Citations in Minnesota
Statistics, citations and compliance trends for long-term care facilities in Minnesota.
Statistics for Minnesota (Last 12 Months)
Financial Impact (Last 12 Months)
Latest citations in Minnesota
A resident admitted for skilled nursing services did not have documented TB testing completed on admission. A T-spot was later drawn, but there was no record that the specimen was sent to the lab or that results were obtained. The DON stated the facility missed the resident during TB audit checks and that the sample was not processed because the lab form was not sent with it, despite the facility policy requiring TB screening and testing within 72 hours of admission.
Insufficient nursing staffing led to delayed toileting help, delayed meal assistance, and transfers done outside assessed needs and policy. A resident who was dependent for toileting and transfers was left in bed crying, incontinent, and told to stay in bed and pee her pants until staff could return, while another resident waited 45 minutes for help eating in the dining room. Surveyors also found repeated weekend staffing shortages, and staff described frequent short staffing, late or missing staff, and reliance on agency and float staff.
The facility failed to maintain an infection prevention and control program when staff did not consistently start or follow contact precautions for residents with ongoing diarrhea, including a resident later confirmed with C. diff and norovirus. The surveillance system also did not consistently track residents with signs of infection, and staff were observed providing care without proper hand hygiene or consistent PPE use. Enhanced barrier precautions were also not implemented for residents who met criteria.
Food storage, labeling, and sanitation deficiencies were observed in the kitchen and a serving kitchenette. Undated and unlabeled food items were found in refrigerators and freezers, milk was present past its best-by date, food debris and sticky residue were noted in freezer areas, a ceiling vent was dirty, and cooks with beards were observed without beard nets. The DD verified the findings, and staff stated items past date should be discarded and food items should be labeled and dated when stored.
The facility failed to include EBP instructions in the care plans of residents with a G-tube, a chronic wound, and an indwelling catheter. Observations showed PPE carts and signs directing staff to use gowns and gloves for direct care, but one care plan did not address EBP for G-tube or personal care, another lacked EBP guidance for wound care, and a third lacked EBP guidance for catheter care. The DON stated EBP should be care planned when required and staff were expected to follow the care plan and PPE guidance.
Missed Quarterly Care Conference and Resident Participation: A resident who was cognitively intact and had HTN, arthritis, and schizophrenia did not have documented routine care conferences at the expected quarterly interval. The EMR showed care conferences were documented, but there was no evidence of one between two documented meetings, and the resident stated she had not been invited to any care meetings over the past year. The LSW and Admin both confirmed the lack of documentation and stated residents should be included when able.
Incomplete TB Testing on Admission
Penalty
Summary
The facility failed to ensure that 1 of 5 sampled residents, R12, had completed TB testing upon admission. R12’s admission record showed admission to the facility in March 2026 for skilled nursing services. A progress note dated 5/11/26 documented that an interferon-gamma release assay (T-spot) test was drawn, but there was no further documentation showing that the specimen was sent to the laboratory or that results were obtained. There was also no documentation showing that TB testing had been completed at admission in March 2026 rather than as a delayed test in May 2026. During interview, the DON stated the facility had been auditing for missing TB testing and had missed R12 during that process; she explained that blood had been drawn for the T-spot, but the facility forgot to send the form with the sample to the lab, so the process ended there. Review of the facility’s Resident Tuberculosis Prevention and Control policy showed that all new resident admissions were to have TB screening and testing completed within 72 hours of admission.
Insufficient Nursing Staffing Led to Delayed Care and Missed Assistance
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet residents’ assessed needs and provide required care and services. Surveyors found that staffing shortages resulted in delayed toileting assistance, delayed eating assistance, loss of dignity, and transfers performed contrary to assessed needs and facility policy for 2 of 6 residents reviewed. CMS PBJ Staffing Data Reports also showed excessively low weekend staffing triggers for multiple fiscal year quarters. On the day of survey entry, the facility was locked, the survey team had to call for entry, and an LPN stated the facility was working short because a day shift nurse did not show up and the night nurse had stayed until 10:30 a.m. before leaving. The LPN said she had been answering call lights, helping NAs, and trying to complete her own duties, while only two NAs were in the facility. One resident, who had mild cognitive impairment, dementia, non-traumatic spinal cord dysfunction, diabetes, and was dependent on staff for toileting and transfers, was observed crying in bed wearing only a sweatshirt and incontinent brief with no pants. The resident stated staff told her she had to stay in bed and could not get up, and that they told her to pee her pants and they would clean her up there. The resident said this happened all the time and that staff shut off her call light just about every day because they were short. NA-B later cleaned the resident after she was wet and incontinent of urine and feces, applied barrier cream, and then had to leave to get another staff member for a two-person mechanical lift transfer. The resident was then transferred to her wheelchair with two staff and taken to the dining room. Another resident, who was cognitively intact and independent with eating but had been identified as needing assistance with meals for optimal intake, was observed in the dining room with food in front of her and no staff helping her eat. At least two residents were sitting with food in front of them and were not eating or receiving staff assistance. The resident waited 45 minutes before staff assisted her to eat, and once assisted she ate well. Staff interviews described ongoing staffing problems, frequent use of agency staff, missed or late staff, difficulty getting help from float staff, and expectations that medication staff would assist with call lights and resident care when possible. The DON stated float staff lacked accountability because they had no assigned resident group and planned to change assignments so each nursing assistant, including float staff, would have assigned residents.
Infection Prevention and Control Failures With Diarrhea Precautions, Surveillance, and Hand Hygiene
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program that included systems for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases. Surveyors found that transmission-based precautions were not timely initiated or consistently maintained for two residents with potentially infectious diarrhea, that residents with signs and symptoms of possible infection were not consistently tracked through the surveillance system, that hand hygiene was not consistently followed during resident care, and that enhanced barrier precautions were not implemented for residents who met criteria. One resident had loose stools for several days before stool testing confirmed C. diff and norovirus. The record showed provider notification, lab work, and later stool testing, but nursing progress notes repeatedly failed to identify whether contact precautions were in place. When the resident was observed after the positive results, the room had a contact precautions cart and signage, but staff entered and exited the room inconsistently using PPE. One aide entered without PPE, later returned with gown, gloves, and mask, then reentered the room to care for the roommate without gown or gloves. Other staff entered the room without gown or gloves while touching the resident’s personal items, and housekeeping entered with gloves but without a gown. Staff interviews showed inconsistent understanding of when PPE was required and how the room should be managed. A second resident had ongoing loose stools and received repeated doses of loperamide, but the medical record did not identify that contact precautions were started while stool testing was being considered and obtained. The DON stated precautions should have been started whenever a stool panel was requested for a resident with loose stools and should continue until the diarrhea resolved. The surveillance log also failed to capture residents with signs and symptoms of infection that were not treated, and the DON stated an event tracker should have been started for residents with diarrhea and for a roommate exposed to the infected resident. In addition, during care for an incontinent resident, an aide cleaned feces and urine, applied barrier cream, and then used disposable wipes on her gloves without removing them or performing hand hygiene. The report also noted that enhanced barrier precautions were not implemented for two residents who met criteria.
Food Storage, Labeling, and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food items were properly labeled, dated, stored, and kept clean in the main kitchen and a 3rd floor kitchenette. During observation of the main kitchen, a walk-in storage freezer had boxes stored on the floor and frozen tater tots scattered across one corner of the freezer floor. A refrigerator used for some independent living residents contained a tray of tartar sauce portion cups that were undated, and the bottom shelf was dirty with crumbs and food debris. A walk-in freezer had sticky floors and frozen sausage links scattered on the floor. In the main kitchen refrigerator, a tray of red sauce portion cups was not labeled or dated, a Ziplock bag of sliced meat had a date of 5/6 and appeared to have a grayish white tint, and another Ziplock bag of seasoned meat was in a container with no label or date. A ceiling vent above the main stove had brown/black dust and dirt on it. The Dietary Director verified the undated and unlabeled food items, the food spilled on the freezer floors, the dirty vent, and the lack of a beard net on a cook with a short trimmed beard. In the 3rd floor kitchenette, the small refrigerator by the steam table contained 2 half gallons of skim milk, including one unopened container with a best by date of 6/7/26 and one opened container with approximately 1/2 cup left with a best by date of 6/6/26. A cook with a medium length beard was working on the serving side of the kitchenette and was not wearing a beard net. Nursing staff stated the milk should be tossed, and the cook stated the morning cooks should have reviewed the refrigerator items and that items past their dates should be thrown out. The Dietary Director and administrator stated staff were expected to ensure food items were dated and labeled when stored, refrigerators were reviewed for out-of-date items, beard nets were worn in the kitchen and serving areas, and refrigerators, freezers, and ceiling vents were clean.
Failure to Include EBP in Resident Care Plans
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans that included enhanced barrier precautions (EBP) for 3 of 5 residents reviewed who were identified to be on EBP. One resident had intact cognition, required moderate assistance with bathing, had a G-tube, and diagnoses included Parkinson’s disease, narcolepsy, anxiety, and dysphagia. That resident’s care plan addressed incontinence and G-tube care, but did not include instructions for EBP when staff provided G-tube care or personal care. The resident’s active medication orders directed that numerous medications be crushed and administered through the feeding tube, and a sign outside the room directed staff to wear a gown and gloves for direct care, including G-tube care. The DON stated G-tube care was one instance when EBP should be used and that EBP should be care planned when required. A second resident had severe cognitive impairment, obesity, an unstageable pressure ulcer, and moisture associated skin damage. The resident’s wound assessment identified a stable coccyx ulcer, but the care plan lacked any guidance for EBP use. During observation, an isolation cart outside the room had a contact precaution sign for the roommate and did not address whether the resident was on EBP; the cart contained gloves, masks, and eye/face protection, but no gowns. A nursing assistant stated gowns and gloves were not needed for care of that resident and entered the room without wearing either. A third resident had moderate cognition, an indwelling catheter, renal insufficiency, and urinary retention. The care plan included catheter change, daily catheter care, and infection monitoring, but did not include EBP instructions related to the catheter. Observation showed a cart outside the room with gowns and gloves and a sign identifying the resident as on EBP with instructions to wear gowns and gloves for direct care, including catheter care. The DON stated staff were expected to follow resident care plans and the facility policy regarding PPE for EBP.
Missed Quarterly Care Conference and Resident Participation
Penalty
Summary
The facility failed to provide routine care conferences to allow resident participation for one resident who was reviewed for care conferences. The resident’s quarterly MDS assessment indicated admission to the facility, cognitive intactness, and diagnoses of high blood pressure, arthritis, and schizophrenia. The resident’s EMR showed care conferences were documented on 5/2/25, 10/7/25, 12/30/25, and 3/28/26, but there was no evidence of a care conference between 5/2/25 and 10/7/25. During interview, the resident stated she understood what care conferences were but had not been invited to any type of care meeting over the past year. The LSW stated care conferences should occur at admission, then every three months and/or with a significant change of condition, and that she was responsible for scheduling and documenting them in the EMR. The LSW could not provide documentation of a care conference between 5/2/25 and 10/7/25 and stated, "If it isn't documented it didn't happen." The Administrator confirmed care conferences were expected quarterly and should include residents if able or their representative, and also confirmed there was no documentation of a care conference for the resident during that interval. The facility policy stated residents and their designated responsible party are invited to attend the initial care planning conference and sequential conferences, including annual and significant change conferences.
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Compliance trends in Minnesota
Data through May 2026Comparisons below measure the most recent period Jun 2025 – May 2026 against the prior period Jun 2024 – May 2025 (two equal 12-month windows). The most recent 1 months are excluded because CMS is still publishing them.
Top tags by month · last 24 months
dashed = still reportingMonthly citation counts for the 5 most-cited tags. The dashed tail is the 1-month reporting lag.
Frequency movers
Biggest change in how often each tag is cited, as a rate per 100 inspections (so it isn't skewed by survey volume): Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025. The number is the average severity on the A–L scale (A=0…L=11); the letter is the band it falls in. A rise means the same tag is being cited at a more serious level — note the average can move enough to rank here while staying within the same letter. Same 20-citation minimum applies.
Care domain movers
Citations grouped into CFR care domains — F-tags by their §483 regulatory section (CMS State Operations Manual, Appendix PP) — measured as a rate per 100 inspections: Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025. Share is the domain's portion of citations this period; avg severity is the mean scope/severity letter and immediate jeopardy the percentage cited at J–L, both over the current period. Domains with at least 20 citations in both periods are shown; the sparkline tracks the last 12 months (left = oldest).
Immediate jeopardies · this period
Citations at the most serious scope/severity — J–L, immediate jeopardy, residents placed at risk of serious harm or death — over Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025. "Surveys with an IJ" counts distinct health inspections that had at least one.
Survey activity · by month
faded/dashed = still reportingCitations each month split into complaint-driven (unscheduled, triggered by grievances) vs standard surveys — bars, left axis — with the number of inspections as a line on the right axis. Rising inspections signal more scrutiny; a rising complaint share means more off-cycle surveys. The most recent 1 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025; the most recent 1 months are still being reported (dashed).
Penalties · by month
faded = still reportingTotal civil money penalty dollars imposed on the state's facilities each month — how hard the state is enforcing. The most recent 1 months are still being reported, and penalties often lag citations by several months.
Emerging tags
Tags that weren't established last period but surged — an early warning, distinct from movers (which track already-common tags). Criteria: fewer than 20 citations in the prior period, but at least 10 this period and 2.5× their prior volume. The sparkline shows monthly counts over the last 12 months (left = oldest).
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release July 29, 2026) and official state health department websites — never guesswork.
Some of the Latest Corrective Actions taken by Facilities in Minnesota
- Reeducated staff using the facility’s mechanical lift competency checklist via shift huddles and 1:1 sessions conducted by the DON, nurse manager, and staff development nurse (J - F0689 - MN)
- Completed audits/observations of mechanical lift transfers using the lift competency checklist to verify correct practice (J - F0689 - MN)
- Identified all residents using sit-to-stand/mechanical lifts and verified correct sling/harness sizing through therapy documentation, direct measurement, manufacturer guidelines, and care plan accuracy (J - F0689 - MN)
- Reviewed and updated the mechanical lift transfer policy to require sling/harness size documented in the care plan and Kardex, require 2-assist transfers when indicated, require staff verification of sling size prior to transfer, and require cinching of waist/middle straps before elevation (J - F0689 - MN)
- Updated care plans, Kardex, and care sheets to specifically identify lift type, assist level, and sling/harness size and ensure consistency across documents (J - F0689 - MN)
- Educated licensed nurses and other certified individuals on mechanical lift use including manufacturer recommendations, proper sling application, proper strap placement and cinching, when sit-to-stand lifts were contraindicated, and following the care plan (J - F0689 - MN)
Improper Mechanical Lift Transfer Leading to Resident Fall and Rib Fractures
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe mechanical lift transfer by not confirming that all four sling straps were properly attached before moving a resident. The resident involved was an elderly female with hemiplegia and hemiparesis following cerebral infarction affecting the left side, osteoarthritis, and fibromyalgia, who required a mechanical lift with assistance of two staff for transfers and used a medium-sized sling. On the day of the incident, two NAs used the mechanical lift and the appropriately sized sling to transfer the resident from her wheelchair to her bed. One NA attached the right upper and lower loops of the sling while positioned on the resident’s right side, and the other NA attached the lower loops and was responsible for operating the lift. After the sling was attached, the NAs raised the resident into the air and moved the lift backward, pausing between the wheelchair and the bed to obtain the resident’s weight using the lift’s weighing feature. During this process, the top left strap of the sling came loose from the lift, causing the resident to fall from the lift onto her left shoulder. The resident sustained acute displaced fractures of the 2nd and 3rd left ribs and required transfer to the hospital for further evaluation and care. The incident was documented in a progress note and an incident report, and an IDT meeting was held regarding the fall. Interviews conducted during the survey revealed that facility policy and staff expectations required that all four sling loops be checked for secure attachment before moving a resident, including lifting the resident slightly off the surface to verify tension and stability of the loops. The DON and nurse manager stated that staff are expected to perform a safety check by slightly lifting the resident and visually confirming that all sling loops are tight and completely attached before proceeding with the transfer. The DON’s investigation concluded that the upper left loop of the sling was either not attached or not properly attached by one of the NAs, and that both NAs failed to complete the required pause and safety check prior to moving the resident away from the original surface. This failure to follow established procedures for mechanical lift use led directly to the resident’s fall and injuries.
Removal Plan
- Removed the mechanical lift and sling involved in the incident from the floor
- Interviewed the staff involved and completed reenactments/demonstrations to determine what happened
- Suspended NA-A and NA-B pending investigation findings
- Immediately reeducated all staff on shift using the existing mechanical lift competency checklist used for onboarding
- Continued retraining for all shifts, including part-time staff and staff returning from leave as applicable
- Provided education via shift huddles and 1:1 reeducation sessions conducted by the DON, nurse manager, and staff development nurse
- Completed audits/observations of mechanical lift transfers for like-residents using the lift competency checklist to verify correct practice
Failure to Provide Adequate Supervision and Individualized Elopement Interventions
Penalty
Summary
The deficiency involves the facility’s failure to ensure an environment free from accident hazards and to provide adequate supervision and individualized, care-planned interventions for residents at risk of elopement. One resident with severe cognitive impairment and a diagnosis of malnutrition was initially assessed on admission as non-wandering and completely dependent for mobility and personal care. However, an elopement assessment completed days later identified this resident as an elopement risk who was able to self-propel a wheelchair, was cognitively impaired, actively exit-seeking, and expressing a desire to go home. The resident’s care plan, initiated after this assessment, included use of a wander device, monitoring the device for proper functioning, and prompt response to door alarms, but it lacked specific supervision measures and individualized interventions tailored to the resident’s escalating exit-seeking behavior. In the days leading up to the elopement, multiple progress notes documented that this resident was wandering up and down the hallway, confused, disoriented, and repeatedly attempting to leave the facility despite staff redirection. On the day of the elopement, documentation indicated the resident was very agitated, wandering into other residents’ rooms, calling the police, stating staff were holding her hostage, and attempting to leave multiple times. Video surveillance from the floor exit area showed the resident making several attempts over the course of the evening to open the stairwell and exit doors, triggering alarms that were reset by staff who redirected her away from the doors. Despite these repeated attempts and clear evidence of escalating exit-seeking, no additional formal interventions beyond the wander device were implemented, and staff did not revise the care plan to include increased supervision or other individualized strategies. Later that evening, the video showed the resident successfully exiting through the floor door without staff present. A police report documented that the resident, who was not dressed for the weather and wearing all black, was later found about five blocks from the facility after knocking on a private residence’s door and asking for help. She was transported to the hospital for evaluation and was discharged in stable condition without injuries. Interviews with staff revealed that agency NAs working that shift were not informed which residents were at risk for elopement and that their care sheets did not identify elopement risks or related interventions. Additional residents assessed as elopement risks also had care plans that included wander devices and general directions to monitor for exit-seeking and answer door alarms, but these plans similarly lacked specific supervision measures and individualized interventions, and NA care sheets did not consistently reflect elopement risk status. The facility’s elopement policy directed staff to establish a process to check bracelet alarm/device batteries according to manufacturer directions, and the user guide for the wander management transmitters required at least weekly testing to verify proper operation. Interviews with nursing and management staff showed inconsistent understanding of responsibilities for testing and ensuring functionality of wander devices, as well as for updating care plans and communicating elopement risk to direct care staff. Some nurses believed only nurse managers or the DON could change care plans, while the DON stated all nurses could make care plan changes. Nurse managers reported that residents at risk for elopement should be noted on NA care sheets, but agency NAs reported they were not alerted to any residents at risk to wander or elope. These documented gaps in assessment translation to care plans, supervision, communication, and device management contributed to the resident’s elopement and the identified deficiency. Three additional residents identified as elopement risks had diagnoses including dementia, moderate to severe cognitive impairment, and conditions such as breast cancer and acute encephalopathy. Their elopement assessments indicated confusion, disorientation, and requests to go home. Their care plans directed use of wander devices, monitoring and documentation of exit-seeking behavior, prompt response to door alarms, and inviting them to activities, but similarly lacked explicit supervision requirements and individualized interventions to prevent elopement. NA care sheets for these residents either did not indicate elopement risk or did not include interventions to prevent elopement. These findings showed that the facility failed to consistently integrate elopement risk assessments into clear, individualized supervision strategies and to communicate those strategies to all staff responsible for resident care.
Removal Plan
- Audited the care plans of residents identified as elopement risks
- Provided education to staff regarding the elopement policy
- Provided education to staff regarding elopement assessments
- Provided education to staff regarding one-to-one supervision
- Provided education to staff regarding safety checks
- Provided education to staff regarding wander device management
- Developed and implemented individualized care plans with interventions including supervision for residents at risk for elopement
Failure to Manage NPO, Food-Seeking Resident on G-Tube Feeding
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, care plan, implement interventions, and provide supervision for a resident who was NPO and dependent on G-tube feedings, despite known food-seeking behaviors and severe cognitive impairment. The resident’s admission MDS documented severe cognitive impairment, dependence on staff for ADLs, incontinence, and G-tube nutrition, with NPO status due to dysphagia and a history of silent aspiration. On 2/19, the care plan and a risk-versus-benefit form identified that the resident self-sought food and fluids while NPO, required reminders and redirection, and was at risk for aspiration, pneumonia, loss of airway, hospitalization, and possible death if consuming oral intake. The RD documented that the resident was self-seeking food and fluids, had impaired cognition, and could not repeat back understanding of the NPO education, and an order was added to the TAR to observe for self-seeking food and provide re-education as needed. Subsequent clinical notes showed ongoing concerns that the resident was eating and drinking despite strict NPO orders. On 2/25, the NP documented that staff reported continued food- and fluid-seeking, and the resident nodded yes when asked if she was eating or drinking; a chest X-ray was ordered, which was normal. On 3/4, the NP again documented silent aspiration, cough, coarse lung sounds, and that the resident continued to report oral intake despite strict NPO, and another chest X-ray was ordered and read as normal. An email exchange on 2/24 showed the IDT was aware of the resident’s low SLUMS score indicating dementia, wandering, and the need for a memory care bed, but no new interventions were established beyond continued monitoring when no memory care bed was available. Staff interviews and documentation revealed multiple unaddressed episodes of food-seeking and wandering into areas where food was present. A staff member reported seeing the resident eating a gummy jolly rancher given by another resident and observing her wandering into other residents’ rooms and attempting to eat food from leftover trays, as well as being in the dining room during and after meals; the record lacked evidence of any action taken in response to these events. Another staff member also reported seeing the resident wandering all over the unit and in the dining room during and after meals. The SLP stated the resident had severe cognitive deficits, wandered around the unit, did not understand what NPO meant, and was at high risk for aspiration if she ate regular food or fluids, based on a prior hospital video swallow study recommending NPO. The NP later stated she was never informed about the resident eating gummy candy and would have expected immediate notification for further assessment and monitoring. Ultimately, the resident was found unresponsive with heavy breathing and a very high temperature, was sent to the ED, and was diagnosed with acute hypoxic and hypercarbic respiratory failure with aspiration pneumonia; large food material was suctioned from the oropharynx, and the resident required intubation and CPR for a brief cardiac arrest. The surveyors concluded that the facility failed to assess, develop, and implement appropriate interventions and supervision for this known NPO, food-seeking resident, resulting in an immediate jeopardy situation.
Removal Plan
- Completed a full house audit of residents with modified diets
- Audited care plans for residents with modified diets
- Provided training to staff on modified diets and changes made to care plans
Failure to Recognize and Respond to Resident’s Change in Condition Leading to Sepsis and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to identify and act on a resident’s change in condition despite clear signs of acute illness and a care plan for potential infection. The resident had intact cognition per the annual MDS and no baseline hallucinations, delusions, or behaviors. Her care plan identified a self-care deficit and potential for infection related to urinary incontinence, with directions to update the provider as needed. Beginning several days before hospitalization, progress notes documented new hallucinations and emotional distress, including the resident yelling and crying about her babies being murdered and being taken from her, and an IDT discussion noting hallucinations and behavioral changes. These symptoms were atypical for this resident and represented a change from her baseline. Over the following days, the resident developed and sustained fevers and other signs of systemic illness. Vital signs showed temperatures of 101.7°F with a pulse of 140 bpm, later rising to 103.2°F and remaining elevated around 101–100°F over multiple readings, along with low-grade fevers on subsequent days. Progress notes documented vomiting, visible shaking, feeling cold, episodes of incontinent diarrhea, reports of pain “everywhere,” crying, tearfulness, fatigue, and refusal of medications and meals. Despite these findings, nursing staff treated the resident only with scheduled acetaminophen and did not conduct a documented comprehensive nursing assessment or notify the provider when the fevers and other symptoms emerged and persisted. The IDT discussed the resident’s fevers, fatigue, medication refusals, and verbal behaviors but did not review the progress notes or vital signs in detail, and no provider notification occurred at that time. Staff interviews further confirmed that the change in condition was not appropriately recognized or escalated. One RN stated she had not identified anything out of the ordinary beyond weakness and a presumed low-grade influenza, and that staff believed the resident might be recovering when a single temperature reading was normal. Another RN acknowledged that the resident’s change in condition occurred over a weekend when the IDT was not present and that the team did not review the progress notes or vital signs during the subsequent IDT meeting. A different RN reported that she did not assess the resident after the IDT discussion because the resident was asleep and her temperature had decreased slightly, and she felt that the resident’s bipolar diagnosis and prior behaviors had masked the change and interfered with judgment. The facility’s own policy required licensed nurses to evaluate significant changes in condition, obtain vital signs, and notify the provider of abnormal vital signs, behavioral or neurological changes, and worsening pain, but this process was not followed for this resident, resulting in delayed recognition and treatment of sepsis and subsequent hospitalization. Ultimately, the resident was sent to the ED only after she appeared pale with a grey hue, had dark circles under her eyes, was shivering, reported generalized pain, and continued to feel unwell. In the ED, she was found to be ill-appearing and toxic-appearing, with a high fever, tachycardia, hypotension, low GFR, and a diagnosis of sepsis with acute renal failure, septic shock, acute kidney injury, ureteral obstruction, and UTI. The attending MD later stated that the facility had not contacted her when the resident developed a fever and that earlier evaluation could have avoided the septic shock. The NP who saw the resident in the ED described her as barely responsive, with low blood pressure requiring IV fluids and vasopressors, and indicated that while the ureteral stone itself was not avoidable, the sepsis and unnecessary pain could have been prevented if the resident had been sent to the ED sooner. These facts support the finding that the facility failed to provide appropriate treatment and care according to orders, the resident’s preferences and goals, and its own change-in-condition policy.
Removal Plan
- Review policies and procedures related to change in condition and physician notification.
- Review all residents for a potential change in condition.
- Educate nursing staff on policies and procedures related to change of condition and resident monitoring, qualifying factors for a change of condition, assessment of resident symptoms without bias, and timely physician notification and treatment of resident symptoms.
Failure to Protect Cognitively Impaired Resident From Physical and Verbal Abuse and Delayed Response to Allegation
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident from physical and verbal abuse by a nurse aide and to respond appropriately once the allegation was reported. On the evening in question, two nurse aides were providing toileting and peri-care to the resident, who had non-Alzheimer’s dementia, depression, a psychotic disorder, and moderately impaired cognition with long- and short-term memory loss. The resident functioned at an estimated developmental level of an 8-year-old, had unclear speech, responded only to simple direct communication, and was dependent on staff for all ADLs including toileting and hygiene. During care, the resident became combative, yelling and swinging her arms, and one aide (NA‑B) responded by raising her voice, using foul and aggressive language, and striking the resident on the bare buttocks while stating that if the resident wanted to act like a child, she would be treated like one. A trained medication assistant (TMA‑A) standing outside the closed door heard NA‑B yelling at the resident to hurry up and grab the “fucking bar” and to walk to bed, and later learned from the other aide (NA‑A) that NA‑B had swatted the resident’s buttocks. NA‑A, who was in the room, described NA‑B’s tone as loud, aggressive, and intimidating, and reported that the resident was grunting and appeared nervous. NA‑A stated that after the resident yelled and grunted during brief placement, NA‑B told the resident that if she wanted to act like a child she would be treated like one, then smacked her on the right buttock with an open hand, skin-to-skin, producing a loud smack. NA‑A reported feeling very uncomfortable and believed the conduct was verbal and physical abuse. After leaving the room, NA‑A immediately told TMA‑A what had happened and, within about five minutes, located the charge nurse (LPN‑A) and reported the incident. NA‑A completed an Employee Concern form describing the incident and placed it in the DON’s box. TMA‑A also informed LPN‑A during the evening medication count that she had heard raised voices, swearing, and the resident crying, and that NA‑B had smacked the resident’s buttocks. Despite these reports, LPN‑A did not read the written complaint, did not conduct an immediate assessment of the resident, did not contact the on‑call nurse, and allowed NA‑B to continue working the remainder of the 12‑hour shift, caring for the resident and other residents without additional supervision. In the hours and days following the incident, the resident demonstrated changes in behavior and mood that were documented by staff. The next morning, staff noted the resident was tearful, withdrawn, and refusing food and drink, including favorite beverages, and she cried while in her wheelchair in a common area. Nursing notes and behavior monitoring entries over the subsequent days documented increased yelling, hitting, scratching, cursing, and physical aggression during care, as well as episodes of sadness, tearfulness, withdrawal, and isolation. Staff familiar with the resident, including RN‑A and NA‑E, reported that this withdrawn, tearful, and non‑eating behavior was not typical for her and that she usually did not cry without a reason. Although a full body assessment was later documented as showing no bruising and no verbalized pain, the facility’s own records and interviews describe that the resident became more tearful, had decreased appetite, and increased crying following the incident, and that she appeared different than normal—quiet, exhausted, withdrawn, and refusing to participate in usual activities and intake. These events, combined with the failure of the charge nurse to act on the initial reports and remove the alleged perpetrator from resident care, led to the cited deficiency for failure to protect the resident from abuse.
Removal Plan
- Reported abuse to the State Agency (SA).
- Investigated allegations of physical and verbal abuse and implemented resident protection.
- Re-educated staff on abuse and neglect, reporting, abuse prevention, resident rights, dementia, and vulnerable adults.
- Verified education through interviews and training records.
Improper Mechanical Lift Use and Inadequate Fall Root Cause Analysis
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe use of sit-to-stand and total body mechanical lifts, including correct sling/harness sizing, proper strap application, and adherence to care plans and manufacturer instructions. One resident (R4), with diagnoses including heart failure, chronic kidney disease, pancreatic cancer, diabetes, osteoarthritis, and a history of falls, was assessed as high fall risk and required assistance of two staff with a sit-to-stand lift using a large harness for all transfers. Despite this, on a prior date R4 experienced a witnessed fall from a sit-to-stand lift when a nursing assistant transferred the resident alone, contrary to the care plan, and the resident slipped out of the harness and fell to the floor, later reporting left shoulder pain. The facility’s documentation of that incident did not identify the sling size used, did not show a comprehensive assessment to determine the correct sling size for subsequent transfers, and the care plan was not revised to address the resident’s tendency to fall asleep in the lift. On a later observation, two nursing assistants (NA-C and NA-D) prepared to transfer R4 from bed to shower chair using a sit-to-stand lift with an extra-large (XL) harness draped over the lift, which they both believed was the correct size. Neither had a resident care guide in the room identifying the correct harness size. After the surveyor intervened and prompted verification, NA-D checked the resident care guide and discovered R4 was supposed to use a large harness, not an XL, and had to obtain the correct size from another unit because it was not available on R4’s wing. During the same transfer, after the large harness was applied and R4 was raised to standing, the torso strap was not cinched until the surveyor intervened and instructed the staff to tighten it. NA-C acknowledged she knew the torso strap needed to be cinched as the resident stood and that failure to do so could allow a resident to fall out of the lift, but stated she had overlooked this step. Staff also reported they had not received any re-education on proper mechanical lift use or following care plans since initial orientation. A second resident (R9), with diagnoses including heart failure, chronic respiratory failure, and chronic kidney disease, required total mechanical lift transfers and had been assessed via a sling/harness sizing assessment as needing a large sling. However, the resident’s care plan and Kardex directed staff to use an XL sling, conflicting with the sizing assessment. During observation, R9 was seated in a wheelchair on top of a sling whose size markings were washed off; a trained medication aide identified the sling as XL based on its color coding and confirmed via the Kardex that the resident was supposed to be in a large sling. The aide stated the resident could have fallen out of the oversized sling. The DON later confirmed that staff had been using the paper nurse aide care guide to verify sling size and that R9 had not been transferred with the correct sling size. The facility also failed to comprehensively investigate and analyze falls for root cause and to implement appropriate, person-centered interventions for another resident (R3) with malignant brain neoplasm, heart failure, osteoporosis, moderate cognitive impairment, and a history of falls. R3’s fall care plan included general interventions such as following the fall protocol, routine safety checks, anticipating needs, and reviewing past falls to determine causes, but subsequent fall incident documentation and root cause analysis worksheets were incomplete or lacked clear causal analysis and corresponding interventions. After an unwitnessed bathroom fall assisted by a family member, the root cause section was left blank, and the only care plan revision was to encourage family not to transfer the resident and to ask staff for assistance. Later falls, including one where the resident was found on the bathroom floor without a walker and another where the resident independently walked to the bathroom and lost balance, identified factors such as brain cancer, weakness, and self-transfers, but did not show comprehensive analysis or immediate interventions to mitigate further falls. One intervention, placing a dycem mat in the wheelchair seat, lacked a documented rationale linked to the identified causal factors. The DON acknowledged that comprehensive causal analyses had not been completed for each of R3’s falls and that toileting, identified as a root cause, was not addressed in the care plan until several days after repeated falls. The immediate jeopardy began when NA-C and NA-D had to be stopped from using the wrong harness size for R4 and failed to cinch the torso strap during a sit-to-stand transfer, despite R4’s prior fall from a sit-to-stand lift and existing care plan requirements. The medical director stated that any resident being transferred using a mechanical lift without the care plan and/or policy being followed had the likelihood to cause serious harm, serious injury, or death in the event of a fall from the lift.
Removal Plan
- The facility identified all residents who use a sit-to-stand lift, assessed each resident for the correct harness size needed, and educated each member of the nursing staff who will or may use the sit-to-stand lift.
- The facility assessed R4 and all residents using mechanical lifts for proper transfer method, correct sling/harness size, and care plan accuracy.
- The facility verified sling/harness size for each resident through therapy documentation, direct measurement, manufacturer guidelines, and care plan accuracy.
- The facility reviewed and updated the mechanical lift transfer policy to require sling/harness size documented in the care plan and Kardex, require 2-assist transfers when indicated, require staff verification of sling size prior to transfer, and require cinching of waist/middle straps before elevation.
- The facility updated care plans to specifically identify type of lift, assist level, and sling/harness size.
- The facility updated the Kardex to match the care plan.
- The facility updated care sheets to match the care plan.
- The facility provided education to all licensed nurses and other certified individuals on manufacturer recommendations, proper sling application, proper strap placement and cinching, when sit-to-stand lifts are contraindicated, and always following the care plan.
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