Citations in Minnesota
Comprehensive analysis of citations, statistics, 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 with dementia, diabetes, kidney disease, incontinence, and recent functional decline after a wrist fracture developed new skin breakdown on the buttocks and scrotum that was documented on routine skin checks but not promptly measured, characterized, or consistently treated. Early notes identified moisture-associated skin damage and planned barrier cream, yet the treatment record did not show consistent application, and a comprehensive CAA incorrectly stated there were no pressure ulcers. A wound care PA later recommended Triad paste, frequent repositioning, an APM, and RD review, but only the topical treatment was started promptly; the APM and nutritional evaluation were delayed for weeks while the wounds progressed to unstageable pressure ulcers and additional areas of breakdown developed. The IDT did not complete a comprehensive assessment or root cause analysis of the initial wound or its progression until after the resident was hospitalized and did not return.
A resident with schizophrenia, dementia, traumatic brain injury, and mild cognitive impairment, care planned for risk of abuse and rarely understood, was sitting in a wheelchair near an elevator when a contracted lab technician approached, gestured for the resident to move, and then slapped the resident’s face in view of others, causing facial redness. The lab technician stated he slapped the resident in response to a derogatory comment. The DON acknowledged that a slap is abuse and that facility staff did not supervise lab technicians. Both the DON and administrator reported that contracted lab staff did not receive or have verified VA abuse-prevention training, and the facility’s VA Abuse Prevention policy did not address abuse-prevention education for contracted staff.
A contracted lab technician slapped a resident in the face while the resident was seated in a wheelchair near an elevator, in view of other residents and staff. The technician later stated he would slap anyone who spoke derogatorily about his mother. Interviews with the lab supervisor, DON, and administrator showed that contracted lab staff did not receive VA abuse prevention training from the facility, and the facility did not verify any prior abuse-prevention education before allowing them to work with residents. The written VA Abuse Prevention policy, although stating zero tolerance for abuse by anyone including outside agency staff, lacked protocols for verifying abuse-prevention education for contracted personnel.
A resident with DM, peripheral neuropathy, malnutrition, and anxiety, who was independent with ambulation and eating, sustained a significant partial-thickness burn to the right thigh and groin after hot water from a plastic thermal mug spilled when the lid popped off during lunch. The resident reported severe pain, difficulty removing clothing, and a delay before a nurse arrived, while an NA described a large, very red area with a forming blister. Initial nursing documentation noted only redness and use of Vaseline, with later notes identifying a blistered burn and subsequent debridement, and a hospital wound consult later measuring the wound at 15 x 26 x 0.1 cm. Staff interviews revealed that residents had not been assessed for hot liquid safety before the incident, the resident’s care plan lacked hot liquid precautions at the time, and dietary staff acknowledged serving very hot water, with one report that reheated water had been temped at 138°F despite an existing hot liquid safety policy requiring assessment and individualized interventions.
A resident with severe cognitive impairment, hemiplegia, aphasia, dysphagia, and end-of-life cancer was care planned as a vulnerable adult requiring a calm, consistent approach, monitoring for emotional status, and protection from abuse. Video evidence showed a CNA removing a clean incontinent pad the resident kept under his pillow, throwing it on the floor, pushing the bed toward the wall, striking the resident’s hand with the call light, and repositioning the bed and remote out of his easy reach while he softly protested. The CNA then repeatedly gave the resident the middle finger, mocked him with facial expressions and grunting sounds, threw a bedspread over him, and left him in a lowered bed struggling to reach the remote, during which he cried and appeared visibly upset. Family interviews confirmed the resident became tearful, felt frustrated and defeated, and later more distrustful and withdrawn, while the facility’s written abuse prevention policy expressly prohibited such maltreatment.
A resident with diabetes, peripheral neuropathy, malnutrition, and anxiety, who was cognitively intact and independent with a walker, spilled hot water on the upper thigh, resulting first in redness and then in a large blistered area requiring wound care and later hospital debridement. Facility documentation showed physician and provider orders for topical treatment and dressings, but the DON and administrator acknowledged that, although they were notified soon after the incident, they did not consider the injury significant at first and did not report the allegation of neglect or serious bodily injury to the State Agency within the required 2-hour timeframe, contrary to the facility’s Abuse, Neglect, and Exploitation Policy.
Surveyors found that the facility failed to develop and update care plans to address repeated bath/shower refusals and assistance needs for two residents. One resident with stroke-related paralysis and total dependence for bathing frequently refused showers over several weeks, yet the care plan lacked interventions for refusals, did not document offering alternate times, and did not include the resident’s preference for certain staff. Another resident with traumatic brain injury, seizure disorder, heart and lung disease, and weakness was care planned as independent with bathing despite needing supervision or touch assistance and refusing showers for multiple consecutive weeks. This resident appeared disheveled with body odor and reported not bathing weekly and not being offered help, while nursing staff acknowledged missed baths, lack of documented independent showers, and absence of care plan interventions to address refusals or promote regular bathing, contrary to the facility’s stated expectations and care planning policy.
A resident with stroke-related expressive aphasia, cognitive impairment, and multiple comorbidities was allowed to leave independently for community outings without a documented assessment of community safety skills or corresponding care plan interventions. The MDS noted moderate cognitive impairment and did not assess community ambulation abilities, while the care plan addressed independence with ADLs and communication supports but not independent leave. Nursing notes showed repeated unsupervised outings, and staff interviews revealed no standardized process or clear criteria to determine which residents could safely go out alone, no provider order authorizing independent leave, and no consultation with therapy disciplines to evaluate communication and functional safety in the community, despite facility policies requiring comprehensive, person-centered assessment and care planning.
A resident with severe cognitive impairment was sexually abused by another resident with a documented history of sexually inappropriate behaviors, including prior breast touching and repeated attempts to touch female residents. Despite referral information and ongoing progress notes describing escalating behaviors such as handholding, rubbing arms and chest, standing over women, and persistent attempts to approach a particular female resident, the facility did not initially incorporate the full sexual behavior history into assessments and care planning, and staff did not consistently prevent physical contact. The abuse occurred when the male resident was found in a common area with his hand under the female resident’s shirt touching her breast while she rested in a recliner, after months of documented, inadequately controlled sexually inappropriate conduct toward female residents.
A resident with recent stroke, right-sided hemiparesis, severe cognitive impairment, and high fall risk was care planned for Hoyer lift transfers with assist of two. Shortly after admission, family brought in a power lift recliner that staff began using without notifying administration or obtaining the required RN/therapy assessment for safe use. Multiple staff transferred the resident into the lift chair over several days, despite her dependence for all mobility and poor safety awareness, and the remote was left where she could potentially access it. The resident was later found on the floor next to the lift chair, which was in the full stand position, and was diagnosed in the ER with a trimalleolar ankle fracture with talar subluxation, attributed to an unwitnessed fall from the unassessed lift chair.
Failure to Timely Assess and Implement Interventions for New Pressure Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to promptly assess and treat newly developed skin breakdown and to timely implement ordered interventions for pressure ulcer care for one resident. The resident initially had intact skin documented on a weekly skin inspection at the end of November, and a significant change MDS in early December showed no unhealed pressure ulcers, though it noted a recent fall with wrist fracture and increased need for assistance. A Braden assessment shortly after the fall scored the resident as low risk, despite dementia, diabetes, stage III kidney disease, incontinence, and increased dependence with mobility and transfers. On 12/6, a weekly skin inspection documented an “ongoing open area on left buttock” but did not include measurements, wound characteristics, or any treatment provided. A subsequent CAA signed 12/11 stated the resident did not have any pressure ulcers, even though it identified the resident as at risk for skin breakdown. On 12/11, another weekly skin inspection noted redness and a wound to the scrotum, again without clarifying whether this was the same area as previously documented or whether the earlier area had healed, and without documenting any treatment. On 12/12, skin issues were formally measured and recorded as MASD on the sacrococcygeal area and left gluteus, and another note the same day identified MASD to the scrotum and left buttocks with a plan for barrier cream, but there was no corresponding documentation on the TAR to show that barrier cream was consistently applied. On 12/16, a wound care PA evaluated the resident and documented scattered erosions over the right buttock and sacrum, with MASD to the buttock/sacrum, and recommended meticulous pericare, Triad paste BID and PRN, repositioning per Braden protocol, initiation of an APM, and RD review of nutritional needs. The record shows Triad paste treatments beginning 12/17, but the APM and RD evaluation were not implemented at that time. By 12/23, the sacrococcygeal area had progressed to an unstageable pressure ulcer with necrotic tissue, and the wound care PA again documented that the requested APM was not in place, re-requested it, and again asked for RD evaluation and wound-healing supplements. The care plan was not updated with new skin interventions until 12/24, and the APM was not documented as in place until 12/29, despite being readily available. Throughout December, provider regulatory visits did not address the resident’s skin condition, and Braden scoring continued to rate the resident as low risk. By 12/30, skin assessments documented multiple unstageable pressure ulcers and additional MASD areas, with the sacral wound significantly enlarged and new pressure ulcers on the buttocks, while the IDT did not complete a comprehensive assessment of the initial buttock wound identified on 12/6 or its progression from MASD to pressure ulcer until after the resident was hospitalized in early January. The facility’s own policy on Skin Assessment & Wound Management required that when a new pressure wound is found, staff notify the provider, initiate a skin and wound evaluation, refer to dietary as needed, and review and update the care plan interventions. The record lacked evidence that these steps were carried out when the first open area was documented on 12/6 or as additional areas and worsening wounds were identified. The TAR showed that the first documented treatment for the developed skin breakdown did not begin until 12/17, despite earlier documentation of open areas and MASD. Recommendations from wound care providers for an APM and RD evaluation were not acted upon for weeks, and the IDT did not complete a pressure injury root cause analysis or comprehensive review of the wounds until after the resident had been transferred to the hospital and did not return. Interviews with nursing staff and leadership confirmed that the root cause analysis process was not initiated when the wounds first developed and that the RD was not notified in a timely manner of the need for nutritional evaluation related to the resident’s wounds.
Failure to Protect Resident From Physical Abuse by Contracted Lab Technician
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by a contracted laboratory technician. The resident had diagnoses including disorganized schizophrenia, dementia, a history of traumatic brain injury, and mild cognitive impairment, and was documented as rarely understood with moderately impaired cognition. The resident’s care plan identified a focus on potential for abuse, neglect, and/or exploitation related to vulnerable adult status, with interventions directing staff to follow the Vulnerable Adult (VA) policy to keep the resident free from exploitation, abuse, and/or neglect. A general condition note documented that the resident was hit at 2:00 p.m. by an external vendor, resulting in slight redness to the left cheek. Video footage from the date of the incident showed the resident sitting in a wheelchair by the elevator doors with several other residents and staff in the area. A tall male, identified by the DON as a contracted laboratory technician, approached the elevator, motioned for the resident to move back, and then stepped forward and slapped the resident’s face with an open right hand. The technician later stated he slapped the resident because the resident said something derogatory about his mother and that he would slap anyone who did so. The DON stated that a slap on the face is considered abuse and acknowledged that facility staff did not supervise laboratory technicians and that residents were supposed to be protected from abuse by contracted staff through VA abuse prevention training. The DON and administrator both stated that the facility did not provide or verify VA abuse prevention training for contracted laboratory staff, and the VA Abuse Prevention policy did not address VA abuse prevention education for contracted staff.
Failure to Implement Abuse Prevention and Verification for Contracted Lab Staff
Penalty
Summary
The deficiency involves the facility’s failure to implement and operationalize written policies and procedures to prohibit and prevent abuse, neglect, and theft by contracted staff. Video footage showed a contracted laboratory technician approach a resident seated in a wheelchair near the elevator, motion for the resident to move back, and then slap the resident’s face with an open hand in the presence of other residents and staff. The technician later stated to the ADON that the resident had said something derogatory about his mother and that he would slap anyone who did so. The ADON questioned what the technician might do in a resident room with a resident who could not speak up for themselves. Interviews with the lab supervisor, DON, and administrator revealed that contracted laboratory technicians did not receive VA abuse prevention training, and the facility did not verify VA abuse prevention education for these contracted staff before they worked with residents. The DON and administrator both stated that residents were protected from abuse by contracted staff through VA abuse prevention training, yet acknowledged that the facility neither provided this training to lab technicians nor verified that they had received it elsewhere. Review of the VA Abuse Prevention policy, revised 10/1, showed it did not address protocols for assuring verification of abuse prevention education for contracted staff, even though the policy stated the facility does not tolerate abuse or misappropriation of resident property by anyone, including staff of other agencies serving the individual.
Failure to Assess and Protect Resident From Hot Liquid Burn
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from avoidable accidents related to hot liquids and to have an effective system to assess residents’ safety with hot liquids. A cognitively intact resident with diagnoses including diabetes, peripheral neuropathy, malnutrition, and anxiety was independently ambulatory with a walker and independent with eating. The resident’s care plan initially identified independence with eating, and only after the incident was a revision made to specify that staff should ensure the lid was on and secure for hot liquids. At the time of the incident, there was no documented individualized assessment or care plan intervention addressing the resident’s ability to safely handle hot liquids despite her peripheral neuropathy and other comorbidities. On the day of the incident, the resident was having lunch when hot water from a plastic thermal mug spilled onto her upper right thigh. The resident later reported that the lid was not sitting correctly on the mug and popped off, causing hot water to splash onto her hand, startling her and leading her to jerk, which caused the remaining hot water to spill onto her right thigh. She stated that the hot water soaked through her sweatpants and into her incontinent brief, burning most of the top of her right thigh and the right groin fold. The resident reported experiencing horrible pain and stated it took 20–30 minutes for a nurse to come while she struggled to remove her clothing. A nursing assistant confirmed being notified by dietary staff that the resident had spilled hot water, immediately taking her back to her room, and then leaving to find the charge nurse, describing the resident’s leg as a large, very red area with a forming blister and noting the resident’s significant pain and frustration. Clinical documentation following the incident showed that the initial nursing note described visible redness to the upper thigh, with education provided to the resident to be careful with hot liquids and to ask for help. The physician ordered Vaseline and pain medication. The following day, documentation identified a reddened area with a blister approximately five inches by three inches, and orders were obtained for Xeroform and dressings. A subsequent wound note documented a partial thickness burn acquired in the facility, but the measurements recorded were later verified as incorrect. The resident’s primary care provider’s visit note from the day after the incident did not mention the thigh burn, describing the skin as warm and dry with no rashes or lesions on exposed skin. Later documentation identified the burn as a stage 2 burn site requiring debridement and daily wound care. A hospital wound care consult subsequently measured the burn at 15 x 26 x 0.1 cm and described it as a partial thickness burn that was blistered, fragile, bleeding, and erythematous. Staff interviews revealed that prior to this incident, the facility had not been conducting hot water assessments on residents, and there was inconsistency in staff accounts regarding the existence and implementation of a hot liquid policy and temperature monitoring at the time the resident was burned. Additional staff interviews highlighted issues related to hot liquid temperatures and supervision. The dining specialist stated that all hot water and coffee were served from the kitchen and that the water was too hot, noting that on the day of the interview the temperature was being turned down. She reported being on duty when the resident was burned but did not know who provided the hot water, and she assumed, based on the severity of the burn, that the water had been way too hot. The certified dietary manager reported that a dietary staff member reheated the water in the microwave and stated that the water was reportedly 138°F when checked, with staff expected to log temperatures. The facility’s hot liquid safety policy, implemented prior to the incident, required assessment of all residents for their ability to handle containers and consume hot liquids, with individualized interventions on the care plan, and described the time–temperature relationship for serious burns, including that at 133°F a third-degree burn could occur in 15 seconds and at 140°F in 5 seconds. Despite this policy, interviews and documentation showed that residents had not been systematically assessed for hot liquid safety and that the resident involved in the incident did not have appropriate hot liquid precautions in place at the time of the burn.
Failure to Protect a Vulnerable Resident From Physical and Verbal Abuse by a Nursing Assistant
Penalty
Summary
The deficiency involves the facility’s failure to protect a vulnerable resident from staff-to-resident abuse by a nursing assistant (NA-A). The resident had a history of stroke, cancer with a prognosis of less than six months to live, hemiplegia and hemiparesis affecting one side of the body, aphasia, dysphagia, a prior neck of femur fracture, depressed mood, restlessness, and anxiety. The admission MDS documented severe cognitive impairment, no mood or behavioral issues at baseline, and dependence on staff for ADLs, with bladder and bowel incontinence. The care plan identified the resident as a vulnerable adult expected to decline due to end-of-life status, required assistance with incontinent care and transfers, and directed staff to use a calm, consistent approach, monitor for pain and emotional status, avoid overstimulation, and maintain an environment free of abuse, neglect, and exploitation. On the date of the incident, video footage showed the resident lying in bed wearing only an incontinent pad and partially covered by a sheet. NA-A removed a clean incontinent pad from under the resident’s pillow and tossed it on the floor, then used her hip to push the bed toward the wall. The resident, in a soft voice, said “no, no, no” while looking at the pad on the floor. NA-A told the resident he already had one on his body and did not need the extra pad. NA-A then grabbed the resident’s call light, moved to the other side of the bed, and when the resident raised his left hand, she hit his hand with the call light and told him to stop before plugging the call light into the wall and stating she was trying to help him. She then lowered the bed to the floor and placed the bed remote on the bedside dresser handle, out of the resident’s immediate reach. The video further showed that as NA-A picked up items from the floor, the resident pointed and faintly said “here, here, here,” indicating the area where the pad had been thrown. Standing at the foot of the bed, NA-A dropped a clear bag on the floor, raised and lowered her right hand, extended her middle finger toward the resident three times, and stuck her tongue out at him. She walked past him mocking him with facial expressions while picking up dirty linen. The resident pointed his finger and said “no, no, no,” after which NA-A left the room and the resident began crying, placed his left hand over his forehead, and appeared visibly upset. He struggled to reach the bed remote on the nightstand handle to raise his bed. When NA-A re-entered, she made grunting sounds mimicking the resident, threw a bedspread over him, lowered the bed back to the floor, placed the bed remote inside the bedside stand, and left the room with the lights on, without addressing or speaking to him. The resident again struggled to reach the remote and remained lying on his side looking at the floor with the bed in the lowered position. Family interviews corroborated the impact of the incident on the resident. One family member reported that she monitored a camera in the resident’s room, noticed his bedding torn apart, and called the facility for assistance, then observed the abusive interaction on the camera. She explained that the resident liked to keep an incontinent pad under his pillow to try to change himself and that he became very upset when NA-A took it away and threw it on the floor. She stated he briefly cried because of how he was treated and his inability to communicate or speak up, and that he felt angry, frustrated, then defeated, and ultimately very upset and tearful when NA-A flipped him off. Another family member stated the incident made the resident more distrustful of staff and withdrawn, and that in the moment it made him cower and cry, and she believed he felt disrespected, helpless, and in physical danger. The facility’s abuse prevention policy stated that maltreatment of residents, including abuse and neglect, would not be tolerated and that all employees were responsible for ensuring residents were free from maltreatment, but the actions of NA-A toward this resident constituted physical and verbal abuse contrary to that policy. The facility’s written Abuse Prevention and Prohibition policy, reviewed in 2022, specified that the facility would not tolerate maltreatment of residents, including abuse and neglect, and that all employees were responsible for assuring residents were free of maltreatment. It also stated that the facility would not knowingly employ individuals who had been convicted of abusing, neglecting, or mistreating individuals, and that reports of maltreatment would be promptly and thoroughly investigated. Despite these written expectations, the documented and observed conduct of NA-A toward this resident—throwing his clean incontinent pad on the floor, hitting his hand with the call light, mocking him with gestures and facial expressions, extending her middle finger at him multiple times, mimicking his vocalizations, and placing the bed and remote out of his reach while he cried and was visibly upset—constituted the abusive actions and inactions that led to the cited deficiency for failure to protect the resident from abuse.
Failure to Timely Report Significant Burn Injury as Alleged Neglect
Penalty
Summary
The facility failed to immediately report an allegation of neglect involving a resident who sustained a significant burn injury from hot liquid. The resident, who had intact cognition, ambulated independently with a walker, and was independent with eating, had diagnoses including diabetes, peripheral neuropathy, malnutrition, and anxiety. Progress notes documented that the resident spilled hot water on the right upper thigh, resulting in visible redness, and was educated to be careful with hot liquids and to ask for help when needed. A physician ordered Vaseline to the affected area and pain medication. The following day, documentation showed a reddened area with a blister approximately five inches by three inches, and the provider ordered Xeroform dressings, ABD pad, Kerlix, and added the resident to wound rounds. Despite these findings and the development of a large blistered area, the facility did not report the incident to the State Agency within the required two-hour timeframe for events involving alleged abuse or resulting in serious bodily injury, as required by its Abuse, Neglect, and Exploitation Policy. A later hospital wound care consult identified a partial thickness burn on the resident’s right thigh measuring 15 x 26 x 0.1 cm, described as blistered, fragile, bleeding, and erythematous, and requiring chemical and mechanical debridement. The DON stated she was notified of the burn on the date of occurrence but did not consider it significant until several days later and confirmed the burn was not reported to the State Agency. The administrator also confirmed that although staff notified him immediately after the incident, it was not reported to the State Agency, and there was no evidence the facility assessed residents for mitigation of hazards related to hot liquids prior to this event.
Failure to Care Plan for Bath/Shower Refusals and Assistance Needs
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and update comprehensive care plans addressing residents’ refusals of baths/showers. One resident with intact cognition, paralysis on one side related to a stroke, and full dependence on staff for bathing had a care plan noting a self-care deficit, left-sided weakness, a history of refusing ADLs, and the need for staff assistance with bathing. However, the care plan did not include any interventions for refusals of bathing or showers. Weekly skin assessments over several weeks documented that this resident refused showers, and nursing assistants reported that the resident frequently refused showers, sometimes only allowing certain staff to assist, but these preferences and alternate shower times were not reflected in the care plan or medical record. Nursing staff acknowledged that the resident missed baths, had a history of refusals, lacked a risk/benefit form, and that the care plan did not contain interventions for staff to follow when refusals occurred. Another resident with intact cognition and diagnoses including traumatic brain injury, seizure disorder, heart disease, and lung disease had a care plan indicating a self-care deficit related to weakness but incorrectly documented the resident as independent with bathing and did not reflect the need for supervision or touch assistance. Weekly skin inspections over multiple weeks showed this resident refused showers, and during observation the resident appeared disheveled with body odor and reported not bathing weekly due to feeling physically weak, stating staff did not offer help or ask about showers and being unsure of the last shower. Nursing staff later acknowledged that the resident did not bathe weekly, had refused showers for four consecutive weeks, and had no documented independent showers during that period, and that the care plan lacked interventions to promote bathing when the resident refused or did not bathe independently. The DON stated that the expectation was for staff to conduct risk/benefit education, notify the provider and power of attorney, and try different approaches when residents refused baths, and that successful interventions should be added to the care plan and updated with changes, but confirmed this had not been done for these residents despite missed baths over several weeks.
Failure to Assess and Care Plan Resident’s Safety for Independent Community Outings
Penalty
Summary
The deficiency involves the facility’s failure to assess and implement individualized interventions to ensure safe independent community access for a resident with expressive aphasia and cognitive impairment. The resident had multiple diagnoses including stroke, bipolar disorder, aphasia, diabetes type II, anxiety disorder, cognitive symptoms, and encephalopathy. The admission MDS documented moderate cognitive impairment and noted that community ambulation abilities (such as navigating uneven surfaces, managing curbs/steps, and car transfers) were not assessed. The resident’s care plan identified independence with ADLs, transfers, and ambulation, and noted vulnerability due to communication impairment with interventions such as clear, simple instructions and visual prompts, but it did not address community outings or independent leave. Nursing notes documented multiple occasions when the resident left the facility independently for outings, with staff noting expected return times, but there was no documentation between the admission date and the survey period of any assessment of the resident’s ability to safely navigate community environments, manage emergencies, or obtain assistance while outside the facility. During observation and interview, the resident was seen ambulating independently and demonstrated use of a cell phone to call family members, but the contact list did not include the facility’s phone number or address. Staff interviews revealed inconsistent understanding and lack of clear criteria regarding which residents were safe to leave independently; CNAs and RNs relied on factors such as ability to walk, absence of a WanderGuard, or checking the care plan or provider orders, but they did not reference any standardized assessment tool. Clinical staff, including a speech therapist and occupational therapist, reported they had not been consulted to assess the resident’s safety for independent community access, despite the speech therapist expressing concerns related to communication and suggesting that written word lists could assist the resident. The vice president of clinical services described an informal approach using hospital history, elopement assessment, and cognition to determine safety, and stated she would document in the care plan if a resident was not safe to leave alone, but there was no such documentation for this resident. The nurse practitioner stated she would expect an assessment of cognition, mobility, and functional abilities such as crossing the street, using a bus, or handling money before a resident went out independently. Facility policies on resident leave of absence and comprehensive person-centered care planning did not include protocols or criteria for determining when residents could leave independently, contributing to the lack of a formal assessment and care plan interventions for this resident’s unsupervised community outings.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse by Known Sexually Inappropriate Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a severely cognitively impaired female resident from sexual abuse by a male resident with a known history of sexually inappropriate behaviors. Prior to admission, referral documents from a previous facility clearly identified that the male resident had engaged in public urination, following female residents, rubbing their shoulders and arms, and an incident involving touching a woman’s breast, which had been serious enough to be reported to the State Agency. That prior facility had revised his care plan to include 1:1 supervision to prevent further sexually inappropriate behavior, and progress notes documented that while on 1:1 supervision he had no further incidents of touching female residents. Despite receiving these records, the admitting facility did not initially incorporate this history of sexually inappropriate behaviors into his vulnerability assessment or care plan. After admission, the male resident’s behaviors toward female residents, particularly one female resident with severe cognitive impairment, escalated over several months. Progress notes documented repeated episodes of him holding and rubbing female residents’ hands, rubbing or attempting to touch their arms and chest, standing over or very close to them, staring at them, and attempting to touch their breasts. Staff repeatedly redirected him, but the behaviors persisted and often required frequent or constant redirection. Although the care plan was eventually updated to address “touching of other residents” and directed staff not to allow physical contact, progress notes showed that staff did not consistently prevent physical contact, and the male resident continued to approach and touch female residents, including the cognitively impaired female resident who became the primary focus of his attention. On the day of the abuse incident, a nursing assistant observed the male resident standing over the cognitively impaired female resident, who was resting in a recliner, with his hand under her shirt touching her breast. Another resident pointed toward them, prompting the assistant to intervene, tell him to stop, and direct him away. The female resident, who had severe cognitive impairment and required extensive assistance with ADLs, awoke and questioned what he was doing, indicating she was unable to independently protect herself from the unwanted sexual contact. This event occurred in the context of documented ongoing and escalating sexually inappropriate behaviors by the male resident toward female residents, including this particular resident, and despite prior knowledge from referral records, guardian reports, and internal documentation that he had a pattern of progressing from seeking proximity and handholding to touching women’s breasts.
Failure to Assess and Safely Manage Use of Power Lift Chair Resulting in Fall With Fracture
Penalty
Summary
The deficiency involves the facility’s failure to implement its standards of practice for assessing and safely using a power lift chair for a resident with severe cognitive and physical impairments. The resident was admitted after a recent left PCA stroke with right-sided hemiparesis, expressive and receptive aphasia, severely impaired cognition, disorganized thinking, impaired vision, and dependence on staff for all ADLs and transfers. On admission, therapy evaluations and the care plan identified that the resident could not bear weight on the right lower extremity, had right knee buckling, poor trunk control, leaned to the right, and required a Hoyer lift with assistance of two for transfers. The Morse Fall Scale score placed the resident at high risk for falls, and the care plan directed staff to follow therapy recommendations, including use of a Hoyer lift for transfers. After admission, the resident’s family brought in an electric lift recliner that the resident had never used before and was not familiar with. The family did not explicitly notify administrative staff, but facility staff observed the chair being delivered and began using it for the resident within a day or two of admission. Multiple NAs and RNs reported transferring the resident into the lift chair using a Hoyer lift on several occasions over the following days. Staff interviews revealed that no lift chair assessment was completed by nursing or therapy prior to the resident’s use of the chair, despite an existing facility policy requiring evaluation of a resident’s ability to safely operate an electric recliner by therapy or an RN. Several staff members acknowledged they were aware that a lift chair assessment should have been completed before use, but they either assumed the chair was safe because it was in the room or did not verify whether an assessment existed. Therapy staff, including the PTA and PT, observed the resident seated in the lift chair during therapy sessions and used the remote themselves to adjust the chair, but no formal lift chair assessment was initiated. Interviews with the DON, care coordinator RN, MDS coordinator, therapy staff, and NAs consistently described the resident as confused, forgetful, unable to stand or walk, with right-sided paralysis and poor safety awareness, and indicated that the resident would not have been safe to use the lift chair or its remote independently. On the day of the incident, NAs transferred the resident via Hoyer lift from bed to the lift chair, elevated the feet with the remote, reclined the chair, covered the resident with a blanket, and placed the remote either over the left armrest or in the side pocket, in a manner that still allowed the resident potential access to the cord or remote. Shortly thereafter, the resident was found on the floor on her right side between the bed and the lift chair, with the chair in the fully upright stand position and the right foot in eversion with obvious ankle deformity. The resident was unable to provide a clear account of what happened. ER evaluation and x-rays confirmed a new trimalleolar fracture of the right ankle with lateral subluxation of the talus, which staff and providers attributed to the unwitnessed fall from the lift chair in the context of the resident’s inability to safely use or tolerate the lift mechanism.
Some of the Latest Corrective Actions taken by Facilities in Minnesota
- Completed mandatory staff education on elopement, missing residents, facility policies and procedures, and the specific elopement event (J - F0689 - MN)
- Re-educated nursing staff on completing the elopement risk assessment accurately and completely (J - F0689 - MN)
- Checked the wander guard system and confirmed it was in working order for all residents identified as an elopement risk (J - F0689 - MN)
- Reviewed charts and care plans for other at-risk residents and added interventions as needed (J - F0689 - MN)
Failure to Prevent Elopement of High-Risk Resident Despite Wander Guard and Known Exit-Seeking Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to implement appropriate, individualized interventions to prevent elopement for a resident who had been assessed as an elopement risk. The resident was admitted with diagnoses including repeated falls, dizziness and giddiness, unspecified mental disorder, and dementia with behavioral disturbance, and used a wheelchair. An elopement risk assessment identified the resident as an elopement risk due to verbal expressions of wanting to go home, wandering behavior, recent admission, and not accepting the situation. Suggested clinical actions included notifying staff of wandering and elopement risk, using exit alarms, and frequently monitoring the resident’s location. The care plan included a focus on wandering/elopement with goals that the resident would not leave the facility unattended and would remain safe, and interventions such as identifying de-escalation behaviors and providing reorientation. A nursing order directed staff to check the resident’s wander guard on the wrist daily and its function weekly. In the days leading up to the elopement, multiple progress notes documented escalating exit-seeking and behavioral issues. Notes indicated the resident wanted to go back to a prior place, was wandering, attempting to elope, hitting staff, and looking for her husband. The resident was described as alert and oriented to self with confusion at baseline, with chronic disorientation, some confusion, and chronic short-term memory loss. Staff documented that the resident had been on one-to-one supervision on a previous shift after attempting to leave the facility and becoming aggressive when redirected. On the morning of the elopement, a progress note recorded that the resident came into the hallway undressed, kicking and cursing at staff. Staff interviews confirmed that the resident had previous exit-seeking behaviors, was not easy to redirect, would refuse care, and was often kept at the nursing station for increased supervision. On the day of the elopement, staff assigned to the resident reported difficulty keeping track of residents during shift change and could not explain how the resident left the building while under their assignment. One NA stated the resident kept approaching the exit and setting off the wander guard alarm and that he had been assigned to watch the resident in the common area for a period before taking a break. At shift change, responsibility for watching the resident was to be handed off to other staff, but when the NA returned from break, the resident was missing. Another nurse reported that the resident had packed belongings and was waiting in the common area for transportation to another facility, and that around shift change staff left to find a replacement to supervise the resident; when they returned, the resident could not be located. Staff were unsure whether the wander guard alarm sounded, whether someone assisted the resident out the door, or how the resident exited the building, and the resident was still wearing the wander guard when later found. The facility’s location near several bus stations and the lack of camera coverage on the inside of the exit door were noted, and camera footage from outside showed the resident talking with other residents who were smoking and then following turkeys down a hill away from the building. The facility’s own policies required staff to attempt to prevent a resident’s departure if observed leaving and allowed use of a wander management system for residents at risk of elopement, but the events show that despite the resident’s known risk and documented behaviors, supervision and monitoring were not effectively maintained at the time of the elopement.
Removal Plan
- Facility began an investigation.
- Transferred R1 to a sister nursing facility with the capacity to keep her in a secured memory unit.
- Completed mandatory staff education on elopement, missing residents, facility policies and procedures, and the specific elopement event.
- Re-educated nursing staff on completing the elopement risk assessment accurately and completely.
- Checked the wander guard system and confirmed it was in working order for all residents identified as an elopement risk.
- Reviewed charts and care plans for other at-risk residents and added interventions as needed.
Failure to Control Smoking Materials and Prevent Oxygen-Related Fire
Penalty
Summary
The deficiency involves the facility’s failure to prevent an unintentional fire and to control smoking materials for a resident who used continuous oxygen and had documented dementia with moderate cognitive impairment. The resident’s diagnoses included pulmonary fibrosis, COPD, depression, nicotine dependence, and dementia. A smoking evaluation dated 12/19/25 identified the resident as safe to smoke independently, with no cognitive loss, no visual or dexterity problems, and allowed her to store and handle her own cigarettes and lighter. This evaluation did not address whether the resident understood safety measures related to removing or positioning oxygen equipment prior to smoking. The initial smoking care plan, initiated 12/23/25, set a goal for the resident to smoke safely and independently, noted education on the dangers of oxygen and smoking, and stated she was independent with smoking per evaluation, but did not include specific interventions regarding oxygen placement or removal before or during smoking. On 12/24/25, the resident was found smoking in her room, contrary to facility expectations. The incident analysis identified that she was a new admission and independent with smoking per her admission form. She was re-educated, and the plan was to remove smoking materials and keep them at the nursing station. A smoking evaluation dated 12/24/25 again documented no cognitive loss despite the MDS showing moderate cognitive impairment and a dementia diagnosis, and it specified that the resident could light her own cigarette but could not store her own smoking materials, which were to be kept at the nursing station. However, the smoking care plan was not revised until 12/29/25 to add the intervention to store smoking materials at the nurse station. A Risk vs Benefits form dated 12/30/25 identified the concern of the resident smoking in her room while on oxygen and described the dangers of oxygen-related fires, but it did not list any benefits, was not signed by the resident or representative, and there was no documentation of monitoring or evaluation of the effectiveness of the intervention to store smoking materials at the nurse’s station. On 1/29/26 at 8:39 a.m., progress notes documented that the resident was smoking in her room and caused a fire, indicating that the 12/29/25 intervention to keep smoking materials at the nurse’s station was not followed. The resident denied smoking and refused a respiratory assessment and skin check. An incident analysis for 1/29/26 stated that staff heard the roommate yelling for help and found a fire on the resident’s oxygen tank in her room while the resident was smoking, though she denied it. The fire was extinguished, and both residents were assessed with no injuries found. A search of the room revealed a pack of cigarettes, which was taken to the nurse’s station. The smoking evaluation dated 1/29/26 again documented no cognitive loss despite the MDS and dementia diagnosis, noted that the resident smoked 5–10 times per day, could light her own cigarette, could not store her own smoking materials, and that smoking materials were supposed to be kept at the nurse’s station. It also stated that daily room checks were to be done, that the resident used oxygen, had been educated to remove and store oxygen prior to smoking, and had a wanderguard on her portable oxygen tank. Following the fire, the care plan was updated on 1/29/26 with interventions such as daily room searches with the resident’s permission, safety checks, posting signs in Spanish about no smoking and oxygen being flammable, visualizing the room every shift to remove visible smoking materials, and using a wanderguard on the portable oxygen tank. However, between 1/29/26 and 2/2/26, the record did not include a comprehensive assessment or analysis supporting that 15-minute checks were appropriate or sufficient to prevent the resident from smoking, nor did the care plan provide instructions for staff if the resident was non-compliant with surrendering smoking materials. There was no documented assessment of the resident’s task-specific decisional capacity to safely engage in smoking while using oxygen, despite her dementia, moderate cognitive impairment on the MDS, and prior non-compliance on 12/24/25 and 1/29/26. On 2/2/26, the resident told an interviewer she did not trust staff with her smoking materials and admitted refusing to give them up when asked. She produced a box of cigarettes and a lighter from her coat pocket while wearing a nasal cannula connected to oxygen at 2 LPM. A nursing assistant reported that the resident often refused to give up her smoking materials after returning from smoking outside and that staff did not always have time to check residents after smoking to ensure materials were turned in. Another nursing assistant and an RN stated the resident was non-compliant with smoking rules, hid smoking materials, and that residents sometimes shared supplies, but these refusals and hiding behaviors were not documented in the record between 12/23/25 and 2/2/26. An LPN showed that the drawer designated for smoking materials at the nurse’s station contained only office supplies and confirmed there was no log to track smoking supplies. The DON acknowledged that family brought in smoking materials without first bringing them to the nursing station and that it was difficult to take items from the resident. These observations and interviews demonstrated that the resident remained in possession of cigarettes and a lighter after the fire, that staff were aware of ongoing non-compliance and family involvement in supplying materials, and that there was no effective system or documentation to ensure smoking materials were secured as care planned, resulting in continued risk of fire.
Removal Plan
- Reviewed smoking policies with the medical director and ombudsman input.
- Developed and implemented a comprehensive system to prevent accidents, hazards, and fires related to smoking inside the facility, including a plan for residents who fail to comply with safe smoking practices.
- Reassessed R1's capacity to make safe decisions regarding smoking.
- Revised R1's care plan with individualized interventions.
- Identified residents with similar smoking risks and their level of compliance with facility smoking policy.
- Implemented individualized interventions for residents with similar smoking risks to prevent unsafe smoking.
- Re-educated residents on safe smoking policies and administered a knowledge check quiz.
- Educated all staff on smoking policies and administered a knowledge check quiz to demonstrate understanding.
Failure to Immediately Initiate CPR and Activate EMS for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to immediately initiate CPR and activate EMS for a resident with a documented full code status who was found unresponsive. The resident had diagnoses including enterocolitis due to Clostridium difficile, a non-pressure ulcer of the left foot, and peripheral vascular disease, and required partial to moderate assistance with grooming and transfers. A physician order indicated the resident was full code, and the resident’s MDS showed a BIMS score of 15, indicating cognitive intactness. According to the report, around midnight a nursing assistant observed that the resident’s chest was not rising, the resident did not respond to attempts at arousal, and appeared not to be breathing. The NA immediately notified an LPN, who went to the room and found the resident in bed with the head of the bed elevated and the head tilted to the right. The LPN was unable to locate a radial pulse, observed no chest rise, and noted the resident’s forehead felt cool. The LPN did not pull back the covers to further assess the resident, did not verify the code status, did not announce a code blue, and did not give instructions to the NA. Instead, the LPN called another nurse to come to the unit, stating that before anything could be done, a second nurse was needed, and then waited approximately five minutes for that nurse to arrive. When the second LPN arrived, she found the first LPN and the NA standing outside the resident’s room. Upon entering, she assessed that the resident was not breathing, checked the code status, and determined the resident was full code. She noted the resident’s body was warm and that rigor mortis had not set in, and immediately initiated CPR, directing staff to call 911, announce a code blue, and obtain the AED and crash cart. The facility’s policy specified that for an unresponsive resident with a full code order, EMS should be activated immediately and CPR initiated unless there were obvious signs of clinical death such as rigor mortis, dependent lividity, decapitation, transection, or decomposition, or other specified exceptions. The failure of the first LPN to promptly assess for irreversible signs of death and to immediately initiate CPR and activate EMS for this full code resident resulted in an Immediate Jeopardy citation.
Removal Plan
- Completed an investigation and identified that a nurse failed to initiate CPR immediately on a full code resident found unresponsive.
- Conducted a root cause analysis and identified that CPR was not initiated per facility policy and that delegation of duties during the code situation did not occur.
- Placed the involved nurse on leave pending the investigation and terminated employment.
- Educated staff on the processes and procedures to follow when a resident is found unresponsive.
- Audited and verified all residents’ code statuses as correct.
- Reviewed facility policies.
Explore Popular Searches
