Fair Meadow Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Fertile, Minnesota.
- Location
- 300 Garfield Avenue Southeast, Fertile, Minnesota 56540
- CMS Provider Number
- 245545
- Inspections on file
- 19
- Latest survey
- September 10, 2025
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Fair Meadow Nursing Home during CMS and state inspections, most recent first.
A resident with intact cognition and COPD was allowed to self-administer nebulized medications without a comprehensive assessment or care plan in place. An LPN prepared and left the medications for the resident to take independently, and staff interviews confirmed that no formal assessment or approval for self-administration had been completed, contrary to facility policy.
A resident was subjected to physical restraints that were not required for medical treatment, in violation of regulations mandating that residents remain free from unnecessary restraints.
A resident with moderate cognitive impairment and multiple mobility-related diagnoses was transferred from a wheelchair to a recliner by a nursing assistant without the use of a gait belt, contrary to the resident's care plan and facility policy. The nursing assistant lifted the resident by the torso, and interviews with an LPN and the DON confirmed that a gait belt is required for all assisted transfers. Facility policy also directs staff to use a gait belt for wheelchair transfers.
A resident with cognitive impairment and urinary issues had an indwelling catheter order that lacked specific type and size details. Staff relied on the care plan, not a physician order, for catheter specifications, resulting in the use of a catheter and balloon size not clearly ordered by a physician. The DON and NP confirmed that staff were expected to follow explicit physician orders, but this was not done, leading to inconsistent catheter care and documentation.
A resident with multiple chronic conditions did not consistently receive required routine physician visits every 60 days. An LPN responsible for scheduling visits used a handwritten schedule that was discarded after each visit, and could not account for the missed evaluations. The DON confirmed that staff were expected to track and report such lapses, but this was not done, resulting in noncompliance with facility policy.
A resident was administered medications in incorrect doses and given a medication not currently ordered, resulting in a medication error rate of 9.09%. An RN prepared two potassium tablets instead of one, one vitamin D3 tablet instead of two, and included oxybutynin, which was not ordered. The errors were only identified after a surveyor intervened, and the RN acknowledged not following proper medication administration procedures.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified during the survey.
Several residents with complex medical conditions did not have required physician progress notes documented during routine visits, despite the presence of signed order summaries. An LPN responsible for medical records provided verbal reminders to physicians about missing notes but did not document these reminders or formally report the issue to administration. The DON and administrator were not fully aware of the extent or duration of the missing documentation, which was not in compliance with facility policy requiring progress notes at each visit.
A resident with multiple fractures and osteoarthritis fell during a transfer with a mechanical stand device, resulting in a head injury and a hip fracture. The facility did not thoroughly investigate the incident, as required by policy, and failed to inspect the equipment or verify the cause of the fall. Interviews indicated potential issues with the harness and securing of the resident, but no follow-up was conducted.
The facility failed to educate three residents on immunizations per CDC guidance. One resident with a history of COVID-19 and another with chronic pulmonary edema had received previous pneumococcal vaccines but lacked documentation of education on boosters. A third resident with congestive heart failure had not been offered the PCV13 vaccine. Interviews revealed that the infection preventionist did not provide education on PCV20 unless asked, contrary to facility policy and CDC guidance.
A resident with severe cognitive impairment was subjected to continuous use of a seatbelt as a physical restraint without comprehensive reassessment or adherence to care plan interventions. Despite being a good candidate for restraint elimination, the facility failed to explore less restrictive alternatives or document the necessity and effectiveness of the restraint, leading to a deficiency.
A resident with moderate cognition and Parkinson's disease frequently used a golf cart for off-campus activities without a comprehensive assessment of their ability to safely operate it. The facility did not evaluate the resident's physical and cognitive abilities for safe golf cart use, and the care plan lacked relevant interventions. Staff assumed an assessment had been completed, but none was found in the medical record. The facility also lacked a policy on motorized golf cart use.
A resident with MRSA was not properly managed under contact precautions, as staff failed to consistently use PPE and adhere to hand hygiene protocols. Despite signage and policy guidelines, staff entered the resident's room without gowns or gloves and did not wash hands between glove changes during care. Interviews revealed a lack of awareness about the resident's infection and necessary precautions.
Failure to Assess and Care Plan for Self-Administration of Nebulized Medications
Penalty
Summary
The facility failed to comprehensively assess and care plan a resident's ability to self-administer nebulized medications. The resident, who had intact cognition and diagnoses including a circulatory disorder, aneurysm, and COPD, was observed receiving prepared nebulizer medication from an LPN, who then left the resident to self-administer the medication independently. The care plan for the resident included interventions for altered respiratory status and directed staff to administer medications as ordered, but did not include any evidence of an assessment or approval for the resident to self-administer nebulized medications. Interviews with staff revealed that the LPN assumed an assessment had been completed and routinely left multiple nebulized medications with the resident to self-administer during the night, checking back later to confirm administration. The RN responsible for assessments confirmed that no formal assessment or order for self-administration had been completed, as she was unaware the resident was independently administering the medications. The DON stated that facility policy required a self-administration assessment and care planning if a resident requested to self-administer medications, but this process had not been followed for the resident in question.
Use of Physical Restraints Without Medical Necessity
Penalty
Summary
A deficiency was identified regarding the use of physical restraints on residents. The report notes that residents were not consistently free from the use of physical restraints, except when required for medical treatment. This indicates that physical restraints were used in situations where they were not medically necessary, contrary to regulatory requirements.
Failure to Use Gait Belt During Assisted Transfer
Penalty
Summary
A deficiency occurred when staff failed to implement required safety interventions during a transfer for a resident with moderate cognitive impairment and multiple diagnoses, including osteoporosis, osteoarthritis, muscle weakness, and low back pain. The resident's care plan specified that transfers should be performed with maximal assistance of one staff member and the use of a full wheeled walker and gait belt. During an observed transfer, a nursing assistant moved the resident from a wheelchair to a recliner without using a gait belt, instead lifting the resident by wrapping her arms around the resident's torso. The nursing assistant stated that she did not use a gait belt because the transfer was short and did not require steps. Interviews with facility staff, including an LPN and the DON, confirmed that the facility's policy requires the use of a gait belt for all assisted transfers, regardless of the distance. The DON acknowledged that not using a gait belt and lifting the resident by the torso could have caused injury or pain and that there would have been no secure way to assist the resident if she began to fall. Review of the facility's policy further confirmed that staff are directed to apply a gait belt for all wheelchair transfers.
Failure to Ensure Proper Physician Order and Catheter Specification
Penalty
Summary
The facility failed to ensure a proper physician order for an indwelling urinary catheter for a resident with obstructive and reflux uropathy, dementia, and benign prostatic hyperplasia. The physician order on file directed staff to change the Foley catheter every 90 days but did not specify the type or size of the catheter to be used. The resident's care plan indicated the use of a 16 French catheter with a 10 ml balloon, but this information was not reflected in the physician order. During care, staff referenced the care plan for catheter specifications rather than a physician order, and a registered nurse provided a stock 14 French catheter with a 30 ml balloon, stating she would only use 10 ml of saline in the balloon to match the care plan, not the actual balloon size. The director of nursing confirmed that staff were expected to follow physician orders and document all relevant details during catheter changes, but acknowledged that using a 30 ml balloon with only 10 ml of saline was not in accordance with the order. Interviews revealed that the nurse practitioner expected staff to have a specific order for a 16 French catheter with a 10 ml balloon and to follow it accordingly. The facility's policy on catheter-associated UTI prevention described the insertion procedure but did not address the requirement for a physician order specifying catheter type and size. The lack of a clear, specific physician order and reliance on the care plan for catheter details led to inconsistencies in catheter care and documentation for the resident.
Failure to Ensure Timely Routine Physician Visits
Penalty
Summary
The facility failed to ensure that a long-term resident received routine physician visits every 60 days as required. The resident, who was cognitively intact and had diagnoses including atrial fibrillation, major depressive disorder, morbid obesity, and lymphedema, did not consistently receive timely evaluations by a medical provider. Review of the medical record showed gaps in the timing of provider visits. During interviews, an LPN responsible for scheduling these visits could not explain the missed evaluations and stated that she maintained a handwritten schedule, which was discarded after each provider visit. The DON confirmed that staff were expected to track and ensure timely physician evaluations, and that this lapse should have been reported to administration. Facility policy required physician visits at least every 60 days after the first 90 days of admission, with a 10-day grace period, but this was not consistently followed for the resident in question.
Medication Administration Errors Result in Elevated Error Rate
Penalty
Summary
A medication error rate of 9.09% was identified during a survey observation of medication administration for one of seven residents. The registered nurse (RN) prepared medications for a resident, including potassium chloride and vitamin D3, but initially selected incorrect doses—two potassium tablets instead of one, and one vitamin D3 tablet instead of the ordered two. The error was identified only after the surveyor intervened and asked the RN to review the prepared medications. Additionally, the RN prepared and included oxybutynin, a medication not currently ordered for the resident, in the medication cup. The RN admitted she was working too quickly and was unsure if she would have caught the errors without the surveyor's intervention. The facility's policy required staff to compare the medication listed on the resident's Medication Administration Record (MAR) with the medication container label at three separate points and to follow the eight rights of medication administration. The RN did not adhere to these procedures, as evidenced by the preparation of incorrect doses and the inclusion of a medication not listed on the MAR. The director of nursing confirmed that staff are expected to closely check the MAR and medication bottles to prevent such errors.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive program but does not provide specific details about individual residents, staff actions, or particular infection control lapses observed during the survey.
Failure to Maintain Complete Physician Progress Notes in Medical Records
Penalty
Summary
The facility failed to maintain complete medical records by not ensuring that physician progress notes were written, signed, and dated during routine visits for four residents. Specifically, the medical records for these residents did not contain the required physician progress notes for their respective visits, despite having order summary reports signed by the physicians. The residents involved had various diagnoses, including atrial fibrillation, major depressive disorder, morbid obesity, lymphedema, cerebral palsy, epilepsy, Alzheimer's disease, type 2 diabetes, dementia, hypertension, insomnia, weakness, and osteoarthritis. The absence of these progress notes was identified through document review and interviews. During interviews, an LPN responsible for medical records explained that when physicians made rounds, she provided a list of residents needing evaluation and waited for the completed progress notes to be returned for scanning into the medical record. However, in some cases, such as when a physician resigned from their clinic, the notes were not entered into the record in a timely manner. The LPN stated that reminders to physicians about missing notes were given verbally but not documented, and the issue was not formally reported to administration. The administrator confirmed awareness of some missing documentation but was unaware of the extent or duration of the problem. Facility policy required physicians to review care and document progress notes at each visit, which was not consistently followed.
Failure to Investigate Fall from Mechanical Stand Device
Penalty
Summary
The facility failed to thoroughly investigate an allegation of neglect involving a resident who experienced a fall during a staff-assisted transfer with a mechanical stand device. The resident, who had multiple fractures of the pelvis and osteoarthritis, was dependent on staff for transfers. An incident report indicated that the resident was found on the bathroom floor after slipping out of the harness strap during a transfer. The resident hit her head and was later diagnosed with a non-displaced fracture of the acetabulum. Despite the incident, the facility did not conduct a thorough investigation to determine the cause of the fall. Interviews revealed that the nursing assistant had used a medium-sized sling and leg straps during the transfer, but the director of nursing did not inspect the harness or the lift after the incident. The physical therapist suggested that improper securing of the resident's knees or harness could lead to a fall, but no inspection was conducted to verify these possibilities. The facility's policy required an internal investigation, including staff and resident interviews, but this was not adequately followed, leading to a deficiency in addressing the alleged neglect of care.
Failure to Provide Immunization Education per CDC Guidance
Penalty
Summary
The facility failed to provide education on immunizations per CDC guidance for three residents reviewed for immunizations. Resident 15, who had a history of COVID-19, received the pneumococcal polysaccharide vaccine (PPSV23) and the pneumococcal conjugate vaccine (PCV13) in previous years, but there was no evidence that they or their representative received education regarding a pneumococcal vaccine booster. Similarly, Resident 22, diagnosed with chronic pulmonary edema, had received both PPSV23 and PCV13, but their medical record lacked documentation of education about a pneumococcal vaccine booster. Resident 36, with congestive heart failure, had received PPSV23 but not PCV13, and there was no evidence of education or offering of the pneumococcal vaccine booster. Interviews with facility staff revealed that the infection preventionist, LPN-B, did not provide education about the PCV20 immunization unless specifically asked by the resident or their representative. The Director of Nursing acknowledged that residents or their representatives should have been educated about the PCV20 and that this should have been documented in the medical records. The facility's policy required education on the benefits and potential side effects of pneumococcal immunizations, aligning with CDC guidance that recommended shared clinical decision-making for administering PCV20 at least five years after the last pneumococcal vaccination.
Failure to Reassess and Appropriately Use Physical Restraints
Penalty
Summary
The facility failed to ensure a comprehensive reassessment was completed for a resident, R9, regarding the use of a seatbelt as a physical restraint. R9, who had severe cognitive impairment and multiple diagnoses including Alzheimer's disease, was using a seatbelt in a tilt-in-place wheelchair daily. The care plan indicated the seatbelt was necessary for positioning due to R9's tendency to lean forward and reach for her feet, a behavior linked to her past as a seamstress. However, the facility did not adequately reassess the necessity of the restraint or explore less restrictive alternatives, despite R9 being identified as a good candidate for restraint elimination. Observations and interviews revealed that staff consistently failed to release R9's seatbelt according to care plan interventions. During meals and activities, when staff were present and could supervise R9, the seatbelt was not removed, contrary to the care plan's directives. Staff interviews indicated a lack of clarity and consistency in the application and removal of the seatbelt, with some staff stating it was always used, while others mentioned it was checked every 30 minutes and removed every two hours. Despite R9 exhibiting no agitation or behaviors while seated, the seatbelt remained fastened, indicating a failure to follow the care plan and facility policy. The facility's policy on restraint use emphasized that restraints should only be used for medical symptoms that cannot be addressed by less restrictive interventions. The policy required regular reassessment and documentation of the restraint's necessity and effectiveness. However, the documentation for R9 lacked detailed information on the frequency and necessity of the restraint, and there was no evidence of ongoing re-evaluation or attempts to reduce or eliminate the restraint. This oversight contributed to the deficiency, as the facility did not adhere to its own policies or federal regulations regarding restraint use.
Failure to Assess Resident's Safe Use of Golf Cart
Penalty
Summary
The facility failed to comprehensively assess and develop interventions for the safe use of a motorized golf cart by a resident with moderate cognition and Parkinson's disease. The resident, who had upper extremity impairment and was independent or needed supervision with activities of daily living, frequently left the facility independently using a golf cart. Despite the resident's regular use of the golf cart for off-campus activities, the facility did not conduct an assessment to evaluate the resident's physical and cognitive abilities for safe operation of the golf cart. Additionally, the resident's care plan lacked any focus, goals, or interventions related to the safe use of the golf cart. Interviews with staff revealed that while some staff members believed the resident was a safe driver, no formal assessment had been completed to confirm this. The social services designee and other staff members assumed that an assessment had been done but did not verify its existence in the resident's medical record. The assistant director of nursing confirmed that the facility had not assessed the resident's ability to safely operate the golf cart and had not implemented any interventions to ensure the resident's safe return after leaving the facility. Furthermore, the facility did not have a policy regarding the use of motorized golf carts.
Failure to Follow Infection Control Protocols for Resident with MRSA
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols for a resident diagnosed with a multi-drug resistant organism (MDRO), specifically methicillin-resistant Staphylococcus aureus (MRSA). The resident, who required extensive assistance with activities of daily living, was placed on contact precautions due to a boil-like area on her labia that tested positive for MRSA. Despite the presence of signage indicating the need for personal protective equipment (PPE) upon entering the resident's room, staff members were observed not following these precautions. For instance, a nursing assistant entered the resident's room without donning a gown or gloves and interacted with the resident, including providing a drink of water, before using hand sanitizer only after exiting the room. Further observations revealed additional lapses in infection control practices. During a care session, nursing assistants were seen not washing their hands between glove changes while attending to the resident's personal hygiene needs. One assistant removed gloves soiled with feces and continued to work with the resident without washing hands or applying new gloves. This lack of adherence to hand hygiene and PPE protocols was compounded by a lack of awareness among staff about the specific infection and the necessary precautions, as evidenced by interviews with nursing assistants who were unaware of the resident's MRSA diagnosis and the required contact precautions. Interviews with nursing staff, including a licensed practical nurse and a registered nurse, highlighted a communication gap regarding the resident's infection status and the necessary precautions. Staff were not adequately informed about the resident's MRSA infection or the rationale behind the contact precautions. Although the facility's infection prevention and control policy outlined the need for hand hygiene and PPE use, these guidelines were not consistently followed, leading to potential risks of infection transmission within the facility.
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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