Augustana Care Hastings Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Hastings, Minnesota.
- Location
- 930 West 16th Street, Hastings, Minnesota 55033
- CMS Provider Number
- 245224
- Inspections on file
- 19
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 2 (1 serious)
Citation history
Health deficiencies cited at Augustana Care Hastings Health And Rehabilitation during CMS and state inspections, most recent first.
A resident with hemiplegia and other comorbidities, who required a mechanical lift with two-person assistance, was being transferred from a wheelchair to a bed using a floor-based full body sling lift. Two NAs attached the sling loops and raised the resident, then moved the lift away from the chair to obtain a weight without first performing the required safety check to verify that all four sling loops were securely attached and under tension. The upper left sling loop came loose, causing the resident to fall onto her shoulder and sustain displaced fractures of two left ribs. Interviews and document review showed that facility policy and staff training required a pause and visual/tactile verification of all sling attachment points before moving a resident, but this procedure was not followed during the transfer.
A resident with multiple complex conditions, including pyoderma gangrenosum, was not consistently assessed or monitored for non-pressure related skin injuries. Despite having multiple wounds and ongoing treatment orders, staff did not perform or document weekly comprehensive wound assessments, and there was no evidence of physician notification when dressing changes were refused. The facility's updated policy contributed to the lack of monitoring and documentation, resulting in a deficiency in quality of care.
Surveyors found that kitchen staff failed to properly clean a commercial can opener and did not sanitize a food thermometer between checking different food items, using a dirty washcloth instead of alcohol wipes or sanitizing solution. The culinary director and DON confirmed these were infection control issues and not in line with facility policy.
Staff did not consistently remove PPE or perform hand hygiene before exiting rooms for residents on enhanced barrier precautions, and housekeeping staff failed to change gloves and sanitize hands between cleaning different rooms. During meal assistance, nursing assistants did not perform hand hygiene between helping multiple residents, and in one case, used bare hands to assist with eating. These actions were not in line with facility policies or infection prevention expectations.
A resident with multiple medical conditions and total assistance needs for transfers experienced delays in receiving incontinence care after requesting help, resulting in discomfort and distress. Staff did not promptly respond to the resident's request, and there was a lack of awareness and implementation of the resident's care plan and toileting preferences. The incident demonstrated a failure to provide care in a respectful and dignified manner as required by facility policy.
The facility did not follow physician orders for daily monitoring of heart failure symptoms for a resident, omitting required assessments and documentation of lung sounds, edema, and oxygen saturations. Additionally, another resident with multiple comorbidities developed a wound on the right great toe that was not comprehensively assessed or documented, with missing wound descriptions and measurements, and the wound was not entered into the wound management system as required by facility policy.
A resident with chronic respiratory failure and hypoxia was not provided continuous oxygen therapy as ordered, resulting in a significant drop in oxygen saturation and observable respiratory distress. Staff confirmed the oxygen was not turned on, and there was no documentation of the incident or the resident's low oxygen levels in the medical record, despite facility policy and physician orders.
A resident with chronic pain and multiple diagnoses did not receive consistent pain assessment and monitoring, as pain ratings and locations were often missing from documentation when PRN pain medications were given. The resident reported ongoing severe pain and lack of follow-up after medication administration, and staff interviews confirmed gaps in pain assessment and documentation, resulting in a deficiency related to pain management.
A resident with a missing front tooth and oral health issues did not receive follow-up for a dental referral or recommended use of an over-the-counter fluoride rinse, despite documented recommendations and facility policy. Staff interviews revealed a lack of awareness and action regarding these dental care needs.
The facility failed to follow infection control measures by using uncovered laundry carts to transport clean personal laundry. Both the laundry aide and the director of environmental services confirmed the carts were not covered, despite the facility's policy requiring clean linen to be stored in enclosed locations.
The facility failed to implement current standards for pneumococcal vaccinations for four residents over the age of 65. Despite having received previous pneumococcal vaccinations, there was no documentation indicating that the PCV20 vaccine was offered or discussed with them. The infection preventionist confirmed that no residents had been offered the PCV20 vaccine and that the facility was not engaging in shared clinical decision-making for this vaccine.
A resident with chronic respiratory failure was not instructed to rinse their mouth after using a corticosteroid inhaler, as required by the Medication Administration Record (MAR) and manufacturer instructions. The LPN administering the inhaler admitted to the oversight, and the facility's assistant director of nursing confirmed the necessity of rinsing to prevent thrush.
The facility failed to provide routine nail care for a resident with moderate cognitive impairment who was dependent on staff for ADLs. Despite the resident's requests and the facility's policy, staff did not trim or clean the resident's long, jagged fingernails containing dark debris. Staff interviews confirmed that the resident did not refuse nail care, yet it was not provided as required.
The facility failed to provide activities of interest to a resident with moderate cognitive impairment on the short-term stay unit. Despite the resident's expressed preference for group activities and social events, there was minimal engagement, and no re-evaluation was conducted as the resident's condition improved. Staff admitted to not tracking activity participation or refusals, and the facility lacked a policy on activities.
A resident with a spinal fracture was observed wearing a Miami J collar incorrectly, with the chin tucked into the collar due to improper application by nursing staff. Interviews revealed a lack of specific training and guidelines for correct application, and the facility lacked a policy on neck brace application.
A resident experienced prolonged UTI symptoms and unnecessary antibiotic use due to the facility's failure to follow its antibiotic stewardship program. Multiple antibiotics were prescribed without proper testing, leading to delayed appropriate treatment and significant impact on the resident's quality of life.
The facility failed to ensure the required nurse staffing information was posted daily and updated with each shift. The staffing coordinator was on vacation, and the responsibility for updating the staff posting was missed by the long-term care nurse manager. Interviews revealed a lack of clarity and communication regarding the responsibility for updating the staff postings during the SC's absence.
The facility failed to notify the Office of Ombudsman for Long-Term Care (OOLTC) of resident hospitalizations, including one resident who had multiple hospitalizations due to various reasons. The administrator confirmed that the responsibility for sending monthly hospitalization listings to the OOLTC had not been fulfilled for an undetermined amount of time.
Improper Mechanical Lift Transfer Leading to Resident Fall and Rib Fractures
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe mechanical lift transfer by not confirming that all four sling straps were properly attached before moving a resident. The resident involved was an elderly female with hemiplegia and hemiparesis following cerebral infarction affecting the left side, osteoarthritis, and fibromyalgia, who required a mechanical lift with assistance of two staff for transfers and used a medium-sized sling. On the day of the incident, two NAs used the mechanical lift and the appropriately sized sling to transfer the resident from her wheelchair to her bed. One NA attached the right upper and lower loops of the sling while positioned on the resident’s right side, and the other NA attached the lower loops and was responsible for operating the lift. After the sling was attached, the NAs raised the resident into the air and moved the lift backward, pausing between the wheelchair and the bed to obtain the resident’s weight using the lift’s weighing feature. During this process, the top left strap of the sling came loose from the lift, causing the resident to fall from the lift onto her left shoulder. The resident sustained acute displaced fractures of the 2nd and 3rd left ribs and required transfer to the hospital for further evaluation and care. The incident was documented in a progress note and an incident report, and an IDT meeting was held regarding the fall. Interviews conducted during the survey revealed that facility policy and staff expectations required that all four sling loops be checked for secure attachment before moving a resident, including lifting the resident slightly off the surface to verify tension and stability of the loops. The DON and nurse manager stated that staff are expected to perform a safety check by slightly lifting the resident and visually confirming that all sling loops are tight and completely attached before proceeding with the transfer. The DON’s investigation concluded that the upper left loop of the sling was either not attached or not properly attached by one of the NAs, and that both NAs failed to complete the required pause and safety check prior to moving the resident away from the original surface. This failure to follow established procedures for mechanical lift use led directly to the resident’s fall and injuries.
Removal Plan
- Removed the mechanical lift and sling involved in the incident from the floor
- Interviewed the staff involved and completed reenactments/demonstrations to determine what happened
- Suspended NA-A and NA-B pending investigation findings
- Immediately reeducated all staff on shift using the existing mechanical lift competency checklist used for onboarding
- Continued retraining for all shifts, including part-time staff and staff returning from leave as applicable
- Provided education via shift huddles and 1:1 reeducation sessions conducted by the DON, nurse manager, and staff development nurse
- Completed audits/observations of mechanical lift transfers for like-residents using the lift competency checklist to verify correct practice
Failure to Assess and Monitor Non-Pressure Skin Injuries
Penalty
Summary
The facility failed to assess and monitor non-pressure related skin injuries for a resident with multiple complex medical conditions, including multiple sclerosis, diabetes, congestive heart failure, and pyoderma gangrenosum. The resident was admitted with several lesions and had a history of moisture-associated skin damage (MASD). Despite ongoing treatment orders and a care plan identifying the need for monitoring and interventions, the facility did not conduct or document weekly comprehensive wound assessments for the resident's multiple wounds. There was also no evidence of monitoring for changes in the wounds or notification to the physician when the resident refused dressing changes on two occasions. Interviews with nursing assistants revealed that they were aware of the resident's bandages but had never seen the wounds themselves, indicating a lack of direct observation or assessment by staff other than the nurse performing dressing changes. The LPN and DON confirmed that weekly comprehensive wound assessments, including measurements and evaluation of wound characteristics, were not being performed as required. The DON was unable to explain how staff would identify changes in the wounds without these assessments and was also unsure of the last dermatology follow-up for the resident. The facility's updated skin integrity policy no longer required weekly comprehensive assessments for non-pressure wounds, which contributed to the lack of ongoing monitoring and documentation. The resident's record lacked evidence of wound care follow-up as ordered by the hospital and did not include documentation of wound progress, measurements, or physician notifications for stagnant or worsening wounds. This failure to consistently assess and monitor the resident's non-pressure related skin injuries until resolution resulted in a deficiency in the facility's quality of care.
Failure to Maintain Sanitary Food Preparation Practices and Equipment
Penalty
Summary
The facility failed to maintain proper sanitation and infection control practices in the main production kitchen, as evidenced by observations of a commercial can opener and food thermometer. The can opener blade was found with dark tan, black, and red debris caked along its surface during two separate observations, and the culinary director confirmed the buildup, stating the can opener was only washed three to four times a week and was unsure of the last cleaning. The director acknowledged that a dirty blade posed a risk for cross-contamination and that it should be cleaned daily. Additionally, a cook was observed using a moist, stained washcloth to wipe a food thermometer between checking different food items, rather than using alcohol wipes or a sanitizing solution as required by facility policy. The cook admitted to never using alcohol wipes and instead would use a clean washcloth to prevent cross-contamination. The culinary director confirmed this was not the facility's procedure and that proper sanitization was necessary. The director of nursing also identified these practices as infection control issues. Facility policies required all food contact surfaces and utensils to be properly washed and sanitized, and specifically stated that thermometers should be sanitized between each food item.
Infection Control Deficiencies in PPE Use, Housekeeping, and Dining Assistance
Penalty
Summary
Staff failed to consistently follow infection prevention and control protocols in several areas of care. For residents on enhanced barrier precautions (EBP), staff did not remove personal protective equipment (PPE) or perform hand hygiene before exiting resident rooms. In one instance, a nursing assistant exited a resident's room wearing a gown and gloves, cleaned a mechanical lift in the hallway, and only then removed PPE and performed hand hygiene. Another nursing assistant removed gloves but not the gown before leaving a resident's room, carrying the gown down the hallway before being corrected by a nurse. Interviews with staff and the infection preventionist confirmed that PPE should be removed and hand hygiene performed before leaving rooms under EBP, but the facility's policy did not clearly specify this requirement for EBP, only for contact precautions. Housekeeping staff also failed to change gloves and perform hand hygiene between cleaning different resident rooms. One housekeeping aide was observed wearing the same gloves while cleaning two separate rooms, handling cleaning equipment, and touching environmental surfaces without changing gloves or sanitizing hands. The director of environmental services and the infection preventionist both stated that gloves should be changed and hand hygiene performed between rooms to prevent cross-contamination, in accordance with facility policy. During meal assistance, nursing assistants did not perform hand hygiene between assisting multiple residents. Staff were observed using the same hand to feed and wipe the mouths of two different residents without sanitizing hands in between, and in one case, a staff member used their bare hands to assist a resident with eating. Staff interviews confirmed awareness of the need for hand hygiene before and after meal assistance, but there was confusion about procedures when assisting more than one resident at a time. The facility's feeding policy required hand hygiene before and after assisting with eating but did not address hand hygiene between residents when assisting multiple individuals.
Failure to Provide Dignified and Timely Incontinence Care
Penalty
Summary
A deficiency occurred when staff failed to address a resident's need for incontinence assistance in a respectful and dignified manner. The resident, who had intact cognition and multiple diagnoses including cancer, anemia, hypertension, diabetes, psychotic disorder, and COPD, was always incontinent of bowel and bladder and required extensive assistance for toileting and total assistance for transfers using a full body mechanical lift. The resident's care plan directed staff to check and change her and/or offer a bed pan at specific times and as needed, but documentation showed the bowel toileting program was inconsistently followed, with the program only implemented one day during a reference week. On the day of the observed incident, the resident requested assistance after an incontinence episode following breakfast. Multiple staff entered and exited the room, assisting the roommate and performing other tasks, but did not promptly address the resident's request for incontinence care. The resident waited for an extended period, expressing discomfort and distress about her situation. Staff interviews confirmed that the resident required assistance of two for transfers and that she did not like using the bed pan due to discomfort. Although the use of a commode had been discussed, it had not been trialed, and staff were not fully aware of the resident's preferences or continence needs. Interviews with nursing staff and administration revealed a lack of awareness regarding the resident's toileting preferences and the implementation of her care plan. Staff responses indicated that assistance was provided after other tasks were completed, and there was no clear communication or prioritization to meet the resident's needs in a timely manner. The facility's policy required residents to be treated with respect and dignity, but the observed delay and lack of individualized care did not align with these expectations.
Failure to Monitor Heart Failure and Document Skin Wound Assessment
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and resident needs for two residents. For one resident with a known history of heart failure and peripheral vascular disease, the discharging hospital physician had directed staff to monitor for signs of heart failure daily, including assessments of lung sounds, peripheral edema, and oxygen saturations at rest and with activity. However, the resident’s electronic medical record lacked any documentation or orders for these assessments, and there was no evidence that staff routinely monitored or documented lung sounds or edema. Oxygen saturations were checked daily, but it was not specified whether these were measured at rest or with activity. Interviews with nursing staff and the assistant director of nursing confirmed that the required monitoring and documentation were not in place, despite the hospital’s explicit instructions. For another resident with multiple comorbidities including heart failure, liver cirrhosis, and polyneuropathy, the facility failed to comprehensively assess and document a non-pressure skin condition on the right great toe. Although the care plan and skin risk assessments required regular skin checks and documentation of any new wounds, the records did not include a description or measurements of the wound when it was first identified. Progress notes referenced a sore and dressing changes, but lacked detailed physical descriptions or measurements. The wound was not entered into the facility’s wound management system as required by policy, and there was no consistent tracking or documentation of the wound’s status over time. Interviews with nursing staff, the assistant director of nursing, and the nurse practitioner revealed that the wound was not properly documented or tracked according to facility policy. The facility’s skin integrity policy required that new wounds be documented in the wound management area with specific details, but this was not done. As a result, the wound’s progression could not be adequately monitored, and there was insufficient information to ensure timely and appropriate interventions.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
A deficiency occurred when a resident with chronic respiratory failure, hypoxia, and other significant health conditions was not provided oxygen therapy as ordered by the physician. The resident had orders for continuous oxygen via nasal cannula at 2 to 4 liters per minute to maintain oxygen saturation above 90%. Multiple observations revealed that the resident's oxygen tank was not turned on while the nasal cannula was in place, and the resident was found with rapid, labored breathing and an oxygen saturation as low as 69%. Staff confirmed the oxygen was not on and that the resident required continuous oxygen. The oxygen was subsequently turned on and the flow rate increased, resulting in improved oxygen saturation. The resident's electronic medical record did not contain documentation of the incident or the drop in oxygen saturation below 90%. Additionally, a safety event was recorded as a medication incident, but lacked vital signs and progress notes. Interviews with staff indicated that nursing assistants were responsible for switching oxygen tanks, while nurses were responsible for monitoring oxygen saturation and flow rates. The nurse manager and DON confirmed that there was no documentation of the incident in the medical record, despite facility policy requiring oxygen to be administered per order.
Failure to Appropriately Monitor and Assess Pain Complaints
Penalty
Summary
The facility failed to appropriately monitor and comprehensively assess pain complaints for a resident with a complex pain history. The resident had diagnoses including fibromyalgia, chronic pain, diabetes, neuropathy, restless leg syndrome, depression, and psychotic disorder, and was prescribed both scheduled and PRN pain medications, as well as non-pharmacological interventions. The resident's care plans and assessments indicated frequent pain that affected sleep and daily activities, and the resident was able to verbalize pain and pain relief. Despite these interventions, documentation and monitoring of pain were inconsistent. Review of the resident's medication administration records and progress notes revealed that pain ratings and pain locations were often missing when PRN pain medications were administered. Specifically, several instances were noted where pain ratings or locations were not documented, and there was a lack of follow-up after pain medication administration. Additionally, the resident reported ongoing severe pain, rating it as eight or nine out of ten, and stated that pain medications were not effective and that nurses did not return to reassess pain after administration. Staff interviews confirmed that pain assessments were not always completed or documented as required, and follow-up on resident complaints was lacking. The facility's pain management policy required ongoing pain assessment, documentation of pain characteristics, and monitoring the effectiveness of interventions. However, the records showed that pain assessments were not consistently performed or documented, and there was insufficient evidence of comprehensive pain monitoring. This failure to follow policy and ensure thorough pain assessment and documentation led to the deficiency identified during the survey.
Failure to Follow Up on Dental Referral and Oral Care Recommendations
Penalty
Summary
The facility failed to ensure that a routine dental referral and recommended oral care interventions were followed for a resident who was cognitively intact and required supervision with oral hygiene. The resident had a history of broken natural teeth, inflamed and bleeding gums, and was self-conscious about a missing front tooth. A dental assessment recommended direct staff supervision for oral care, use of an over-the-counter fluoride rinse twice daily, and a dental referral to repair or replace the missing tooth. However, the resident's care plan did not include interventions for the fluoride rinse, and there were no active orders or documentation indicating the resident was using the rinse or that the dental referral was followed up on. Interviews with facility staff revealed a lack of awareness and follow-through regarding the dental recommendations. The social services designee was unaware if the resident had been scheduled for a follow-up dental appointment, and the Health Information Director (HID) confirmed that the referral for dental repair was not acted upon. The HID also stated that he was responsible for reviewing dental forms and following up on recommendations but had not done so in this case. The registered nurse was similarly unaware of the recommendations for the fluoride rinse and dental follow-up. Facility policy required assistance in obtaining routine dental care, but this was not provided as required for the resident.
Failure to Cover Personal Laundry Carts
Penalty
Summary
The facility failed to ensure appropriate infection control measures were followed related to the transportation of clean personal laundry. On multiple occasions, surveyors observed a four-tiered metal open and uncovered laundry cart being used to deliver residents' personal clothing items on the second floor and the transitional care unit (TCU). The laundry aide confirmed that the cart used for delivering personal laundry was not covered, and the director of environmental services acknowledged awareness of the requirement to cover the carts but admitted that this practice was not being followed. The administrator also confirmed the importance of covering clean linen for infection control purposes. During a tour, it was observed that while the carts used for linens were covered with attached plastic covers, the personal laundry carts were not. The facility's policy on sorting clean linen indicated that clean linen should be stored in enclosed, clean, designated locations. Despite this policy, the personal laundry carts remained uncovered, exposing the clean laundry to potential contamination. The director of environmental services and the laundry aide both verified the lack of covers on the personal laundry carts and recognized the need to address this issue.
Failure to Implement Pneumococcal Vaccination Standards
Penalty
Summary
The facility failed to implement the current standards of vaccinations regarding pneumonia for four residents over the age of 65. The residents' immunization records lacked evidence that they were offered or received education regarding the PCV20 vaccine. The electronic medical records (EMR) also lacked evidence of shared clinical decision-making with the physician for the PCV20 vaccine. The residents involved had various medical conditions, including type 2 diabetes mellitus, emphysema, chronic obstructive pulmonary disease, hypertension, acute respiratory distress, unspecified diastolic heart failure, and chronic kidney disease. Despite having received previous pneumococcal vaccinations (PPSV23 and PCV13), there was no documentation indicating that the PCV20 vaccine was offered or discussed with them. The infection preventionist (IP) confirmed that it was her responsibility to ensure residents were up to date on all immunizations. She stated that immunizations were verified through the Minnesota Immunization Information Connection (MIIC) and that the facility used the current Centers for Disease Control and Prevention (CDC) recommendations for immunization guidelines. However, the IP admitted that no residents had been offered the PCV20 vaccine and that the facility was not engaging in shared clinical decision-making for this vaccine. The IP also verified that the facility's immunization consent forms did not indicate any discussion or education about the PCV20 vaccine, despite the forms showing that the vaccine had been refused. The facility's policy on pneumococcal vaccines, which was reviewed in July 2023, indicated that residents should be offered immunization against pneumococcal disease in accordance with current CDC or state guidelines. However, the policy was not followed, as evidenced by the lack of documentation and education regarding the PCV20 vaccine for the residents in question. The administrator confirmed that immunizations were given upon admission and referred to the infection preventionist and director of nursing for their expertise, but this did not result in the residents being offered the PCV20 vaccine.
Failure to Follow Inhaler Administration Instructions
Penalty
Summary
The facility failed to ensure a dry-powder inhaler was administered in accordance with manufacturer instructions and current standards of care for a resident observed to receive inhalers during the survey. The resident, who was hospitalized with chronic respiratory failure and hypoxia due to aspiration pneumonia, was prescribed Breo Ellipta, an inhaler containing a corticosteroid. The Medication Administration Record (MAR) included instructions to rinse the mouth after use to reduce the risk of thrush, a common side effect of corticosteroids. However, during an observed medication pass, the Licensed Practical Nurse (LPN) administering the inhaler did not instruct or assist the resident in rinsing their mouth after use. The resident confirmed that the care center staff had never instructed them to rinse their mouth after using the Breo Ellipta inhaler. The LPN also admitted to not offering or providing a rinse and spit after the inhaler use, mistakenly believing that the MAR did not include such instructions. Upon reviewing the MAR, the LPN acknowledged the oversight and recognized the importance of rinsing the mouth to prevent medication from remaining in the oral cavity, which could lead to thrush. Further interviews with the facility's assistant director of nursing (ADON) and a pharmacist confirmed the necessity of rinsing the mouth after using a corticosteroid inhaler to prevent thrush. The ADON acknowledged the lapse in following the administration instructions and indicated that education would be completed with the nurses to ensure compliance with the guidelines. The facility's Inhaler Use policy also outlined the need for residents to rinse their mouths after inhaling corticosteroids, which was not followed in this instance.
Failure to Provide Routine Nail Care
Penalty
Summary
The facility failed to ensure routine personal hygiene, specifically nail care, for a resident (R38) who was dependent on staff for activities of daily living (ADLs). R38, who had moderate cognitive impairment and required maximal assistance for ADLs, was observed multiple times with long, jagged fingernails containing dark debris. Despite R38's requests for nail care, staff did not provide the necessary assistance. The resident's care plan and progress notes lacked documentation of any refusal of nail care, and staff interviews confirmed that R38 did not have a history of refusing such care. Observations and interviews with various staff members, including LPNs, NAs, and RNs, revealed that nail care was expected to be performed weekly on bath days and as needed. However, R38's fingernails remained untrimmed and dirty over several days. Staff members acknowledged the need for nail care but failed to provide it, despite the facility's policy requiring nails to be maintained in a clean and neat manner to support resident dignity and avoid problems associated with rough, cracked, or overly long nails.
Failure to Provide Activities of Interest for Resident
Penalty
Summary
The facility failed to ensure activities of interest were offered or provided to enhance the quality of life for a resident (R19) on the short-term stay unit. R19's admission Minimum Data Set (MDS) indicated moderate cognitive impairment and a preference for group activities and social events. Despite this, R19 reported not being invited to or attending any activities and expressed a desire to participate in group games and social events. Observations and interviews revealed that R19 spent most of her time in her room, with minimal engagement in activities, and there was no evidence of re-evaluation to ensure the activities program met her needs as her condition improved. The initial Therapeutic Activities Observation and care plan for R19 outlined her interests in knitting, cooking, social events, and religious activities. However, the care plan only included informing R19 of group activities and providing leisure materials upon request. Progress notes indicated that R19 was informed about the activities department and provided with books but lacked documentation of any further engagement or offers of activities. The activities coordinator admitted to not tracking activity participation or refusals, and there was no evidence of one-to-one activities being offered to R19. Interviews with staff, including a nursing assistant and the activities coordinator, confirmed that there were limited group activities on the TCU unit and that R19 had not been actively engaged in activities despite her expressed interests. The administrator acknowledged the lack of documentation and stated that activities should be charted to provide proof of offerings. The facility did not provide a policy on activities, highlighting a gap in ensuring residents' activity preferences and needs were met, particularly for those with short-term stays and cognitive impairments.
Improper Application of Neck Brace
Penalty
Summary
The facility failed to ensure the correct application of a neck brace for a resident (R34) with a spinal fracture, as observed during multiple instances. The Miami J collar was not applied snugly, allowing the resident's chin and bottom lip to tuck into the collar, which is against the manufacturer's guidelines for proper fit and immobilization. The Velcro strips securing the collar were not pulled tightly enough, leaving gaps between the front and back parts of the collar, indicating improper application. Interviews with the licensed practical nurse (LPN) and the director of nursing (DON) revealed a lack of specific training and physical indicators for ensuring the correct application of the neck brace. The LPN relied on the resident's comfort levels rather than proper fitting guidelines, and the DON was unaware of any recent re-education or reassessment of the collar's fit. The occupational therapist (OT) confirmed that the collar was too loose and required re-education for the nursing staff on its correct application. The resident's medical records did not indicate any refusal to wear the collar correctly or any risk versus benefit education provided to the resident and their representative. The family member also confirmed that the neurology team had recommended a tighter application of the brace, but it was unclear if the nursing staff had followed this recommendation. The facility lacked a policy or procedure regarding neck brace application, contributing to the deficiency in care.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement their antibiotic stewardship program effectively, leading to the unnecessary use of antibiotics for a resident. The resident, who was cognitively intact and required partial assistance with some activities of daily living, experienced ongoing symptoms of a urinary tract infection (UTI) despite being treated with multiple antibiotics. The initial urinalysis indicated a UTI, and the resident was started on Macrobid. However, the urine culture results were inconclusive, and the resident continued to experience symptoms. Despite this, the resident was prescribed another antibiotic, Keflex, without a new urinalysis or urine culture, which was against the facility's antibiotic stewardship protocol. This led to a delay in proper treatment and prolonged the resident's discomfort and weakness. The resident's symptoms persisted, and a second urinalysis and urine culture were eventually ordered. The results confirmed a UTI, and the resident was started on a third antibiotic, Cefuroxime Axetil, which finally led to an improvement in symptoms. Throughout this period, the resident reported significant weakness, pain, and an inability to participate in usual activities, indicating a substantial impact on their quality of life. Interviews with the nursing staff and the infection preventionist revealed that the facility's protocol was not followed, and antibiotics were prescribed without proper testing, leading to inappropriate treatment. The facility's policy on antibiotic stewardship, which was reviewed shortly before the incident, stated that compliance with prescribing expectations and clinical practice guidelines should be monitored. However, the failure to adhere to this policy resulted in the resident receiving multiple antibiotics without proper testing, highlighting a significant lapse in the facility's infection control practices. The staff acknowledged that the correct procedures were not followed, which contributed to the resident's prolonged illness and discomfort.
Failure to Update Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure the required nurse staffing information was posted daily and updated with each shift. During an observation and document review, it was found that the staffing posting dated 4/5/24 was still displayed on 4/8/24, despite the requirement for daily updates. The staffing coordinator (SC) was on vacation, and the responsibility for updating the staff posting was delegated to RN-B, the long-term care nurse manager, who missed updating it on 4/8/24. The SC typically filled out the staff postings for the weekend before leaving, and the morning charge nurse was supposed to discard the previous day's posting to display the current one. However, this process was not followed over the weekend, and RN-C, the charge nurse for that weekend, was unsure who was responsible for the posting in the SC's absence. Interviews with the SC, RN-C, and the assistant director of nursing (ADON) revealed a lack of clarity and communication regarding the responsibility for updating the staff postings during the SC's absence. The facility's Posting of Staffing Hours policy required that the staff posting be displayed daily by 9 a.m. and updated for each shift as needed throughout the day. The failure to adhere to this policy resulted in outdated staffing information being displayed, which had the potential to affect all 58 residents and visitors who may wish to view the information.
Failure to Notify Ombudsman of Resident Hospitalizations
Penalty
Summary
The facility failed to ensure timely notification to the Office of Ombudsman for Long-Term Care (OOLTC) regarding resident hospitalizations, which are considered facility-initiated discharges. This deficiency was identified for one resident (R40) and 11 other residents who had been hospitalized within the last month. R40's medical records showed multiple hospitalizations, but there was no evidence that the OOLTC had been notified of these events. The facility's administrator confirmed that the responsibility for sending monthly hospitalization listings to the OOLTC fell to the medical records personnel, but this task had not been completed for an undetermined amount of time. R40's Minimum Data Set (MDS) records indicated four hospitalizations between December 2023 and March 2024, with the discharge location recorded as a short-term general hospital. An interview with R40 and a family member revealed that R40 had been hospitalized multiple times due to various reasons, including a medication miscommunication in February 2024. Despite these hospitalizations, there was no documentation of OOLTC notifications. The administrator acknowledged the lapse and mentioned that the process would be reviewed and revised if needed. A facility policy on OOLTC notification was requested but not provided.
Latest citations in Minnesota
A resident with dry eye syndrome and degenerative eye disease had orders for cyclosporine ophthalmic emulsion and Refresh Tears, both scheduled at the same time. Medication records and direct observation showed a TMA instilled cyclosporine drops in both eyes and immediately followed with Refresh Tears in both eyes without waiting between medications. This practice conflicted with referenced professional guidance recommending several minutes between multiple eye drops and with the medical provider’s recommendation to wait fifteen minutes between the two ophthalmic medications. No facility policy on ophthalmic medication administration was provided when requested.
A resident with severe cognitive impairment, impaired mobility, and high fall risk was care planned to have wheelchair footrests in place at all times, with staff ensuring proper positioning and monitoring for leaning during transport. A NA transported the resident in a manual wheelchair from the shower without the footrests, and while going through the doorway the wheelchair struck the door frame, causing the resident, who was leaning forward, to fall out. The resident sustained a T12 fracture, head injury with concussion, abrasions and contusions, and multiple right-hand lacerations requiring sutures, and the DON confirmed the care plan had not been followed.
A high‑risk, immobile resident with MS and prior heel DTI developed an avoidable unstageable coccygeal pressure ulcer after staff failed to consistently assess and document skin status, did not transfer or timely provide ordered pressure‑relieving mattresses, and did not reliably perform q2h repositioning. The resident was repeatedly left on a bedpan for prolonged periods despite early reports of this issue, and the toileting care plan was not revised to a bedside commode until after the coccygeal wound had significantly worsened. Wound assessments lacked complete measurements and staging, changes in wound size and color were not promptly recognized as deterioration or reported to providers, and recommended interventions from a wound NP (including an air mattress and offloading) were not promptly implemented. As a result, the coccygeal ulcer rapidly progressed to a large, necrotic, malodorous wound requiring hospital transfer and surgical debridement.
A resident with spastic hemiplegia, muscle weakness, and moderate cognitive impairment was observed using bilateral bed grab bars for bed mobility and transfers, but the care plan did not address grab bar or side rail use. Review of the EMR showed no completed bed mobility device or side rail assessment to determine the necessity or safety of the grab bars, and no documentation that risks and benefits were discussed or that informed consent was obtained. An LPN and the ADON stated that a bed mobility device assessment is required before grab bars are installed and confirmed that no such assessment existed for this resident.
A resident with bilateral heel pressure ulcers and multiple comorbidities received wound care during which an RN removed dressings from both heels, cleansed both wounds, and wiped each heel without changing gloves or performing hand hygiene between wounds or after disposing of soiled dressings. This practice conflicted with the facility’s written wound care procedure, which requires glove removal and hand hygiene after dressing removal and after wound cleansing. In interviews, the RN, NP, and DON/IP acknowledged that hand hygiene and glove changes are expected between dirty and clean tasks and between separate wounds to prevent infection.
A resident with MS, neurogenic bladder, mobility limitations, and existing pressure injuries was identified as dependent for toileting hygiene and at risk for pressure ulcers, yet the care plan lacked an individualized toileting/incontinence plan and a defined repositioning schedule. Despite a new coccyx pressure ulcer and documentation that interventions such as increased repositioning and incontinent care were needed, the care plan was not revised for a period of time to reflect these changes. During this time, the resident sometimes fell asleep on a bedpan and remained on it until staff removed it, and staff were not initially informed that the bedpan should no longer be used. The DON later acknowledged that the care plan revisions for turning, repositioning, and toileting were delayed until after the resident’s coccyx ulcer had significantly worsened.
A resident with diabetes, Crohn’s disease, bowel incontinence, and a history of MASD on the right gluteus developed an open, painful lesion on the right gluteal area that was documented over time without complete wound characteristics, clear etiology, or timely provider notification. Wound care orders were written for a stage 3 pressure ulcer on the left buttocks, while staff reported the wound was only on the right side and applied the left‑sided orders to the right gluteal wound in the absence of specific right‑side treatment orders. The DON acknowledged discomfort with staging the wound, lack of early physician notification, and confusion over wound classification, despite a facility policy requiring comprehensive wound assessment, consistent measurement, and provider notification when treatment orders are absent.
A resident with diabetes, chronic leg ulcer, kidney transplant, and a documented gluteal wound was care-planned for Enhanced Barrier Precautions (EBP), with posted instructions requiring gown and gloves for high-contact care such as transfers and wound care. During a telehealth wound assessment, the DON donned a gown and initially performed hand hygiene but then applied gloves without hand hygiene, removed a soiled dressing from the resident’s gluteal area, discarded it, removed gloves, and applied new gloves again without performing hand hygiene between glove changes. On another occasion, during use of a sit-to-stand lift, an NA wore gown and gloves, but the DON handled the lift harness, the resident’s clothing, and assisted with the transfer and repositioning while wearing a gown but no gloves, despite EBP requirements for transfers. The DON stated EBP was only needed for catheter or wound care and not for transfers, contradicting the posted EBP instructions and facility policy.
A resident with severe dementia, psychiatric disorders, and high dependence for ADLs was verbally abused during evening care when a NA, frustrated with the resident’s crying and resistance, loudly ridiculed her as acting like a two-year-old, threatened to hit her back if struck, told her she would be sent to a locked unit, and questioned who would want to care for her when she cried like a baby. Multiple staff witnessed the loud, stern, and intimidating tone and reported it to an LPN, who recognized it as verbal abuse but did not immediately remove the NA from duty or promptly report the allegation per policy, allowing the NA to continue working on the unit. Following this incident, the resident demonstrated increased crying, combativeness, resistance to care, wandering, self-isolation, and refusal of food, fluids, and medications above baseline, with documentation of significant emotional distress and subsequent ED evaluation for aggressive behaviors and poor intake.
A resident with dementia, bilateral above‑knee amputations, vascular disease, and severe protein‑calorie malnutrition developed a wound on an amputation stump that had a dressing dated several days before any documentation or treatment orders appeared in the record. Although bath audits and nursing notes initially reported no skin issues, a later assessment described a full‑thickness stage 4 ulcer/diabetic ulcer on the stump with exposed bone, erythema/edema, slough, and moderate serosanguineous drainage. Nursing staff interviews showed no one could identify who first discovered the wound or applied the initial dressing, and there was no evidence that the wound was assessed, the provider notified, or standing orders implemented when it was first present, despite facility expectations that new wounds be promptly evaluated and reported.
Failure to Follow Professional Standards for Ophthalmic Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice for administering ophthalmic medications to a resident with dry eye syndrome and degenerative eye disease. The resident was cognitively intact, required assistance with ADLs, and had physician orders for cyclosporine ophthalmic emulsion 0.05% one drop in both eyes twice daily and Refresh Tears ophthalmic solution one drop in both eyes four times daily for dry eyes. The administration summary showed that both eye medications were scheduled for the same time and were documented as being given at the same time on multiple dates. During a medication pass observation, a trained medication aide administered the ordered oral medications, then applied gloves and instilled one drop of cyclosporine in each eye, immediately followed by one drop of Refresh Tears in each eye, without any waiting period between the two medications. The surveyors referenced guidance from the American Academy of Allergy, Asthma, and Immunology stating that when more than one eye drop is ordered, three to four minutes should be allowed between drops in the same eye, and five to fifteen minutes should be allowed between different eye medications to prevent dilution. Interviews with the DON, pharmacy consultant, and medical provider confirmed that best practice and the provider’s recommendation were to wait between administration of cyclosporine and Refresh Tears, with the medical provider specifying a fifteen-minute interval. The facility did not provide a policy on ophthalmic medications when requested. The observed practice and documented administration times demonstrated that staff did not follow these professional standards or the medical provider’s recommended interval between the two eye medications.
Failure to Follow Wheelchair Transport Care Plan Leads to Fall With Injuries
Penalty
Summary
The deficiency involves the facility’s failure to implement care-planned fall prevention interventions for a resident at high risk for falls, resulting in a fall with injury. The resident had diagnoses including aphasia, dysphagia, muscle weakness, traumatic brain injury, and impaired mobility, with severe cognitive impairment documented on the MDS and dependence on staff for transfers and wheelchair transport. A care plan addressing wheelchair transport safety and positioning directed staff to ensure the resident was fully positioned and supported in the wheelchair prior to transport, verify footrests were in place prior to transport, and monitor for leaning, sliding, or unsafe positioning. An additional care-planned approach required wheelchair pedals to be on at all times. On the date of the incident, a nursing assistant transported the resident in a manual wheelchair from the shower room to the resident’s room without the foot pedals in place, contrary to the care plan. While being wheeled through the doorway, the wheelchair struck the door frame, causing the chair to stop and the resident, who had begun leaning forward, to fall out of the wheelchair onto the floor. Progress notes and ED documentation identified that the resident sustained a T12 vertebral fracture, a head injury with concussion, an abrasion and contusion to the head, a bruise to the left knee, and multiple lacerations to the right hand requiring sutures. The nursing assistant later acknowledged awareness that the foot pedals should have been on but did not apply them because the transport was only from the shower to the room. The DON confirmed that the resident’s care plan had not been followed when the fall occurred.
Failure to Implement and Update Pressure Ulcer Prevention and Treatment Led to Avoidable Unstageable Coccygeal Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, monitor, and implement individualized pressure ulcer prevention and treatment interventions for multiple high‑risk residents, resulting in an avoidable, unstageable coccygeal pressure ulcer for one resident that required surgical debridement and hospitalization. The resident had primary progressive multiple sclerosis, hereditary spastic paraplegia, obesity, and pre‑existing pressure‑related deep tissue injury to the left heel, and was identified as high risk for pressure ulcers on the Braden Scale due to constant moisture, chairfast status, very limited mobility, inadequate nutrition, and friction/shear risk. Hospital records on readmission documented irritant contact dermatitis of the bilateral gluteal cleft with specific cleansing and barrier cream orders, and facility documentation showed the resident could not reposition in bed or chair and required assist of two and a full‑body mechanical lift for transfers. Despite this, the admission/readmission skin assessment and weekly skin checks lacked measurements and detailed wound characteristics for the heel ulcer and gluteal dermatitis, and the care plan did not include comprehensive, individualized interventions beyond generic repositioning and wound care orders. After a new coccyx pressure ulcer was identified and documented as a stage 2 lesion, the facility failed to promptly and accurately update the care plan and implement recommended pressure‑relieving interventions. The wound nurse practitioner on 3/5 ordered coccyx wound care, an air mattress, pressure offloading, and a dietician consult, but the care plan was not revised and there was no evidence that an air mattress was placed on the bed for nearly two weeks. The environmental services director later confirmed that when the resident was moved to a new room, the gel mattress was not transferred, and the air mattress requested on 3/17 was not actually placed until the following day, despite being marked as completed. During this period, TAR documentation showed gaps in the every‑2‑hour repositioning order, and staff interviews revealed that CNAs were unaware of which residents were on repositioning programs, were not consistently repositioning residents, and had not received recent education on pressure ulcer prevention. The DON and RN case manager acknowledged that the coccyx wound increased in size and changed color between assessments, that the bed lacked the ordered gel mattress, and that the physician was not notified of the wound’s deterioration at that time. The facility also failed to timely modify toileting and incontinence care practices despite knowledge that the resident was being left on a bedpan for extended periods. The DON reported hearing before an IDT meeting that the resident had fallen asleep on a bedpan for an undetermined amount of time, but the care plan was not revised to discontinue bedpan use and implement a bedside commode until after the coccyx wound had significantly worsened. CNAs confirmed that the resident sometimes fell asleep on the bedpan and that they were not informed she should no longer use it until after the sore had worsened. Subsequent wound assessments documented rapid progression of the coccyx wound from a small stage 2 ulcer to a large, malodorous, necrotic wound with eschar, slough, erythema, and purulent drainage, ultimately classified as an unstageable pressure ulcer. The DON, NP, PA, and medical director all indicated that the lack of a pressure‑relieving mattress, failure to adjust pressure‑reducing interventions, and prolonged time on a bedpan likely contributed to the development and deterioration of the resident’s pressure ulcer, which was determined to be avoidable and resulted in hospitalization and surgical debridement. Additional documentation and interviews showed systemic assessment and communication failures related to pressure ulcer management. Weekly skin checks and wound assessments often omitted complete measurements, staging, and wound characteristics, and changes in wound size and appearance were not consistently recognized as deterioration or communicated to providers. The DON acknowledged that a 3/12 assessment showing increased wound size and purple discoloration should have been identified as a deep tissue injury and reported to the physician, but this did not occur. When nursing later documented foul odor, increased pain, and expanding necrotic tissue, telemedicine and PA responses deferred in‑person evaluation and ED transfer despite earlier recommendations that the resident be sent to the ED if an in‑person provider could not assess the wound. The NP ultimately found a large, malodorous, purulent wound with expanding eschar and ordered transfer to the hospital, where imaging and surgical findings confirmed a large necrotic sacral wound requiring extensive debridement. Throughout this sequence, the facility did not consistently follow its own pressure ulcer protocols, did not ensure ordered pressure‑relieving equipment was in place, and did not promptly revise care plans or interventions in response to known risk factors and documented wound changes. The report also notes that other residents reviewed for pressure ulcers were affected by similar failures in monitoring and individualized intervention, though detailed narratives focus primarily on this resident. Staff interviews revealed that CNAs relied on paper care guides that did not clearly identify residents on repositioning programs or at risk for skin breakdown, and that they were unaware of some residents’ special mattress orders or toileting restrictions. The DON and medical director stated that residents at risk for pressure ulcers should have immediate pressure‑relieving interventions and that existing ulcers require ongoing evaluation to prevent deterioration, but the documented practices for this resident did not align with those expectations. These combined actions and inactions—insufficient assessment detail, delayed or missing care plan revisions, failure to implement ordered support surfaces and repositioning, and delayed response to wound deterioration—constituted the deficiency in providing appropriate pressure ulcer care and preventing new ulcers from developing.
Failure to Assess, Care Plan, and Obtain Consent for Bed Grab Bar Use
Penalty
Summary
The deficiency involves the facility’s failure to follow required procedures before installing and using bed grab bars for a resident. The resident had diagnoses including spastic hemiplegia affecting the left side and muscle weakness, and an admission MDS indicating moderate cognitive impairment. During observation, the resident was seen in a power chair with bilateral grab bars on the bed and reported using them to roll in bed and for transfers. The resident’s care plan, dated 1/23/26, documented a need for assistance with bed mobility and independence with transfers but did not mention or address the use of grab bars or side rails. Review of the electronic medical record showed no completed grab bar/side rail or bed mobility device assessment to determine the necessity of the grab bars or whether the resident could safely use them. There was also no evidence that the resident or the resident’s representative had been educated on the risks of having a grab bar on the bed or that informed consent had been obtained. In interviews, an LPN and the ADON both stated that a bed mobility device assessment was required to determine need and safety prior to installing grab bars, and both confirmed that no such assessment was present in the resident’s record.
Failure to Perform Hand Hygiene and Change Gloves During Wound Care
Penalty
Summary
Surveyors observed that a registered nurse (RN) and a nurse practitioner (NP) did not follow the facility’s established infection control practices during wound care for one resident. During a wound treatment, the RN wore gloves while removing the dressing from the resident’s left heel, then removed the dressing from the right heel, sprayed both wounds with wound cleanser, wiped the left heel with gauze, and then used a clean gauze pad to wipe the right heel. The RN did not remove her gloves or perform hand hygiene after disposing of the soiled dressings or between cleaning the left and right heel wounds, contrary to the facility’s written wound care procedure, which requires glove removal and hand hygiene after removing the previous dressing and again after cleaning the wound. The resident’s admission MDS documented diagnoses including multiple rib fractures, heart failure, dementia, anxiety, and the presence of a pressure ulcer, and indicated the resident was cognitively intact and required staff assistance with care and transfers. The resident’s care plan identified pressure ulcers on both heels requiring wound care. In interviews, the RN, NP, and the DON/infection prevention nurse each stated that gloves should be changed when moving from dirty to clean areas and that hand hygiene is expected after glove removal and between wounds to prevent infection, confirming that the observed practice did not align with facility policy or expected infection control standards.
Failure to Timely Revise Care Plan for Toileting and Skin Integrity
Penalty
Summary
The deficiency involves the facility’s failure to timely revise and individualize a resident’s care plan to address toileting and incontinence needs in relation to impaired skin integrity. The resident had diagnoses including primary progressive multiple sclerosis, hereditary spastic paraplegia, obesity, and a pressure-induced deep tissue injury to the left heel. A Significant Change MDS identified the resident as dependent for toileting hygiene, with lower extremity range-of-motion limitations, wheelchair use, dependence for transfers, occasional urinary incontinence, intact cognition, and at risk for pressure ulcers with existing unhealed pressure injuries and MASD. The resident’s skin-focused care plan, revised on various dates, included skin inspections, wound care orders, weekly skin checks, pressure ulcer care to the left heel, nutritional supplements, and a gel mattress, but did not include an individualized toileting or incontinence plan. On a weekly skin check dated 3/3/26, nursing staff identified a new Stage 2 pressure ulcer on the coccyx and contact dermatitis on both gluteal folds. An IDT Final Post Review Follow Up dated 3/10/26 (signed 3/23/26) documented that a new skin issue had occurred and that interventions after the incident included wound care treatment orders, increased repositioning, and increased incontinent care. However, the resident’s care plan from 3/3/26 through 3/16/26 did not show revisions reflecting increased incontinence care or a repositioning schedule, and the care plan was not updated to include these elements until 3/17/26. During this period, the care plan still lacked an individualized toileting plan despite the resident’s identified incontinence and new coccyx pressure ulcer. Progress notes on 3/17/26 documented that the resident’s coccyx wound had declined, with an evaluation describing a deteriorating wound characterized as a Kennedy terminal ulcer/End of Life, staged as a Stage 4 pressure ulcer, in-house acquired, with increased size, exudate, odor, pain, and surrounding erythema. On that same date, the skin focus care plan was revised to include prompt incontinence care and keeping the skin clean and dry, and the elimination focus care plan was revised to address incontinence due to neurogenic bladder with use of a bedside commode offered every 2–3 hours. A nursing assistant reported that when working with the resident, the resident would sometimes fall asleep on the bedpan and forget to ask staff to remove it, and that she was not aware the resident was not supposed to use the bedpan until after the sore had worsened. The DON stated that the resident’s care plan had not been revised earlier to include a turning and repositioning schedule or toileting changes, and that it should have been revised as soon as staff learned the resident was falling asleep on the bedpan, rather than waiting until after the pressure ulcer worsened.
Failure to Assess and Notify Provider for Right Gluteal Wound
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess and appropriately manage a non‑pressure skin issue on a resident’s right gluteal area, and to notify the physician in a timely manner. The resident had diagnoses including diabetes, Crohn’s disease, and a kidney transplant, and the MDS indicated occasional bowel incontinence, no pressure ulcers, and no moisture‑associated skin damage at that time. Earlier documentation identified a resolved MASD to the right gluteus, and a progress note later described a sacral wound with creams applied, noting that sores were still open and painful during application, but without any measurements, wound characteristics, or evidence of physician notification. Subsequent wound assessments documented an open lesion on the right gluteus with specific measurements on multiple dates, but did not identify the wound type or other characteristics, and the record did not show physician notification or treatment orders for the right gluteal lesion. Provider orders in place initially addressed cleansing the buttocks and applying barrier cream, and later included a detailed wound care order for a stage 3 pressure ulcer documented on the left buttocks. However, the resident’s record did not contain a specific treatment order for the right gluteal wound, despite the ongoing documentation of an open lesion in that area. Interviews revealed confusion and inconsistency in wound identification and classification. The DON stated that the right gluteal wound was documented as an open lesion because she did not feel comfortable determining the wound type, and acknowledged that the physician should have been notified when the wound was first identified. The DON was unaware that the NP had documented the wound as being on the left buttocks and as a stage 3 pressure ulcer, while the RN reported that the wound had never been on the left buttocks and that she had been applying the left‑sided wound orders to the right gluteal area because there was no open area on the left. The resident reported a recurring painful area on the right buttocks and chronic stool leakage since prior anal fistula surgery. The facility’s own wound treatment policy required comprehensive assessment of wound etiology and characteristics, consistent measurement and documentation, and provider notification in the absence of treatment orders, which were not followed for this resident’s right gluteal wound. The deficiency centers on the lack of a comprehensive wound assessment for the right gluteal lesion, incomplete documentation of wound characteristics, failure to clearly determine and document the wound etiology, and failure to notify the physician and obtain appropriate treatment orders when the wound was identified and remained open. These actions and inactions resulted in a discrepancy between the documented wound location and type and the actual clinical presentation, as well as a period during which the right gluteal wound had no specific, clearly ordered treatment despite being open and painful.
Failure to Perform Hand Hygiene and Implement Enhanced Barrier Precautions During Wound Care and Transfers
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper hand hygiene during wound care and to consistently implement Enhanced Barrier Precautions (EBP) for a resident requiring such measures. The resident had diagnoses including diabetes, a non-pressure chronic ulcer of the right lower leg, and a kidney transplant, and a wound assessment documented an open lesion on the right gluteal area. The resident’s care plan and a sign posted outside the room specified that EBP, including gown and gloves, were required for high-contact care activities such as dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, catheter care, and wound care. During one observation, the DON performed hand hygiene and donned a gown before entering the resident’s room for a telehealth wound assessment. Inside the room, the DON went into the bathroom, applied gloves without performing hand hygiene, removed the resident’s brief, and removed a foam dressing from the right gluteal area that had stool on one corner. After discarding the soiled dressing, the DON removed gloves and then applied new gloves without performing hand hygiene between glove changes. When questioned, the DON stated that hand hygiene should be done when hands or gloves are visibly soiled and before and after removing or applying gloves, and acknowledged that hand hygiene had not been performed each time gloves were removed and reapplied. In a separate observation, the resident was transferred using a sit-to-stand mechanical lift while EBP requirements were not fully followed. An NA entered the room wearing a gown and gloves with the lift, and the DON applied the lift harness under the resident’s arms and cinched the waist strap, encountering the resident’s clothing, while not wearing gloves. After the transfer to bed, the DON pulled down the resident’s pants and removed the harness while touching the resident’s clothes. Following wound care by a CNP-WOC, the DON again assisted the resident by sitting the resident on the edge of the bed, applying the lift harness, and adjusting the resident’s pants and shirt while wearing a gown but no gloves. The DON stated that EBP was only needed for catheter or wound care and not for transfers, and only upon reading the posted EBP sign acknowledged that EBP was required for all high-contact resident care activities, including transfers.
Failure to Protect Resident From Verbal Abuse and Delay in Removing Alleged Perpetrator
Penalty
Summary
The deficiency involves the facility’s failure to protect a vulnerable resident from mental abuse and to respond appropriately to an allegation of abuse. The resident had severe cognitive impairment, Alzheimer’s disease, dementia, anxiety, depression, psychotic disorder, and significant functional dependence, including frequent incontinence and the need for extensive assistance with ADLs and transfers. Her care plan identified behavioral and mood issues such as wandering, yelling, combative behavior, and calling staff names, with interventions including calm approaches, emotional support, redirection, and monitoring for emotional distress and mood/behavior changes. She was identified as a vulnerable adult, with instructions to monitor for signs of emotional distress and to follow the facility’s abuse reporting policy. On the evening in question, while the resident was crying on the phone with her son and expressing a desire to leave, NA-A and NA-B entered to provide evening care using an EZ stand lift. After the resident ended the phone call, multiple staff reported that NA-A spoke to the resident in a loud, stern, and frustrated tone, telling her to stop crying and that she was acting like a two-year-old. When the resident swatted at NA-A, NA-A stated, “If you hit me, I’m going to hit you back,” and later told the resident she was “in trouble now.” Staff reported that NA-A told the resident she would be sent to a locked unit so she could not get out, and questioned who would want to care for her when she cried like a baby, and that nobody would want to keep working with her. NA-C described NA-A yelling commands such as “HOLD ON!” and “Stop crying! Where would you be if you were not here? Probably lying on the floor,” and felt NA-A was obviously upset and overwhelmed. These statements were made in the presence of the resident while she was already distressed and crying. Following this interaction, the resident exhibited crying, yelling, combativeness, resistance to care, wandering into other residents’ rooms, self-isolation, and refusal of food, fluids, and medications above her prior baseline, as documented in behavior charts, target behavior monitoring, and nursing progress notes. Staff documented that she cried most of the morning, was very restless, difficult to redirect, hit and pinched staff, called staff names, and refused care and meals. She required repeated redirection, 1:1 attention, and non-pharmacological interventions, and was ultimately sent to the ED for evaluation of combativeness and emotional distress, where she was treated for dementia with aggressive behavior and hypoglycemia related to poor intake. The report identifies that the resident’s actual response and the reasonable person concept showed serious psychosocial harm, including increased crying and combative behavior above baseline, fear/anxiety manifested as combativeness, resistance to care and social interaction, and self-isolation. The facility also failed to immediately remove the alleged perpetrator from resident care and to promptly report and investigate the allegation in accordance with its abuse policy. After NA-B and NA-C reported to LPN-A that NA-A had yelled at and threatened the resident, LPN-A acknowledged it as verbal abuse but did not initiate immediate protective measures or timely reporting. LPN-A stated she believed she had 24 hours to report because there was no injury, despite facility policy requiring reporting within two hours. NA-A remained on the unit and continued working until the end of her shift, including after staff had clearly communicated their concerns to LPN-A. TMA and NA staff described uncertainty about their authority to remove NA-A and reliance on the nurse to act, while the DON later informed LPN-A that NA-A should have been removed from the floor to prevent further danger to residents. The Immediate Jeopardy was determined to have begun when NA-A’s derogatory, intimidating, and threatening statements were made and continued while she remained on duty with access to the resident and other vulnerable residents.
Failure to Timely Assess and Treat Newly Discovered Stump Wound
Penalty
Summary
The deficiency involves the facility’s failure to provide timely treatment and care for a newly discovered wound on a resident’s above‑knee amputation stump. The resident was admitted with diagnoses including unspecified dementia with behavioral disturbances, vascular dementia, bilateral above‑knee amputations, vascular disease, reduced mobility, and severe protein‑calorie malnutrition, and had no documented ulcers or skin problems on admission or on the most recent MDS. A weekly bath audit on 3/17/26 documented only non‑tender lymph nodes on the right upper hip and did not identify any open areas. However, when the wound was later assessed, the dressing on the stump was dated 3/16/26, indicating that a wound and dressing existed at that time, even though no corresponding assessment, provider notification, or treatment orders were documented. On 3/23/26, nursing staff documented a new skin issue above the resident’s knee at the amputation site, describing a stage 4 pressure ulcer/injury with full‑thickness skin and tissue loss, exposed bone, erythema/edema, and moderate serosanguineous exudate. The wound measured 1.56 cm by 1.64 cm, with 20–29% granulation tissue and 80% slough. A progress note and skin issues assessment on that date confirmed the wound characteristics and staging, and the NP, after reviewing a picture, determined the wound to be a diabetic ulcer with peripheral vascular disease and severe protein‑calorie malnutrition as contributing factors. On that same date, the NP was notified, antibiotic therapy (doxycycline) was ordered for possible cellulitis, and specific wound care orders were initiated, with documentation on the MAR that these treatments were carried out beginning 3/23/26. Multiple interviews with nursing staff revealed that no one could identify who discovered the wound or who applied the initial dressing dated 3/16/26, and there was no documentation of a wound assessment, provider notification, or interim treatment between 3/16/26 and 3/22/26. Several RNs and LPNs who worked shifts from 3/16/26 through 3/20/26 stated they did not notice a wound on the stump and that, per their usual practice, they would have contacted the provider and initiated treatment if they had found one. One LPN recalled seeing a band‑aid with a date on the stump but could not recall the date, and another LPN stated she did not see the wound because she was not looking for one. The facility’s standing orders required staff to assess all wounds daily, change dressings every three days and as needed, treat with normal saline or non‑cytotoxic cleanser and appropriate dressings, and notify the provider the next business day when a new wound or injury was found. Despite these expectations, the wound identified by the dated dressing on 3/16/26 was not assessed, reported, or treated according to orders and facility policy until 3/23/26.
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