Avera Granite Falls Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Granite Falls, Minnesota.
- Location
- 250 Jordan Drive, Granite Falls, Minnesota 56241
- CMS Provider Number
- 245243
- Inspections on file
- 20
- Latest survey
- September 19, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Avera Granite Falls Care Center during CMS and state inspections, most recent first.
A resident with impaired cognition and mobility, dependent on staff for transfers, suffered a traumatic hematoma requiring hospitalization after a mechanical lift sling strap was left unsecured and became entangled in the wheelchair wheel. Staff failed to properly secure or tuck the sling straps after transfer, leading to the resident's leg being pulled backward and injured. The incident was not immediately documented, and the injury was discovered later when the resident reported increased pain.
The facility did not consistently track or document staff illnesses, with missing information on illness symptoms, last day worked, symptom resolution, and return-to-work dates for several employees, including nursing assistants and the infection preventionist. Incomplete illness logs and unclear oversight responsibilities contributed to the deficiency.
The facility did not ensure that the infection preventionist was properly trained or that infection control surveillance and documentation were consistently maintained. Staff illness logs were incomplete, and there was a lack of clear oversight and communication among the infection control team, resulting in missing critical information about staff illnesses and return-to-work status.
A resident with multiple chronic conditions received expired bisacodyl suppositories on two occasions due to the facility's lack of an effective system for monitoring medication expiration. A nurse was found with expired medications in the medication room, and the DON confirmed that required audits were not completed for that area. The facility's policy did not address checking for expired medications prior to administration.
A resident who had previously received PPSV-23 and PCV-13 vaccines was not offered the updated PCV20 or PCV21 vaccines as recommended by the CDC. Staff relied solely on the MIIC database for immunization recommendations, which did not always reflect current guidelines, resulting in the resident not being offered the appropriate vaccinations. The DON confirmed the process was not up to date and no relevant policy was provided during the survey.
The facility failed to ensure consistent mail delivery to residents on Fridays and Saturdays, affecting all 48 residents who received personal mail. Mail delivery was placed on hold on Saturdays due to staff unavailability, leading to mail sitting unsecured until Monday. The administrative assistant and SSD were responsible for mail delivery, but if neither was available, mail was not delivered. The facility lacked a policy for mail delivery when both were unavailable, as confirmed by the DON.
A facility failed to provide a dignified dining experience by allowing insulin injections to be administered at the dining table in front of other residents. A resident expressed discomfort with this practice, which was routine and not addressed in her care plan. The DON was aware of the practice and preferred injections be done in a private area, but the facility's policy did not ensure the dignity of other residents present.
A resident in a LTC facility was found to be using a self-release lap belt as a restraint without proper assessment or documentation. The resident, who had moderate cognitive impairment, was unable to self-release the belt, and staff did not recognize it as a restraint. The facility failed to obtain necessary physician orders, conduct a restraint assessment, or update the care plan, leading to a deficiency in compliance with restraint regulations.
A resident in a LTC facility was unable to self-release a lap belt used in her wheelchair, and the facility failed to update her care plan following a decline in her condition after hospitalization. The care plan did not include necessary assessments, consents, or documentation for the use of the lap belt, which was considered a restraint. Staff were unaware of the restraint classification, and the facility's policy requirements for restraint use were not met.
A resident with intact cognition and multiple medical conditions, including diabetes and cataract, required moderate assistance for personal hygiene. Despite expressing a desire for help with shaving facial hair, staff did not provide the necessary grooming support. Observations showed the resident's facial hair remained unshaven, and interviews revealed a lack of attention to this need. The care plan did not include instructions for facial grooming, and no policy was provided by the facility.
A resident with diabetes did not receive timely insulin administration, leading to a deficiency in pharmaceutical services. The morning insulin was delayed, causing high blood sugar levels, and subsequent doses were mishandled due to poor communication and documentation by nursing staff. The facility's policy requires reporting medication errors and notifying the physician, which was not followed.
A resident with a full code status was found unresponsive, and staff failed to initiate CPR as per physician orders. Despite the resident's condition, the LPN did not start CPR and instead called 911. The ambulance crew began CPR upon arrival, but the resident was pronounced deceased shortly after. The facility's policy requiring CPR initiation was not followed.
Failure to Secure Mechanical Lift Sling Results in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to ensure that a mechanical lift sling was properly secured and free from entanglement hazards after transferring a resident to a wheelchair. The resident, who had moderately impaired cognition and required maximum assistance with mobility, was dependent on staff for all transfers and used a full-body mechanical lift. The care plan specified the use of a particular sling and required that straps be secured in the wheelchair according to the resident's preference. However, after an outing, a lower sling strap was left unsecured and became caught in the front wheel of the resident's wheelchair, pulling the resident's left leg backward and tightly against the chair. Multiple staff members were involved in the incident. The Activity Director was pushing the resident back to her room when the strap became entangled in the wheelchair wheel. A nursing assistant at the nurses' station heard the resident express pain and observed the entanglement, immediately intervening to stop the wheelchair and loosen the strap. At the time, neither the nursing assistant nor the LPN who was notified observed any visible injury, redness, or swelling on the resident's leg. The incident was reported to the LPN, but no documentation was made in the resident's record at that time. Later, the resident experienced increased pain and developed a traumatic hematoma on her left leg, which required hospitalization, surgical intervention, and a blood transfusion due to a significant drop in hemoglobin. The facility's internal investigation confirmed that the leg strap of the lift sling had not been properly secured or tucked away after the transfer, leading to the entanglement and subsequent injury. Staff interviews corroborated that the sling straps should have been tucked back and under the resident to prevent such incidents.
Failure to Track and Document Employee Illnesses in Infection Control Program
Penalty
Summary
The facility failed to properly track and document employee illnesses, resulting in incomplete records for three staff members, including two nursing assistants and the infection preventionist. The employee illness forms and surveillance logs were missing critical information such as the last day worked, symptom resolution, and return-to-work dates. In some cases, the specific symptoms experienced by staff were not recorded. This lack of documentation occurred despite the facility having a form and process in place for tracking staff illnesses, which was not consistently followed. Interviews revealed that the infection preventionist, who was newly hired and still in training, acknowledged that required documentation had lapsed as COVID-19 protocols changed. The infection preventionist was not yet certified and relied on another RN for assistance, but there was confusion regarding oversight responsibilities. The director of nursing admitted that expectations for oversight were not clearly communicated, and concerns about missing illness logs had been raised previously but not addressed.
Inadequate Infection Control Program Oversight and Documentation
Penalty
Summary
The facility failed to ensure that the designated infection preventionist (IP) was appropriately trained and that the infection control (IC) program was properly overseen by management. The IP, hired in April 2025, was still in training and had not yet started certification classes. During this period, the facility did not maintain adequate daily cumulative infection control surveillance activities, nor did it ensure complete documentation of staff illness incidents, findings, and any corrective actions. Review of staff illness forms and surveillance logs revealed missing information such as last day worked, symptom resolution dates, and return-to-work dates for multiple staff members, including the IP. Required details about symptoms and exposure were also inconsistently recorded. Interviews with the IP, a certified RN, and the DON revealed a lack of clear communication and oversight regarding the infection control program. The certified RN, although available to assist, was not officially providing oversight to the new IP and was unaware of any formal delegation of this responsibility. The DON acknowledged that expectations for oversight were not clearly communicated and that there were concerns about incomplete staff illness logs. The facility's job description for the IP required proficiency in surveillance and collaboration with employee health, but these functions were not being fully met during the period in question.
Failure to Monitor and Prevent Use of Expired Medications
Penalty
Summary
The facility failed to establish an effective system for monitoring expired medications, resulting in the administration of expired medication to a resident. During an observation in the medication room, a registered nurse was found to have a box of bisacodyl suppositories with an expiration date that had already passed, and only a portion of the original supply remained. The nurse confirmed that the resident had not used the suppositories in a long time, yet medication administration records showed that the resident received the expired suppositories on two occasions after the expiration date. Additionally, a plastic cup containing what appeared to be chocolate Ensure was found in the medication room refrigerator without a cover, label, date, or resident name. The resident involved had a history of atrial fibrillation, heart failure, hypertension, peripheral vascular disease, and constipation, and required set-up assistance for care but was able to walk independently. The resident confirmed receiving suppositories recently, despite not having frequent issues with constipation. The director of nursing stated that monthly audits were expected but had not received any from the nurse responsible for the area where the resident resided. The facility's medication administration policy did not include procedures for checking medication expiration dates prior to administration.
Failure to Offer Updated Pneumococcal Vaccines per CDC Guidelines
Penalty
Summary
The facility failed to ensure that one of five sampled residents was offered or provided updated pneumococcal vaccinations in accordance with current CDC recommendations. Review of the resident's immunization record showed she had previously received PPSV-23 and PCV-13 vaccines, but there was no evidence she was offered the newer PCV20 or PCV21 vaccines upon admission, as recommended for adults 65 years or older. During an interview, the DON stated that staff relied solely on the Minnesota Immunization Information Connection (MIIC) for recommendations, and if no recommendations were listed, no vaccines were offered. The DON acknowledged that their process was not up to date, as the MIIC did not always reflect current CDC guidelines, and agreed that the resident should have been offered the updated vaccines. No policy regarding this process was provided during the survey.
Inconsistent Mail Delivery to Residents
Penalty
Summary
The facility failed to ensure consistent delivery of mail to residents on Fridays and Saturdays, affecting all 48 residents who received personal mail. During a Resident Council meeting, five residents confirmed that mail was not consistently received on these days. The facility had requested that mail delivery be placed on hold on Saturdays due to the absence of staff available to distribute it, resulting in mail sitting from Friday or Saturday until Monday. The administrative assistant was responsible for mail delivery during the week, but if unavailable, the social services designee (SSD) would deliver the mail. However, if neither was available, mail was not delivered unless someone else chose to do so. The activity director and administrative assistant confirmed that mail delivery had been suspended on Saturdays after the resident council agreed to have it held at the post office to avoid security issues with mail left in an unsecured entry area. The administrator expressed that it was unacceptable to place mail delivery on hold due to staff unavailability. The SSD confirmed that the facility did not have a process for mail delivery when both she and the administrative assistant were unavailable. The facility lacked a policy addressing the delivery of resident mail, as confirmed by the director of nursing.
Lack of Privacy During Insulin Administration in Dining Room
Penalty
Summary
The facility failed to ensure a homelike and dignified dining experience for residents, specifically affecting one resident, R36, and potentially impacting all 21 residents who ate meals in the Neighborhood A dining room. During an observation, a registered nurse (RN-A) administered an insulin injection to a resident (R22) at the dining table in the presence of other residents, including R36. The nurse did not ask R22 to leave the public area for the injection, nor did she consider how it might affect the other residents at the table. Interviews revealed that the practice of administering insulin in the dining room was routine, and no staff had asked the other residents if it bothered them. R36 expressed that watching someone receive an injection during mealtime was bothersome and that it was unpleasant to see another resident pull down their clothing for the injection. Despite these feelings, R36 had not been asked if the practice bothered her, and her care plan lacked any indication of such a discussion. The director of nursing was aware of the practice and preferred that insulin injections be administered in a private area, noting that a room off to the side of the dining room was available for this purpose. The facility's medication policy allowed for medication administration in the presence of other residents if agreed upon by the resident or representative, but it did not address maintaining the rights and dignity of other residents present.
Failure to Properly Assess and Document Use of Physical Restraint
Penalty
Summary
The facility failed to ensure that a resident, identified as R14, was free from the use of physical restraints, specifically a self-release lap belt, which was used as a restraint. Observations and interviews revealed that R14 was unable to self-release the lap belt, which was applied by staff in the morning and removed at night. Despite R14's inability to release the belt, staff did not recognize it as a restraint, believing it was used for safety to prevent falls. R14, who had moderate cognitive impairment and a history of mobility issues, was not aware of the reason for the belt and relied on staff assistance for its application and removal. Interviews with nursing assistants and registered nurses indicated a lack of awareness regarding the classification of the lap belt as a restraint. The staff believed the belt was necessary due to R14's tendency to slouch or slide forward in her wheelchair. However, there were no documented safety concerns or recent falls that justified the use of the belt. The facility's policy required a physician's order and a restraint assessment for any restraint use, but these were not completed for R14. The Director of Nursing confirmed the absence of necessary documentation, including physician orders, care plan updates, and a signed consent from the resident or their representative. The facility's policy on physical restraints outlined the need for clinical justification, physician notification, and regular evaluation of restraint use. However, these procedures were not followed in R14's case. The oversight was attributed to the staff's familiarity with the resident's use of the lap belt and a failure to reassess its necessity following R14's hospitalization. The lack of documentation and proper assessment led to the continued use of the lap belt without appropriate justification or consent, resulting in a deficiency in the facility's compliance with restraint regulations.
Failure to Revise Care Plan for Resident with Lap Belt Restraint
Penalty
Summary
The facility failed to revise the care plan for a resident who utilized a self-release belt but was unable to release it independently. The resident, who had received a new wheelchair in December 2022, was hospitalized for a urinary tract infection and pneumonia, resulting in a decline in cognition, strength, and mobility. Upon return, the resident's care plan was not updated to reflect her inability to self-release the seatbelt, and a restraint assessment was not completed. The resident's significant change Minimum Data Set (MDS) did not identify the use of a seat belt type lap belt, and the care plan failed to include necessary assessments and consents for the use of the device. Observations and interviews revealed that the resident was unable to release the lap belt independently, and staff were applying and releasing the belt for her. The nursing assistant and registered nurse involved were unaware that the lap belt was considered a restraint, and the registered nurse admitted to not completing a restraint assessment or documenting the use of the lap belt. The director of nursing confirmed that the care plan should have been updated to include the use of the lap belt and that necessary documentation and consents were missing. The facility's policy required a signed consent for the use of a restraint device, inclusion of the device in the care plan, and regular assessments and reviews by the interdisciplinary team and physician. The policy also mandated supervision and monitoring by staff, as well as quarterly documentation of attempts for restraint reduction. However, these requirements were not met, leading to the deficiency in the resident's care plan and the improper use of the lap belt as a restraint.
Failure to Assist Resident with Grooming Needs
Penalty
Summary
The facility failed to provide adequate grooming assistance to a resident, identified as R22, who required moderate assistance for personal hygiene and dressing due to her medical conditions, including diabetes, depression, heart disease, arthralgia, and cataract. Despite having an intact cognition, R22 often forgets to shave her facial hair and expressed a desire for staff assistance, which was not provided. Observations on consecutive days revealed that R22 had a noticeable patch of facial hair on her chin, which remained unshaven, indicating a lack of grooming support from the staff. Interviews with the resident and staff members highlighted a gap in the care plan, which did not include instructions for staff to assist with facial grooming or shaving. A nursing assistant admitted to not noticing the resident's facial hair, and a registered nurse acknowledged the expectation for staff to offer shaving assistance to female residents with facial hair, even if it was not specified in the care plan. The facility was unable to provide a policy regarding this aspect of care by the end of the survey, further underscoring the deficiency in addressing the resident's grooming needs.
Failure to Administer Insulin Timely
Penalty
Summary
The facility failed to ensure timely administration of insulin for a resident with diabetes mellitus, leading to a deficiency in pharmaceutical services. On a specific day, the resident did not receive her morning insulin until 11:00 a.m., resulting in a blood sugar level exceeding 300. When approached by a different nurse at 11:30 a.m. for her noon insulin, the resident refused, citing the recent administration of her morning dose. The nurse did not follow up with the previous nurse, did not complete a medication error report, and failed to contact the physician for guidance. The incident was further compounded by the actions of another registered nurse who, due to a hectic morning, initially prepared to administer the insulin but forgot to do so after being distracted. This nurse later administered the insulin at 10:30 a.m. but did not update the administration record or report the late administration. The director of nursing expressed an expectation for better communication and adherence to the facility's policy, which mandates reporting medication errors and notifying the physician. The facility's November 2023 Medication Orders Administration Policy requires immediate documentation of medication administration and reporting of errors.
Failure to Initiate CPR for Full Code Resident
Penalty
Summary
The facility failed to follow physician orders for a resident who was designated as full code and did not initiate CPR as per the resident's wishes. The resident, who had diagnoses of coronary artery disease, heart failure, high blood pressure, and anxiety, was found without a pulse or respirations. Despite the resident's full code status, staff did not initiate CPR, and the resident expired. The incident resulted in an immediate jeopardy (IJ) situation, which was later addressed by the facility with corrective actions. The resident's physician order indicated a full code status, but the record did not include a corresponding POLST or signed advanced directives. The care plan also did not reflect the resident's code status. On the night of the incident, the resident was found unresponsive by a nursing assistant, who then called for a licensed practical nurse (LPN). The LPN noted a rapid heart rate but did not initiate CPR, instead calling 911 and retrieving an AED. When the ambulance crew arrived, they confirmed the resident's full code status and began CPR, but the resident was pronounced deceased shortly after. Interviews with staff revealed that the LPN was unsure of what to do and did not start CPR, despite knowing the resident was a full code. The Director of Nursing (DON) was not aware that CPR had not been initiated until it was reported by a quality assurance nurse. The facility's policy required staff to start CPR in the absence of obvious signs of clinical death, but this was not followed in this case. The facility later reviewed and revised their policies and provided additional training to staff to prevent future occurrences.
Removal Plan
- Reviewed their policy and systems and made the following changes: Implemented full code residents have a red heart at the foot of their bed.
- Implemented the unit group sheets were all revised to identify full code status.
- NA-A received education, LPN-A was put on administrative leave.
- All nursing staff participated in mock code with local ambulance service.
- All staff received education on implementation of POLST orders/CPR and participated in a mock code drill with local ambulance. They were reeducated again.
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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