedule an appointment with an oral surgeon, leaving the resident in pain and with difficulty eating. Interviews revealed a lapse in the process for setting up out-of-facility appointments.
The facility failed to maintain accurate medical records and ensure proper monitoring for two residents, leading to discrepancies in medication lists and lack of monitoring for an intrathecal baclofen pump. The nurse manager and director of nursing confirmed these issues, highlighting deficiencies in medication management and record-keeping practices.
The facility failed to ensure that binding arbitration agreements were clearly communicated and understood by two residents before signing. Both residents, despite having intact cognition, could not recall being informed that signing the agreement was not a condition of admission or having the agreement explained in a manner they understood. The social worker and administrator confirmed that the arbitration paperwork was provided by corporate and that they had limited roles in its explanation.
The facility failed to post nurse staffing information on the weekend and in a timely manner at the start of the shift. The displayed information was outdated, and no postings were available for several days. The staffing coordinator admitted to errors in posting dates, and the director of nursing and administrator emphasized the importance of accurate postings. A facility policy for staff posting was not provided.
The facility failed to accurately record and account for thirty morphine tablets ordered for a resident, resulting in the medication being unavailable when needed. Staff interviews revealed a lack of proper procedures for ensuring the medication was received and logged, and the facility's policy did not provide clear guidance on actions to take if medication was not received.
Failure to Serve Meals at Appropriate Temperature
Penalty
Summary
The facility failed to ensure that meals were served at a warm and palatable temperature, affecting the quality of life and nutritional intake for residents. Observations revealed that meal trays, including hot cereal and pancakes, were not maintained at the expected temperature of approximately 155 to 165 degrees Fahrenheit. Instead, the pancakes were measured at 108 degrees Fahrenheit, and the oatmeal at 119 degrees Fahrenheit. The dietary staff, including Cook-A, acknowledged the difficulty in keeping the food warm due to the lack of assistance from nursing assistants, who were occupied with resident care tasks. Interviews with residents revealed dissatisfaction with the temperature and quality of the food served. One resident reported not eating breakfast anymore because it was always served cold, while another expressed reluctance to ask staff to reheat meals due to perceived annoyance from the staff. Another resident mentioned that although meals served in the dining room were better, room-trays were often served cooler, and staff would only reheat food upon request. The facility's In-Room Dining policy, which mandates that hot food must be served hot, was not adhered to, contributing to the deficiency.
Failure to Monitor and Remove Expired Food
Penalty
Summary
The facility failed to ensure proper monitoring and timely removal of food stored in refrigerators and freezers, which could lead to foodborne illness. During an initial tour with the dietary director (DD), it was observed that the walk-in cooler contained two opened plastic bags of sliced ham dated nearly a month prior, two opened undated bags of sliced turkey, and an unopened bag of sliced turkey with an expiration date that had passed. The DD admitted that the deli meat was used quickly, so staff were not expected to date it, and was unable to explain the process for ensuring thawed food was not kept past its safe consumption date. In a follow-up interview, the DD acknowledged that deli meat should be discarded after seven days of opening to prevent illness. The facility's Food Storage policy required date marking on high-risk foods to indicate when they should be consumed, sold, or discarded.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure staff consistently implemented enhanced barrier precautions (EBP) in accordance with CDC guidelines to reduce the risk of infection spread among residents. This deficiency was observed in three residents, each residing on different wings of the care center. For one resident, identified as R4, a staff member was observed providing peri-care without wearing a gown, despite the presence of signage indicating the need for EBP due to the resident's use of an indwelling catheter. The staff member admitted to not using the gown due to being in a hurry, although they were aware of the EBP requirements. Another resident, R28, who had a PICC line and was receiving IV antibiotic therapy for MRSA, also experienced a lapse in EBP. A registered nurse entered the resident's room without wearing a gown and only put on gloves after entering, failing to adhere to the EBP guidelines. The nurse acknowledged the mistake and recognized the potential risk of infection spread due to not following the proper precautions. For resident R12, who had an unstageable pressure ulcer, staff were observed not wearing gowns or gloves while assisting with transfers, despite the presence of EBP signage on the door. One nursing assistant believed the signage was inaccurate, while another did not think a gown was necessary unless performing wound care. The director of nursing confirmed that staff were expected to follow the EBP signs and utilize additional PPE during personal care activities.
Deficiencies in Bowel Management, Skin Condition Care, and PICC Line Management
Penalty
Summary
The facility failed to adequately assess and manage constipation for a resident with moderate cognitive impairment who was on multiple medications, including narcotics. Despite the resident expressing feelings of constipation and a change in bowel movement patterns, the care plan lacked comprehensive interventions beyond medication administration. The facility's documentation did not reflect any evaluation or intervention to address the resident's constipation, and the last continence evaluation was completed two years prior. Another deficiency involved the inadequate management of a resident's non-pressure skin condition, Darier's disease. The resident's care plan did not include specific interventions for this condition, and there were inconsistencies in wound care and shower schedules. The resident reported sitting in dirty bandages and not receiving the necessary supplies, such as Aquaphor and a mesh vest, to manage her skin condition effectively. The facility's documentation lacked comprehensive assessments or reassessments of the resident's wound care needs and preferences. The facility also failed to manage a PICC line for a resident receiving IV antibiotic therapy. There were no orders or documentation regarding the changing of the PICC line dressing or monitoring the insertion site for infection. The dressing was not changed since insertion, and the nurse verified the lack of orders and documentation. The facility's policy on PICC line care was requested but not provided, indicating a lack of adherence to professional standards of care.
Discrepancy in Resident's Code Status Documentation
Penalty
Summary
The facility failed to ensure that a resident's Physician Orders for Life Sustaining Treatment (POLST) matched the code status information in the electronic medical record (EMR). The resident, identified as R112, had a POLST indicating a Do Not Attempt Resuscitation (DNR) status, which was signed by both the resident and a nurse practitioner. However, the EMR displayed a conflicting 'Full Code' status. This discrepancy was discovered during a review of the resident's medical records and interviews with staff, including a registered nurse (RN) and the director of nursing (DON). The resident, R112, had a medical history that included suicidal ideation, opioid use, sleep apnea, diabetes mellitus, and acute kidney failure. During an interview, R112 confirmed their wish for a DNR status, as outlined in the POLST. The RN responsible for R112's care acknowledged the conflict between the EMR and the POLST and expressed concern about the risk of performing unwanted resuscitation. The DON and a registered nurse unit manager confirmed the expectation that the EMR and POLST should match to ensure resident wishes are honored. The facility's policy required a physician order for either DNR or Full Code in all medical records, but it lacked guidance on ensuring consistency between the EMR and POLST.
Failure to Ensure Privacy During Personal Care
Penalty
Summary
The facility failed to maintain privacy during the provision of personal care for a resident, identified as R4, who was observed receiving peri-care with the window blinds open to the outside parking lot. The incident occurred in the early morning when a staff member, dressed in dark-blue scrubs, was assisting R4, whose legs and peri-area were exposed and visible from the sidewalk. The staff member, identified as NA-B, was observed wiping R4's peri-area without closing the blinds, which allowed visibility from outside. Upon being alerted by a surveyor, NA-B acknowledged the oversight and closed the blinds. R4, who had intact cognition and no delusional thinking, later confirmed that staff did not always close the blinds during care and expressed a preference for them to be closed. The Director of Nursing (DON) stated that staff receive training on ensuring privacy during care, which includes closing blinds and doors, but acknowledged that recent audits on privacy had not been conducted. The facility was unable to provide a policy on privacy with care when requested.
Failure to Maintain Cleanliness of Resident's Wheelchair
Penalty
Summary
The facility failed to maintain a clean and safe environment for a resident, identified as R39, who was observed using a motorized wheelchair that was visibly dirty. The wheelchair had dust, food particles, and stains on various parts, including the joystick controller, armrests, foot pedal, and frame. Despite the resident's cognitive intactness and independence in using the wheelchair, the lack of cleanliness was evident during multiple observations over several days. Interviews with nursing assistants and housekeeping staff revealed confusion and inconsistency regarding the responsibility for cleaning motorized wheelchairs, with some staff believing it was the responsibility of housekeeping and others thinking it was the nursing assistants' duty. The resident expressed dissatisfaction with the state of her wheelchair, highlighting that it remained unclean despite her frequent outings. The registered nurse/nurse manager acknowledged the issue, noting the potential for disease or infections due to the unclean condition of the wheelchair. The director of nursing emphasized the importance of maintaining clean wheelchairs to prevent infection and uphold the resident's dignity. However, the facility was unable to provide a policy on wheelchair cleaning, indicating a lack of established procedures for ensuring the cleanliness of residents' mobility aids.
Failure to Provide Adequate Nail Care for Dependent Resident
Penalty
Summary
The facility failed to ensure proper nail care for a resident who was dependent on staff for personal care. The resident, who was cognitively intact and did not refuse care, had several medical conditions including post-polio syndrome, morbid obesity, Type 2 diabetes, and functional quadriplegia, which made him reliant on staff for activities of daily living. Observations revealed that the resident's fingernails were excessively long and had a light brown substance underneath. Despite the resident's requests for nail trimming, staff members repeatedly failed to provide this care. Interviews with the resident and staff confirmed that the resident's nails were not trimmed as expected. The resident reported receiving three bed baths a week, during which nurses were supposed to trim his nails due to his diabetic condition. However, the nurses did not fulfill this responsibility until after the issue was raised by a surveyor. The Director of Nursing stated that the facility's protocol required weekly nail trimming, especially for diabetic residents, but a specific policy on nail care was not provided when requested.
Failure to Reassess and Document ROM Program Participation
Penalty
Summary
The facility failed to comprehensively reassess and develop interventions for two residents, R9 and R39, who were part of a range of motion (ROM) program. R9, who was cognitively intact and had multiple diagnoses including post-polio syndrome and functional quadriplegia, was supposed to receive passive ROM exercises daily. However, documentation showed that R9 only received ROM four times over a 28-day period, refused six times, and there was no documentation for 18 days. Interviews revealed that nursing assistants were often too busy to perform the exercises, and there was a lack of communication about refusals to the nurse manager. R39, also cognitively intact, had diagnoses including cerebral palsy and functional quadriplegia. R39's ROM program included several specific exercises to be performed daily. However, documentation indicated that R39 refused ROM 12 times, participated on four days, and there was no documentation for 14 out of 30 days. Interviews with staff confirmed that R39 often refused the exercises, but these refusals were not communicated to the nurse manager. The facility's director of nursing stated that ROM programs are crucial for maintaining mobility and preventing contractures, and expected follow-up with therapy after several refusals. However, the nurse manager had not been informed of the refusals or lack of participation, and there was no facility policy on ROM provided. This lack of reassessment and communication contributed to the deficiency in maintaining the residents' ROM programs.
Failure to Address Resident's Alcohol Ordering Behavior
Penalty
Summary
The facility failed to comprehensively assess and develop interventions to promote safety and reduce the risk of injury for a resident who attempted to order alcohol via a mobile delivery service. The resident, who had intact cognition and several medical conditions including asthma, a history of seizure disorder, and diabetes mellitus, was found to have ordered alcohol on multiple occasions. Despite this behavior being documented in progress notes, the resident's care plan and medication administration records lacked any interventions or monitoring related to alcohol consumption. Interviews with staff revealed a lack of awareness and direction regarding the resident's attempts to obtain alcohol. Nursing assistants and registered nurses were not informed about the resident's behavior and were unsure of the facility's protocols for handling such situations. The director of nursing and a registered nurse unit manager were also unaware of the resident's actions until informed by the surveyor, indicating a failure to assess or act upon the situation in a timely manner. The facility's policy on alcohol consumption was requested but not provided, further highlighting the deficiency in addressing the resident's safety and care needs.
Failure to Address Significant Weight Gain in Resident
Penalty
Summary
The facility failed to comprehensively assess and care plan appropriate interventions for a resident who experienced significant weight gain. The resident, who was cognitively intact and independent with most activities of daily living, was admitted to the facility weighing 210.6 pounds and gained 78.3 pounds in less than 10 months. Despite being assessed multiple times for significant weight gain, the facility did not implement any interventions or provide education to the resident on healthy choices. The resident expressed a desire to lose weight and reported snacking on unhealthy foods, but the facility's dietary progress notes lacked any recommendations or education on weight management. Interviews with staff revealed a lack of awareness and communication regarding the resident's weight management needs. The resident's care plan and electronic medical record did not include any interventions or discussions about weight loss goals. The dietary director and dietitian had only spoken with the resident once and were focused on residents with significant weight loss. The director of nursing confirmed the absence of care-planned recommendations and staff education to support the resident's weight loss goals. The facility's inaction and lack of communication contributed to the deficiency in addressing the resident's nutritional needs.
Failure to Attempt Gradual Dose Reduction for Psychotropic Medication
Penalty
Summary
The facility failed to attempt a gradual dose reduction (GDR) or document a clinical rationale for not attempting it for a resident reviewed for unnecessary medications. The resident, who was cognitively intact and independent with most activities of daily living, was admitted with diagnoses including unspecified personality disorder, generalized anxiety disorder, and major depressive disorder. The resident was prescribed aripiprazole and duloxetine for anxiety and depression. The pharmacist recommended a GDR for duloxetine, suggesting it could worsen anxiety, and proposed switching to an SSRI. However, the prescriber did not forward this recommendation to the resident's psychiatrist and declined the GDR, citing the resident's ongoing work with a psychiatrist and refusal to change medications. The pharmacist consultant reiterated the GDR recommendation three months later, but it was again declined by the prescriber, who stated the resident refused changes and was followed by psychiatry. The director of nursing confirmed that no GDR had been attempted since the resident's admission. The pharmacist expressed concerns about the use of a stimulating antidepressant like duloxetine for a resident with anxiety, noting better outcomes with less stimulating alternatives. Despite these recommendations, the facility did not document a clinical rationale for not attempting a GDR, leading to the deficiency finding.
Inadequate Surety Bond Coverage for Resident Personal Funds
Penalty
Summary
The facility failed to ensure that resident personal fund accounts were adequately insured with a surety bond to cover the total account balance. An undated resident fund account record, received on December 3, 2024, identified 20 residents with positive balances totaling $27,953.42. However, a Continuation Certificate dated April 2, 2024, indicated that the facility's surety bond only covered up to $25,000. During an interview on December 4, 2024, the administrator acknowledged that the surety bond was insufficient to cover the residents' personal fund accounts and mentioned that the corporate office oversaw the surety bond. The administrator intended to reach out to see if an updated version was available, but no evidence of an updated surety bond was received. The facility's Resident Trust Funds policy, dated December 2023, stated that a surety bond would be purchased by the Home Office to ensure the security of all resident trust funds deposited into the account.
Unqualified Activities Director and Lack of Weekend Programs
Penalty
Summary
The facility failed to have a qualified therapeutic recreation director (TRD) to oversee the activities program, which is a requirement to ensure competent assessment and implementation of activities programming. The current TRD, who had been in the role for approximately three months, had a background in elementary education and lacked prior experience in a healthcare recreation program. The TRD had not completed the necessary certification course for activities programming in a nursing home, having only partially completed the first module of a self-paced online course. Additionally, the TRD had not been recording residents' attendance at activities, which is a critical component of assessing and planning activities for residents. A resident with intact cognition expressed dissatisfaction with the lack of activities on weekends, stating that they often became bored and wandered around to find people to converse with. The facility's job description for the Life Enrichment Coordinator did not specify the need for state-approved certification or occupational therapy credentials, which are required under F680. The administrator acknowledged the TRD's lack of credentials and the importance of having a credentialed activity director to ensure quality care for residents.
Inaccurate Nurse Staffing Information Posting
Penalty
Summary
The facility failed to ensure that the posted nurse staffing information accurately displayed the total number and actual hours worked by licensed staff for each shift on a daily basis. Specifically, the daily staff postings from November 19, 2024, through December 2, 2024, included a row for Licensed Practical Nurses (LPNs) but did not include the total number or actual hours worked by LPNs, unlike the rows for Registered Nurses (RNs) and Certified Nursing Assistants (CNAs). The facility's staffing schedules indicated that LPNs worked on several days during this period. During an interview, the staffing coordinator acknowledged that the LPN hours were not being separately categorized as required and were instead being included in the RN staffing hours. The coordinator attributed this issue to a computer program that was incorrectly pulling the staffing data for the postings. The facility did not provide a policy regarding the posting of nurse staffing information.
Failure to Reconcile Controlled Substances
Penalty
Summary
The facility failed to ensure proper reconciliation of narcotic and controlled substances on two of the three medication carts reviewed, as per their established policies and procedures. This deficiency was identified during a facility-reported incident investigation for possible drug diversion. The facility's Controlled Substances policy required that narcotic records be reconciled by a physical count at the change of each shift by the oncoming and outgoing licensed nurse, with signatures verifying the count. However, numerous instances of unsigned spaces on the Controlled Drug Count Records were observed, indicating that the required counts were not consistently performed. During the investigation, it was found that the 500-hall medication cart had multiple days where the required signatures were missing, with some days having all spaces left blank. Similarly, the hall one medication cart also showed numerous unsigned spaces across several days. Interviews with registered nurses revealed that the counting of controlled substances was supposed to occur at each shift change, but the blanks on the flow sheets indicated that this process was not consistently followed. The Director of Nursing acknowledged that the facility's policy was not being adhered to, as the controlled substances record was not signed for every shift. This lapse in procedure had the potential to affect six residents who had active orders for narcotic and/or controlled substances on the reviewed medication carts. The failure to follow the policy raised concerns about the accountability and security of controlled medications, especially in light of the reported incident of possible drug diversion.
Failure to Provide Ordered Respiratory Care Leads to Resident's Death
Penalty
Summary
The facility failed to provide the ordered respiratory care for a resident, leading to significant harm. The resident was admitted with a primary diagnosis of sepsis and additional diagnoses including bronchiectasis, dysphagia, obstructive sleep apnea, and COPD. The resident was supposed to receive respiratory chest physiotherapy three times a day, but this therapy was not provided. Additionally, the resident received oxygen therapy without a physician's order. The lack of proper respiratory care contributed to the resident's death. The resident's medical records indicated that the facility did not document the administration of the chest physiotherapy vest or obtain the necessary orders for its use. Despite recommendations from respiratory therapy for the use of DuoNebs and hypertonic saline nebulizers in conjunction with chest physiotherapy, these treatments were not consistently administered. The facility's treatment administration record showed incomplete assessments and a lack of documentation regarding the resident's respiratory treatments. Interviews with facility staff and family members revealed that the resident did not consistently receive the prescribed vest therapy. The resident's family expressed concerns about the lack of treatment, and the facility's director of nursing acknowledged that the vest treatment order was missed. The resident's condition deteriorated, leading to hospitalization for acute respiratory failure, and ultimately, the resident passed away due to severe sepsis and pneumonia.
Failure to Maintain a Homelike Environment Due to Loud Music
Penalty
Summary
The facility failed to provide a homelike environment for two residents, R2 and R3, due to the loud music played by another resident, R4. Observations on the 600 hallway revealed that R4 played explicit music loudly with his door open, which could be heard from the front entrance and other hallways. R2 and R3, both cognitively intact, expressed their inability to hear their own music or television due to R4's loud music. R2 reported the issue to her nurse, but was unsure if any investigation was conducted. R3 also mentioned that the loud music had been a problem for about a week. R4 admitted to playing his music loudly to retaliate against other residents who were playing their music and television loudly. He stated that he usually used headphones but felt entitled to play his music loudly since he paid to live there. The DON stated that the facility aims to create a homelike environment by maintaining cleanliness and ensuring noise levels do not disturb other residents. However, the DON was unaware of any complaints regarding loud music. The administrator mentioned that concerns about noise would typically be addressed through discussions with the involved residents, but no policy for a homelike environment was provided upon request.
Failure to Develop Comprehensive Care Plan for Resident with Complex Needs
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident, identified as R1, who had multiple complex medical needs. R1 was admitted with a primary diagnosis of sepsis and had a history of various other conditions, including end-stage renal disease, congestive heart failure, and chronic obstructive pulmonary disease. Despite these significant health issues, the care plan did not address critical areas such as dialysis, tube feeding, respiratory therapy, and risk factors for urinary tract infections. Interviews with facility staff, including the Director of Nursing (DON), nursing assistants, and MDS coordinators, revealed a lack of coordination and communication in creating and updating the care plan. The DON acknowledged that essential elements like dialysis treatment and COPD management should have been included in the care plan. The MDS coordinators also expressed concerns about missing information related to tube feeding and dialysis, indicating that these omissions were not in line with their expectations for comprehensive care planning. The facility's policy on person-centered care planning emphasized the need for a detailed and individualized approach, including measurable objectives and timeframes to meet residents' needs. However, the care plan for R1 lacked specific interventions, preferences, and risk assessments, which were necessary to address the resident's complex medical conditions. This deficiency in care planning was identified through a combination of record reviews and staff interviews, highlighting a significant gap in the facility's adherence to its own policies and procedures.
Failure to Monitor Resident Hydration Status
Penalty
Summary
The facility failed to adequately monitor and assess the hydration status of a resident who was receiving tube feedings. The resident, who had a history of sepsis, hypokalemia, moderate protein-calorie malnutrition, bronchiectasis, dysphagia, COPD, gout, and lymphedema, was admitted with a gastrostomy-jejunostomy and was on a Novasource Renal diet. The treatment administration record indicated that the resident was to receive tube feeding with specific water flushes, which were to be adjusted based on hydration status. However, the facility staff did not monitor or assess the resident's hydration status as required, leading to the resident being severely dehydrated and requiring hospitalization. Interviews with facility staff, including the DON and the dietitian, revealed a lack of communication and responsibility regarding the resident's hydration needs. The dietitian believed the resident was meeting nutritional needs and relied on nursing staff to report any necessary adjustments, while the DON expected the dietitian and facility provider to determine hydration needs. The resident's guardian reported that the resident was so dehydrated during a dialysis session that an ambulance was called. The facility did not provide a policy on assessing hydration status when requested, indicating a systemic issue in monitoring and managing the resident's hydration needs.
Failure to Conduct Pre-and-Post Dialysis Assessments
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident who required such services. The resident, who had a history of sepsis, kidney transplant, anemia in chronic kidney disease, end-stage renal disease, and dependence on renal dialysis, was admitted to the facility with specific orders for pre-and-post dialysis assessments. These assessments were to be conducted on Mondays, Wednesdays, and Fridays, and included checking vital signs, level of consciousness, and other symptoms such as muscle cramping, itching, and pain. However, the facility only completed three such assessments from the time of the resident's admission, despite the requirement for regular monitoring. Interviews with the facility's RN and DON revealed that the assessments were not consistently performed as required. The RN acknowledged that the assessments should have been conducted before and after each dialysis session, while the DON expressed concern over the lack of completed assessments. Additionally, there was no contract between the facility and the dialysis center, and the facility failed to provide a dialysis assessment policy and procedure when requested. This lack of consistent monitoring and absence of a formal policy contributed to the deficiency in care for the resident.
Failure to Document Vital Signs and Assessments
Penalty
Summary
The facility failed to accurately document vital signs and assessments for a resident who required pre-and-post dialysis assessments three times a week. The treatment administration record (TAR) indicated that these assessments were not completed on all but three occasions during the resident's stay. Additionally, vital signs were recorded while the resident was not present in the facility, indicating a lapse in proper documentation and monitoring. The resident had a complex medical history, including sepsis, bronchiectasis, dysphagia, obstructive sleep apnea, and chronic obstructive pulmonary disease (COPD). The resident was admitted to the facility with a primary diagnosis of sepsis and required skilled nursing care, including respiratory therapy and scheduled dialysis. Despite these needs, the facility's records showed inconsistencies in documenting the resident's respiratory status and vital signs, which were crucial for monitoring the resident's condition. Interviews with facility staff revealed a lack of awareness and recall regarding the resident's condition and the completion of required assessments. The registered nurse responsible for the resident on a specific date could not remember the vital sign readings and did not notice any concerns with the resident's appearance. The nurse manager and other staff members also failed to identify respiratory issues, despite the resident's known history of lung problems and the need for continuous oxygen. This lack of documentation and awareness contributed to the deficiency identified in the report.
Failure to Ensure Neutral and Fair Arbitration Process
Penalty
Summary
The facility failed to offer a neutral and fair arbitration process by ensuring both the resident or their representative and the facility agree on the selection of a neutral arbitrator and that the venue is convenient to both parties. This deficiency was identified for 11 of 17 residents reviewed for binding arbitration. The arbitration agreements indicated that the arbitration would be administered by the American Health Lawyers Association (AHLA) and conducted at a site selected by the facility. Interviews with residents and staff revealed that residents were not aware they were giving up their right to litigation in a court proceeding and that the arbitrator and location were decided by the facility. Staff members, including the social worker and business office manager, acknowledged the importance of having a neutral arbitrator and a mutually agreed-upon site but stated that the arbitration agreement was provided by corporate and they had no input or training regarding its contents. One resident, who had intact cognition and diagnoses of heart failure, diabetes, and depression, stated she did not understand the implications of signing the arbitration agreement. The social worker and business office manager both expressed concerns about the lack of neutrality in the arbitration process and the potential stress caused by the facility-selected site. The facility's policy on voluntary binding arbitration agreements directed that the facility should provide for the selection of a neutral arbitrator agreed upon by both parties and a venue convenient for both parties. However, the facility's practice did not align with this policy, leading to the identified deficiency.
Infection Control Deficiencies in Glucometer Use and Wound Vac Placement
Penalty
Summary
The facility failed to ensure community use glucometers were properly cleaned and disinfected between patient use for four residents. During observations, a registered nurse (RN) was seen using the same glucometer for multiple residents without disinfecting it between uses, despite the manufacturer's guidelines requiring cleaning and disinfecting with Medline Micro-Kill+ disinfecting wipes. The RN acknowledged the importance of disinfecting the glucometer but admitted to not doing so between uses. Another RN also confirmed that the glucometer should be cleaned between uses but was observed wrapping it in a sani-cloth instead of following proper disinfection procedures. The Director of Nursing (DON) and the facility's policy both emphasized the need for cleaning the glucometer between uses to prevent infection spread, but this was not adhered to during the observations. Additionally, the facility failed to ensure a wound vac machine was kept off the floor for a resident reviewed for wound care. The resident had a stage 4 pressure ulcer and required a wound vac machine, which was observed on the floor next to the resident's bed. The RN verified that the wound vac should not be on the floor due to the risk of bacteria traveling up to the wound. The nurse manager and the infection preventionist/DON both stated that the wound vac should be kept in a bag and hung away from the floor to prevent infection. The facility's policies on infection prevention and control, as well as surveillance and monitoring, were not followed in these instances. The failure to disinfect the glucometer between uses and to keep the wound vac machine off the floor posed significant infection control issues, as confirmed by multiple staff members and the facility's own guidelines.
Failure to Assess and Supervise Self-Administration of Medications
Penalty
Summary
The facility failed to assess the ability of two residents to self-administer medications (SAM). Resident R27, who was cognitively intact and had multiple medical diagnoses including multiple sclerosis, psychosis, and diabetes, was found to be self-administering Calazinc and diclofenac creams without a SAM assessment. The resident had been receiving these medications via mail and applying them as needed, with the nurses providing the creams without proper documentation or assessment. The Director of Nursing confirmed that a SAM assessment was necessary but had not been completed for R27. Resident R10, who had moderate cognitive impairment and multiple medical conditions including chronic obstructive pulmonary disease and heart failure, was observed self-administering oral medications and using a nebulizer without supervision. Despite a SAM assessment indicating that R10 was not appropriate for self-administration, the resident was found with medications on her bedside table and a nebulizer set up for unsupervised use. Interviews with nursing staff confirmed that R10 required supervision for medication administration and should not have been left alone with her medications. The facility's failure to conduct proper SAM assessments and ensure appropriate supervision for medication administration led to these deficiencies. The Director of Nursing acknowledged the need for assessments and supervision but did not provide a facility policy on self-administration of medication when requested by the surveyors.
Failure to Complete and Document PASARR for Two Residents
Penalty
Summary
The facility failed to ensure a Level II Pre-Admission Screening and Resident Review (PASARR) was conducted, documented, and retained for two residents reviewed for PASARR. Resident R4, who was admitted on 3/10/21, had diagnoses including bipolar disorder, depression, diabetes, and delusional disorder. Despite an initial Pre-Admission Screening (PAS) indicating the need for further evaluation by the county or managed care program, R4's medical record lacked evidence of a final determination. The medical records clerk acknowledged the incomplete status of the Level II PASARR and admitted to giving up on following up after a few attempts. The administrator confirmed the expectation for staff to complete and follow up on PASARRs but did not ensure this was done for R4. Similarly, Resident R27, who had diagnoses including multiple sclerosis, unspecified psychosis, polyneuropathy, generalized anxiety, major depression, and personality disorder, also lacked evidence of a final determination for the Level II PASARR. The initial PAS indicated a referral for mental illness OBRA Level II to the lead agency, but the facility did not follow up on the results. The medical records clerk confirmed the lack of follow-up, and the administrator stated it was the clerk's responsibility to ensure the PASARR was completed. A policy on PASARR was requested but not received, indicating a possible lack of formal procedures in place to ensure compliance.
Infection Control and Monitoring Deficiencies
Penalty
Summary
The facility failed to ensure appropriate infection control techniques during wound care for two residents. For one resident, the registered nurse (RN) used uncleaned medical scissors and a single towel for wound care on both legs, and placed medical tape on unclean surfaces before using it on the resident. The RN admitted to not cleaning the scissors between uses and acknowledged the improper handling of medical tape. The Director of Nursing (DON) expressed disappointment in the staff's failure to follow proper infection control protocols, especially given the residents' vulnerability to infections. Another resident also received wound care with improper infection control techniques. The RN placed medical tape on an uncleaned drawer before using it on the resident's wound dressing. The RN admitted to not knowing if the drawer was clean and acknowledged that the tape should not have been placed on an unclean surface. The DON reiterated the importance of proper infection control techniques and expressed concern over the staff's actions. Additionally, the facility failed to comprehensively assess, monitor, and provide necessary care for a resident with an intrathecal baclofen pump. The resident's medical records lacked documentation of the pump's placement, dose, and rate of medication. Staff members, including a registered nurse and a nurse manager, were unaware of the pump's existence and did not monitor it. The DON confirmed the lack of monitoring and documentation for the baclofen pump, emphasizing the importance of staff awareness and proper monitoring of such devices.
Failure to Assist Resident with Hearing Aids
Penalty
Summary
The facility failed to provide assistance for hearing appliances for a resident (R17) who had bilateral hearing aids. R17, who had moderate cognitive impairment and several diagnoses including Parkinson's, encephalopathy, chronic pain, anxiety, dementia, diabetes, and depression, was observed multiple times without her hearing aids. Despite the care plan and Kardex indicating that R17 required bilateral hearing aids, staff members were unaware of the location of the hearing aids and had not been assisting R17 with them. R17 expressed that she did not know where her hearing aids were, and staff members, including a registered nurse and nursing assistants, confirmed that they had not been putting the hearing aids in for her or were unaware of their existence. R17's family member also confirmed that the hearing aids were necessary for her to understand conversations and avoid feelings of isolation, but noted that the hearing aids were never in her ears during visits. During interviews, staff members indicated that they expected information about hearing aids to be on the Kardex and that they would be responsible for putting them in if they were aware. However, multiple staff members, including nursing assistants who had worked with R17 for an extended period, stated they had never seen the hearing aids. The Director of Nursing acknowledged the importance of hearing for R17's quality of life. The facility's policy on hearing aids was requested but not provided, indicating a potential gap in policy adherence or availability.
Failure to Administer Appropriate Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate administration of oxygen therapy and CPAP therapy for a resident with multiple respiratory conditions. The resident, who had intact cognition and required assistance with daily activities, was observed receiving oxygen at a rate higher than prescribed without proper documentation or notification to the nurse practitioner. The resident's medical records indicated a history of obstructive sleep apnea, COPD, and heart failure, and the hospital discharge summary recommended the use of a CPAP machine, which the resident had not used since admission to the facility in 2021 due to a misplaced machine. The resident's oxygen levels were inconsistently monitored, with several missed assessments and instances where oxygen was administered at a rate of three liters per minute, contrary to the prescribed one liter per minute. The resident reported shortness of breath to an aide, leading to an increase in oxygen, but this change was not communicated to the nurse practitioner or documented in the progress notes. The nurse manager and floor nurse were unaware of the increased oxygen rate, and the nurse practitioner expressed concern about the potential adverse effects of excessive oxygen on the resident's health. The facility also failed to follow up on the resident's need for a new CPAP machine. Despite the resident's request for information about obtaining a new CPAP and the importance of CPAP therapy for her health, no steps were taken to schedule a sleep apnea test or update the CPAP settings. The director of nursing acknowledged that the facility was unaware of the resident's need for a CPAP machine and emphasized the importance of reviewing hospital notes to ensure appropriate respiratory care for residents.
Failure to Monitor Side Effects of Psychotropic Medications
Penalty
Summary
The facility failed to provide appropriate side effect monitoring for a resident (R24) who was on psychotropic medications. R24 had severe cognitive impairment and was dependent on assistance with activities for daily living. The resident's care plan included the use of antipsychotic and antidepressant medications, but there was no evidence of monitoring for side effects, orthostatic blood pressures, or non-pharmacological interventions for sleep or behaviors. The medication administration record (MAR) for March lacked documentation of these essential monitoring activities. R24's care plan identified the need for monitoring side effects of psychotropic medications and listed specific interventions, such as observing and recording target behaviors and documenting abnormal findings. However, the care plan lacked evidence of non-pharmacological interventions attempted and their effectiveness. Additionally, the progress notes for the last 90 days and the vital signs summary lacked evidence of orthostatic blood pressure monitoring, which is crucial for patients on psychotropic medications. Interviews with the nurse manager and the director of nursing confirmed that side effect monitoring should be documented in the MAR, but they were unable to locate such documentation for R24. The director of nursing verified that R24 had not been receiving orthostatic blood pressure monitoring and that there were no non-pharmacological interventions in place. The facility's policy on PRN psychotropic medication also lacked information on monitoring for side effects and effectiveness, further contributing to the deficiency.
Failure to Administer Prescribed Medications
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors. Specifically, the resident did not receive the prescribed medications metoprolol and atorvastatin for a period of 30 days. The resident's quarterly Minimum Data Set (MDS) indicated that the resident was cognitively intact and required minimal assistance with daily activities. The resident had multiple medical diagnoses, including hypertension and high cholesterol, which required the administration of metoprolol and atorvastatin, respectively. However, the facility's medical orders did not include these medications, and the Medication Administration Record lacked documentation of their administration between 2/13/24 and 3/13/24. Interviews with the nurse manager and the Director of Nursing (DON) confirmed that the orders for metoprolol and atorvastatin were not included in the facility's physician orders and that the resident had not received these medications during the specified period. The DON stated that it was expected for nurses to check medication orders received from a provider on the same day and reconcile them with the facility's physician orders. The facility's policy on medication management was requested but not provided, indicating a potential lapse in procedural adherence and documentation.
Failure to Act on Dental Needs for Resident
Penalty
Summary
The facility failed to ensure dental needs were appropriately acted upon for a resident (R47) who required dental care. R47's quarterly Minimum Data Set (MDS) indicated that the resident had intact cognition, no behaviors, and required setup assistance with oral hygiene. The resident was diagnosed with heart failure, diabetes, and depression. A dental progress note dated 1/4/24 recommended that R47 have five teeth extracted due to fractured teeth/root tips that were causing pain and were not restorable. However, by 2/27/24, a progress note indicated that R47 still had obvious cavities or broken natural teeth, and no follow-up appointment had been scheduled with an oral surgeon as recommended by the dentist. During an interview on 3/11/24, R47 expressed that no one had followed up regarding the dental appointment, and the resident continued to experience mouth pain and difficulty eating due to the dental issues. Interviews with the nurse manager (NM-E) and the medical records clerk (MRC) revealed that the responsibility for setting up out-of-facility appointments, including dental referrals, fell to the MRC. However, the MRC admitted that she had not seen the dental referral for R47 until the interview on 3/12/24, and therefore, no appointment had been scheduled. The director of nursing (DON) confirmed that the MRC was responsible for scheduling these appointments and emphasized the importance of doing so. A policy regarding dental needs was requested but not received, indicating a potential gap in the facility's procedures for managing dental care referrals and follow-ups.
Failure to Maintain Accurate Medical Records and Monitor Medication
Penalty
Summary
The facility failed to maintain accurate medical records for two residents, leading to discrepancies in medication lists and lack of proper monitoring and interventions. For one resident, the facility's medication orders did not match the clinic's current medication list, missing several medications and having incorrect dosages for others. The nurse manager confirmed these discrepancies and acknowledged that the medication orders were not reconciled as expected. The medical director and the director of nursing both expressed concerns about the mismatched lists and emphasized the importance of reconciling medication orders to prevent negative outcomes for the resident. For another resident, the facility's records lacked evidence of an order for an intrathecal baclofen pump, including details about the placement, dose, and rate of medication. The medication administration record and care plan did not include monitoring or assessment of the pump, and progress notes lacked coordination with the agency responsible for filling the pump. The resident confirmed that staff did not monitor the pump, and the nurse manager verified the absence of current orders and monitoring practices. The director of nursing acknowledged the importance of staff being aware of the pump and its dose, confirming that no monitoring was in place. The facility's failure to maintain accurate medical records and ensure proper monitoring and interventions for these residents highlights significant deficiencies in their medication management and record-keeping practices. The lack of accurate and up-to-date information in the residents' medical records poses risks to their health and safety, as evidenced by the discrepancies and omissions found during the survey.
Failure to Clearly Communicate Binding Arbitration Agreements
Penalty
Summary
The facility failed to ensure that binding arbitration agreements were clearly communicated and understood by residents prior to signing. Two residents, one with multiple sclerosis and another with heart failure, diabetes, and depression, were reviewed for binding arbitration agreements. Both residents had intact cognition according to their Minimum Data Set (MDS) assessments. However, during interviews, neither resident could recall being informed that signing the arbitration agreement was not a condition of admission, nor could they recall the agreement being explained in a manner they understood. The signed agreements indicated that the residents were giving up their rights to bring lawsuits or have jury trials for disputes with the facility. The social worker responsible for reviewing the admission packet, which included the arbitration agreement, stated that the packet was provided by corporate and that she had no input or training regarding the arbitration agreement. She also mentioned that her process for determining competency was based on her judgment of the resident's demeanor and diagnosis. The administrator confirmed that the arbitration paperwork came from the corporate office and that his role was limited to ensuring it was included in the admission paperwork and discussed during admission. The facility's policy required obtaining the resident's acknowledgment that the arbitration agreement was explained in a manner they understood, which was not adhered to in these cases.
Failure to Post Timely Nurse Staffing Information
Penalty
Summary
The facility failed to ensure nurse staffing information was posted on the weekend and in a timely manner at the start of the shift. During an entrance to the nursing home, it was observed that the staffing information displayed was dated four days prior, and there was no visible nurse staffing information posted for the subsequent days. The administrative assistant verified the outdated posting and confirmed that no other nurse staff information postings were present. The staffing coordinator admitted to sometimes getting the dates mixed up and acknowledged that incorrect postings could misrepresent staffing levels or census data. The director of nursing emphasized the importance of having the correct staff posting to accurately depict staffing in the building. The administrator also highlighted that the staff posting provides an account of the number of residents and the staff responsible for them. Despite requests, a facility policy for staff posting was not provided. This deficiency had the potential to affect all 69 residents, staff, and visitors who might wish to review the nurse staffing information.
Failure to Account for Controlled Substances
Penalty
Summary
The facility failed to have a system in place to record accurate narcotic reconciliation, resulting in the inability to account for thirty morphine tablets ordered for a resident. The deficiency was identified when a pharmacy receipt for the morphine delivery was not found in the facility's receipt bin, and the narcotic logbook did not include the physician's order for the morphine. Interviews with staff revealed that the morphine was delivered by a third-party courier and signed for by a staff member whose signature was later disputed. The resident's hospice nurse discovered the missing medication when attempting to administer it, leading to an investigation that confirmed the medication was never properly logged or accounted for in the facility's records. The resident involved had cognitive impairment and required moderate assistance for daily activities. The resident was admitted to hospice care and prescribed morphine for severe pain and air hunger. Despite the medication being delivered, it was not available when needed, and staff interviews indicated a lack of awareness and proper procedures for ensuring the medication was received and logged. The facility's policy on controlled substances did not provide clear guidance on actions to take if medication was not received, contributing to the oversight and failure to identify the missing morphine in a timely manner.
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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