Fairview Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Dodge Center, Minnesota.
- Location
- 702 10th Avenue Northwest, Dodge Center, Minnesota 55927
- CMS Provider Number
- 245344
- Inspections on file
- 26
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Fairview Care Center during CMS and state inspections, most recent first.
A resident with a history of stroke, HTN, and depression had a POA document on file naming one family member as attorney-in-fact and another as successor, but the facility continued to treat the successor as the primary contact based on admission paperwork. When the NOMNC was issued, staff notified and obtained a signature from the successor contact, informing that person of the last Medicare coverage day and appeal process, while the named POA reported not being informed of the coverage termination or appeals. Interviews with the administrator, Medicare Account Technician, and social services designee showed that staff relied on the original emergency contact listing and did not update the first contact to the POA after the POA paperwork was uploaded, leading to failure to notify the correct representative.
A resident developed a stage 3 pressure ulcer due to the facility's failure to assess and manage a blister that ruptured and worsened. The facility did not notify the physician or update the care plan, leading to the wound's deterioration. Staff interviews revealed communication breakdowns and inadequate wound management procedures.
The facility failed to properly label and store medications, including insulin pens and tuberculin solution, and did not remove expired medications from stock. An LPN was observed using an insulin pen without an opened date, and several expired medications were found in the medication cabinet. The DON acknowledged the need for monthly checks to prevent such issues.
A resident with mild cognitive impairment and multiple diagnoses, including COPD and asthma, was observed self-administering a nebulizer treatment without proper assessment. Staff set up the nebulizer and left the resident alone, contrary to facility policy, which requires an assessment and care plan for self-administration. Interviews confirmed the resident was not assessed for this ability.
A facility failed to ensure residents with swallowing difficulties were assisted by qualified individuals. An activity aide fed a resident with dysphagia a mechanical soft diet, despite the need for a pureed diet. The resident's care plan required staff assistance to prevent aspiration, but unlicensed staff were allowed to feed residents, contrary to speech therapy recommendations and federal guidelines.
A resident with Alzheimer's and a history of falls had a care plan that was not updated promptly after a fall incident, leading to confusion among staff about the correct transfer method. The interdisciplinary team had decided on a new intervention, but it was not reflected in the care plan until weeks later, resulting in conflicting instructions. Staff interviews highlighted the expectation for timely updates and review of care sheets, which was not met.
The facility failed to assess and monitor bruises in three residents, including one with impaired cognition and another on anticoagulant therapy. Despite multiple observations of bruising, the facility did not document comprehensive assessments or monitoring of these injuries. The DON acknowledged the lack of proper assessment and monitoring in the residents' medical records.
A resident with chronic hyponatremia secondary to SIADH did not receive prescribed Urea doses due to pharmacy delays, and the facility failed to report this as a medication error. The resident's POA and physician were not notified of the omission, and the facility's policy lacked clear guidelines for handling such errors.
The facility failed to timely dispose of over 2000 discontinued medications, including narcotics, which were improperly stored and mixed with active medications. Staff interviews revealed inconsistencies in following the medication disposal process, with narcotics remaining in the medication cart until removal by the DON or ADON. The facility's policy required controlled medication disposal by two licensed nurses, but this was not adhered to, resulting in a significant deficiency.
A resident with a history of urinary complications experienced discomfort and bleeding due to improper placement of an indwelling urinary catheter by a nurse, who failed to advance the catheter beyond the point of urine return. This led to the resident's transfer to the hospital, where a CT scan revealed the catheter was incorrectly positioned in the posterior urethra. The facility's policy was not followed, and improper handling of a used urinary drainage bag was also noted.
Failure to Notify Designated POA of Medicare Coverage Termination
Penalty
Summary
The facility failed to properly recognize and notify the appropriate resident representative regarding the end of Medicare coverage and related appeal rights for one resident. The resident, who was cognitively intact and had a history of stroke, hypertension, and depression, was admitted with a consent form listing one family member (FM-B) as the first emergency contact and guarantor, and another family member (FM-A) as the second emergency contact. The consent form was signed by FM-B. A statutory short form power of attorney (POA) document, dated several years earlier, identified FM-A as the attorney-in-fact and FM-B only as the successor attorney-in-fact, to act if the named attorney-in-fact could not serve. This POA document was uploaded into the resident’s medical record after admission. When the Notice of Medicare Non-Coverage (NOMNC) was issued, it stated the last day of Medicare coverage and included a handwritten note that FM-B was updated by phone about the last coverage day, the appeal process, and the email address to which the document was sent; the NOMNC was signed by FM-B. FM-A later reported she had provided the POA paperwork to the facility before the NOMNC was issued and that she was never informed of the end of Medicare coverage or the appeals process. The administrator stated the NOMNC was issued to FM-B because she had signed the admission papers and was indicated as the first contact, and reported being unaware that POA paperwork had been provided at that time. The Medicare Account Technician confirmed sending the NOMNC to FM-B based on her status as first contact and did not look for POA documentation, expecting social services to update the chart if POA paperwork was received. The social services designee stated that although the POA paperwork for this resident had been uploaded, the first contact had not been changed to the POA, resulting in the failure to notify the designated attorney-in-fact.
Failure to Manage Pressure Ulcer Development
Penalty
Summary
The facility failed to comprehensively assess and manage a pressure ulcer for a resident who entered the facility without any pressure ulcers. The resident, who had a diagnosis of a right femur fracture and was dependent on staff for all care, developed a stage 3 pressure ulcer. Initially, a fluid-filled blister was noted on the resident's left upper thigh/buttock region, believed to be caused by a tight personal wheelchair and difficulty with a mechanical lift sling. Despite the blister rupturing and the wound worsening, the facility did not notify the physician or update the care plan to address the wound. The resident's wound was not appropriately staged or assessed after the blister ruptured, and the care plan was not revised to include interventions to prevent further deterioration. The facility's staff failed to communicate the changes in the wound to the physician, and the wound continued to worsen without appropriate treatment. The wound eventually measured 8.0 cm x 5.0 cm and was determined to be at least a stage 3 pressure ulcer with slough and eschar present. Interviews with facility staff revealed a breakdown in communication and a lack of proper wound management procedures. Staff members admitted to not notifying the physician of the wound changes and not updating the care plan. The facility's wound management program was not effectively implemented, leading to the resident's wound worsening without appropriate interventions or physician involvement.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, specifically insulin pens and tuberculin solution, as well as the removal of expired medications. During an observation, an LPN was preparing an insulin pen for a resident without an opened date on the pen, which is against the manufacturer's guidelines. The LPN acknowledged the missing date and disposed of the pen, retrieving a new one to continue the preparation. Additionally, the facility's practice of requiring two nurses to verify insulin was noted as a measure to prevent medication errors. Further investigation into the medication storage revealed that a bottle of tuberculin solution in the refrigerator was nearly empty and lacked an opened date. The review also uncovered several expired medications in the stock medication cabinet, including senna plus, stool softeners, iron tablets, nasal sprays, and vitamin D. The DON admitted that monthly checks should be conducted to prevent expired medications from being available, as per the facility's policy on medication administration and storage.
Failure to Assess Resident for Self-Administration of Nebulizer Treatment
Penalty
Summary
The facility failed to assess a resident, identified as R31, for their ability to self-administer nebulizer treatments. R31, who was mildly cognitively impaired with a diagnosis of dementia, heart failure, COPD, and asthma, was observed self-administering a nebulizer treatment without proper assessment. The resident's care plan indicated a need for assistance with activities of daily living and noted the resident's forgetfulness, requiring staff to anticipate their needs. Despite this, the registered nurse and trained medication aide set up the nebulizer treatment and left the resident alone, contrary to the facility's policy. Interviews with staff, including an LPN and the Director of Nursing, confirmed that R31 was not assessed for self-administration of medication. The facility's policy required an order for self-administration, a completed assessment, and an established care plan, none of which were in place for R31. The Director of Nursing verified that R31 was not assessed to be left alone with the nebulizer running, indicating a failure to adhere to the facility's policy on self-administration of medication.
Inadequate Supervision of Feeding for Resident with Dysphagia
Penalty
Summary
The facility failed to ensure that residents with difficulty swallowing were assisted with meals by qualified individuals. During an observation, an activity aide was seen feeding a resident who was supposed to be on a pureed diet but was given a mechanical soft diet at the family's request. The resident, who had a history of stroke, dysphagia, and left-sided hemiplegia, was at risk of aspiration and required staff assistance during meals. Despite these needs, the facility allowed unlicensed staff to feed the resident, contrary to the recommendations by speech therapy and the facility's own policies. The resident's care plan and shared risk agreement indicated the need for a mechanically soft diet with honey thick liquids, acknowledging the risks of aspiration and pneumonia. However, the facility's director of nursing confirmed that unlicensed staff were permitted to feed residents, including those with swallowing concerns. The medical director was unaware that staff had not reassessed who could feed the resident, highlighting a lack of communication and oversight. The facility's training program for feeding assistants did not align with federal requirements, which state that feeding assistants should only assist residents without complicated feeding problems, such as difficulty swallowing.
Failure to Update Care Plan Leads to Confusion in Resident Care
Penalty
Summary
The facility failed to revise the care plan for a resident after changes were made to fall prevention measures. The resident, who has Alzheimer's disease and a history of repeated falls, experienced an unwitnessed fall resulting in injuries. The interdisciplinary team reviewed the incident and decided on a new intervention to address the resident's restlessness in bed. However, this intervention was not updated in the care plan until several weeks later, leading to confusion among staff regarding the appropriate transfer method for the resident. During an observation, a nursing assistant attempted to use an incorrect transfer method due to outdated information on the care sheet. The assistant was unaware of the change to a total mechanical lift transfer, as the care plan had conflicting instructions. Interviews with the RN and DON revealed that care plans should be updated promptly, and staff are expected to review care sheets before their shifts. The facility's policy requires care plans to be revised as the resident's status changes, which was not adhered to in this case.
Failure to Monitor and Assess Bruises in Residents
Penalty
Summary
The facility failed to adequately assess and monitor non-pressure related skin injuries, specifically bruises, for three residents. For Resident 1, the facility did not document a comprehensive assessment of the bruises, including their location, size, and any associated pain. Despite multiple observations of bruising on different parts of Resident 1's body, the records lacked detailed monitoring and assessment of these injuries over time. The facility's documentation did not include a comprehensive skin assessment and monitoring of the bruises identified on various dates. Resident 2, who had a severely impaired cognition and was on anticoagulant therapy, was found with a bruise on the dorsal right hand. The facility's records did not include a comprehensive skin assessment and monitoring of this bruise. The care plan for Resident 2 included interventions to observe for signs and symptoms of adverse side effects related to anticoagulant medication, but the facility failed to document a thorough assessment and monitoring of the bruise. Resident 3, diagnosed with Alzheimer's disease and dementia, was found with bruising around the wrists and forearms. The facility's records lacked measurements and comprehensive monitoring of these bruises. Despite the resident's high risk of bruising due to anticoagulant therapy, the facility did not conduct a comprehensive skin assessment and monitoring of the bruises identified on multiple occasions. The Director of Nursing acknowledged that the facility was not currently assessing or monitoring for healing, and no comprehensive skin assessments were documented in the residents' medical records.
Failure to Administer Prescribed Medication for Hyponatremia
Penalty
Summary
The facility failed to ensure medications were administered according to physician orders for a resident diagnosed with chronic hyponatremia secondary to Syndrome of Inappropriate Antidiuretic Hormone (SIADH). The resident, who had a history of chronic kidney disease and hypoosmolality, was prescribed sodium chloride tablets and Urea to manage her low sodium levels. However, upon returning from a hospital stay, the resident did not receive the prescribed Urea doses on two consecutive days due to the medication not being available from the pharmacy. The facility's documentation did not indicate that the resident's Power of Attorney (POA) or physician was notified of the omitted doses. Interviews with facility staff revealed that the omission was not reported as a medication error, and no medication error form was filled out. The facility's policy on medication errors did not clearly define the process for handling such errors, including notifying the medical provider and family. The resident's sodium levels were critically low, prompting hospitalization, and upon discharge, the resident required close monitoring and an adjusted medication regimen. Despite the critical nature of the resident's condition, the facility's failure to administer the prescribed medication and lack of communication with the medical provider and family constituted a significant medication error.
Failure to Timely Dispose of Discontinued Medications
Penalty
Summary
The facility failed to appropriately and timely dispose of 95 prescribed medications, totaling over 2000 pills, that had been discontinued. These medications were observed in the medication room, mixed with active medications, and included narcotics that were not properly segregated. During an observation and interview, it was noted that the medications were stored in bubble packs, vials, and ziplocked bags, and were not disposed of in a timely manner, leading to potential diversion risks. Interviews with the nursing staff revealed that the process for medication disposal was not consistently followed. LPN-A stated that narcotics were kept in the medication cart until the DON or ADON removed them, and that nurses verbally informed the DON or ADON of medications needing destruction. RN-A mentioned that narcotic medications stayed in the cart until they could be destroyed by two nurses, and the DON was responsible for tracking medication disposition. The DON acknowledged the complexity of the medication return policy and confirmed oversight of the destruction and return process. The facility's Medication Administration policy required controlled medication disposal to be done by two licensed nurses and co-signed in the Narcotics Log Book. However, the facility did not adhere to this policy, as evidenced by the large quantity of medications that were not disposed of in a timely manner. The pharmacy manager confirmed that the pharmacy would accept returns within 30 days if the medication was the full quantity dispensed, but controlled medications were not accepted for return. The facility had a MedSafe box for destroyed medications, but the process was not effectively managed, leading to the observed deficiency.
Improper Catheter Placement Leads to Resident Discomfort and Hospitalization
Penalty
Summary
The facility failed to correctly place an indwelling urinary catheter in a resident, leading to discomfort, bleeding, and the need for emergent medical services. The resident, who had a history of urinary tract infections, chronic kidney disease, and other urinary complications, required maximum assistance with toileting hygiene and had an indwelling urinary catheter. The care plan included specific interventions to prevent complications, such as changing the catheter as ordered and maintaining a closed drainage system. On a particular day, a registered nurse encountered difficulties flushing the resident's catheter and replaced it with a new one. However, the nurse did not advance the catheter beyond the point of urine return, which is against the facility's policy. This resulted in bright red blood in the catheter, and despite attempts to resolve the issue by flushing with normal saline, the resident was transferred to the hospital. A CT scan at the hospital revealed that the catheter had been placed in the posterior urethra, causing hematuria and leading to further complications. Interviews with staff revealed that the nurse believed the catheter was correctly placed due to urine return, but did not follow the policy of advancing the catheter further. Additionally, the clinical manager noted improper handling of a used urinary drainage bag, which was not disposed of or cleaned properly. The director of nursing confirmed the expectation for staff to follow the facility's catheter placement policy, which includes advancing the catheter beyond the point of urine return and ensuring proper disposal of used equipment.
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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