Browns Valley Health Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Browns Valley, Minnesota.
- Location
- 114 Jefferson Street South, Browns Valley, Minnesota 56219
- CMS Provider Number
- 245564
- Inspections on file
- 19
- Latest survey
- April 21, 2026
- Citations (last 12 mo.)
- 7 (1 serious)
Citation history
Health deficiencies cited at Browns Valley Health Center during CMS and state inspections, most recent first.
A cognitively impaired resident, dependent on staff for all ADLs and functioning at a child-like level, was verbally and physically abused during toileting care when a NA used foul, aggressive language and struck the resident’s bare buttocks after the resident became combative. A second NA in the room and a TMA outside the closed door witnessed or overheard the yelling, swearing, and the smack, and both promptly reported the incident to the charge LPN and in writing. The LPN did not read the written complaint, did not immediately assess the resident, did not notify the on-call nurse, and allowed the NA accused of abuse to continue working the remainder of the shift with the resident and other vulnerable residents. In the following days, staff documented that the resident became withdrawn, tearful, refused meals and favorite drinks, and showed increased behavioral disturbances, representing serious psychosocial harm linked to the abusive incident.
A resident with dementia, depression, and a psychotic disorder, who was dependent on staff for ADLs and incontinent care, was allegedly subjected to verbal and physical abuse by a NA during toileting, including foul language, an aggressive tone, and an open-hand smack to the buttocks. A TMA overheard yelling and abusive language and, along with another NA who witnessed the smack, reported the incident to an LPN and completed a complaint form. The LPN did not read the complaint, did not further question staff, and did not immediately assess the resident or notify the on-call nurse. The facility’s incident report to the State Agency was not submitted until well after the required two-hour reporting window, while the alleged abuser continued working with residents.
A resident with dementia, depression, psychotic disorder, and moderate cognitive impairment, dependent on staff for all cares, was allegedly subjected to verbal and physical abuse by a NA during evening cares, including aggressive, profane language and an open-hand smack to the bare buttock while the resident cried and whimpered. Two staff members reported the incident to a charge LPN that evening, but the LPN did not immediately notify the on-call nurse, did not ensure the resident’s immediate safety, and did not document or complete a timely skin or behavior assessment. The alleged abuser continued working with residents until the next morning, and when the investigation was later initiated, it was limited to interviews of a small number of verbally responsive residents, without documented skin checks or behavior chart reviews for non-verbal residents and without interviewing all relevant night staff, contrary to the facility’s maltreatment reporting policy.
The facility failed to ensure proper food safety and hygiene practices, affecting all 28 residents. The dietary manager was observed handling clean dishes without a hair restraint, and multiple food items in the kitchen and resident refrigerators were improperly labeled or expired. This was against facility policies requiring hair restraints and proper food labeling to prevent foodborne illness.
A facility failed to disinfect a multi-use glucometer between uses for two residents requiring blood glucose monitoring. The RN and LPN involved did not follow the manufacturer's disinfection guidelines, risking the spread of infections. The facility's infection preventionist and DON confirmed the improper disinfection practices, which contradicted both the manufacturer's instructions and the facility's policy.
A resident with diabetes received insulin without the pen being primed, contrary to manufacturer's instructions. An RN administered 8 units of Humalog insulin without priming the pen, believing it was unnecessary. Interviews with the consultant pharmacist and DON highlighted the importance of priming to ensure correct dosage. The facility's policy and manufacturer's guidelines were not followed, resulting in a significant medication error.
The facility failed to submit accurate staffing data to CMS for a quarter, as discrepancies were found between the PBJ report and actual staffing records. Licensed nursing staff, including RNs and LPNs, were present on the dates in question, but incorrect coding of LPNs and TMAs led to inaccuracies. The administrator confirmed the issue, acknowledging the PBJ report's inaccuracy.
The facility failed to ensure proper wheelchair positioning for a cognitively impaired resident, whose feet were observed dangling without support, and did not comprehensively assess or implement interventions for another resident with edema. Staff interviews revealed a lack of recent therapy evaluations and inconsistencies in edema assessments, with no physician's order for compression stockings despite the resident's preference. The facility's policies for adaptive equipment and compression stockings were not followed, contributing to these deficiencies.
Failure to Protect Cognitively Impaired Resident From Physical and Verbal Abuse and Delayed Response to Allegation
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident from physical and verbal abuse by a nurse aide and to respond appropriately once the allegation was reported. On the evening in question, two nurse aides were providing toileting and peri-care to the resident, who had non-Alzheimer’s dementia, depression, a psychotic disorder, and moderately impaired cognition with long- and short-term memory loss. The resident functioned at an estimated developmental level of an 8-year-old, had unclear speech, responded only to simple direct communication, and was dependent on staff for all ADLs including toileting and hygiene. During care, the resident became combative, yelling and swinging her arms, and one aide (NA‑B) responded by raising her voice, using foul and aggressive language, and striking the resident on the bare buttocks while stating that if the resident wanted to act like a child, she would be treated like one. A trained medication assistant (TMA‑A) standing outside the closed door heard NA‑B yelling at the resident to hurry up and grab the “fucking bar” and to walk to bed, and later learned from the other aide (NA‑A) that NA‑B had swatted the resident’s buttocks. NA‑A, who was in the room, described NA‑B’s tone as loud, aggressive, and intimidating, and reported that the resident was grunting and appeared nervous. NA‑A stated that after the resident yelled and grunted during brief placement, NA‑B told the resident that if she wanted to act like a child she would be treated like one, then smacked her on the right buttock with an open hand, skin-to-skin, producing a loud smack. NA‑A reported feeling very uncomfortable and believed the conduct was verbal and physical abuse. After leaving the room, NA‑A immediately told TMA‑A what had happened and, within about five minutes, located the charge nurse (LPN‑A) and reported the incident. NA‑A completed an Employee Concern form describing the incident and placed it in the DON’s box. TMA‑A also informed LPN‑A during the evening medication count that she had heard raised voices, swearing, and the resident crying, and that NA‑B had smacked the resident’s buttocks. Despite these reports, LPN‑A did not read the written complaint, did not conduct an immediate assessment of the resident, did not contact the on‑call nurse, and allowed NA‑B to continue working the remainder of the 12‑hour shift, caring for the resident and other residents without additional supervision. In the hours and days following the incident, the resident demonstrated changes in behavior and mood that were documented by staff. The next morning, staff noted the resident was tearful, withdrawn, and refusing food and drink, including favorite beverages, and she cried while in her wheelchair in a common area. Nursing notes and behavior monitoring entries over the subsequent days documented increased yelling, hitting, scratching, cursing, and physical aggression during care, as well as episodes of sadness, tearfulness, withdrawal, and isolation. Staff familiar with the resident, including RN‑A and NA‑E, reported that this withdrawn, tearful, and non‑eating behavior was not typical for her and that she usually did not cry without a reason. Although a full body assessment was later documented as showing no bruising and no verbalized pain, the facility’s own records and interviews describe that the resident became more tearful, had decreased appetite, and increased crying following the incident, and that she appeared different than normal—quiet, exhausted, withdrawn, and refusing to participate in usual activities and intake. These events, combined with the failure of the charge nurse to act on the initial reports and remove the alleged perpetrator from resident care, led to the cited deficiency for failure to protect the resident from abuse.
Removal Plan
- Reported abuse to the State Agency (SA).
- Investigated allegations of physical and verbal abuse and implemented resident protection.
- Re-educated staff on abuse and neglect, reporting, abuse prevention, resident rights, dementia, and vulnerable adults.
- Verified education through interviews and training records.
Failure to Timely Report Alleged Verbal and Physical Abuse to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of abuse to the State Agency within the required two-hour timeframe after the allegation was made. On 2/21/26 in the evening, a trained medication assistant (TMA-A) stood outside a resident’s closed door preparing medications and heard the resident and a nursing assistant (NA-B) yelling. TMA-A heard NA-B say in a rude and aggressive tone, “hurry up and grab the fucking bar you know how to fucking walk so walk to the bed.” After NA-A and NA-B exited the room, NA-A told TMA-A that NA-B had swatted the resident on the butt. TMA-A considered this verbal and physical abuse and reported what she heard and what NA-A told her to the charge nurse (LPN-A) during a medication count shortly after 7:00 p.m., assuming LPN-A would notify the on-call nurse. NA-A reported that while assisting the resident in the bathroom, the resident became combative and yelled after NA-B told her to stand up. NA-B responded, “if you want to act like a child then you will be treated like one,” and with an open hand smacked the resident on the right buttock, skin-to-skin, producing a loud smack. NA-B then grabbed the resident’s walker and directed her to walk to bed. NA-A described NA-B’s tone as loud, aggressive, and accompanied by foul language, and stated the resident was whining, whimpering, and making grunting sounds as if nervous. After leaving the room, NA-A and TMA-A reported the incident to LPN-A, who provided NA-A with a complaint form. NA-A completed the form and placed it in the DON’s box, believing the incident would be handled and reported. The resident involved had non-Alzheimer’s dementia, depression, and a psychotic disorder, with unclear speech, limited verbal and non-verbal skills, disorganized thinking, and moderately impaired cognition with long- and short-term memory loss. She was dependent on staff for personal and toileting hygiene, transfers, bathing, and lower body dressing, and was always incontinent of bladder and frequently incontinent of bowel. Despite the information provided by TMA-A and NA-A, LPN-A did not read the written complaint, did not further question staff about the incident, and did not immediately assess the resident or contact the on-call nurse. The facility’s incident report was not submitted to the State Agency until 2/22/26 at 4:22 p.m., well beyond the policy requirement to report suspected maltreatment, including abuse, to the State Agency immediately but no later than two hours after the allegation is made. During this time, NA-B continued to work the remainder of the shift and care for residents.
Failure to Protect Resident and Conduct Thorough Abuse Investigation
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient protections and assessment following an allegation of staff-to-resident abuse, and failure to conduct a thorough investigation. A resident with non-Alzheimer’s dementia, depression, a psychotic disorder, moderately impaired cognition, disorganized thinking, unclear speech, and dependence on staff for all cares and transfers was allegedly subjected to verbal and physical abuse by a nursing assistant during evening cares. According to staff interviews, the nursing assistant spoke loudly, aggressively, and with profanity, telling the resident to hurry up and grab the bar and to walk to the bed, and stated that if the resident wanted to act like a child, she would be treated like a child. Staff reported that the nursing assistant used an open hand to smack the resident’s bare buttock, which sounded like a loud smack, while the resident was whining, whimpering, and making grunting sounds. The incident was reported by two staff members to the charge nurse on the evening of the alleged abuse. A trained medication assistant reported hearing the loud, aggressive, and profane language from outside the resident’s closed door and, after speaking with another nursing assistant who had been in the room, learned of the smack to the resident’s buttock. That nursing assistant also directly reported to the charge nurse that the staff member had been verbally aggressive and had smacked the resident’s right buttock. The charge nurse responded verbally but did not immediately contact the on-call nurse as required by facility policy, did not ensure the resident’s immediate safety, and did not initiate the required assessment and protective measures at that time. The resident’s medical record contained no documentation of a skin assessment or behavior assessment on the date of the incident, and there was no evidence of a documented skin check following the initial report of the allegation or the following day. The facility’s investigation process was also deficient. The alleged perpetrating staff member continued to work with residents for the remainder of the shift and into the next morning after the incident, and the allegation was not brought to the attention of supervisory nursing staff until the following day. When the investigation was initiated, the clinical coordinator interviewed a limited number of residents who were verbally responsive and in their rooms, totaling 11, and did not verify that skin checks or behavior chart reviews were completed for residents who could not be interviewed. Night staff who had worked with the accused nursing assistant, including the nursing assistant on the night shift with her, were not interviewed. The DON acknowledged that the charge nurse did not follow the facility’s maltreatment reporting guidelines, which required immediate reporting, suspension of the involved staff, and initiation of an investigation including resident and staff interviews, observations, and medical record review. The DON also acknowledged that resident skin monitoring and behavior chart review were not completed as expected, and that the facility’s policy was not followed by the charge nurse regarding communication of the incident and immediate protective actions.
Deficient Food Safety and Hygiene Practices
Penalty
Summary
The facility failed to ensure proper food safety and hygiene practices in the kitchen, which had the potential to affect all 28 residents receiving food and beverages. During an observation, the dietary manager was seen handling clean dishes without wearing a hair restraint, despite having hair approximately 1/4 inch in length. This was against the facility's policy that required all dietary staff to wear hair restraints to prevent hair from contacting exposed food or clean dishes. The dietary manager was unaware of the need for a hair restraint due to the short length of his hair. Additionally, the facility did not adhere to proper food labeling and storage practices. Several food items in the kitchen refrigerator, freezer, and resident refrigerator were found without proper labeling, dating, or were past their expiration dates. Items such as slices of ham, hamburger patties, apple pie, salsa, mayonnaise, and various other food products were either not dated or had expired, which was contrary to the facility's policy on perishable food management. The dietician confirmed that all food items should have been dated when opened and discarded after their shelf life or expiration date to prevent foodborne illness.
Failure to Disinfect Glucometer Between Uses
Penalty
Summary
The facility failed to properly disinfect a multi-use glucometer after use for two residents who required blood glucose monitoring. This deficiency was observed during the care of two residents, both of whom had cognitive impairments and required assistance with activities of daily living. The registered nurse (RN) and licensed practical nurse (LPN) involved in the incidents did not follow the manufacturer's guidelines for disinfecting the glucometer between uses, which is necessary to prevent the spread of blood-borne infections. The RN did not disinfect the glucometer after using it on one resident, while the LPN incorrectly used an alcohol wipe, believing it was sufficient for disinfection. The facility's infection preventionist and director of nursing confirmed that the glucometer was used for multiple residents and acknowledged that the use of an alcohol wipe was not appropriate for disinfection. The manufacturer's guidelines specified the use of an EPA-registered disinfectant or a bleach solution for proper disinfection. The facility's policy also required decontamination of reusable equipment between residents according to the manufacturer's instructions. This oversight in infection control practices had the potential to affect all residents requiring blood glucose monitoring.
Failure to Prime Insulin Pen Leads to Medication Error
Penalty
Summary
The facility failed to ensure professional standards of practice were followed during the administration of insulin to a resident with severe cognitive impairment and diabetes mellitus. The resident's care plan required staff to administer diabetic medications as ordered. However, during an observation, a registered nurse (RN) prepared and administered 8 units of Humalog insulin to the resident without priming the insulin pen as per the manufacturer's instructions. The RN did not prime the pen, which involves wasting 2 units of insulin to remove air bubbles, because she believed it was unnecessary since she had administered insulin to the resident earlier in the day. Interviews with the consultant pharmacist and the director of nursing confirmed the importance of priming the insulin pen to ensure the correct dosage is administered. The manufacturer's package insert and the facility's medication administration policy both emphasize the need to prime the pen before each injection to avoid administering too much or too little insulin. The failure to prime the pen was a deviation from these guidelines, leading to a significant medication error in the administration of insulin to the resident.
Inaccurate Staffing Data Submission to CMS
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) for the first quarter, as required by CMS specifications. This deficiency was identified during a review of the Payroll Based Journal (PBJ) Report, which highlighted several dates where there was a failure to have licensed nurse coverage 24 hours per day. The review of staffing schedules and time cards from October 1, 2023, through December 31, 2023, showed that licensed nursing staff, including registered nurses (RNs) and licensed practical nurses (LPNs), were present and worked on the dates in question. However, discrepancies were found between the PBJ report and the facility's staffing records. During an interview, the facility administrator confirmed the findings and acknowledged that the PBJ report was inaccurate. The administrator explained that the LPN staff and trained medication aides (TMAs) were not coded correctly in the PBJ system, which led to the inaccuracies. The facility's policy on PBJ, dated April 1, 2019, mandates the electronic submission of staffing information based on payroll data to ensure compliance with regulatory requirements. The Employment System Department (ESD) is responsible for reviewing all PBJ data for accuracy before submission to CMS, but this process was not followed correctly, resulting in the deficiency.
Deficiencies in Wheelchair Positioning and Edema Management
Penalty
Summary
The facility failed to ensure proper wheelchair positioning for a resident with severe cognitive impairment and multiple diagnoses, including dementia, arthritis, and low back pain. The resident was observed multiple times with her feet dangling from the wheelchair, indicating a lack of proper support and positioning. Interviews with staff revealed that the resident had not been assessed for wheelchair positioning, and there was no recent therapy evaluation to address this issue. The facility's policy required referrals to occupational or physical therapy for wheelchair assessments, but this was not followed. Additionally, the facility did not comprehensively assess and implement interventions for a resident with edema, who had diagnoses including heart failure, hypertension, chronic kidney disease, and diabetes mellitus. The resident's care plan included monitoring for edema, but there were inconsistencies in the assessment records, with some entries left blank. The resident expressed a preference for wearing compression stockings, but staff reported difficulties in applying them, and there was no physician's order for their use. The facility's policy required continuous assessment and monitoring of lower extremities when using compression stockings, which was not adequately documented or communicated to the primary care physician. Interviews with the director of nursing confirmed that the facility's usual process for wheelchair assessments was not followed, and the resident's feet should not have been dangling. The director also acknowledged the lack of a physician's order for compression stockings and the need for proper measurement and fitting. The facility's failure to adhere to its policies and procedures for adaptive equipment and compression stockings contributed to the deficiencies observed in the care of these residents.
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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