Wabasso Restorative Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Wabasso, Minnesota.
- Location
- 660 Maple Street, Wabasso, Minnesota 56293
- CMS Provider Number
- 245400
- Inspections on file
- 42
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 28
Citation history
Health deficiencies cited at Wabasso Restorative Care Center during CMS and state inspections, most recent first.
A resident with paraplegia, reduced mobility, and dependence on staff for transfers developed new swelling and edema of the right lower leg, initially denying any known trauma. Nursing staff notified the physician, applied ACE wraps, and later sent the resident to the ED when swelling and vascular concerns worsened, where imaging revealed acute fractures of the right tibia and fibula. Although the injury’s origin was initially unknown and no clear root cause was established, facility leadership did not submit an incident report to the State Agency, relying instead on later documentation suggesting the leg was accidentally hit by a wheelchair.
The facility failed to accurately assess and document mechanical lift sling sizes for two residents who required total assistance with transfers using a Hoyer lift. Manufacturer instructions required sling selection based on both height and weight, but staff and the DON described using primarily weight and did not consistently consider height. For one resident with paraplegia and multiple mobility impairments, the care plan and lift assessment specified use of a full lift with two staff but omitted the resident’s height, weight, and sling size. For another resident with lumbar spondylosis, muscle weakness, and spinal stenosis, the lift assessment contained a weight range inconsistent with the MDS and did not identify sling size, and the care plan did not specify sling size or transfer device. Staff interviews showed confusion about who determined sling size and where this information was documented, with no sling size information found in care plans or the NA binder.
A resident with multiple pain-related conditions, including neuropathy, fracture, and chronic wounds, had care plans and PRN orders for various analgesics and non-pharmacological interventions, but the plan did not specify an acceptable pain level or clearly direct which analgesic to use before wound treatments. Records showed no comprehensive assessment or specific interventions for preventing pain during wound care, and on one morning only aspirin was given despite a documented pain level of 6, with no evidence that other ordered PRN pain medications or non-pharmacological measures were offered. During an observed buttock dressing change, the resident repeatedly yelled and verbalized pain while being turned and treated, and pain medication was not offered before the procedure began. Staff interviews confirmed the resident frequently screamed in pain with repositioning, that PRN medications were often given only if requested or directed, and that the LPN and DON later acknowledged that stronger pain medication and earlier intervention should have been used based on the facility’s pain scales and the resident’s reported pain levels.
Two residents with pressure ulcers received wound care during which an LPN and an RN repeatedly failed to follow the facility’s hand hygiene policy and did not consistently ensure clean work surfaces. For one resident with multiple stage 4 pressure ulcers and enhanced barrier precautions, the LPN did not sanitize the work area before placing wound supplies and repeatedly changed gloves without performing hand hygiene while handling genital areas, shared gauze containers, and open wounds. For another resident with a stage 3 pressure ulcer, the LPN initially placed supplies on an unsanitized overbed table, examined the genital area, cleansed a sacral ulcer, and applied dressings while frequently changing gloves without hand hygiene, and the assisting RN also changed gloves without sanitizing hands. These actions were inconsistent with the facility’s policy that glove use does not replace hand hygiene and that hand hygiene must be performed before donning and after removing gloves and when moving from contaminated to clean body sites.
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 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.
A resident with severe cognitive impairment and high care needs was physically abused by another resident, who pulled her hair, struck her head, and pushed her wheelchair. The victim reported the incident to several staff and a family member, who contacted law enforcement after being unable to reach the facility. Staff interviews confirmed the abuse was reported, but there was a delay in administrative response and awareness. The aggressor had a history of behavioral issues and recent medication changes. The facility failed to prevent and promptly address the abuse, leading the victim to leave due to fear for her safety.
A resident with severe cognitive impairment reported being physically assaulted by another resident, and although nursing staff were informed immediately and internal monitoring was initiated, the facility did not report the allegation to the State Agency within the required timeframe. The incident was reported to law enforcement by the resident's family before the facility submitted the required report.
A resident with cognitive impairment was unable to locate survey results, and review of the facility's survey binder revealed missing recertification surveys, complaint investigations, and plans of correction. Staff confirmed that not all required documents were available, and no policy for posting survey results was provided, limiting access to important information for all residents, families, and staff.
Staff did not promptly inform a resident, the resident's doctor, and a family member about important events such as injury, decline, or room changes, as required. This lapse in communication was identified during the survey.
The facility did not honor a resident's right to voice grievances without discrimination or reprisal and failed to establish or follow a grievance policy or make prompt efforts to resolve grievances.
A resident with mental health diagnoses did not receive morning medications as preferred because staff failed to wake her, leading to behavioral escalation. The care plan did not reflect her established preferences for wake-up and medication times, and staff were unaware of these needs until after the incident.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a failure to meet individualized care requirements.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
A resident with PTSD and cognitive impairment experienced ongoing unwanted sexual advances and explicit notes from another resident, leading to psychosocial harm. Despite multiple reports from residents and staff, the facility did not conduct a comprehensive assessment, update care plans, or implement effective supervision and interventions to ensure safety, resulting in continued distress and a lack of protection for the affected resident.
A resident with severe cognitive impairment and mental health issues, along with several other female residents, reported ongoing sexual harassment, inappropriate advances, and theft by another resident. Despite being aware of these allegations and conducting internal investigations, facility staff did not report the incidents to the State Agency within the required timeframe, failing to follow policy and protect residents.
A resident with severe cognitive impairment and mental health diagnoses reported ongoing sexual harassment and inappropriate advances from another resident, including unwanted letters and verbal behaviors. Multiple residents expressed feeling unsafe, but the facility did not conduct a thorough investigation, failed to document interviews or protective actions, and did not prevent further incidents, despite repeated complaints and its own policy requiring immediate response.
A resident with complex behavioral and mental health needs was transferred to another facility without being given adequate notice, the right to appeal, or the opportunity to remain during the appeal process. The transfer was conducted rapidly, with the resident not signing a discharge agreement, not being allowed to discuss the move with an advocate, and experiencing emotional distress after the move. The facility did not follow its own policies regarding resident rights and discharge procedures.
Two residents with PTSD did not receive trauma-informed care when one was repeatedly harassed and sexually approached by another, despite both having documented trauma histories. The facility failed to update care plans, assess psychosocial harm, or implement effective monitoring and interventions, resulting in ongoing distress and unaddressed triggers for both individuals.
A resident with severe cognitive impairment and psychiatric conditions did not have required physician documentation for routine visits over a 60-90 day period. Although the physician saw the resident and signed orders, no note was entered in the medical record, contrary to facility policy.
Two residents with significant behavioral health needs, including PTSD and cognitive impairment, were not provided with comprehensive assessments or individualized, person-centered interventions. One resident experienced ongoing harassment and triggering of trauma symptoms by another resident, with insufficient safety measures or supportive services implemented. The facility did not follow its trauma-informed care policy or provide evidence of effective behavioral health planning.
The facility did not adequately identify or document the specific care and practices needed for residents with PTSD in its facility-wide assessment, and failed to maintain the required full-time Social Services Designee (SSD) position, instead splitting the SSD's time between two locations. This resulted in insufficient social services support for residents with behavioral health needs, including those with PTSD.
A resident with a history of substance abuse left the facility and was found intoxicated at a bar. The facility lacked protocols to monitor or prevent substance abuse, and the resident's care plan was not updated following the incident. Staff were unaware of how to handle the situation, and there was no documentation of vital signs or assessments upon the resident's return.
A resident with congestive heart failure experienced significant weight gain and symptoms such as shortness of breath and chest pain, but the facility failed to monitor and report these changes to the physician. Despite hospital discharge orders for daily weight monitoring, the facility did not adhere to these instructions, leading to the resident's hospitalization for CHF exacerbation and a heart attack.
The facility failed to provide accurate Ombudsman contact information to residents, as observed during a resident council meeting. Five residents were unaware of how to contact the Ombudsman, and the posted information was outdated. Interviews confirmed the inaccuracy, despite previous requests for updates. The facility's assessment and admission packet indicated residents should be informed of their rights and provided with accurate contact information, which was not effectively implemented.
The facility failed to provide necessary physical therapy (PT) services to residents due to the absence of PT staff since August 2024, affecting residents who required these services. Despite having physician orders for PT, residents did not receive the necessary therapy. Additionally, the facility's staffing plan was not adhered to, particularly on weekends, where the number of staff scheduled was less than required. The administrator acknowledged the need to update the facility assessment to reflect the actual services provided.
The facility failed to adequately explain the binding arbitration agreement to 16 residents, leading to a lack of understanding and awareness of their right to refuse signing. Interviews revealed that many residents did not recall receiving an explanation or understanding the agreement, with some feeling pressured to sign without full comprehension. This deficiency affected the residents' rights to make informed decisions about their care and legal options.
A facility failed to implement enhanced barrier precautions for a resident with surgical wounds and a PICC line, as required by CDC guidelines. Observations showed no signage on the resident's door, and staff did not wear gowns during dressing changes. Additionally, the facility's infection control surveillance was inadequate, with critical sections left blank, making it impossible to determine if precautions were implemented timely. The DON, new to her role, admitted to being unsure about necessary precautions, and oversight from a sister facility's IP was minimal.
Two residents in a facility expressed fear of retaliation from staff, feeling intimidated and unable to voice concerns. One resident, admitted with multiple health issues, felt the social services designee was unapproachable and feared being expelled. Another resident, with chronic pain and other conditions, believed the facility misrepresented its services and was denied access to a doctor. During a resident council meeting, several residents shared similar fears. The facility's policy on reporting concerns lacked specific avenues for addressing fears of retaliation from management.
The facility failed to securely store lighters for residents who smoked, leading to potential fire hazards. Residents were observed keeping lighters and cigarettes in unsecured locations, contrary to the facility's policy. Staff reported challenges in enforcing the policy, as residents often kept lighters in their possession. The facility's smoking policy did not explicitly address the secure storage of lighters, contributing to inconsistent enforcement and increased fire risk.
A facility failed to ensure nursing staff were competent in identifying and responding to an emergent change in condition for a resident with congestive heart failure, leading to a delay in emergency medical evaluation. The resident experienced significant weight gain, shortness of breath, and chest pain, but staff did not notify the physician or send the resident to the emergency department. Interviews revealed a lack of timely updates to the physician and insufficient staff training on recognizing changes in condition.
The facility failed to maintain adequate staffing levels on weekends as per their assessment, with only one licensed nurse on the day shift for 12 out of 26 weekend days. The administrator was unaware of the staffing requirements and questioned the accuracy of data submitted to CMS.
A resident with intact cognition and a history of stroke, heart failure, renal insufficiency, and diabetes mellitus reported missing personal items to the Social Service Director (SSD). Despite the report, the SSD did not recall the grievance, and no documentation was found in the facility's grievance log. The facility also failed to provide a grievance policy, indicating a lack of follow-up and documentation.
A facility failed to ensure a resident could communicate with their county care coordinator (CC), resulting in multiple unsuccessful contact attempts by the CC. The social services designee (SSD) instructed the CC to direct communication needs to her, but the CC faced difficulties reaching the SSD and the resident was not informed of the calls. Interviews revealed no directive to forward calls to the SSD, and residents could take calls privately. The resident was unaware of the CC's attempts, indicating a communication breakdown.
A facility failed to accurately code the MDS for a resident with a non-pressure chronic ulcer and other medical conditions. Despite medical records confirming the presence of a skin ulcer, the MDS did not reflect this, leading to discrepancies in the resident's care documentation. Interviews revealed that the resident was aware of ongoing wound care, but staff were not consistent in coding practices, and the DON was unaware of the MDS coding process.
The facility failed to revise care plans for two residents, leading to deficiencies in their care. One resident's care plan lacked monitoring for behaviors associated with anti-anxiety medication and did not address potential adverse reactions or signs of increased depression. Another resident's care plan did not include daily weight monitoring as ordered, resulting in significant weight gain and hospital readmission with congestive heart failure.
The facility failed to assess and document target behaviors and non-pharmacological interventions for residents on psychotropic medications. One resident with severe cognitive impairment and worsening behaviors lacked a care plan with specific target behaviors. Another resident's care plan did not include non-pharmacological interventions for anxiety and depression. A third resident's care plan failed to document target behaviors or side effects of medications. The DON acknowledged these deficiencies, which were not in line with the facility's psychotropic medication policy.
The facility failed to label two opened vials of Tuberculin (TB) PPD solution with an open date, as required by the manufacturer's guidelines. The vials were found in the medication room refrigerator without an open date, despite being dispensed on a specific date. An LPN confirmed the absence of an open date, and the DON expected medications to be dated and initialed upon opening. A policy on medication labeling and storage was not provided.
A resident with intact cognition and multiple health conditions, including stroke and diabetes, repeatedly requested a dental appointment due to missing molars. Despite oral assessments documenting these requests, the facility failed to schedule the necessary dental services. The Social Service Director did not recall the request and missed an email notification from the RN responsible for oral assessments.
Two residents at the facility did not receive physician-ordered physical therapy (PT) services due to the unavailability of PT providers. One resident, admitted to regain strength and return to independent living, did not receive PT after August 2024. Another resident, with moderate cognitive impairment and requiring assistance with daily activities, also did not receive PT as ordered. The facility lacked a plan to provide PT services in the interim, and no policy on skilled therapy services was available.
The facility failed to ensure the DON, also serving as the IP, had the necessary training and oversight for effective infection control management. The DON was new to the role and had not completed required training, leading to incomplete documentation and analysis of infection control measures. Surveillance records showed gaps in isolation and precaution documentation for residents with infections, including COVID-19, resulting in deficiencies in infection control practices.
A resident with a history of aggressive behavior physically abused two other residents in the smoking area of an LTC facility. Despite a care plan requiring supervision, the resident was not adequately monitored, leading to repeated incidents of aggression. Staff and other residents expressed concerns about the resident's behavior, highlighting a failure in the facility's abuse prevention measures.
A resident with a history of unsafe smoking behavior was frequently observed smoking without supervision, despite being deemed unsafe to smoke independently. The facility's failure to enforce its smoking policy and provide necessary supervision led to multiple incidents, including resident-to-resident altercations. Staff acknowledged challenges in monitoring the resident, who was able to access cigarettes and lighters against facility policy.
The facility failed to report an allegation of abuse to the State Agency (SA) for a resident with moderate cognitive impairment who required staff assistance with daily activities. Despite being notified by the county sheriff's department, the facility's staff believed that since the allegation had already been reported by an outside facility, they did not need to report it to the SA again. This failure to report the allegation as required by federal regulations constitutes a deficiency.
The facility failed to analyze and evaluate identified PIP concerns within their QAPI program. Meeting minutes lacked documentation on data analysis, intervention modifications, and decisions on project continuation. The executive director and DON acknowledged these deficiencies during an interview.
The facility failed to ensure that all licensed nursing staff were appropriately trained and competent to administer insulin. An LPN administered insulin without priming the pen, and the DON confirmed no insulin competencies had been completed. Additionally, there were no drug books or manufacturer's directions available for reference.
The facility failed to provide mandatory training on its specific QAPI Program to all staff. Interviews revealed a lack of awareness and understanding of the facility's QAPI goals and elements, with staff either not receiving any QAPI training or only receiving generalized training through Relias. The executive director of operations acknowledged the issue, and the review of training records showed outdated or missing QAPI training for several staff members.
The facility failed to ensure that four out of nine staff members received the required initial and annual training on Alzheimer's disease or related disorders, ADLs, problem-solving with challenging behaviors, and communication skills. The training records for the DON, an LPN, and two NAs were incomplete, leading to deficiencies in staff preparedness.
A facility failed to ensure a resident appropriately disposed of cigarette butts, posing a risk to other residents. Despite being aware of the designated receptacle, the resident stored used cigarette butts in her jacket pocket and discarded them in her room's trash bin. Staff were aware of the issue but did not effectively enforce the smoking policy.
A resident with moderate cognitive impairment and respiratory issues was observed multiple times with incorrect oxygen settings, contrary to physician orders. Staff confirmed the discrepancy and adjusted the oxygen setting, but the facility failed to ensure proper adherence to oxygen administration policies.
Failure to Timely Report Injury of Unknown Origin Involving Lower Extremity Fractures
Penalty
Summary
The deficiency involves the facility’s failure to timely report an injury of unknown origin to the State Agency within the required two-hour timeframe for one resident with fractures of the right tibia and fibula. The resident had paraplegia, reduced mobility, weakness, adult failure to thrive, neuralgia, neuritis, and a history of right tibia and fibula fractures with routine healing. The resident required staff assistance with dressing, turning, and transfers using a mechanical lift, and used a wheelchair for mobility. On the morning of 4/14, the night nurse reported new edema of the resident’s right lower leg; the resident denied hitting his leg on anything. The physician was notified and ordered ACE wraps and observation, with an x-ray to be obtained if the condition did not improve. Later that night, due to increased swelling, +3 pitting edema, and poor capillary refill, the on-call physician was notified and the resident was sent to the emergency department for suspected fracture. In the emergency department, imaging showed an acute oblique longitudinal fracture of the distal tibial shaft with a lateral cortical step-off and a mildly displaced distal fibular shaft fracture. The ED documentation noted that swelling had started one to two days earlier, there were no recent falls or notable injury, and it was reported that the resident accidentally hit his right lower leg in a wheelchair. The resident returned to the facility with a diagnosis of closed fractures of the right tibia and fibula, and the DON was notified. No incident report related to these fractures was submitted to the State Agency. During interview, the DON acknowledged that the incident was not reported and that, prior to hospital transfer, the resident did not know how the injury occurred. The admissions director stated that, because hospital paperwork later attributed the injury to the wheelchair, they determined it did not meet criteria for reporting, even though the origin of the injury was initially unknown and a definitive root cause could not be established.
Failure to Accurately Assess and Document Mechanical Lift Sling Sizes for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate, comprehensive assessments and care planning for full body mechanical lift sling sizing according to the manufacturer’s guidelines for two residents. The manufacturer’s Sling Selection Guide required sling size selection based on both height and weight, emphasizing the importance of using the correct size and proper fit prior to lifting. Despite this, facility staff and leadership described sling selection practices that relied primarily on resident weight and did not consistently incorporate height, and there was no clear, documented process in the care plans or other nursing documents specifying sling sizes for individual residents. One resident (R2) had paraplegia, fractures of the right tibia and fibula with routine healing, reduced mobility, weakness, and adult failure to thrive. R2’s MDS showed no cognitive issues, bilateral lower extremity impairment, dependence on staff for dressing, turning, and transfers, and use of a wheelchair, with a recorded weight of 235 lbs and height of 69 inches. R2’s ADL care plan identified total dependence of two staff with a Hoyer lift for transfers but did not specify the sling size to be used. The Lift Mobility Status assessment for R2 documented that the resident could not stand, pivot, or walk and would continue to use a full lift with two staff assist, but it did not include the resident’s height, weight, or required sling size. Another resident (R4) had diagnoses including lumbar spondylosis without myelopathy or radiculopathy, muscle weakness, unsteadiness on feet, and spinal stenosis. R4’s MDS indicated no cognitive issues, substantial assistance needed for bed mobility and sitting/standing transitions, and dependence on staff for transfers, with a recorded weight of 220 lbs and height of 71 inches. R4’s Lift Mobility Status assessment stated the resident could not stand, pivot, or walk, could tolerate a semi-reclined position, and required a Hoyer lift, but it inaccurately listed the resident’s weight as between 376–420 lbs and did not identify the sling size. R4’s ADL care plan documented dependence for transfers but did not specify sling size or transfer device. Staff interviews revealed inconsistent understanding of who determined sling size and how it was documented, with NAs and the DON indicating reliance on weight alone and reference to a sling size guide in a storage closet, while the DON confirmed that sling sizes were not in care plans or the NA binder.
Failure to Individualize and Provide Adequate Pain Management During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement an individualized pain management plan for a resident with multiple pain-related diagnoses, particularly in relation to wound treatments and repositioning. The resident had documented conditions including polyneuropathy, a left femur neck fracture, polyosteoarthritis, chronic pain related to absence of toes on both feet, and gastroesophageal reflux disease. The admission MDS showed mild cognitive impairment, verbal behaviors, and rejection of care on some days. Care plans identified use of aspirin therapy and opioid pain medication related to fracture, with goals to avoid discomfort and adverse side effects, and interventions to administer analgesics as ordered, monitor side effects and effectiveness, and assess pain on a 0–10 scale. However, the care plan did not identify the resident’s acceptable level of pain, and while a pressure wound care plan stated to treat pain per orders prior to treatment/turning, there was no corresponding physician order specifying which analgesic to use or when to administer it before wound care. The resident’s physician orders included aspirin 81 mg daily, PRN acetaminophen 1,000 mg every 6 hours for moderate pain, PRN gabapentin 600 mg every 8 hours for pain, and PRN oxycodone 5 mg every 4 hours for severe pain, with a maximum daily dose. The MAR listed non-pharmacological interventions such as ice, distraction, and rest, with instructions to document effectiveness and non-pharmacological measures used alongside medications. Record review showed no comprehensive assessment, treatment orders, or care plan interventions specifically addressing pain prevention during wound treatments. On one morning, the MAR documented administration of aspirin with a recorded pain level of 6, but there was no indication that non-pharmacological interventions were offered or that PRN acetaminophen, gabapentin, or oxycodone were offered or administered at that time. During an observed dressing change to the resident’s buttocks, the resident repeatedly yelled out, stated he was cold and hurting, and vocalized pain while being turned and while the wound was cleaned, using exclamations and profanity. The LPN performing the dressing change did not offer pain medication before starting the procedure and acknowledged that the dressing change had already begun and that pain medication should perhaps have been given beforehand, noting the resident was in pain every time he was turned. Staff interviews indicated the resident screamed in pain whenever turned or repositioned, and that this was reported to nurses and TMAs. A TMA reported she only administered PRN pain medication if a resident asked or a nurse instructed her, and during the morning pass she gave aspirin and recorded a pain level of 6 without notifying the LPN; the resident did not request additional pain medication at that time. The LPN later stated that, based on the resident’s pain level and the facility’s FACES and numeric pain scales, oxycodone should have been used for severe pain, and the DON stated the resident should have been offered pain medication when pain was identified at 6 and that the dressing change should have been stopped when the resident voiced pain. These findings show the facility did not individualize and implement pain management for wound care and did not provide adequate pain control during the observed treatment.
Failure to Perform Hand Hygiene and Maintain Clean Surfaces During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program by not ensuring proper hand hygiene and clean work surfaces during wound care for two residents with pressure ulcers. One resident had paraplegia and multiple stage 4 pressure ulcers on the right and left buttocks and sacral region, required assistance with mobility and personal care, and was on enhanced barrier precautions due to open wounds, colostomy, and urinary catheter. During an observed wound care session, the LPN entered the room wearing enhanced barrier precautions but did not sanitize the work surface before placing or using wound supplies. Throughout the wound care procedure for this resident, the LPN repeatedly removed and reapplied gloves without performing hand hygiene in between glove changes. The LPN examined the resident’s genital area, handled gauze from a shared container, applied barrier cream, removed and replaced dressings on three pressure ulcers, cleansed the wounds, and applied Calcium Alginate and Mepilex dressings, all while frequently changing gloves but not sanitizing hands between glove removals and reapplications. The LPN also reached into the gauze container multiple times after contact with contaminated areas, and only washed hands after leaving the room and disposing of the garbage. For the second resident, who had a stage 3 pressure ulcer and no cognitive impairment, the LPN again entered wearing enhanced barrier precautions and brought wound supplies into the room, initially placing them on an overbed table that had not yet been sanitized. The LPN examined the resident’s enlarged testicles and genital area with gloved hands, used gauze from a container to cleanse the area, and repeatedly removed and reapplied gloves without hand hygiene. After lifting the wound supplies to wipe down the overbed table, the LPN continued the dressing change, including cleansing a sacral ulcer and applying Calcium Alginate and Mepilex, again changing gloves multiple times without sanitizing hands. An RN who assisted with the procedure also examined the genital area, applied cream, and changed gloves without performing hand hygiene between glove changes. The facility’s hand hygiene policy stated that glove use does not replace hand hygiene and that hand hygiene must be performed before donning and immediately after removing gloves, and when moving from a contaminated to a clean body site, which was not followed in these observed instances.
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 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 Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A resident with severe cognitive impairment and significant physical care needs was subjected to physical abuse by another resident. The incident occurred in the facility's smoking area, where the aggressor pulled the victim's hair, struck her in the back of the head, and pushed her wheelchair into a fence. The victim immediately experienced pain and reported the incident to several nursing staff, though she could not recall exactly whom she told. The victim also contacted a family member, expressing fear for her safety, especially after the aggressor threatened her the following day. The family member attempted to reach the facility but, unable to get a response, contacted the Sheriff's department to conduct a welfare check. Multiple staff interviews confirmed that the victim reported the abuse shortly after it occurred, with several nursing assistants recalling the resident's complaints of being hit and having her hair pulled. The aggressor admitted to grabbing the victim by the hair and shaking her during a verbal altercation. Documentation showed that the victim had a pain level of ten and required medication for her symptoms. The aggressor had a history of behavioral issues, including previous verbal altercations and threats, and had recently experienced a medication change that increased his discomfort and irritability. Despite the victim's immediate reports to staff, there was a delay in administrative awareness and response. The charge nurse on duty did not recall the incident, and the director of nursing was not informed until the following day. The facility's policy required protections against abuse, but the events indicate a failure to prevent and promptly address resident-to-resident physical abuse, resulting in the victim's decision to leave the facility against medical advice due to ongoing fear and lack of perceived safety.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse in a timely manner to the State Agency (SA) as required by policy. An incident occurred in which one resident, who had severe cognitive impairment and required substantial assistance with activities of daily living, reported that another resident pulled her hair, struck her in the back of the head, and pushed her wheelchair while outside in the smoking area. The incident was reported by the affected resident to nursing staff immediately after it happened, and the nursing assistant informed both the assistant director of nursing and the charge nurse. The residents involved were placed on 15-minute checks following the report. Despite the immediate internal notification, the facility did not submit the Facility Reported Incident (FRI) to the SA until approximately 25.5 hours after the event, exceeding the required reporting timeframe of no later than 2 hours for allegations involving abuse. The administrator confirmed that the FRI was submitted late, as she was not aware of the full details of the incident until the following day. Additionally, law enforcement was contacted by the resident's family member, and a welfare check was conducted prior to the FRI being submitted to the SA. Facility policy required immediate reporting of all alleged violations to the administrator, state agency, and other authorities within specified timeframes, which was not followed in this case.
Failure to Provide Complete and Accessible Survey Results
Penalty
Summary
The facility failed to ensure that survey results, including recertification surveys, complaint investigations, and facility plans of correction, were readily available for review by residents, family, visitors, and staff. During interviews and document review, it was found that a resident with moderately impaired cognition expressed a desire to view the results of state agency surveys but was unable to locate them. Upon inspection, the binder labeled as containing facility survey results was found behind other documents and was missing several required survey reports and plans of correction. Specifically, recertification surveys from certain dates and multiple complaint investigations, as well as associated plans of correction, were not present in the binder. Further interviews with facility staff confirmed that the survey results are considered public knowledge and should be accessible, but the binder did not contain all required documents. The administrator acknowledged difficulty in maintaining the availability of these documents, stating that they often go missing. No facility policy regarding the posting of survey results was provided when requested. This deficiency had the potential to affect all residents, family members, visitors, and staff by limiting access to important regulatory information.
Failure to Immediately Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors during the review of facility practices and records. The deficiency centers on the facility's failure to ensure that all required parties were promptly informed when significant events impacting the resident occurred, as mandated by regulations.
Failure to Honor Resident Grievance Rights
Penalty
Summary
The facility failed to honor the resident's right to voice grievances without discrimination or reprisal. The facility did not establish or follow a grievance policy and did not make prompt efforts to resolve grievances as required. This deficiency was identified based on the facility's actions and inactions regarding the handling of resident grievances.
Failure to Update Care Plan for Medication Administration Preferences
Penalty
Summary
The facility failed to revise and update the care plan for a resident with anxiety disorder, borderline personality disorder, and delusional disorder, who exhibited new behaviors when her medications were not administered according to her preferences. The resident, who typically wakes up around 9:00 to 9:30 a.m. but sometimes sleeps later, relies on staff to wake her for morning medications. On the day of the incident, staff attempted to administer her medications but did not wake her, resulting in the medications being marked as not given. When the resident later requested her medications, she became visibly upset, raising her voice, pacing, and repeatedly returning to the medication cart. The situation was only resolved after the clinical registered nurse consultant contacted the on-call physician and obtained an order to administer the medications outside the usual time frame. Review of the resident's care plan revealed it did not address her preferences for wake-up times or being woken for medication administration, despite staff and the resident confirming this was her usual routine. Interviews with staff indicated a lack of awareness and documentation regarding the resident's preferences, and the care plan was not updated to reflect these needs until after the incident occurred. The facility's policy requires a comprehensive, person-centered care plan based on the resident's assessment and preferences, which was not followed in this case.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with established directives or the expressed wishes and objectives of the resident, resulting in noncompliance with required standards for individualized care.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated.
Failure to Prevent and Assess Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to ensure adequate supervision and a comprehensive assessment to prevent resident-to-resident sexual abuse. A resident with a history of PTSD and cognitive impairment reported receiving unwanted, sexually explicit notes and advances from another resident over a period of months. Multiple residents expressed feeling unsafe due to the behaviors of the resident delivering the notes, and several staff members, including the DON and social worker, were made aware of the situation through direct reports, grievances, and resident council meetings. Despite these reports, the facility did not complete a comprehensive assessment of the affected resident for psychosocial harm, nor did it implement effective interventions or monitoring systems to ensure her safety and well-being. The affected resident had a documented history of childhood sexual abuse, PTSD, anxiety, depression, and cognitive impairment. Her care plan identified a need for a safe environment and support for coping with trauma, but interventions were limited to general reassurances and reminders, without specific measures to address the ongoing harassment. The resident repeatedly reported feeling unsafe, experiencing increased PTSD symptoms, and having trouble sleeping due to the unwanted attention and fear of further abuse. Other residents and staff corroborated the ongoing nature of the harassment, including the delivery of sexually explicit notes and unwanted advances in unsupervised areas such as the smoking area. The facility's response to the reports was inadequate, as staff primarily addressed the issue by speaking to the resident delivering the notes and advising the affected resident to avoid him. There was no evidence of a thorough assessment of the affected resident's psychosocial harm, no clear documentation of interventions to ensure her safety, and no updates to the care plan of the resident exhibiting the inappropriate behaviors. The facility also failed to monitor or restrict interactions effectively, and did not promptly report the abuse to the State Agency as required. The lack of comprehensive assessment, supervision, and timely intervention resulted in ongoing psychosocial harm to the affected resident and a failure to protect her and others from further abuse.
Failure to Timely Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to timely report multiple allegations of abuse, neglect, and theft involving a resident with severe cognitive impairment and a history of mental health issues. Over a period of several weeks, the resident and other female residents reported feeling unsafe due to another resident's sexually inappropriate behavior, harassment, and theft. Specific incidents included unwanted letters, verbal advances, and being followed to common areas, as well as reports of items being stolen. Despite these ongoing concerns, the facility did not report the allegations to the State Agency within the required timeframe. Documentation and interviews revealed that staff, including the DON and social services, were aware of the inappropriate behaviors and the residents' discomfort. The DON acknowledged receiving complaints and conducting internal investigations but chose not to report the incidents, citing a belief that the resident involved was capable of consenting to the interactions. However, there was no clear determination of the resident's capacity to consent, and the facility's own assessments indicated the resident was at risk for abuse due to cognitive impairment and other vulnerabilities. The facility's policy required immediate reporting of all alleged violations, including abuse and neglect, to the administrator, state agency, and other authorities. Despite this, the allegations were not reported until well after the incidents occurred, and some staff members were unaware of all the events. The delay in reporting and lack of timely action failed to provide the required protections for the residents involved.
Failure to Investigate and Protect Residents After Sexual Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate and protect residents following allegations of sexual abuse and harassment involving a resident with severe cognitive impairment and a history of mental health issues. Multiple reports were made by female residents, including one who reported feeling unsafe due to another resident's sexually inappropriate behavior, unwanted advances, and persistent letter writing. Despite these reports, the facility did not provide documentation of a comprehensive investigation, nor did it demonstrate that effective measures were taken to prevent further abuse or address the concerns raised by the residents. Documentation shows that the resident with severe cognitive impairment, along with other female residents, repeatedly expressed discomfort and fear regarding the behavior of another resident, who had a documented history of verbal and behavioral symptoms. The facility's response included minimal actions such as speaking to the alleged perpetrator and providing education, but there was no evidence of a thorough investigation, interviews, or protective interventions. The affected resident continued to receive inappropriate letters even after submitting a grievance, and staff interviews revealed a lack of documentation and uncertainty about the steps taken to ensure resident safety. The facility's own policy requires immediate and thorough investigation of abuse allegations, including interviews, documentation, and protective measures for residents. However, the facility was unable to provide requested investigation records, timelines, or evidence of actions taken to protect residents from further harm. Reports from staff, social services, and law enforcement indicated ongoing issues with harassment and a lack of effective response, further highlighting the facility's failure to meet its investigative and protective obligations.
Failure to Provide Resident Rights and Proper Discharge Process During Transfer
Penalty
Summary
The facility failed to ensure that a resident was provided with appropriate choices and rights during a transfer/discharge process. The resident, who had a history of emotional lability, alcohol use, cognitive communication deficits, depression, anxiety disorder, and osteonecrosis, was identified as having moderately impaired cognition and required staff assistance for mobility and daily activities. The care plan noted ineffective coping, a history of trauma, and a preference for female caregivers. The resident also exhibited behavioral issues, including negative statements, isolation, and anxiety, and was on 15-minute safety checks due to recent incidents involving other residents. Despite these complex needs, the facility did not provide the resident with adequate notice or options regarding the transfer. The discharge notice was completed on the same day as the transfer, and the resident was moved to a sister facility within a short timeframe, reportedly without being given the opportunity to discuss the decision with an advocate or to appeal the transfer. The Ombudsman was not notified until several days after the transfer, and the resident did not sign a discharge agreement. Interviews revealed that the resident felt rushed, was not allowed to process the discharge, and experienced emotional distress following the move. The facility's own policies require that residents be given notice, the right to appeal, and the opportunity to remain during the appeal process, none of which were followed in this case. Staff interviews indicated confusion about who initiated the discharge and whether the interdisciplinary team had discussed the transfer. The resident expressed a desire to return to the original facility and reported feeling isolated and depressed at the new location. The transfer was described as sudden, with the resident's belongings hastily packed and some personal items discarded. The facility did not document that the resident's mental health and substance use history were considered in the decision-making process, nor did they ensure the resident was prepared for a safe and supported transition.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to implement trauma-informed care for two residents diagnosed with post-traumatic stress disorder (PTSD). One resident had a history of childhood molestation and was identified as having severe cognitive impairment, depression, anxiety, and PTSD. Despite documentation of her trauma history and potential triggers, her care plan was not updated to address current PTSD-related symptoms or triggers. When this resident reported feeling unsafe due to harassment and sexual advances from another resident, the facility's response was limited to offering an alternative smoking area and notifying law enforcement, without comprehensive assessment or ongoing monitoring for psychosocial harm or exacerbation of PTSD symptoms. The second resident, also with a history of childhood sexual abuse and other mental health diagnoses, exhibited behaviors such as writing sexual notes and following female residents, including the first resident, to unsupervised areas. Although his care plan noted a preference for female caregivers and a history of trauma, it did not address his sexual behaviors toward others or include updated interventions. Reports from multiple residents about his inappropriate behavior were met with education for the resident, but there was no evidence of behavior management, supervision, or monitoring to mitigate the risk of re-triggering PTSD in other residents. Interviews with the affected resident and her family revealed ongoing distress, including increased PTSD symptoms, trouble sleeping, and feelings of being unsafe, despite repeated reports to staff. The facility's trauma-informed care policy required identification of triggers, individualized interventions, and ongoing evaluation with resident and family input, but these steps were not followed. The lack of comprehensive assessment, care plan updates, and effective interventions contributed to the deficiency in providing trauma-informed care.
Lack of Physician Documentation for Routine Visits
Penalty
Summary
The facility failed to ensure that a resident with severe cognitive impairment and multiple psychiatric diagnoses had proper physician documentation for routine visits as required by facility policy. The resident's medical record showed physician visits occurred on several dates, but there was a lack of documentation for routine 60-90 day visits between two specific dates. During an interview, the DON confirmed that the physician had seen the resident and signed orders but did not document a note for the visit, and the physician could not recall the reason for this omission. The facility's policy requires residents to be seen by a physician within 30 days of admission, every 30 days for the first 90 days, and at least every 60 days thereafter, with documentation of these visits in the medical record.
Failure to Provide Comprehensive Behavioral Health Assessment and Person-Centered Planning
Penalty
Summary
The facility failed to implement comprehensive assessment and person-centered planning to ensure that the individualized behavioral health needs of two residents were met. One resident, with diagnoses including alcoholic encephalopathy, PTSD, anxiety, depression, and a history of childhood trauma, was admitted under a court commitment order and required multiple therapies and substance abuse treatment. Despite documented cognitive impairment and a history of trauma, the care plan lacked evidence that the facility identified the resident's responses to stressors or utilized person-centered interventions developed by the interdisciplinary team (IDT). The care plan was not reviewed or revised when interventions were ineffective or when the resident experienced a change in condition related to ongoing abuse. The resident reported feeling unsafe due to harassment and inappropriate sexual advances from another resident, including receiving disturbing notes and being followed in unsupervised areas. These incidents triggered the resident's PTSD symptoms, leading to increased anxiety, sleep disturbances, and emotional distress. The facility's records did not indicate that a comprehensive assessment was completed to determine psychosocial harm, nor were there clear interventions or monitoring systems implemented to ensure the resident's safety or provide supportive services. Family members also expressed concerns about the lack of follow-through on safety plans and the ongoing nature of the harassment. The second resident involved had a history of emotional lability, alcohol use, depression, and anxiety, and was reported by multiple female residents for inappropriate behavior, including writing notes and following them. Staff responses included educating the resident and checking on the affected resident during smoking breaks, but there was no evidence of a comprehensive behavioral health assessment or effective interventions. The facility's trauma-informed care policy outlined the need for individualized interventions and ongoing evaluation, but there was no documentation that these practices were followed in these cases. The facility did not provide additional policies related to behavioral health services.
Failure to Identify PTSD Care Needs and Maintain Social Services Staffing
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment (FA) that accurately identified the specific care and practices necessary to meet the needs of residents with post-traumatic stress disorder (PTSD). The assessment did not sufficiently address the requirements for managing PTSD, despite the presence of residents with this diagnosis or history. The FA was intended to use evidence-based, data-driven methods to evaluate the care needs of the resident population, including behavioral health and psychiatric conditions, but did not specify the interventions or resources required for PTSD care. Additionally, the facility did not maintain the identified number of staff required to provide social services, as the Social Services Designee (SSD) position was split between two facilities, resulting in only part-time coverage at each location. The administrator believed the SSD's time at the facility was sufficient, but the documented staffing plan called for one full-time SSD. This staffing shortfall had the potential to affect all residents with behavioral health needs, including those with PTSD, as the facility did not ensure adequate social services support as outlined in their own assessment and policy.
Failure to Monitor and Prevent Substance Abuse in Resident
Penalty
Summary
The facility failed to adequately assess and monitor a resident with a known history of substance use/abuse, leading to a deficiency in preventing and managing substance abuse incidents. The resident, who was wheelchair-bound and had a history of opioid, cocaine, and other stimulant abuse, left the facility and was later found intoxicated at a bar. Despite being aware of the resident's condition, the facility staff did not have protocols in place to monitor or prevent substance abuse, nor did they update the resident's care plan following the incident. Upon returning to the facility, the resident was found to be intoxicated and asleep, but there was no documentation of vital signs being taken or assessments performed to monitor the resident's condition. Interviews with staff revealed a lack of awareness and protocols for handling residents under the influence of alcohol or drugs. The charge nurse on duty was not informed of the resident's departure from the facility, and there was no clear guidance on how long to monitor the resident or what interventions to implement. The facility's existing care plan for the resident did not include specific interventions to prevent substance abuse or monitor for signs of intoxication. The facility's policy on safety for residents with substance use disorder did not address specific interventions for potential or actual substance abuse, highlighting a gap in the facility's preparedness to handle such situations. This lack of assessment, monitoring, and protocol contributed to the deficiency identified in the report.
Failure to Monitor and Report CHF Symptoms
Penalty
Summary
The facility failed to identify a significant change in condition and provide timely medical intervention for a resident with congestive heart failure (CHF), resulting in actual harm. The resident, who had a history of CHF, hypertension, diabetes, and coronary artery disease, experienced a significant weight gain of 61.8 pounds over a period of approximately five weeks. Despite the hospital discharge orders to monitor daily weights and report significant weight changes, the facility did not adhere to these instructions, and the resident's weight gain was not reported to the physician in a timely manner. The resident's medical records indicated multiple instances of shortness of breath, chest pain, and edema, yet there was a lack of documentation showing that the physician was notified of these symptoms or the significant weight gain. The facility's staff failed to follow the hospital's discharge orders and the medical director's modified orders for daily weights, which were only followed for one week. The resident continued to gain weight, and despite complaints of shortness of breath and chest pain, the facility did not seek immediate medical evaluation or treatment. Interviews with facility staff, including the RN, physician, and director of nursing, revealed that the facility did not have adequate procedures or training in place to recognize and act on changes in a resident's condition. The facility lacked a policy on identifying and responding to changes in condition, and there was no evidence of training for the majority of the nursing staff on this issue. The resident was eventually admitted to the hospital with CHF exacerbation and a heart attack, where she was treated with IV diuretics, resulting in a 20-pound weight loss before being discharged back to the facility.
Failure to Provide Accurate Ombudsman Contact Information
Penalty
Summary
The facility failed to provide accurate and accessible information regarding Ombudsman services to residents, as observed during a resident council group meeting. Five residents attending the meeting were unaware of how to contact the Ombudsman, and there was no mention of this information in the resident council minutes from June to November 2024. Although Ombudsman contact information was posted near the main entrance, it was outdated and incorrect, listing a former employee who no longer represented the facility. Interviews with the Ombudsman, the administrator, and the social service designee confirmed the inaccuracy of the posted information. The Ombudsman had previously requested updates to her contact details, but these were not made. The facility's August 2024 assessment and admission packet indicated that residents should be informed of their rights and provided with accurate contact information for relevant agencies, including the Ombudsman. However, this was not effectively implemented, leading to a deficiency in ensuring residents' rights to access advocacy services.
Deficiency in Physical Therapy Services and Staffing
Penalty
Summary
The facility failed to implement a comprehensive facility-wide assessment to ensure adequate resources and staffing were available to meet the needs of residents, particularly in the area of physical therapy (PT) services. The report highlights that the facility did not have PT services available from the end of August 2024, affecting residents who required these services. Despite having physician orders for PT, residents R20 and R37 did not receive the necessary therapy due to the absence of PT staff. Interviews with staff, including the Speech Therapist, Director of Nursing, and Registered Nurse, confirmed the lack of PT services and the absence of a plan to address this gap. Resident R37, who had intact cognition and was independent with activities of daily living, was dependent on staff for emotional, intellectual, physical, and social needs due to physical limitations. Despite having orders for PT, the facility did not provide these services, which were crucial for his mobility and strengthening. Similarly, Resident R20, who had moderate cognitive impairment and required substantial assistance with daily activities, was not seen by a physical therapist despite having orders for PT and OT evaluations and treatments. The facility's failure to provide PT services as ordered had the potential to affect all 32 residents. Additionally, the facility's staffing plan was not adhered to, particularly on weekends, where the number of staff scheduled was less than required. The facility assessment identified the need for two licensed nurses on the day shift, but this was not implemented. The administrator acknowledged the discrepancy in the staffing plan and the need to update the facility assessment to reflect the actual services provided. The lack of PT services and inadequate staffing were significant deficiencies identified in the report.
Failure to Explain Arbitration Agreement
Penalty
Summary
The facility failed to ensure that the binding arbitration agreement was fully explained to 16 out of 32 residents and/or their representatives, leading to a lack of understanding and awareness of their right to refuse signing the agreement. The social service designee (SSD) was responsible for explaining the arbitration agreement during the admission process, but interviews with residents revealed that many did not recall receiving an explanation or understanding the agreement. Some residents, such as R148 and R10, reported not being aware of signing any agreement, while others, like R32, did not remember any discussion about the arbitration agreement. During a resident council meeting, several residents expressed that they were unaware of signing an arbitration agreement upon admission and did not understand what it entailed. The SSD had informed residents that the arbitration agreement was not a precondition for admission, but failed to ensure that residents comprehended the implications of signing the agreement. This lack of communication and understanding was further highlighted by R37, who initially claimed to understand the agreement but later admitted to feeling intimidated and unaware of what he had signed. The report also noted that some residents, such as R40, felt pressured to sign the documents without fully understanding them, fearing retaliation from staff. The SSD's failure to adequately explain the arbitration agreement and ensure residents' comprehension resulted in a significant deficiency, affecting the residents' rights to make informed decisions about their care and legal options.
Failure to Implement Enhanced Barrier Precautions and Inadequate Infection Surveillance
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for a resident with surgical wounds and a PICC line, as required by CDC guidelines. The resident, who was a new admission, had undergone multiple surgeries due to frostbite, resulting in amputations and the placement of an orthopedic pin. Despite the care plan identifying the need for EBP, observations revealed that there was no signage on the resident's door to indicate these precautions, and staff did not wear gowns during dressing changes. Interviews with staff confirmed the lack of awareness and implementation of EBP, with reliance on door signage that was absent. Additionally, the facility's infection control surveillance was inadequate, failing to monitor infections through to resolution over a three-month period. The Director of Nursing (DON), who was new to her role as both DON and Infection Preventionist (IP), admitted to being unsure about the necessary transmission-based precautions and acknowledged gaps in the surveillance process. Critical sections of the surveillance records, such as isolation status and resolution dates, were often left blank, making it impossible to determine if precautions were implemented timely or at all. The facility's infection surveillance policy required comprehensive tracking and analysis of infection-related data, but this was not effectively carried out. The DON had limited time to devote to infection control, and oversight from a sister facility's IP was minimal due to their absence. The administrator recognized the need for extensive oversight and improvement in the surveillance tracking system to prevent the potential spread of infection.
Fear of Retaliation Among Residents
Penalty
Summary
The facility failed to implement policies to ensure residents could voice concerns without fear of retaliation. Two residents, identified as R37 and R40, expressed fear of being retaliated against by facility staff. R37, who was admitted following an acute hospitalization for various diagnoses including metabolic encephalopathy and alcohol abuse, reported feeling intimidated by the social services designee (SSD) and feared being kicked out of the facility. He admitted to lying about understanding an arbitration agreement due to this fear. R37 also felt that the SSD was unapproachable and dismissive when he sought assistance with his concerns about housing and employment. R40, who was admitted with conditions such as vertebrogenic low back pain and sheltered homelessness, also reported fear of retaliation. She believed that the facility would expel residents who raised concerns, yet did not address issues with problematic residents. R40 felt that the facility misrepresented the services they could provide and was denied a request to see the MD by the DON. The facility administrator, when interviewed, stated that retaliation did not occur and expected concerns to be reported to her, although she was unaware of any such issues. Additionally, during a resident council meeting, several residents expressed discomfort in voicing concerns to the SSD due to fear of retaliation. The facility's Abuse, Neglect, and Exploitation policy outlined procedures for reporting concerns without fear of retaliation but lacked specific avenues for addressing fears of retaliation from management. The admission packet provided information on residents' rights and procedures for filing complaints without fear of reprisal, but the residents did not feel comfortable utilizing these resources.
Failure to Securely Store Lighters for Smoking Residents
Penalty
Summary
The facility failed to ensure that lighters were stored securely away from residents, leading to potential fire hazards for several residents who smoked. Observations and interviews revealed that residents were keeping their smoking materials, including lighters, in their rooms or on their person, contrary to the facility's policy. The policy required lighters to be stored at the nurse's station, but staff reported difficulty in enforcing this rule as residents often purchased additional lighters and kept them in their possession. Several residents, including those with cognitive impairments and various medical conditions, were observed keeping lighters and cigarettes in unsecured locations such as unlocked drawers or bedside tables. Despite the facility having an automatic wall-mounted lighter in the designated smoking area, residents continued to use personal lighters. Interviews with staff and residents indicated a lack of consistent enforcement of the smoking materials policy, with some residents never being asked to turn in their lighters. The facility's smoking policy outlined safety measures for the designated smoking area but did not explicitly mention the secure storage of lighters. Staff interviews highlighted challenges in managing residents' compliance with the policy, as they were unable to search residents' rooms or forcibly take lighters from them. This lack of enforcement and secure storage of lighters posed a risk of fire hazards within the facility.
Failure to Identify and Respond to Emergent Change in Condition
Penalty
Summary
The facility failed to ensure that five out of six nursing staff were competent in identifying an emergent change in condition and the need for hospital transfer for emergency medical evaluation for a resident with a history of congestive heart failure, hypertension, diabetes mellitus, and coronary artery disease. The resident experienced significant weight gain, shortness of breath, and chest pain, which are indicative of a potential heart attack or acute heart failure. Despite these symptoms, the staff did not follow the facility's assessment or develop policies and procedures to ensure staff had demonstrated competencies to perform care for residents. The resident's care plan required staff to monitor for signs and symptoms of congestive heart failure and report any significant changes, such as weight gain or shortness of breath. However, the facility did not complete the hospital discharge order to obtain a baseline weight, and the resident experienced a weight gain of 61.8 pounds since re-admission. Multiple nursing progress notes documented the resident's complaints of shortness of breath, chest pain, and significant weight gain, yet there was no indication that the physician or discharging hospital was notified, or that the resident was sent to the emergency department for further evaluation and treatment. Interviews with the facility's medical director, attending physician, and director of nursing revealed that the facility did not update the physician with the resident's weight changes in a timely manner. The facility lacked a policy on identifying and acting on a change in condition, and there was no professional reference for nursing staff to utilize. Only one of the five licensed nurses on staff had received training on recognizing and communicating resident changes in condition. The facility's failure to ensure staff competency and adherence to care plans resulted in a delay in emergency medical evaluation and treatment for the resident.
Inadequate Weekend Staffing Levels
Penalty
Summary
The facility failed to ensure adequate staffing levels on weekends as determined by their facility assessment. The Payroll Based Journal (PBJ) Report for quarter 3 identified excessively low weekend staffing, which triggered a deficiency. The facility assessment indicated that the day shift required two licensed nurses and three direct care staff, while the night shift required one licensed nurse and two direct care staff. However, a review of working schedules and timecards revealed that for 12 out of 26 weekend days, the day shift was staffed with only one licensed nurse, contrary to the facility's assessment requirements. Interviews with the administrator revealed a lack of awareness regarding the facility assessment's staffing requirements. The administrator reported that the low weekend staffing was attributed to the census and that the facility no longer cut hours since COVID. Despite the administrator's expectation for staffing to align with the facility assessment, she was unaware that the assessment required two licensed nurses on the day shift. The administrator also expressed uncertainty about the accuracy of the data submitted to CMS, as she believed there was a discrepancy in the reported staffing levels. The facility's policy required the submission of complete and accurate staffing information to CMS, verified by the administrator, HR director, and director of nursing, but this was not adhered to, leading to the deficiency.
Failure to Address Resident Grievance
Penalty
Summary
The facility failed to address a verbal grievance reported by a resident, identified as R5, who had intact cognition and a medical history including stroke, heart failure, renal insufficiency, and diabetes mellitus. R5 reported to the Social Service Director (SSD) that his gel pens, a key to his locked drawer, and a stylist were missing. Despite R5's report, the SSD did not recall the grievance and no documentation was found in the facility's grievance log from May to November 2024. Additionally, the facility did not provide a grievance policy by the end of the survey, indicating a failure to follow up on the resident's complaint and to maintain proper grievance documentation.
Failure to Facilitate Resident Communication with Care Coordinator
Penalty
Summary
The facility failed to ensure that a resident was provided with communication access to their county care coordinator (CC) and did not discourage or obstruct these communications. The CC made multiple attempts to contact the resident, R18, without success. On one occasion, the CC left contact information with an unidentified charge nurse, but the resident was not informed of the call. The social services designee (SSD) instructed the CC to direct all communication needs to her, citing the nurses' busy schedules. Despite this, the CC experienced difficulty reaching the SSD and was unable to contact R18, leading to a personal visit to the facility. During this visit, R18 reported not receiving any messages from the CC, indicating a breakdown in communication. Interviews with facility staff, including a trained medication aid (TMA) and a licensed practical nurse (LPN), revealed that there was no directive to forward calls to the SSD, and residents could take calls in a private room. The SSD confirmed that residents had the right to receive phone calls and that calls could be forwarded to her if necessary. However, the CC's repeated attempts to contact R18 were unsuccessful, and the resident was unaware of the attempts made to reach him. This situation suggests a failure in the facility's communication process, preventing the resident from accessing necessary services.
Inaccurate MDS Coding for Resident with Wounds
Penalty
Summary
The facility failed to ensure the accurate coding of the Minimum Data Set (MDS) for a resident, identified as R26, who was reviewed for wounds. R26 was admitted in September 2023 with medical conditions including an abscess on the buttocks, a non-pressure chronic ulcer with fat layer exposed, protein-calorie malnutrition, and end-stage renal disease. Despite these conditions, the MDS completed on 9/21/24 did not mention the non-pressure skin ulcer, although it noted the application of a nonsurgical dressing. Subsequent medical records, including a history and physical on 9/29/23 and a wound care progress note on 10/09/24, confirmed the presence of a left buttock abscess and a skin ulcer with fat layer exposed, respectively. Interviews conducted with the resident and staff revealed discrepancies in the MDS coding process. The resident was aware of daily wound dressing changes but was unsure why the wound had not healed over nine months. A registered nurse confirmed the presence of a non-pressure ulcer and acknowledged that the wound was previously coded under surgical wounds in the MDS. The Director of Nursing was unaware of the MDS coding process, and the MDS Coordinator's job description emphasized the need for accurate assessments and compliance with regulations. The facility's MDS 3.0 Completion policy required accurate assessment and identification of care needs, which was not adhered to in this case.
Failure to Revise Care Plans for Two Residents
Penalty
Summary
The facility failed to revise the care plans for two residents, R33 and R40, leading to deficiencies in their care. For R40, the care plan did not include target behaviors to be monitored despite her receiving anti-anxiety medication. Additionally, the care plan failed to identify potential adverse reactions to the antidepressant medication and did not address signs of increased depression or suicidal ideation, despite R40's history of suicidal thoughts. R40's medical conditions included vertebrogenic low back pain, muscle spasm, and a history of substance abuse, and she required both medication and non-medication interventions for pain management. For R33, the facility did not follow hospital discharge orders to obtain a baseline weight the morning after discharge and failed to conduct daily weight monitoring as required. The care plan did not include instructions for daily weights or when to report significant weight changes to the physician. This oversight resulted in a 60-pound weight gain over a month, leading to R33's readmission to the hospital with congestive heart failure and other complications. The facility delayed adding the physician's order for daily weights to the administration record, and the care plan was not updated to reflect these critical monitoring requirements.
Failure to Document Target Behaviors and Non-Pharmacological Interventions
Penalty
Summary
The facility failed to comprehensively assess and identify target behaviors and non-pharmacological interventions for residents receiving psychotropic medications. For one resident, identified as R8, the Minimum Data Set (MDS) assessment indicated severely impaired cognition and worsening behaviors, including hallucinations and intrusiveness. Despite being on multiple psychotropic medications, R8's care plan lacked specific target behaviors to monitor, and there was no mention of non-pharmacological interventions. The Director of Nursing (DON) acknowledged these deficiencies during an interview. Another resident, R246, was diagnosed with anxiety and major depressive disorder and was on antidepressant and anti-anxiety medications. The care plan for R246 did not specify non-pharmacological interventions, and the DON agreed that these should have been included upon admission. The care plan was updated only after surveyors pointed out the deficiencies. For resident R42, who had anxiety, depression, and PTSD, the care plan failed to identify specific target behaviors or side effects of the prescribed medications. Interviews with staff revealed a lack of documentation on target behaviors and side effects in the care plan. The DON was unaware of the side effects related to psychotropic medication use and planned to collaborate with the nursing team to address this issue. The facility's psychotropic medication policy required documentation of residents' responses to medications, including symptoms and therapeutic goals, which was not adhered to in these cases.
Failure to Label Opened PPD Vials
Penalty
Summary
The facility failed to ensure that two opened vials of Tuberculin (TB) purified protein derivative (PPD) solution were labeled according to the manufacturer's guidelines with an open date. During an observation, two open vials of PPD solution were found in the medication room refrigerator, with the pharmacy-labeled bag dated as dispensed on 9/28/24. However, neither vial was dated to indicate when they had been opened. The pharmacy list indicated that the solution was good for 30 days from the date opened. An LPN confirmed that medications were supposed to be dated when opened and acknowledged the absence of an open date on the vials. The DON stated that her expectation was for medications to be dated and initialed on the date of opening. A policy on medication labeling and storage was requested but not provided by the time of exit.
Failure to Provide Scheduled Dental Services
Penalty
Summary
The facility failed to provide scheduled routine dental services upon request for a resident, identified as R5. R5's quarterly Minimum Data Set (MDS) assessment indicated that his cognition was intact, and he had diagnoses of stroke, heart failure, renal insufficiency, and diabetes mellitus. During interviews conducted on two separate occasions, R5 reported that he had requested a dental appointment when he was first admitted to the facility, as he was missing all his molars and believed he would benefit from a partial denture. Observations confirmed that R5 was missing all but one upper molar. Additionally, oral assessments conducted on three different dates by RN-A documented R5's requests for a dental appointment. RN-A, who conducted the oral assessments, stated that she always asks residents if they would like a dental appointment and communicates their requests to the Social Service Director (SSD) either verbally or via email. An email dated June 4, 2024, from RN-A to the SSD confirmed that R5 had requested a dental appointment, noting that he had several cavities but no pain or difficulty chewing at the time. However, the SSD claimed she did not recall R5's request and acknowledged that she must have missed the email notification. This oversight resulted in the facility's failure to arrange the necessary dental services for R5.
Failure to Provide Physical Therapy Services
Penalty
Summary
The facility failed to provide physician-ordered physical therapy (PT) services for two residents, R20 and R37, due to the unavailability of PT services. R37, who had intact cognition and was independent with activities of daily living, was admitted to the facility following hospitalization with the goal of regaining strength and returning to independent living. Despite having orders for PT services, R37 did not receive PT after the end of August 2024, as the facility no longer had PT services available. Interviews with staff, including the director of nursing and the administrator, confirmed that PT services were not provided due to the lack of a PT provider. R20, who had moderate cognitive impairment and required substantial assistance with daily activities, was also affected by the lack of PT services. R20 had medical diagnoses including an artificial knee joint and osteoporosis, and was supposed to receive PT and occupational therapy (OT) as per physician orders. However, the facility could not provide documented evidence that R20 had been seen by a physical therapist. Interviews with the occupational therapist and the administrator revealed that the facility had been without a PT provider since the end of August 2024, and there was no interim plan to ensure PT services were provided. The facility's failure to provide PT services was further highlighted by the absence of a policy on the provision of skilled therapy services, which was requested but not provided by the end of the survey. The facility's August 2024 assessment indicated that it would provide ancillary services, including PT, but the lack of a PT provider and the absence of a plan to address this gap resulted in the deficiency noted in the report.
Inadequate Infection Control Management Due to Lack of Training and Oversight
Penalty
Summary
The facility failed to ensure that the Director of Nursing (DON), who also served as the Infection Preventionist (IP), had the appropriate training and oversight to manage the infection control program effectively. The DON was new to her role and had only been in the position for approximately two weeks. She had not yet completed the necessary training course and was unsure about the types of transmission-based precautions (TBP) needed. The surveillance records from August 2024 through November 2024 showed several critical sections, such as isolation status, were left blank, making it impossible to determine if TBP had been implemented timely or at all. The DON had limited time to devote to infection control and was relying on assistance from a staff member at a sister facility, who was unavailable due to vacation and minimal prior interaction. The infection control surveillance records revealed significant gaps in documentation and analysis. Of the 45 entries reviewed, only one healthcare-acquired infection (HAI) and one isolation were recorded. Specific cases, such as a resident with Clostridium Difficile and others with resistant bacteria strains, lacked documentation on precautions and resolution of symptoms. Additionally, 33 residents were identified with COVID-19 or upper respiratory infections, but there was no indication of TBP implementation or analysis to prevent further outbreaks. The facility's infection surveillance policy required ongoing data collection and analysis, but these processes were not adequately followed, leading to deficiencies in infection control management.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, specifically in the case of resident-to-resident abuse involving three residents. On two separate occasions, one resident physically abused two other residents. The first incident involved the resident hitting another resident in the ankle with a rock, and the second incident involved the resident punching another resident in the face. These incidents occurred in the designated smoking area, where the resident was not adequately supervised by staff, despite having a care plan that required supervision due to a history of aggressive behavior. The resident involved in the abuse had a history of moderate cognitive impairment and was known to have aggressive tendencies, as noted in their care plan. Despite this, the facility failed to implement effective measures to prevent further incidents. The resident was able to access cigarettes and a lighter, despite a doctor's order prohibiting smoking for health and safety reasons. The resident's behavior was not adequately monitored, and staff were not consistently present to supervise the resident in the smoking area, leading to repeated incidents of aggression. Interviews with other residents and staff revealed that the resident's aggressive behavior was well-known, and there was a general sense of fear and discomfort among other residents when the resident was present in the smoking area. Staff interviews indicated that the facility's attempts to supervise the resident were inconsistent and ineffective, with staff acknowledging that they were unable to consistently monitor the resident's activities. The facility's policy on abuse prevention was not effectively enforced, leading to a failure to protect residents from harm.
Inadequate Supervision of Resident Smoking
Penalty
Summary
The facility failed to provide adequate supervision and safety interventions for a resident identified as R1, who was deemed unsafe to smoke by her physician. Despite the care plan indicating that R1 required 1:1 staff supervision when outside in the smoking area, multiple observations and interviews revealed that R1 was frequently smoking without supervision. R1 had a history of smoking-related incidents, including burning clothing and smoking in bed, and was observed falling asleep with a lit cigarette. The facility's policy required that residents who are unsafe to smoke should have their smoking materials maintained by nursing staff, but R1 was found with cigarettes and a lighter in her possession. Interviews with staff and other residents indicated that R1 was able to access cigarettes and lighters despite the facility's policy against it. R1 was observed smoking outside without staff supervision on multiple occasions, and other residents reported incidents of R1 attempting to steal cigarettes and lighters. The facility's staff, including nursing assistants and the director of nursing, acknowledged the difficulty in supervising R1 due to her quick movements and the inability to always catch her when she went outside to smoke. The facility's failure to implement the necessary supervision and safety measures resulted in several incidents of resident-to-resident altercations involving R1. Other residents reported being physically assaulted by R1 in the smoking area, and staff interviews confirmed that R1 was not consistently monitored as required by her care plan. The facility's policies on smoking safety were not effectively enforced, leading to ongoing safety risks for R1 and other residents.
Failure to Report Allegation of Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency (SA) for a resident who was reviewed for allegations of neglect. A Vulnerable Adult Maltreatment Report was submitted to the SA by an undisclosed person, alleging that the resident was sexually and physically abused in the facility. The resident had moderate cognitive impairment and required staff assistance with eating, toileting, and transferring. The facility's Incident Report Log identified the alleged abuse and noted that a MAARC report was filed against them. The facility's investigative note indicated that the social service designee (SSD) was notified by the county sheriff's department of the allegation, and the director of nursing and administrator were informed. However, the SSD, director of nursing, and administrator all believed that since the allegation had already been reported by an outside facility, they did not need to report it to the SA again. Instead, they initiated an internal investigation of the abuse allegation. During interviews, the SSD, director of nursing, and administrator all confirmed that they were aware of the allegation but did not report it to the SA, believing it was unnecessary due to the prior report by an outside facility. The facility's policy on abuse, neglect, exploitation, and misappropriation prevention, last revised in April 2021, indicated that the facility was required to investigate and report any allegations within the timeframes required by federal requirements. The failure to report the allegation to the SA as required by federal regulations constitutes a deficiency in the facility's handling of the abuse allegation.
Lack of Analysis and Evaluation in QAPI Program
Penalty
Summary
The facility failed to provide evidence of analysis and evaluation of identified Performance Improvement Project (PIP) concerns within their Quality Assurance Performance Improvement (QAPI) program. Specifically, the QAPI meeting minutes from 9/28/23 lacked identification and analysis of the Mantoux PIP project, which aimed to ensure new admissions completed a Mantoux Skin Test correctly. Additionally, the meeting minutes did not identify any new high-risk or problem-prone areas. The QAPI meeting minutes from 3/28/24 revealed four ongoing PIP projects, including call light response times, fall reduction, Relias training completion, and grievance reduction. However, none of these projects included documentation on data analysis, intervention modifications, or decisions on whether the projects should continue. During an interview on 4/24/24, the executive director of operations acknowledged the lack of data analysis and intervention modifications for the PIP projects. The director of nursing (DON) confirmed that all department heads were responsible for daily rounds but could not provide specific details on who was completing the fall rounds. The executive director also admitted that the Relias training project lacked analysis and that the grievance PIP project was not appropriately chosen. The facility's QAPI policy, dated 1/1/24, stated that the committee should meet quarterly to evaluate activities, identify issues, and develop corrective plans, but this was not adequately followed as per the findings in the report.
Failure to Ensure Competency in Insulin Administration
Penalty
Summary
The facility failed to ensure that all licensed nursing staff were appropriately trained and deemed competent to administer insulin. During an observation and interview, an LPN administered insulin to a resident without priming the insulin pen with 2 units of insulin prior to dialing up the ordered dose. The LPN expressed surprise at forgetting to prime the pen. The resident's Medication Administration Record indicated they were receiving multiple doses of Novolog and Lantus insulin daily for diabetes management. The manufacturer's instructions for the Lantus Solostar pen clearly state that the pen should be primed with 2 units of insulin before administering the dose, a step that was missed by the LPN during the observed administration. The Director of Nursing (DON) confirmed that staff should be priming insulin pens and admitted that no insulin competencies had been completed with licensed nurses. Additionally, there were no drug books or manufacturer's directions available for nurses to reference at the nurses' station, medication room, or medication cart, although the DON had requested a new drug book from the executive director of operations. The executive director of operations stated that they would expect the DON to ensure licensed nurses were competent with insulin administration. No policy related to insulin administration was provided by the end of the survey.
Failure to Provide Mandatory QAPI Training to All Staff
Penalty
Summary
The facility failed to provide mandatory training on its specific Quality Assurance Performance Improvement (QAPI) Program to all staff. Interviews with various staff members, including a nursing assistant, maintenance supervisor, director of nursing, social service director, trained medication aide, dietary aide, and dietary manager, revealed a lack of awareness and understanding of the facility's specific QAPI goals and elements. The staff reported either not receiving any QAPI training or only receiving generalized QAPI training through Relias, which did not cover the facility-specific details. The director of nursing and other staff members were unable to identify specific QAPI projects or performance improvement projects (PIPs) currently being worked on by the facility. The executive director of operations acknowledged that while staff were trained on the elements of the facility's QAPI program, they were quick to forget what they had learned. The review of the Relias training records showed that several staff members had outdated or no QAPI training listed. Additionally, the facility's August 2022 In-Service Training policy indicated that staff were required to complete training on the elements and goals of the QAPI program, which was not being adhered to. This lack of proper training and awareness among staff led to the deficiency in the facility's QAPI program implementation.
Deficiency in Staff Training on Alzheimer's and Related Disorders
Penalty
Summary
The facility failed to ensure that four out of nine staff members received the required initial and annual training on Alzheimer's disease or related disorders, assistance with activities of daily living (ADL), problem-solving with challenging behaviors, and communication skills. Specifically, the Director of Nursing (DON) did not complete training on Alzheimer's disease and related disorders upon hire. Licensed Practical Nurse (LPN)-A did not complete training on communication needs upon hire. Nursing Assistant (NA)-A did not complete annual training on ADLs, and NA-C did not complete annual training on Alzheimer's disease and related disorders. The facility's Resident Admission Packet and In-Service Training policy indicated that staff should receive training on understanding the Alzheimer's disease process, behaviors, assisting with ADLs, and communication skills. However, the policy lacked specific identification of required training on Alzheimer's disease or related disorders, assistance with ADLs, communication needs, and problem-solving with challenging behaviors. This discrepancy led to the identified deficiencies in staff training records.
Failure to Ensure Proper Disposal of Cigarette Butts
Penalty
Summary
The facility failed to ensure that a resident appropriately disposed of cigarette butts after smoking, which had the potential to affect other residents who also smoked. During an interview, the resident stated that she stored used cigarette butts in her jacket pocket and discarded them in the trash bin in her room, despite being aware of the designated receptacle outside. Observations confirmed that the resident continued this practice, and the facility had signs posted instructing residents to dispose of cigarette butts in the proper receptacle. The resident's smoking review assessment indicated she had a visual deficit and understood the smoking policy, but her Minimum Data Assessment did not identify her use of tobacco products. The care plan aimed to prevent injury from unsafe smoking practices and included educating the resident on smoking locations and times. Interviews with staff revealed that the facility had signs posted to inform residents about proper cigarette disposal, but the nursing assistant was not fully aware of the resident's practices. The Director of Nursing acknowledged finding cigarette butts in the resident's room and stated that the resident had been educated on the facility's smoking policy in the past. However, the Director was unaware that the resident continued to store used cigarette butts in her pocket. The facility's smoking policy required a designated smoking area with ashtrays for proper disposal, but this was not effectively enforced for the resident in question.
Failure to Administer Oxygen Per Physician Orders
Penalty
Summary
The facility failed to ensure that a resident's oxygen was administered per physician orders. The resident, who had moderate cognitive impairment and a diagnosis of pneumonia, anxiety, depression, and respiratory failure, was observed multiple times with her oxygen set at 4 liters, contrary to the physician's order of 2 liters at rest and 5 liters with activities. Despite being observed asleep, watching television, and eating a meal, the oxygen setting remained incorrect. Both a nursing assistant and a licensed practical nurse confirmed the discrepancy and adjusted the oxygen setting accordingly. The Director of Nursing stated that staff are expected to follow physician orders related to oxygen use and that interventions should be in place to prevent contamination of oxygen tubing. However, there were no orders to titrate the oxygen between the baseline 2 liters and the maximum 5 liters. The facility's policy on oxygen administration requires that oxygen be administered as prescribed by the physician, following professional standards of practice. The failure to adhere to these orders was identified during the survey, highlighting a deficiency in the facility's respiratory care practices.
Latest citations in Minnesota
A resident with intact cognition and multiple diagnoses, including AFib, HF, stroke, anxiety, and depression, was permitted to self-administer nebulizer treatments after staff setup without an IDT self-administration assessment. The EMR lacked documentation of the resident’s competency and safety to manage the nebulizer, including understanding the medication, following directions, operating the equipment, recognizing side effects, and storing the medication and equipment. Staff and the DON confirmed the assessment had not been completed before the self-administration order was implemented.
Failure to Assess and Monitor Antipsychotic Use: A resident with severe cognitive impairment, dementia, anxiety, and mood disorder received Risperidone for agitation and paranoia, but the EMR did not show an AIMS assessment on admission or timely target behavior monitoring. The RN case manager and DON confirmed that baseline AIMS and ongoing behavior monitoring should have been in place when the antipsychotic was started, but the resident’s record lacked measurable target behaviors and documentation of medication effectiveness.
Incomplete Care Plans for Anticoagulant Therapy and Cardiac-Related Needs: The facility failed to include key diagnoses, devices, and medication-related risks in care plans for two residents. One resident’s plan did not address Eliquis use, cardiac conditions, pacemaker presence, or condom catheter care, and another resident’s plan did not address Eliquis therapy or related bleeding-risk monitoring. The DON and RN case manager confirmed these items should have been care planned.
Failure to provide scheduled bathing and grooming assistance: Two residents with intact cognition and ADL dependence did not receive bathing as documented on a weekly schedule, and one resident also had unaddressed facial hair and greasy, unkempt hair. Records did not show consistent weekly baths, additional refusals, or reasons for missed care, and staff interviews confirmed residents were expected to receive at least weekly bathing unless they refused and that facial hair should be shaved when noticed.
A resident with intact cognition and multiple diagnoses, including BPH and stroke, had a physician order for a condom catheter at bedtime, but the EMR lacked orders or instructions for cleaning, disinfecting, monitoring, or changing the drainage bag. During observation, the bag was seen hanging in the bathroom, and an LPN, RN case manager, and DON all confirmed the absence of documented guidance for the catheter drainage bag care.
Failure to preserve dignity occurred when staff placed a brief on a cognitively intact resident who was continent of bowel and bladder. The resident stated the brief made him feel like a baby, and a NA confirmed she applied it even though he was not incontinent; RN and DON both verified the resident was continent and that briefs should not be placed on continent residents.
Failure to provide restorative ambulation and respond to a decline in mobility: A resident with dementia, weakness, chronic pain, and limited physical mobility was care planned for daily ambulation with a FWW and staff assist of 1, but the rehab record repeatedly showed ambulation as not applicable and staff interviews confirmed the task was often not done. The resident stated she could no longer walk, staff reported she had not walked for weeks and now required a sit-to-stand lift with assist of 2 for transfers, and the chart lacked an ADL decline assessment or revision of the ambulation care plan.
A resident with mild cognitive impairment, hemiplegia, hemiparesis, and limited ROM had restorative orders for PROM, stretching, and hand splints, but staff did not consistently offer or complete the interventions. Documentation showed the splints were sometimes marked not applicable instead of refused, and leg stretches were completed only a few times with no explanation for missed care. Staff interviews confirmed the restorative tasks often were not done, and the DON stated the resident’s restorative program needed to be updated.
Dirty can opener and contaminated dry storage bins: The DCS observed four labeled dry-goods bins with dirty rims, dry matter on the bin walls, and a scoop left inside a flour bin with flour on it. The attached can opener also had dry red matter on the blade, and the cook said it had been used that morning to open cream of corn for lunch. The DCS verified the findings and stated the can opener should be washed after each use and the dry bins and scoops should be kept clean.
Dignified Medication Administration Not Maintained: A resident with severe dementia, hallucinations, anxiety, PTSD, and delusional disorder was observed during med pass in the dining room. An RN attempted to administer meds by pouring them from a plastic cup into the resident’s mouth, continued despite the resident pulling away and moving her head, and then raised her voice and questioned why the resident would not take the meds after one pill was spit out and thrown on the floor. The resident stated the nurse was not being nice, and the RN left with the refused meds.
Missing Self-Administration Assessment for Nebulizer Use
Penalty
Summary
The facility failed to ensure an interdisciplinary team (IDT) assessment was completed before allowing a resident to self-administer nebulizer treatments. The resident had intact cognition and required assistance with ADLs, and diagnoses included atrial fibrillation, heart failure, BPH, stroke, malnutrition, anxiety disorder, and depression. Physician orders showed Ipratropium-Albuterol nebulizer treatments three times daily, and the EMR later included an order permitting the resident to self-administer nebulizer treatments after staff setup, but there was no evidence that an IDT self-administration assessment had been completed first. The record also lacked documentation showing the resident’s competency and safety to self-administer the nebulizer medication and treatment, including the ability to understand the medication purpose, follow directions, safely operate the equipment, recognize side effects or adverse reactions, and ensure safe administration and storage. During observation, the resident had nebulizer equipment and medication available in the room. The resident stated staff set up the medication cup and left while the treatment ran, then returned to ensure the machine was turned off; staff cleaned the nebulizer mask afterward. An LPN and RN confirmed the treatment was set up by staff, and the RN and DON stated a self-administration assessment should have been completed before the resident was permitted to self-administer medications.
Failure to Assess and Monitor Antipsychotic Use
Penalty
Summary
The facility failed to ensure that a resident receiving psychotropic medications was adequately assessed and monitored. R3’s admission MDS identified severe cognitive impairment and the need for assistance with ADLs, with diagnoses including non-traumatic brain dysfunction, unspecified dementia without behavioral, psychological, mood, or anxiety disturbances, non-Alzheimer’s dementia, anxiety disorder, and mood affective disorder. The resident’s physician orders included Risperidone 0.25 mg, two tablets by mouth every four hours PRN for agitation and paranoia, with a maximum of three PRN doses in 24 hours, and Risperidone 0.5 mg, one tablet by mouth three times daily for paranoia/agitation. R3’s EMR did not show that an AIMS assessment was completed upon admission despite the resident receiving antipsychotic medication, and the assessment was only completed after surveyor request. The record also lacked evidence that target behavior monitoring had been initiated for the antipsychotic use, with no measurable target behaviors documented, including frequency, duration, severity, precipitating factors, or response to interventions for agitation and paranoia. Interviews with the RN case manager and DON confirmed that AIMS assessment and behavior monitoring should have been completed upon admission or initiation of antipsychotic medications, and both acknowledged that target behavior monitoring had not been initiated.
Incomplete Care Plans for Anticoagulant Therapy and Cardiac-Related Needs
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents with significant medical conditions and medication-related needs. One resident had intact cognition and diagnoses including atrial fibrillation, heart failure, BPH, stroke, malnutrition, anxiety disorder, depression, and a cardiac pacemaker, and was receiving Eliquis. The resident also had a physician order for a condom catheter at bedtime and removal when getting up for the day. The comprehensive care plan printed 5/20/26 did not identify interventions or monitoring related to anticoagulant use, including bleeding risk, adverse effect monitoring, or staff awareness of anticoagulant precautions, and it also lacked interventions related to the resident’s cardiac conditions, pacemaker, and condom catheter use, including skin integrity monitoring and resident-specific catheter care preferences. A second resident with severe cognitive impairment and diagnoses including non-traumatic brain dysfunction, unspecified dementia, non-Alzheimer’s dementia, anxiety disorder, and mood affective disorder was also receiving Eliquis. The resident’s comprehensive care plan printed 5/19/26 did not include anticoagulant therapy, bleeding risk precautions, monitoring for adverse effects, or other interventions related to anticoagulant medication use. During interviews, the RN case manager and DON confirmed that anticoagulant therapy, the condom catheter, cardiac conditions, and pacemaker presence should have been addressed on the care plans and acknowledged that these items were not included.
Failure to Provide Scheduled Bathing and Grooming Assistance
Penalty
Summary
The facility failed to ensure that two residents who required assistance with activities of daily living received routine bathing and grooming services needed to maintain personal hygiene and dignity. R2’s MDS identified intact cognition and a need for ADL assistance, and the care plan directed staff to assist with dressing, grooming, bathing, and oral care while honoring personal hygiene preferences. R21’s MDS also identified intact cognition and a need for ADL assistance, and the care plan directed staff to assist with dressing, grooming, bathing, and oral care. R2’s bathing record showed a weekly bathing schedule, but the documentation did not show bathing was completed every week as scheduled. Baths were documented on several dates, but the time between some baths exceeded one week, and the record did not show additional refusals or reasons why scheduled baths were missed. During observation, R2’s hair was messy and greasy, and long white chin hairs were present. R2 stated she did not get baths very often because the facility was short staffed and said she did not have access to tweezers, a shaver, or a mirror. The EMR did not document that grooming assistance had been offered or provided for facial hair care. R21’s bathing record also showed a weekly bathing schedule, but the documentation did not show bathing was completed every week as scheduled. The record showed one refusal and several baths, but some intervals between baths exceeded one week, and there was no documentation of additional refusals or reasons for missed baths. R21 stated she had been in the facility since mid-April and had yet to have a bath or shower, and said staff were waiting for physician approval because of wounds, though that had been a while. R21 also stated she had only had her hair washed once with a shampoo shower cap while in bed. Staff interviews confirmed residents were expected to receive at least one bath weekly unless they refused, refusals should be documented, and facial hair should be addressed when noticed.
Missing Orders and Documentation for Condom Catheter Drainage Bag Care
Penalty
Summary
The facility failed to ensure appropriate care and services were provided for management of a resident’s external urinary catheter system. The resident had intact cognition and required assistance with ADLs, and diagnoses included atrial fibrillation, heart failure, BPH, stroke, malnutrition, anxiety disorder, and depression. Physician orders dated 4/29/26 indicated use of a condom catheter at bedtime, but the electronic medical record did not contain physician orders or documented instructions for cleaning, disinfecting, monitoring, or routinely changing the associated catheter drainage bag. During observation on 5/19/26 at 11:57 a.m., the resident’s catheter drainage bag was seen hanging on the side rail in the bathroom. Record review and observation did not identify documentation that the drainage bag was routinely cleaned, disinfected, monitored, or replaced according to accepted standards of practice. An LPN confirmed there were no physician orders addressing when the drainage bag should be changed or instructions for cleaning or disinfecting it. An RN case manager stated the drainage bag should have been changed weekly, but no orders related to changing, cleaning, or disinfecting were present. The DON stated the facility expected clear physician orders and nursing instructions for catheter care, cleaning, monitoring, and replacement schedules, and confirmed the facility could not provide evidence that such orders or guidance were in place for the resident’s condom catheter drainage bag care.
Failure to Preserve Dignity by Placing a Brief on a Continent Resident
Penalty
Summary
The facility failed to provide services in a dignified manner for 1 resident who was cognitively intact and had diagnoses including renal insufficiency, DM, and hypertension. The resident’s MDS identified him as continent of bowel and bladder and needing staff assistance with ADLs including bed mobility, transfers, and toileting. A bowel and bladder assessment also identified the resident as continent, and the care plan stated he was aware of the need to void or defecate and would request to use the toilet as needed. During interview, the resident stated staff put diapers on him even though he was not incontinent and said it made him feel like a baby. During observation, a NA placed a brief on the resident, and the resident showed the surveyor the brief and stated it had just been put on him a few minutes earlier. The NA verified she placed a brief on the resident that morning even though he was not incontinent and said she was unsure why she did so. RN-A confirmed the resident was continent and stated staff put a brief on him out of habit. The DON stated staff should not place a brief on residents who are continent and that it was important to maintain the resident’s dignity.
Failure to Provide Restorative Ambulation and Address Decline in Mobility
Penalty
Summary
The facility failed to provide restorative ambulation services and failed to respond to a decline in ambulation status for one resident who had mild cognitive impairment, dementia, hypertension, diabetes, weakness, and chronic pain. The resident’s care plan and restorative documentation directed daily ambulation with a front wheeled walker and staff assistance of one, and the resident was also identified as having limited physical mobility and being at risk for falls due to weakness, chronic pain, and an unsteadied gait and balance. However, the nursing rehab point-of-care record repeatedly documented ambulation as “not applicable,” with only one entry showing the resident ambulated for 15 minutes and one entry showing refusal. The resident stated she could no longer walk and that staff needed to help her get into bed and her wheelchair. Staff interviews confirmed the ambulation task was not being completed. A nursing assistant stated aides were responsible for ambulation but were not completing it, and another nursing assistant stated ambulation was supposed to be done but was not done very often; that staff documented it as not applicable when it did not get done; and that the resident had not walked at all for several weeks and was using a sit-to-stand lift with assist of two for all transfers. An RN stated the task just did not get done and that no plan had been created to fix it. The DON stated the resident’s condition had changed and a therapy evaluation should have been requested, and also stated the care plan needed revision because the resident would not be transferred with an assist of one. The resident’s medical record lacked an assessment for ADL decline, including any revision to the ambulation care plan.
Failure to Complete and Document Restorative ROM and Splinting
Penalty
Summary
The facility failed to ensure range of motion (ROM) was completed in accordance with therapy recommendations to maintain mobility for one resident with mild cognitive impairment who was dependent on staff for all care areas and had diagnoses including diabetes, hemiplegia, and hemiparesis. The resident’s care plan identified limited physical mobility, fall risk, weakness, contractures, and limited ROM, and included restorative nursing interventions for bilateral lower extremity passive ROM to active ROM, passive hamstring and heel cord stretches, PROM to both hands, and splint use for the hands. The resident’s restorative documentation from 4/20/26 through 5/19/26 showed the hand splints were worn 41 times and marked not applicable 20 times out of 90 opportunities, but the documentation did not identify refusals to wear the splints. The leg stretches were completed 3 times out of 30 opportunities, and the documentation did not identify why the stretches were not performed or whether they were refused. The resident’s untitled nurse aide care sheet also identified a restorative program and encouragement to participate in the Well Fit program. During interviews, a nursing assistant stated staff were supposed to encourage participation in the Well Fit program and complete PROM and AROM, but it did not get done very often and was often documented as not applicable because it was not offered. An RN stated nursing assistants were responsible for restorative programs but they did not get done, and no plan had been created to fix the issue. The DON stated staff should have offered the tasks and documented refusals, but believed staff may have stopped offering after repeated refusals; the DON also stated the restorative program needed to be updated and that staff were documenting tasks as not applicable, which she was unaware of.
Dirty can opener and contaminated dry storage bins
Penalty
Summary
The facility failed to keep 1 of 1 commercial can opener clean and sanitary and failed to store dry goods removed from original packaging in a manner that reduced the risk of cross-contamination. During an initial tour with the Director of Culinary Services (DCS), four white plastic bins in the food preparation area were observed on the floor and labeled for flour, white sugar, rice, and powdered sugar. The flour bin was about one-third full and had a black scoop partially covered with flour, including the handle. The bin labeled white sugar had yellowish-tan dry matter on the right lateral wall, and the front wall had red dry matter measuring 6-7 cm in diameter. The rims around the lids of all four bins were dirty with dark dust-like particles, and the DCS verified these findings and stated the scoop should not be left inside the bins and needed to be clean inside and out. The attached [NAME] brand can opener was also observed with its blade halfway covered with dry, red-colored matter. On a later kitchen tour, the can opener blade still had dry red matter, which had been pushed upward by 0.2 cm, and a small light amber particle was noted below it. The cook stated he had used the can opener that morning to open a can of cream of corn used for lunch. The DCS verified the dry matter on the can opener and stated it should be washed every time it was used to prevent cross contamination. Facility policy stated dry storage areas would be maintained to keep food safe and free of infestation or contamination, and the sample cleaning schedule stated can openers should be clean after each use.
Dignified Medication Administration Not Maintained
Penalty
Summary
The facility failed to provide a dignified experience for 1 of 2 residents, R20, during medication administration. R20’s records showed severely impaired cognition, inattention, disorganized thinking, verbal behaviors toward others, and diagnoses including severe dementia with psychotic disturbance, visual hallucinations, generalized anxiety disorder, PTSD, and delusional disorder. Her care plan identified mood, behavior, and sleep alterations related to Alzheimer’s disease, dementia, generalized anxiety disorder, paranoia, public outbursts, and accusations that people were throwing medications down her throat, and it directed staff to redirect and reapproach when she was resistive or combative, use a calm approach, provide reassurance, and offer comfort items. During observation, RN-A brought medications to R20 in the dining room and attempted to pour them from a small plastic cup into her mouth. When R20 removed one medication, Divalproex, and threw it on the floor, RN-A attempted again to pour the remaining medications into her mouth while R20 moved her head back and forth and tried to pull away. RN-A then raised her voice, stated the resident’s name, told her she needed to take her medications, pulled her chair back from the table, picked up the Divalproex from the floor, placed it in a separate cup, and asked why she would not take her medications. R20 responded that it was because the nurse was not being nice. RN-A then left with the remaining refused medications and stated R20 would take them later and that she always had a behavior when taking her morning medications.
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