2024 Year in Review - Minnesota

A resident experienced a delay in emergency medical response due to the facility's failure to train staff on unlocking the main entrance doors after hours. The doors were locked for security reasons, but agency staff were not trained on how to access them, leading to a ten-minute delay for EMS personnel. This deficiency placed all residents at risk for serious harm.

No penalty information released

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

A nursing assistant in a LTC facility took and shared humiliating photos and videos of residents on social media, violating their privacy and dignity. The assistant was aware of the facility's policies against such actions but continued to engage in abusive behavior, including physical aggression and inappropriate gestures. The residents involved had various medical conditions, making them vulnerable to abuse.

No penalty information released

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

The facility implemented a policy review and provided appropriate education and training to all employees to address the deficiency.

The facility failed to thoroughly investigate injuries of unknown origin for four residents with suspicious bruises. The injuries were not witnessed, and the residents could not explain how they occurred. The facility did not conduct thorough investigations or document the incidents properly, leading to unverified rationales and a failure to implement corrective actions.

Inspection fine: $146,055

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

Interviews and physical assessments were conducted with residents, nursing leadership and staff were educated on investigating injuries of unknown origin, the facility's policy was reviewed, and the administrator will monitor compliance and audit incidents, addressing any concerns and trends through Quality Assurance and Performance Improvement meetings.

A resident with a documented DNR status was subjected to CPR due to a failure in verifying code status. Despite multiple staff members questioning the decision, the DON relied on an outdated paper chart indicating full code, leading to unwanted medical interventions. The incident highlights a deficiency in the facility's handling of advance directives and emergency response protocols.

No penalty information released

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

The facility reviewed its policy on advance directives, educated staff on verification procedures, initiated a binder system for code status verification, and implemented an audit process to ensure accuracy.

A resident with a history of cardiovascular issues experienced chest pain, but the facility staff failed to promptly assess and notify the physician, delaying treatment. Despite the resident's symptoms and family member's concerns, staff waited for physician rounds. The resident was eventually sent to the hospital, diagnosed with an acute anterior STEMI, and passed away after complications.

No penalty information released

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

The facility implemented corrective actions including re-education for the nurse management team on recognizing and responding to changes in resident conditions, posting and reviewing signs/symptoms of cardiac episodes at nurses' stations, administering a quiz to nurses on handling changes in condition, reviewing similar resident cases to ensure no additional risks, and scheduling a nurse meeting to reinforce the education provided.

A facility failed to follow care plans for mechanical lift transfers, resulting in falls for two residents. One resident fell from an EZ-Stand due to a nurse aide's lack of awareness of the two-staff requirement, while another passed out during a transfer and was hospitalized for a leg fracture. A third resident was transferred without clear parameters for using a full lift, highlighting inadequate training and care plan adherence.

No penalty information released

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

Policies related to care sheets, care plans, and the use of the EZ Lift/Stand were reviewed and updated, with all licensed staff, nursing assistants, and agency staff receiving education and competency assessments on their proper use. The orientation checklist for agency staff was updated, residents using the EZ Stand were re-assessed for partial weight-bearing capability per manufacturer's guidelines, and staff were educated on incident reporting to the SA.

The facility failed to prevent falls and conduct necessary neurological assessments for three residents, leading to a traumatic brain injury for one resident. Despite multiple falls, the facility did not update care plans or implement new interventions. Additionally, there was a lack of documentation and communication regarding follow-up care for another resident who fell in the community.

No penalty information released

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

The facility implemented corrective actions by updating the Fall Risk Assessment Policy and Procedure, revising the protocol and form for neurological assessments, and training nursing staff on new neurological assessments and post-fall procedures. They reviewed falls for all affected residents, updated their care plans, performed post-fall assessments, and completed Falls Risk Assessments for each identified resident.

Two residents requiring 1:1 supervision during meals were left unsupervised, leading to choking risks. One resident with dysphagia experienced multiple coughing episodes and a severe choking incident, while another was found asleep with food in his mouth. Staff failed to follow care plans and therapy recommendations, resulting in immediate jeopardy.

No penalty information released

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

The facility revised their meal assistance policy, updated resident care plans to align with current ST recommendations, implemented a new system for therapy recommendations, conducted staff education with a post-quiz on the meal assistance policy, and completed audits to ensure residents needing meal assistance or supervision were properly supported.

A resident fell from a mechanical lift due to improper use, resulting in spinal fractures. The facility failed to ensure correct sling sizes and safety checks for multiple residents, leading to discrepancies between care plans and actual practices. Staff were unaware of proper procedures, increasing the risk of injury.

No penalty information released

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

Two residents with moderately impaired cognition had POLST forms inaccurately reflecting their resuscitation wishes, leading to an immediate jeopardy situation. Despite verbal confirmations of their DNR preferences, the forms indicated full code status due to errors by nursing staff. This discrepancy could have resulted in CPR being performed against the residents' wishes.

No penalty information released

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

A resident with cognitive impairment and a history of wandering eloped from the facility due to a failure in the alarm system. The door alarm did not sound because it was not reset after a previous incident, and the resident's wander guard was non-functional. Staff were not trained to reset the alarm, leading to the resident's unsupervised exit and subsequent return by police.

No penalty information released

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

Staff received training on door reset procedures, the door alarm company inspected all door tags, equipment was installed to display alarmed doors on TVs, and the camera system's motion detection was extended from 3 to 10 seconds.

A resident suffered an ankle fracture due to unsafe transfer practices when staff failed to follow the care plan, which required the use of a standing lift. Multiple instances of improper transfer techniques were observed, including the absence of gait belts and lifting residents by the underarms. Staff interviews revealed a lack of awareness and understanding of care plans, contributing to preventable falls and injuries.

No penalty information released

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

A resident admitted with multiple fractures and a surgical wound in the left groin area was not properly assessed or treated according to physician orders. The facility failed to transcribe the discharge instructions into the resident's records, leading to a lack of monitoring and documentation of the surgical wound. This oversight resulted in the wound dehiscing and becoming infected, necessitating a five-day hospital stay for surgical intervention and antibiotic therapy.

1 days payment denial

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

The facility failed to assess falls for root cause and implement interventions for two residents with a history of falls. One resident sustained multiple injuries after an unwitnessed fall due to inadequate supervision and care plan implementation. Another resident experienced multiple falls without a comprehensive analysis or updated care plan interventions.

No penalty information released

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

A resident with dementia was sent to a dental appointment without an escort, despite requiring supervision. The facility was unaware of the resident's whereabouts for 20 hours. The transport company was not informed of the need for an escort, and the resident was left unsupervised at the dental office. The facility failed to follow its policy on safety and supervision, resulting in an immediate jeopardy situation.

No penalty information released

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

A resident with a history of brain hemorrhage became unresponsive, and the facility failed to perform a comprehensive assessment or notify the physician promptly. Despite being unresponsive and having a fever, the resident's condition was not adequately communicated to the physician, leading to a delay in hospitalization. The resident was later diagnosed with a new brain hemorrhage and passed away.

No penalty information released

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

A resident with a full code status was found unresponsive in a LTC facility, but CPR was not initiated, leading to the resident's death. Despite being trained and certified in CPR, staff failed to follow the protocol, resulting in a critical deficiency.

No penalty information released

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

A resident with multiple medical conditions fell from a mechanical lift due to improper use of a toileting sling, resulting in serious brain injuries. The nursing assistants involved had not received proper training on sling use, leading to the resident's arms being placed inside the sling and the waist buckle not being secured, causing the fall.

No penalty information released

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

The facility reviewed and updated policies on mechanical lift use, re-assessed residents for proper sling size, re-educated staff with competency testing, and conducted audits on lift transfers, with results to be reviewed by the QAPI committee.

A resident with complex medical needs, including diabetes and recent amputations, was discharged from a facility to a homeless shelter that could not meet his care requirements. The discharge plan was incomplete, lacking necessary assessments and instructions for medication and wound care management. The resident was left without adequate support, posing a risk to his health and safety.

No penalty information released

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

A resident fell from a mechanical lift in an LTC facility, resulting in a fractured sternum and hip hematoma. The incident occurred during a transfer from a commode to a bed when a sling strap detached. Staff failed to check the tension and security of the sling straps, leading to the fall. The equipment was found to be in working order, suggesting operator error.

No penalty information released

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

A resident's ventilator alarmed 237 times over several hours without staff response, indicating high pressure or obstruction. Staff were occupied with other residents, and the facility lacked a policy for alarm response. The deficiency highlighted a gap in monitoring and responding to critical alarms.

Inspection fine: $54,270

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

A resident with a known shellfish allergy was served shrimp pasta salad, leading to a severe allergic reaction and hospitalization. Despite the dietary aide preparing the correct meal, the nursing assistant delivered the wrong tray. The resident was treated with epinephrine and transported to the ICU. The facility's investigation into the incident was inconclusive.

Inspection fine: $20,965

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

A facility failed to report and investigate sexual abuse incidents involving two residents, leading to repeated abuse. A resident with cognitive impairments and a history of inappropriate behavior touched another resident inappropriately on two occasions. Despite staff witnessing the first incident, it was not reported or investigated, and the resident's care plan lacked interventions for sexually inappropriate behaviors. The facility's abuse prohibition policy was not followed, contributing to the subsequent incident.

No penalty information released

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

Implemented 1:1 supervision for the resident, updated care plans with new interventions, and provided staff education on reporting vulnerable adult abuse.

A resident with a history of respiratory failure and septicemia was found with a heart rate of 156 bpm, but the nurse on duty did not notify a provider. The resident was later found unresponsive and died despite CPR efforts. The facility failed to follow standing orders and policies requiring provider notification for significant changes in condition.

No penalty information released

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

Nursing staff, including agency/contract staff, will be re-educated by the DON or designee on change in condition protocols, documentation, and vital sign parameters, with education verified through random staff interviews and further 1:1 sessions as needed. The policy and procedure for these areas have been reviewed.

A resident with dysphagia was served a regular diet instead of a pureed diet, leading to a choking incident requiring the Heimlich Maneuver. Staff failed to verify and serve the correct diet, highlighting a lack of training and understanding of diet textures.

Inspection fine: $24,2005 days payment denial

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

Policies and procedures for serving resident meals were reviewed and revised, with comprehensive staff education on diet recognition and the importance of serving correct textured meals. A training plan was implemented to ensure all staff are trained before their next shift.