Cornerstone Nsg & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Bagley, Minnesota.
- Location
- 416 Seventh Street Northeast, Bagley, Minnesota 56621
- CMS Provider Number
- 245307
- Inspections on file
- 22
- Latest survey
- September 26, 2025
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Cornerstone Nsg & Rehab Center during CMS and state inspections, most recent first.
Two residents with significant medical conditions and a history of pressure ulcers were not accurately assessed or documented for wound type and staging. Despite ongoing skin issues, including open areas, maceration, and the presence of eschar and slough, wound documentation was inconsistent and often lacked clear identification or staging. The DON was unable to provide accurate staging during surveyor interviews, and facility records did not meet policy requirements for comprehensive wound assessment.
A staff member served food to residents in a dining room without wearing a hair net, contrary to facility policy and professional standards. The staff member, a TMA, routinely dished and delivered food without a hair net and had not been instructed to do so. Facility policies and the FDA Food Code require hair restraints to prevent contamination, but this was not followed during the observed meal service.
The facility did not complete or submit required discharge MDS assessments for two residents who were discharged, despite documentation of their discharge planning and transitions. Staff interviews confirmed that the necessary assessments were not performed in accordance with facility policy and CMS requirements.
Staff did not consistently use enhanced barrier precautions, such as gowns and gloves, during high-contact care activities for two residents with wounds and one with an indwelling catheter. Observations showed that care was provided without proper PPE, and staff were sometimes unaware of the need for EBP, especially when new wounds developed or after returning from time off. Facility policy required EBP for residents with wounds or indwelling devices, but these protocols were not always followed, resulting in lapses in infection prevention.
A facility failed to ensure proper labeling and expiration management of medications, leading to potential medication errors. A resident received Omeprazole based on a MAR indicating a twice-daily dosage, while the bottle label stated once daily, with no indication of a change. Additionally, medications in a medication room were found to be unlabeled, expired, or improperly labeled, posing risks of medication errors and adverse effects.
The facility failed to create individualized care plans for three residents, each with specific medical and psychosocial needs. One resident with dementia lacked non-pharmacological interventions in their care plan, while another with chronic pain had a general plan without specific non-medication interventions. A third resident, receiving antianxiety and antidepressant medications, had a care plan that did not document effective non-pharmacological interventions known to staff. The facility's policy required comprehensive care plans, but these were not adequately developed.
A resident with pressure ulcers was not repositioned as required by their care plan, leading to a deficiency in care. Despite having a stage 3 and a stage 4 pressure ulcer, staff failed to reposition the resident every two to three hours, as observed over a morning period. Interviews revealed that some staff assumed the resident would refuse repositioning, leading to neglect in offering assistance. The facility's policy required comprehensive care plans to prevent functional decline, which was not adhered to in this case.
A facility failed to conduct a comprehensive smoking risk assessment for a resident who smoked on the premises. The resident, who required assistance with daily activities and had undetermined cognition, was observed smoking without a prior assessment or care plan addressing smoking risks. Staff were aware of the resident's smoking habits but did not complete the necessary assessments until after surveyors began investigating. The facility's policy required assessments for residents with a history of tobacco use, which was not adhered to in this instance.
The facility failed to attempt a gradual dose reduction (GDR) of psychotropic medications for two residents, R33 and R30, or provide a rationale for not doing so. R33, with severe cognitive impairment, was on Ativan and paroxetine, and the primary provider rejected a dose reduction without detailed rationale. R30, with intact cognition, was on lorazepam and escitalopram, and despite being on a higher than recommended dose, the primary provider rejected dose reduction recommendations without specific explanation. The facility's policy required GDR unless contraindicated, but this was not followed.
A resident with venous/arterial ulcers received dressing changes without proper infection control practices. An RN used the same contaminated gloves throughout the procedure, failed to perform hand hygiene, and used dirty scissors on clean dressings. A blood-soaked sock was improperly handled, contrary to the facility's policy. The DON expected adherence to infection control protocols.
The facility failed to offer timely pneumococcal vaccinations to three residents with chronic conditions, as recommended by the CDC. The residents' immunization records lacked evidence of being offered the newer PCV15 or PCV20 vaccines, and there was no documentation in their EMRs indicating they had been informed or offered these vaccinations. A misunderstanding about the timing of the new PCV20 vaccine contributed to this deficiency.
A resident sustained a superficial burn due to improper application of a hot pack without a proper barrier, contrary to the manufacturer's recommendations. The facility's outdated policy and lack of staff education contributed to the incident.
Failure to Accurately Assess and Stage Pressure Ulcers
Penalty
Summary
The facility failed to accurately assess and document pressure ulcers, including the type and staging of wounds, for two residents with significant medical histories and skin integrity issues. For one resident with multiple sclerosis, depression, and incontinence, records showed a history of pressure ulcers and high risk for further skin breakdown. Despite ongoing documentation of open areas, maceration, and the presence of eschar and slough on the buttocks, wound assessments inconsistently identified the type and stage of the wounds. Observations revealed large, darkened, and macerated areas with open wounds, but the Director of Nursing (DON) was unable to provide accurate staging during the survey. Another resident, also with multiple sclerosis and a history of chronic osteomyelitis and diabetes, was documented as having a stage IV pressure ulcer on admission. Wound management reports and progress notes described ongoing issues with open wounds, granulation tissue, slough, and drainage, but the wounds were often labeled as "unspecified ulcers" without clear identification of type or stage. During interviews, the DON stated that wound types were recorded based on provider input and did not provide further clarification or accurate staging according to CMS guidelines. Facility policy required comprehensive wound documentation, including type, assessment data, and changes in condition, at least weekly. However, the records reviewed showed inconsistent and incomplete documentation regarding wound type and staging, as well as discrepancies between observed wound conditions and what was recorded. These actions and inactions led to a deficiency in the facility's assessment and documentation practices for pressure ulcers.
Staff Failed to Wear Hair Net While Serving Food
Penalty
Summary
A staff member was observed serving food to residents in the 400-unit dining room without wearing a hair net, as required by facility policy and professional standards. The staff member, a trained medication aide (TMA), was seen dishing food from a steam table and delivering it to residents while wearing gloves but not a hair net. This occurred while seven residents were present in the dining room and one resident was eating in their room. The TMA stated that she routinely served food in this manner and had not been instructed to wear a hair net during food service. Further interviews revealed that nursing staff, rather than dietary staff, were responsible for serving food in the 300-unit and 400-unit dining rooms, and that all staff were expected to wear gloves and hair nets when serving food. Facility policies and the FDA Food Code require the use of hair restraints to prevent hair from contaminating food and to reduce the risk of cross-contamination. The facility's infection control and employee hygiene policies both specify the need for hair nets or caps during food handling, but the observed practice did not align with these requirements.
Failure to Complete and Submit Discharge MDS Assessments
Penalty
Summary
The facility failed to complete and submit discharge Minimum Data Set (MDS) assessments to the Centers for Medicare and Medicaid Services (CMS) database for two residents who were discharged. For one resident, who was admitted for short-term rehabilitation following hospitalization for respiratory failure, pneumonia, and influenza, the medical record showed that discharge planning was conducted and the resident was discharged home with in-home services. However, there was no evidence that a discharge MDS was initiated, completed, or submitted as required. For the second resident, who was readmitted after a hospital stay for an amputation and later transferred to another facility, the documentation included progress notes about the resident's care and discharge process. Although a quarterly MDS and an entry tracking record were completed, there was no discharge MDS completed or submitted after the resident's discharge. Staff interviews confirmed that the required discharge MDS assessments were not completed for both residents, contrary to facility policy and regulatory requirements.
Failure to Implement Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
Staff failed to implement enhanced barrier precautions (EBP) in accordance with CDC guidelines for residents with wounds and indwelling medical devices. For one resident with an indwelling catheter and chronic wounds, staff did not consistently wear gowns during high-contact care activities such as catheter care and wound dressing changes. Observations showed that a nursing assistant performed catheter and wound care without a gown, despite facility protocols and signage indicating EBP requirements. The resident confirmed that staff did not always wear gowns during these procedures and expressed the importance of this practice to prevent infection spread. Another resident with a history of chronic skin issues and newly developed open wounds on the lower legs did not have EBP signage or PPE available in the room during wound care. Both an LPN and a nursing assistant performed dressing changes on open, draining wounds without wearing gowns, only using gloves. The staff involved acknowledged after the fact that they should have used gowns but proceeded with the care without them. The lack of EBP was only addressed after the wound care was completed and the open wounds were reported to the registered nurse, who then initiated the appropriate precautions. Facility policy required EBP for residents with indwelling medical devices or wounds, with clear instructions for staff to use gowns and gloves during high-contact care activities. However, documentation and interviews revealed that staff were not always aware of the need for EBP, particularly when new wounds developed or when returning from time off. The failure to consistently implement EBP as outlined in facility policy and CDC guidelines led to lapses in infection prevention during care for residents at high risk of infection.
Medication Labeling and Expiration Deficiencies
Penalty
Summary
The facility failed to ensure medications were properly labeled, leading to potential medication errors for a resident identified as R37. During a medication pass, a trained medication aid (TMA) administered Omeprazole 20 mg to R37, based on the medication administration record (MAR), which indicated a twice-daily dosage. However, the medication bottle label stated a once-daily dosage, and there were no identifying marks or stickers to indicate a change in the medication order. The director of nursing (DON) confirmed that the medication label should reflect the most current instructions and that a label change sticker should have been placed on the bottle until a new label could be issued. Additionally, the facility failed to ensure that medications in one of the medication rooms were not expired and had proper identifying labels. During an inspection of the North medication room, several medications were found to be unlabeled, expired, or improperly labeled. These included unlabeled Lidocaine patches, expired medications belonging to various residents, and medications with unclear expiration or open dates. The administrator confirmed that medications should have a resident label, expiration date, and dosing instructions, and that expired medications should not be dispensed. The facility's policy on the storage of medications, dated 4/1/22, requires that drug containers with missing, incomplete, improper, or incorrect labels be returned to the pharmacy for proper labeling before storage. The failure to adhere to this policy resulted in the presence of expired and improperly labeled medications in the facility, posing a risk of medication errors and adverse effects for the residents.
Failure to Develop Individualized Care Plans for Residents
Penalty
Summary
The facility failed to develop person-centered comprehensive care plans for three residents, R33, R20, and R30, to address their psychosocial, mental, and medical needs. R33, who had severe cognitive impairment and a diagnosis of dementia, was receiving psychotropic medication. However, the care plan did not specify individualized non-pharmacological interventions for managing behaviors such as grinding teeth and resisting care. Similarly, R20, who had moderate cognitive impairment and chronic pain, had a care plan that lacked specific non-medication interventions for pain relief, despite receiving multiple pain medications. The care plan was described as very general and not tailored to the resident's specific needs. R30, who had intact cognition and required assistance with all ADLs, was receiving antianxiety and antidepressant medications. The care plan aimed to prescribe the lowest effective dose of medications but did not include specific non-pharmacological interventions for managing anxiety and pain. Interviews with staff revealed that R30 responded well to certain interventions, such as environmental changes and breathing exercises, but these were not documented in the care plan. The facility's policy required comprehensive care plans to address each resident's medical, nursing, mental, and psychosocial needs, but the plans for these residents did not meet this standard.
Failure to Reposition Resident with Pressure Ulcers
Penalty
Summary
The facility failed to ensure timely repositioning for a resident with pressure ulcers, leading to a deficiency in care. The resident, who had moderately impaired cognition and was dependent on staff for all activities of daily living, had a stage 3 pressure ulcer acquired at the facility and a stage 4 pressure ulcer present on admission. Despite physician-ordered treatments and a care plan that required repositioning every two to three hours, staff did not reposition the resident as needed. Observations showed the resident remained in the same position for several hours without repositioning, which was crucial for preventing further pressure ulcer development and promoting healing. Interviews with staff revealed a pattern of neglect in offering repositioning assistance. A nursing assistant admitted to not repositioning the resident, assuming refusal based on past behavior. Similarly, a licensed practical nurse acknowledged that while newer aides consistently offered assistance, more experienced staff often did not, believing the resident would refuse. The director of nursing confirmed that staff were expected to offer repositioning as per the care plan, highlighting the importance of this intervention for pressure ulcer prevention and healing. The facility's policy emphasized the need for comprehensive care plans to meet residents' needs and prevent functional decline.
Failure to Conduct Comprehensive Smoking Risk Assessment
Penalty
Summary
The facility failed to ensure comprehensive smoking risk assessments for a resident who smoked on facility grounds. The resident, who required assistance with dressing and transfers and had undetermined cognition due to communication difficulties, was observed attempting to ambulate independently to smoke. Despite the resident's medical record lacking a smoking assessment, staff were aware of the resident's smoking habits. The care plan did not identify the resident's smoking or include interventions, and a smoking assessment was only completed after surveyors began investigating the concern. Interviews with staff revealed that they were aware of the resident's smoking activities but had not completed the necessary assessments or care planning. The smoking assessment, conducted after the surveyor's inquiry, was based on previous observations and did not occur while the resident was smoking. The assessment identified the resident as a safe smoker but lacked details on safety concerns, monitoring, and storage of smoking materials. The facility's policy required assessments for residents with a history of tobacco use, which was not followed in this case.
Failure to Attempt Gradual Dose Reduction of Psychotropic Medications
Penalty
Summary
The facility failed to attempt a gradual dose reduction (GDR) of psychotropic medications or provide a rationale for not doing so for two residents reviewed for unnecessary medications. One resident, identified as R33, had severe cognitive impairment and was dependent on staff for activities of daily living. R33 was receiving medications for anxiety and depression, including Ativan and paroxetine. The primary provider rejected a dose reduction recommendation from the consultant pharmacist, citing that benefits outweighed risks, but failed to provide a detailed clinical rationale for this decision. Additionally, there were no progress notes indicating any physical behaviors that would justify the continued use of these medications. Another resident, identified as R30, had intact cognition and was receiving lorazepam and escitalopram for anxiety and depression. The resident's care plan included a goal to prescribe the lowest effective dose of medication, but no previous dose reductions had been attempted. The primary provider rejected a dose reduction recommendation, stating that the risk was less than the benefit of continued use, but did not provide a specific rationale. The consultant pharmacist noted that the resident was on a higher than recommended dose of escitalopram and suggested a review of medications, but the primary provider again rejected the recommendation without further explanation. The facility's policy on tapering medications and GDR required that residents using antipsychotic drugs receive GDR and behavioral interventions unless clinically contraindicated. The policy also stated that tapering should be considered when the resident's condition had improved or stabilized, or when non-pharmacological interventions had been effective. However, the facility failed to adhere to this policy, as evidenced by the lack of documented rationale for not attempting GDR for the two residents in question.
Infection Control Breach During Dressing Changes
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during dressing changes for a resident with venous/arterial ulcers. The resident, who had no cognitive impairment and was diagnosed with peripheral vascular disease and diabetes, required daily dressing changes on both lower legs. During an observation, a registered nurse (RN) was seen performing dressing changes without following standard precautions. The RN used the same contaminated gloves throughout the procedure, failed to perform hand hygiene between tasks, and used dirty bandage scissors on clean dressings. Additionally, the RN placed a blood-soaked sock on the floor instead of disposing of it in a biohazard bag. The RN admitted to not changing gloves or performing hand hygiene as required, and acknowledged the improper handling of bloody items. The facility's policy on dressing changes clearly stated that gloves should be changed and hand hygiene performed between each wound, which was not adhered to in this instance. The director of nursing expressed that she expected staff to follow proper infection control procedures, highlighting a lapse in adherence to the facility's established protocols.
Failure to Offer Timely Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that recommended pneumococcal vaccinations, as outlined by the CDC, were offered and/or provided in a timely manner to three residents reviewed for immunizations. These residents, who had various chronic conditions such as congestive heart failure, chronic obstructive pulmonary disease, and Alzheimer's disease, did not receive the newer recommended pneumococcal conjugate vaccines (PCV15 or PCV20). The immunization records for these residents lacked evidence of being offered these vaccines, and there was no documentation in their electronic medical records indicating that they had been informed or offered the newer vaccinations. During an interview, the Director of Nursing and a registered nurse revealed that the facility had reached out to their pharmacy for information on the new pneumococcal vaccines. However, the pharmacy's list of residents eligible for the new vaccinations did not include two of the residents in question. The facility was under the incorrect impression that the new PCV20 should be offered ten years after the last pneumococcal vaccination, rather than the correct five years. This misunderstanding contributed to the failure to offer the vaccines in a timely manner, as outlined in the facility's policy on vaccination of residents.
Failure to Follow Hot Pack Application Protocols
Penalty
Summary
The facility failed to ensure policies were consistent with manufacturer's recommendations for the use of hot packs and did not provide adequate education to staff, resulting in a resident sustaining a superficial burn. The resident, identified as R1, had intact cognition and was able to change position in bed independently. R1's care plan indicated a risk for skin alteration and an abscess to the mons pubis. The facility's standing orders directed the application of hot packs for pain and swelling, but the hot pack used was labeled to be wrapped before applying and warned against direct skin contact due to peak temperatures reaching 160 degrees Fahrenheit. Despite this, the hot pack was applied without a proper barrier, leading to burns on R1's skin. On the night of the incident, an LPN placed the hot pack on an abdominal pad and a towel, but later, a nursing assistant found the hot pack directly on R1's skin, causing red, splotchy areas consistent with burns. Interviews with staff revealed inconsistencies in the application process and a lack of proper documentation and assessment of the wound. The facility's policy on hot pack application was outdated and did not align with the manufacturer's instructions, contributing to the incident. The staff involved received education post-incident, but the deficiency highlighted a gap in training and adherence to safety protocols.
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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