Episcopal Church Home Of Minnesota

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Medications and biologicals were not consistently stored in locked or otherwise secure locations, and expired or discontinued insulin pens were found in storage. During observation of one medication cart outside the TCU team room, a small med cup with two white pills sat beside a large bottle of acetaminophen on top of the cart while no staff were present. The RN later returned to the cart, left the medications unsecured again, and then eventually disposed of the cup with the pills. The RN stated the acetaminophen had been prepared for a resident but was left out when the resident was found to be in therapy, and acknowledged it should not have been left where anyone walking by could have taken it. A tote beside the same medication cart contained three insulin pens in a clear graduated cylinder, not in individual plastic bags and touching each other. The pens were identified as insulin lispro for one resident and insulin aspart and insulin glargine for another resident. The RN stated insulin pens should not be left out in the open, should normally be stored in the top drawer of the med cart, and should not be stored in direct contact with another resident’s insulin pens. In another observation, an unattended medication cart on the May unit had a bottle of acetaminophen and a teriparatide injection sitting on top of it while staff and a family member walked by. An LPN stated she had forgotten to place the injectable medication in the refrigerator and lock the acetaminophen in the cart. A medication for one resident was also found in the room of a different resident. In the room of a resident with intact cognition and severe glaucoma, a bag containing diclofenac gel was sitting on the bedside table. The resident did not know what the medication was, and the label showed it belonged to another resident. Staff who entered the room stated it appeared to have been left there earlier in the day and could not explain why it was in the wrong resident’s room. In addition, review of insulin storage found an insulin aspart pen and a Lantus pen labeled for one resident even though the aspart was not a current order and the Lantus had been discontinued months earlier; the RN stated both pens should not have remained in storage.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Appropriate hand hygiene was not ensured during incontinence care for a resident who had severely impaired cognition, was always incontinent of bowel and bladder, and was dependent on staff for toileting and lower body dressing. During an observation, two nursing assistants assisted the resident into bed and one nursing assistant performed bowel care while wearing gloves, cleaned the resident, tucked soiled wipes into the brief, removed the soiled brief, and then continued care with the same soiled gloves. The nursing assistant placed a new brief under the resident, opened an emollient jar, and used the same contaminated gloves to scoop out ointment and apply it to the resident’s backside before removing the gloves. The nursing assistant later stated the gloves should have been changed after incontinence care and acknowledged it was a mistake to use soiled gloves in the emollient jar. Other staff stated gloves should have been changed, hand hygiene performed, and new gloves put on before touching anything else. Appropriate hand hygiene was also not ensured for a resident during meal service. The resident had severely impaired cognition, dementia, and required assistance from staff with personal hygiene. Observations showed the resident’s fingernails on both hands were approximately two inches long with brown matter caked underneath them. During multiple meal observations, staff placed food in front of the resident and did not offer to wash the resident’s hands or use hand sanitizer before eating or after meals. The resident ate with her hands, touched food with her fingers, licked her fingers, and handled food and crumbs at the table. Nursing assistants and an RN stated staff were responsible for ensuring residents’ hands and fingernails were clean and for offering hand washing or sanitizer before and after meals. The facility also failed to ensure appropriate PPE was worn for a resident on enhanced barrier precautions. The resident had cellulitis, an abscess of the right lower extremity, a history of sepsis, and a weeping right lower extremity wound that required frequent dressing changes because the dressing became saturated and leaked. During an observation, a nursing assistant entered the room with a mechanical standing lift to complete a transfer without wearing PPE. Staff stated the resident was not on precautions because there was no PPE bin or signage outside the room. Other staff later stated that if a resident was on enhanced barrier precautions, a gown should be worn for high-contact care and direct care, including transfers, and that signage and a PPE bin should be present. The resident’s care plan did not include enhanced barrier precaution interventions.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure medications were administered safely for 2 residents who had been assessed as unable to safely self-administer medications. One resident had COPD, OSA, and a functional decline related to a right scapula and rib nonunion. Her care plan and provider orders included calcium carbonate antacid, but the EMR lacked orders allowing self-administration or bedside medication storage, and her SAM assessment indicated she did not want to self-administer medications and agreed to have them administered by the facility. During observation, she had an unlabeled inhaler and a cup with two chewable tablets on her bedside table, and an LPN confirmed the medications were a Symbicort inhaler and Tums that should not have been left at the bedside because she was not assessed as safe for SAM. The second resident’s quarterly MDS indicated cognitive intactness, but provider orders stated she may not self-administer medication, and the SAM assessment indicated she was not safe to self-administer medications and had hoarded and used multiple OTC medications. Despite this, Biofreeze topical analgesic was observed in a bin on her bedside table on multiple occasions, and the resident stated she applied it herself. A nursing assistant confirmed the Biofreeze was in the room because the resident used it when needed. Staff interviews and facility policy stated medications should not be left at the bedside unless the resident had been assessed as safe for SAM and had the required provider order.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the PCP and wound care provider were notified of a change in condition for a resident with severely impaired cognition, diabetes mellitus, and non-Alzheimer's dementia who was dependent on staff for toileting, bed mobility, transfers, and lower body dressing. The resident was admitted with an unstageable pressure injury to the left heel and had a care plan focused on that wound, but the care plan did not include any toe concerns. A weekly skin audit later identified ischemic tissue on the tip of the right first toe, measuring 1.2 cm by 0.9 cm, and a nursing progress note documented that an on-call senior care NP was notified and instructed staff to continue monitoring and update the PCP wound nurse on the next business day. The required update was not completed. The consultant wound care NP visit on 4/16/26 documented the left heel wound as healed and noted no new skin issues were reported, and the NP was not informed about the new right first toe skin alteration first observed on 4/4/26. When the wound provider later evaluated the toe, it was documented as a non-pressure wound of unknown duration, full thickness, and at least greater than 14 days old, with measurements of 1.2 cm by 1.8 cm. The wound had increased in width by 0.9 cm since it was first measured, and new orders were issued for Betadine and off-loading. During observation, the resident's right first toe was exposed and black on the top, and staff described it as a bruise of unknown duration. Interviews confirmed the facility did not complete the ordered update to the PCP wound care provider and did not maintain consistent monitoring of the necrotic toe. The DON stated the facility should have updated the PCP or wound provider as identified in the on-call order and documented the change in the medical record, and the wound care NP's medical liaison confirmed their service was not updated on the new skin alteration.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure a new skin alteration on a resident’s right first toe was comprehensively assessed and monitored in accordance with nursing standards of practice, and failed to enter provider orders for monitoring and referral into the EMR. The resident had severely impaired cognition, was dependent on staff for toileting, bed mobility, transfers, and lower body dressing, and had diagnoses including diabetes mellitus and non-Alzheimer’s dementia. She was admitted with an unstageable pressure injury to the left heel and was identified as being at risk for pressure injuries, but her care plan did not include any notation or interventions for toe concerns. Weekly skin audits documented the right first toe change beginning with ischemic tissue on the tip of the toe measuring 1.2 cm by 0.9 cm, followed by later audits that either omitted the toe alteration or described hard dark tissue and cyanosis/bruising without measurements. A nursing progress note documented that the on-call provider was notified and instructed staff to continue monitoring and update the PCP wound nurse, but the MAR, TAR, and EMR lacked orders to monitor the toe or to complete the update. Because the weekend provider orders were not transcribed into the EMR, staff did not continue consistent monitoring or obtain further measurements, and the PCP wound nurse was not updated as ordered. After hospitalization, a wound care NP documented the left heel wound had healed and no new skin issues were reported at that visit. Later, another wound care NP assessed the right first toe as a non-pressure wound of unknown duration, full thickness, with measurements of 1.2 cm by 1.8 cm, showing increased width compared with the earlier measurement. During interviews, the ADON, LPN, senior care NP, and DON stated that the order to update the PCP wound provider should have been completed, that weekend orders should be entered into the EMR, and that weekly skin audits should include measurements and progress documentation. The facility skin care policy required assessment of ulcer type, characteristics, infection, pain, dressings and treatments, along with daily monitoring and at least weekly documentation.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure a resident was safe to have a lift reclining chair. The resident had severe cognitive impairment, lower extremity impairment on one side of the body, a history of falls, dependence on staff for transfers, and diagnoses including dementia, disorientation, anxiety, muscle weakness, and a right pubis fracture. The resident’s care plan identified high fall risk related to impaired mobility, confusion, and dementia, and directed staff to keep the call light within reach and encourage use of it. The care plan also stated the resident required two staff to assist with transfers using a standing lift as needed, but it did not identify use of a lift reclining chair. The physical device review also did not identify an electric recliner chair or other lift type reclining chair. During observation, the resident was transferred into the lift chair by therapy staff, who lowered it from an upright position to a seated and then reclining position. The remote for the lift chair and the call light were both placed on the resident’s lap next to each other. The PTA stated she was not aware of any assessment for safe use of the lift chairs, and nursing and therapy staff stated they were not aware of any formal lift chair assessment for the resident. The DON stated therapy worked with residents who had lift chairs and was not aware of any formal assessment, and later stated the resident should have had an assessment completed to determine if she was safe to have a lift chair. The DON also stated the resident was cognitively impaired and could accidentally use the lift chair remote when intending to push the call light.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to immediately respond, investigate in a timely manner, and implement resident protections following allegations of verbal, mental, and physical abuse, as well as neglect of care, for two residents. In the first case, a resident with dementia and impaired mobility required staff assistance for repositioning. The resident and a family member reported that a nursing assistant used inappropriate language and physically handled the resident in a rough manner, including throwing the resident's legs against the wall. The incident was reported to the social worker, and both the administrator and DON were notified. However, the investigation lacked interviews with other staff or residents, and there was no documentation of protective measures taken during the investigation. Progress notes did not mention the incident, and the staff member involved was not immediately suspended. In the second case, a resident with moderate cognitive impairment and limited mobility required assistance with activities of daily living and was at risk for pressure injuries. The resident's family member reported overhearing a nursing assistant refuse to provide timely incontinence care, make threatening statements about using the call light, and remove the resident from her room while she was wet and in her nightgown, placing her in a public area without her phone. The investigation documentation lacked interviews with other staff or residents, and the staff member was only removed from caring for the resident but continued to work with other vulnerable residents. The incident was not reported to the State Agency as required, and the investigation was not thorough. Interviews with facility staff, including the social worker, LPN, RN, and administrator, revealed inconsistencies and gaps in the investigation process. Staff acknowledged that best practices, such as suspending the alleged perpetrator and interviewing all relevant parties, were not followed. Facility policy required prompt reporting, suspension of the alleged perpetrator, and comprehensive investigation, but these steps were not consistently implemented. The administrator and DON did not ensure timely communication with families or complete documentation, and there was a lack of clarity regarding which incidents were reportable and how investigations should be conducted.

Removal Plan

• Reviewed and revised policies and procedures related to abuse reporting, protections, and investigating allegations of abuse.
• Educated all staff and leadership on the above policies and procedures with competency. Training included conducting thorough investigations.
• Assessed all residents for abuse who had contact with implicated staff.
• Care plans for R2 and other affected residents were updated to include specific protections and interventions.
• Staff involved in the allegations were removed from the schedule to eliminate access to resident pending completion of the investigations.
• Thorough investigations were completed for the incidents and were reported to the State Agency.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that annual performance reviews were completed for four out of five nursing assistants whose personnel files were reviewed. Specifically, one nursing assistant had not received a performance review since October 2022, another since February 2023, a third since July 2023, and for the fourth, no documentation of any performance review could be provided. The administrator confirmed that annual performance reviews should be conducted by nurse managers and overseen by the DON, but acknowledged that documentation for recent reviews was missing for these staff members. The employee handbook states that annual reviews are to be provided on or around each employee's anniversary date of employment. This deficiency had the potential to affect all residents who could receive care from these staff members.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to promote dignity and respect for three residents requiring assistance with activities of daily living. One cognitively intact resident reported being handled roughly by a nursing assistant, including having his legs thrown against the wall and being spoken to in a disrespectful manner. The resident's family member overheard the incident via phone, including staff using inappropriate language and physically spinning the resident in bed, which led to the resident requesting not to work with that staff member again. Another resident with moderate cognitive impairment and limited mobility was left sitting in a public area by the nurses' station in a wet brief and nightgown after requesting assistance for incontinence care. The nursing assistant told the resident that staff no longer provided toileting on demand and made the resident wait for rounds. The resident was also denied access to her phone during this time. Staff interviews confirmed that the resident was left in a public space in inappropriate attire and that the communication used by the nursing assistant was not appropriate and could be perceived as punitive or degrading. A third resident with moderate cognitive impairment and impaired mobility reported being struck on the legs by a nursing assistant while being awakened for dinner. The resident expressed distress about being handled roughly. Staff interviews confirmed that striking a resident to awaken them was not appropriate and that alternative, respectful methods should be used. The facility's own dignity policy requires all residents to be treated with dignity and respect at all times, which was not upheld in these incidents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to immediately report allegations of physical and verbal abuse to the State Agency (SA) within the required two-hour window for three residents after family members or the residents themselves reported the alleged abuse. In one case, a resident with dementia and impaired mobility, who required staff assistance for repositioning, and his family member reported that a nursing assistant used inappropriate language and physically handled the resident in a rough manner. The incident was documented by the social worker, and both the administrator and DON were notified, but the required report to the SA was not filed in a timely manner. The resident later expressed reluctance to return to the facility due to the abuse. Another incident involved a resident with moderate cognitive impairment and limited mobility, who was dependent on staff for toileting and transfers. The resident's family member overheard a nursing assistant making punitive statements and denying the resident timely toileting assistance, resulting in the resident being left in a wet brief and nightgown in a public area. The incident was reported to facility leadership, but the SA was not notified within the mandated timeframe. Interviews with staff confirmed that the actions and communication by the nursing assistant could be considered abusive and should have been reported immediately. A third case involved a resident with moderate cognitive impairment who reported being struck on the legs by a nursing assistant when being awakened for dinner. The incident was reported to the SA, but not within the required two-hour window. Facility policy required immediate reporting and suspension of the alleged perpetrator pending investigation, but in these cases, the facility either delayed reporting or did not report at all, and did not consistently suspend the staff involved. Interviews with facility staff and administrators revealed uncertainty and inconsistency in the reporting process, with some incidents being classified as customer service issues rather than abuse, leading to failures in timely reporting as required by regulation.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that three out of five nursing assistants reviewed for annual training completed the required 12 hours of in-service education within the last 12 months. Personnel file reviews showed that one nursing assistant had completed only 8.6 hours, another had completed four hours, and a third had completed zero hours of the required training. The facility used a computer-based education system (Relias) to track training hours, and these deficiencies were identified through document review. Interviews with staff development and the administrator revealed that annual education was expected to be completed in person during each staff member's anniversary month, with online training assigned if in-person sessions were missed. However, the staff development department confirmed that the three nursing assistants had not completed the required training and had not been assigned the necessary online modules. The facility's policy required a minimum of 12 hours of annual in-service training, with completion documented in personnel files, but this process was not followed for the identified staff.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to adequately monitor and assess for signs and symptoms of urinary tract infections (UTIs) and to document the effectiveness and potential adverse reactions to antibiotics for two residents who experienced a change in condition. For one resident with impaired cognition, frequent incontinence, and a history of lumbar fracture and encephalopathy, there was an order for a urinalysis and culture, but the resident's family opted for outside testing. Upon return with a UTI diagnosis and an order for oral antibiotics, the resident's records lacked evidence of consistent monitoring for UTI symptoms beyond vital signs, such as changes in incontinence, burning, odor, or frequency, and did not consistently document monitoring for antibiotic side effects. Another resident, with diagnoses including congestive heart failure and depression, was also identified as frequently incontinent of bladder. After being diagnosed with a UTI and prescribed a five-day course of oral antibiotics, the resident's documentation did not indicate what UTI symptoms were present or provide consistent notes on the presence, increase, or decrease of symptoms, nor on any side effects from the antibiotic. There was no clear documentation to determine if the resident's urinary symptoms had resolved or if the antibiotic was effective after the treatment course. Interviews with nursing staff and the DON confirmed that facility policy requires documentation of UTI symptoms, vital signs, and any adverse reactions to antibiotics every shift following a UTI diagnosis. However, the records for both residents lacked this required documentation, including initial symptoms, provider notifications, and follow-up monitoring. The facility's own policies on change in condition and UTI management were not followed, as assessments, interventions, and resident responses were not consistently recorded in the medical record.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that frozen food items were stored properly to prevent cross-contamination in two of the three unit kitchenettes reviewed. During an observation of the second-floor kitchenette, an opened plastic bag of frozen, pre-cooked bacon was found unsealed and dated 3/3. Additionally, a resealable gallon-sized bag of frozen, pre-cooked sausage links was also dated 3/3. A sealed plastic bag of frozen, pre-cooked pancakes was found with a thick layer of white ice crystals inside. Nursing assistant (NA)-J confirmed the dates and stated that the unit typically went through the food items in three days per policy. However, the opened bags of bacon and sausage links were not removed by the main kitchen staff, who were expected to check and remove undated and old food items each morning. Further observation of the first-floor kitchenette revealed an opened and unsealed bag of frozen, pre-cooked bacon dated 3/4, which was not resealed in its original packaging, leaving it exposed to air in the freezer. The culinary supervisor (CS) confirmed that kitchen staff were expected to remove outdated or bad-looking food items and that everything in the fridge and freezer should be covered or sealed. The culinary manager (CM) verified the opened food packages and stated that both kitchen and nursing staff were expected to remove outdated and opened items. The facility's policy required all food products not in their original containers to be placed in approved, seamless, tightly sealed containers to prevent freezer burn and spoilage. The administrator also expected food to be labeled and sealed appropriately to prevent cross-contamination.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure timely provider notification when a skin alteration was identified for a resident, R24, who was at risk for skin breakdown due to conditions such as kidney failure, diabetes, and vascular disease. On 2/8/25, a nurse noted R24's right little toe was blackened and malodorous, but there was no indication that the provider or family was notified. The situation worsened by 2/9/25, with the toe appearing gangrenous, yet again, there was no documentation of provider or family notification. It was not until 2/10/25 that the nurse practitioner assessed the toe and sent R24 to the hospital for surgery, resulting in a toe amputation. Further deficiencies were noted in the follow-up care of R24's surgical incision. From 2/28/25 to 3/5/25, there was no documentation of changes to the surgical incision or notification to the provider or surgical team. Interviews with staff revealed a lack of communication and documentation regarding the resident's condition. The facility's policy required prompt notification of the provider for changes in condition, which was not adhered to in this case, leading to a delay in appropriate medical intervention.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to comprehensively assess and document a new skin alteration and changes in a surgical incision for a resident who developed a gangrenous toe requiring surgical treatment. The resident, who was cognitively intact and had diagnoses including kidney failure, diabetes, and vascular disease, was at risk for skin breakdown. Despite the care plan directing staff to monitor and report skin changes, the facility did not notify the family or provider when the blackened, malodorous toe was first observed. The lack of comprehensive assessment and documentation continued until the resident was sent to the emergency room, where a partial foot amputation was deemed necessary. Additionally, the facility failed to ensure proper coordination of care for a hospice patient with a change in condition. The hospice patient, who had severe cognitive impairment and was on hospice care for a terminal illness, experienced multiple seizures. Despite documented seizure activity, the primary provider was not updated, leading to a discrepancy in the provider's notes, which stated no seizures had occurred since a previous date. The hospice case manager and consultant pharmacist were unaware of the ongoing seizure activity, indicating a lack of communication between the facility, hospice, and primary care providers. Interviews with facility staff, including registered nurses and the Director of Nursing, revealed expectations for documentation and communication that were not met. The facility's policy required collaboration and communication between hospice and facility staff, but this was not effectively implemented. The Director of Nursing acknowledged potential issues with communication due to nurse managers' availability, and the medical doctor confirmed a lack of updates regarding the hospice patient's condition. The facility's failure to adhere to its policies and ensure timely communication and documentation contributed to the deficiencies identified in the report.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure a safe smoking environment for two residents, leading to a deficiency in maintaining a hazard-free area. One resident, identified as R50, was observed smoking without a proper disposal receptacle for cigarette butts, resulting in him extinguishing cigarettes on the ground. His care plan indicated he was independent with smoking and used a smoking apron, but there was no description of safe disposal of smoking materials. During observations, R50 was seen without his smoking apron, and staff did not remind him to wear it, despite acknowledging its necessity to prevent burns. The designated smoking area lacked an ashtray or container for safe disposal, and maintenance staff confirmed this was an ongoing issue due to theft of the receptacles. Another resident, R55, also faced issues with the lack of a smoking receptacle. Despite being on smoking restrictions due to dental surgery, R55 admitted to not always following them and disposed of cigarette butts on the sidewalk or trash can. The facility's smoking policy required smoking waste to be cleaned up and kept out of sight, but observations showed this was not adhered to. Interviews with staff revealed that maintenance checks were not documented, and the facility's policy was not effectively enforced, contributing to the unsafe smoking environment.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain a dialysis fistula site according to professional standards of care for a resident requiring dialysis. The resident, who was cognitively intact and had diagnoses of kidney failure, diabetes, and vascular disease, required dialysis three times a week. However, the resident's provider and nursing orders did not specify the location of the fistula or any restrictions for taking blood pressure on the left arm. During an observation, a trained medication assistant (TMA) took the resident's blood pressure on the left arm, which was the same arm as the dialysis fistula site. The TMA was unaware of any restrictions regarding blood pressure measurements on the arm with the fistula and needed to verify with the nurse. Interviews with staff revealed a lack of communication and documentation regarding the resident's dialysis care needs. The registered nurse confirmed that blood pressure should not have been taken on the left arm and noted that the resident was wearing a sweatshirt, which may have obscured the fistula site. The Director of Nursing expected staff to take blood pressures on the opposite arm of the fistula, and this information should have been included in the orders and communicated to the nursing assistants. The facility's policy on dialysis did not address standards of care for dialysis residents, contributing to the oversight.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that antifungal medications prescribed to two residents were monitored and evaluated for the appropriateness of continued use. Resident R17 was prescribed clotrimazole cream for a fungal infection, which was applied twice daily for over a year without an end date or reassessment of its necessity. Despite the absence of any documented skin issues or candidiasis in R17's records, the medication continued to be administered. The primary care provider's notes lacked any review of the continued use of clotrimazole, and the medication was not reconciled with the provider's list, indicating a lack of communication and oversight. Similarly, Resident R27 was prescribed nystatin powder and later Zeasorb-AF powder for skin conditions, with orders lacking end dates. The nystatin powder was used for nearly three years without reassessment, and the addition of Zeasorb-AF was not accompanied by discontinuation of the nystatin, despite its ineffectiveness. The resident's care plan and medical records did not document any ongoing fungal infections, and the primary care provider's notes did not address the continued use of antifungal medications. The hospice RN case manager later identified that the nystatin should have been discontinued when Zeasorb-AF was started. The facility's policy on unnecessary medications requires regular review of each resident's medication regimen to prevent excessive durations and ensure appropriate indications for use. However, the facility did not adhere to this policy, as evidenced by the prolonged use of antifungal medications without proper evaluation or documentation of need. Interviews with staff revealed a lack of consistent practice in reviewing and updating medication orders, particularly for topical antifungals, contributing to the deficiency.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure proper hand hygiene and adherence to transmission-based precautions (TBP) for residents, leading to deficiencies in infection prevention and control. Resident R24, who was cognitively intact and had a history of MRSA, was observed to have inadequate TBP measures in place. Despite the presence of signs indicating Enteric Contact Precautions, staff members, including a trained medication assistant and a registered nurse, were unsure of the specific precautions required and failed to don appropriate personal protective equipment (PPE) when entering R24's room. Additionally, during personal care, a nursing assistant did not perform hand hygiene after glove removal and reused washcloths inappropriately, further compromising infection control. Resident R84, who had severe cognitive impairment and was dependent on staff for personal care, also experienced lapses in infection control practices. During a brief change, nursing assistants failed to change gloves and perform hand hygiene before touching clean items such as blankets and bed controls. This was acknowledged by the staff involved, who admitted to not following proper hand hygiene protocols as outlined in the facility's policy. The facility's policies on hand hygiene and Enhanced Barrier Precautions were not adequately followed, as evidenced by the staff's actions and statements. The Director of Nursing expected staff to adhere to TBP and perform hand hygiene after glove removal, but these expectations were not met. The lack of clear communication and understanding of the required precautions contributed to the deficiencies observed during the survey.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that two residents, R59 and R211, were offered and/or provided updated vaccinations for pneumococcal disease, and one resident, R59, was not offered an updated influenza vaccination in accordance with CDC guidelines. R59, who was admitted with a diagnosis of diabetes, had not been offered the necessary pneumococcal vaccinations despite being at higher risk for pneumococcal diseases. His medical record lacked documentation of a discussion regarding additional pneumococcal vaccines, a signed declination, or documentation of risks and benefits. Although R59 received a pneumococcal conjugate vaccine in 2017 and an influenza vaccine in 2023, the facility did not ensure his vaccinations were up to date. R211, who had diagnoses of heart failure and hypertension, also did not have up-to-date influenza and pneumococcal vaccinations. His immunization report lacked documentation of any vaccinations, a signed declination, or information regarding risks and benefits. The Director of Nursing (DON) stated that the health unit coordinator was responsible for entering vaccine information into the computer system, and the nurse was responsible for offering and administering the vaccines. However, the facility did not have a Minnesota Immunization Information Connection (MIIC) report for R211, and the facility's policy on influenza and pneumococcal vaccinations was not provided upon request.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide a timely COVID-19 vaccination to a resident, identified as R211, who had requested it. R211 was admitted with intact cognition and diagnoses of heart failure and hypertension. The resident's immunization report lacked documentation of a COVID-19 vaccination, and there was no signed consent or declination form with the risks and benefits for the COVID-19 vaccination in the medical record. During an interview, R211 stated he had not been vaccinated in years and had inquired about receiving various vaccinations, including COVID-19, but was told they could only be administered at the care center, which had not occurred. The Director of Nursing/Infection Preventionist confirmed that the facility did not have a Minnesota Immunization Information Connection report for R211 and that the resident had not received the COVID-19 vaccination. The facility's policy required documentation of vaccine administration or declination, which was not followed in this case.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide appropriate treatment, monitoring, and care for a resident (R1) who developed skin ulcerations. R1's primary physician was not immediately notified when the first wound was discovered or when the wound had a significant change. R1 was admitted to the hospital with wounds on both legs requiring surgical interventions, but the facility was only aware of the wound on R1's right leg. The care plan for R1 did not include any focus, goals, or interventions for potential skin integrity concerns, and there was a lack of documentation and communication regarding the wounds. R1's nursing assistant skin monitoring documentation indicated multiple instances of skin tears and open areas, but the audit did not provide detailed information. The facility's records showed that R1 had a cognitive impairment and required assistance with daily activities. Despite being at risk for pressure ulcers, R1's care plan did not address these concerns. The facility's weekly skin body audits were incomplete, and there was a delay in notifying the wound care team and the primary care provider about the worsening condition of R1's wounds. Interviews with staff revealed a lack of communication and coordination in addressing R1's wounds. Nursing staff did not consistently report changes in R1's condition to the primary care provider or the wound care team. The facility's medical director acknowledged communication issues and the need for more consistent staff on the dementia unit. The facility's policy on skin care was not followed, leading to a delay in treatment and the progression of R1's wounds to a critical state requiring hospitalization.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to prevent the development of three pressure ulcers in a resident, identified as R1, who was cognitively impaired and required assistance with daily activities. Despite being at risk for pressure ulcers, R1's care plan did not address potential or actual skin integrity concerns. The resident's condition was not adequately monitored, as evidenced by the absence of documentation for a weekly skin body audit on one occasion and the lack of noted pressure ulcers in subsequent audits. Staff interviews revealed that nursing assistants and registered nurses were aware of changes in R1's skin condition, including redness and missing skin layers, but failed to report these findings or implement a treatment plan. The resident's decline in mobility and increased time spent in bed were noted by staff, yet no adjustments were made to R1's care plan to address these changes. The facility's protocol for wound care, which required daily skin inspections and physician notification for identified wounds, was not followed. The pressure ulcers were only discovered when R1 was admitted to the hospital for wound care, where they were assessed as serious, with one being unstageable and another at Stage III. The hospital's assessment indicated that these pressure injuries were acquired at the nursing facility, highlighting a significant lapse in care and monitoring by the facility staff.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to notify a resident's representative of a change in the resident's health condition when a new medication and treatment were ordered. The resident, identified as R1, was cognitively impaired and required assistance with daily activities. R1 was diagnosed with several conditions, including chronic atrial fibrillation, hypertension, renal failure, and dementia. On a specific date, the facility noted a wound on R1's right leg and contacted the primary care physician, who prescribed an antibiotic and a dressing change. However, the facility did not inform R1's representative, who was the power of attorney, about the wound or the new treatment until a care conference was held several days later. The family member, FM-A, who was the power of attorney, only became aware of the wound during the care conference and expressed concern that earlier notification might have prevented the resident's hospitalization. The assistant director of nursing confirmed that there was no documentation of notification to the resident's representative before the care conference. The facility's policy required prompt notification of changes in a resident's condition to the attending medical doctor and the resident's power of attorney, which was not followed in this case.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to report an allegation of neglect immediately, as required, to the State Agency for a resident who was admitted to the hospital for wound care. The resident, who was cognitively impaired and required assistance with daily activities, was found to have three pressure ulcers upon hospital admission. The resident's medical history included chronic atrial fibrillation, anemia, hypertension, renal failure, diabetes type II, and dementia, among other conditions. The facility's records indicated that the resident was at risk for pressure ulcers but did not have any documented wounds prior to the hospital admission. The resident's physician had ordered treatment for blisters on the right leg, but the situation escalated when the nurse practitioner recommended hospital evaluation due to the severity of the wounds. The hospital's assessment revealed extensive necrotic wounds on the resident's lower extremities, requiring surgical intervention. Despite the severity of the wounds and the hospital's involvement, the facility did not report the incident to the State Agency as required. Interviews with facility staff revealed a lack of immediate action in reporting the incident. The social worker acknowledged awareness of the situation through communication with the hospital and family, but the facility did not report the incident. The assistant director of nursing deferred questions to the director of nursing, who was on vacation, and the administrator confirmed awareness of the hospital update but did not perceive the wounds as neglect. The facility did not have a policy on reporting available during the survey.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop a care plan addressing a significant change in a resident's skin integrity and wound treatment interventions. The resident, who was cognitively impaired and had multiple health conditions including chronic atrial fibrillation, anemia, hypertension, renal failure, diabetes type II, and dementia, was at risk for pressure ulcers. Despite this risk, the care plan did not include any focus, goals, or interventions for skin integrity concerns or wound treatment when a wound was discovered. Additionally, the care plan inaccurately indicated that the resident required assistance from one staff member for transfers, while in reality, the resident was using a mechanical lift and a wheelchair for ambulation. Interviews and record reviews revealed that the resident's wound was first noticed on 5/1/24, but the care plan was not updated to include wound care interventions. The resident's family member was not informed of the wound until a care conference on 5/14/24, and the care plan lacked directions for staff regarding the use of a mechanical lift. Nursing staff were aware of the resident's need for daily dressing changes and the use of a mechanical lift, but these were not reflected in the care plan. The Assistant Director of Nursing (ADON) confirmed that skin integrity concerns and the use of the EZ-stand were not included in the care plan, despite facility policy requiring such issues to be addressed in the care plan.