Good Samaritan Society - Mary Jane Brown
Inspection history, citations, penalties and survey trends for this long-term care facility in Luverne, Minnesota.
- Location
- 110 South Walnut Avenue, Luverne, Minnesota 56156
- CMS Provider Number
- 245568
- Inspections on file
- 22
- Latest survey
- April 1, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Good Samaritan Society - Mary Jane Brown during CMS and state inspections, most recent first.
The facility failed to store discontinued controlled narcotic medications separately from in-use medications, as observed during a survey. Discontinued medications for five residents were found in two medication carts alongside active medications. Nursing staff were unaware of proper storage procedures, and the facility's policy lacked documentation on controlled medication storage. The interim DON and consultant pharmacist were also unaware of the improper practice.
The facility failed to consistently deliver mail to residents on Saturdays, affecting two residents with intact cognition. Mail delivery was dependent on the presence of activity staff, who were only available for a limited time on Saturdays. If mail arrived after staff had left, it was not delivered until Monday. The facility lacked a specific policy for mail delivery in long-term care.
A resident with cognitive impairments and multiple diagnoses was served fish despite a documented dislike, due to the facility's failure to update his care plan and communicate dietary preferences effectively. Staff interviews revealed that menu slips were often returned blank, and the dietary manager confirmed the oversight, highlighting a communication breakdown in the facility's meal service process.
An LPN administered levothyroxine to a resident along with calcium and iron supplements, contrary to the medication's label instructions. The LPN did not notice the label's precaution and the instructions were not included in the MAR, leading to the oversight. The IDON confirmed that the medications had likely been administered together for the past three days, contrary to the facility's medication administration policy.
A facility failed to conduct required bi-annual AIMS assessments for a resident on psychotropic medication, as per its policy. The resident, with diagnoses of dementia and depression, was on Seroquel and sertraline. Despite an initial AIMS assessment in September 2023, no further assessments were documented, contrary to the facility's policy requiring such evaluations every six months to monitor for Tardive Dyskinesia.
A resident with a neurogenic bladder had her urinary drainage bag improperly hung from a trash can, contrary to infection control practices. Despite being informed of the risk, the resident continued this practice due to limited placement options. Staff confirmed the practice was inappropriate, highlighting a need for further education on proper infection control techniques.
The facility failed to ensure a newly hired NA received initial training on Alzheimer's disease, ADL assistance, problem-solving with challenging behaviors, and communication skills. The interim DON confirmed the expectation for such training, as outlined in the facility's assessment. However, the facility did not provide a copy of the NA's training policy during the survey.
A facility failed to implement enhanced barrier precautions (EBP) for a resident with a urinary catheter and feeding tube. Staff did not wear gowns and gloves during high contact activities, such as transferring the resident, despite care plan instructions and a doorframe magnet indicating the need for EBP. Interviews revealed staff misunderstandings about EBP application, and the facility's policy supports EBP use to prevent infection spread.
The facility failed to assess falls for root cause and implement interventions for two residents with a history of falls. One resident sustained multiple injuries after an unwitnessed fall due to inadequate supervision and care plan implementation. Another resident experienced multiple falls without a comprehensive analysis or updated care plan interventions.
The facility failed to conduct comprehensive bladder assessments and develop individualized toileting programs for two residents, leading to deficiencies in continence care. One resident experienced a change in mobility and required more assistance with ADLs but did not have a toileting program. Another resident experienced a decline in continence and required assistance with clothing management, yet their care plan did not include a toileting program. The facility's policy did not specify timing for assessments or protocols for changes in condition.
A resident with quadriplegia and dysphagia required a two-handled cup for drinking thickened liquids, as specified in their care plan. However, staff were unaware of this requirement, and the resident's bedside table was not positioned within reach, resulting in the resident being unable to access water without assistance.
A facility failed to consistently assess and monitor a quadriplegic resident's heel wound, which was first noted on 1/21/24. Despite the resident's care plan requiring heel protectors, the wound progressed without proper documentation or new interventions. The DON was informed by the family on 1/17/24 but did not document staff interviews or update the care plan as required by facility policy.
A resident with quadriplegia and a neck fracture developed a heel wound that was inconsistently monitored and documented by the facility staff. Despite the care plan requiring heel protectors, the wound's progress was not consistently assessed, leading to inadequate monitoring. Interviews with staff revealed a lack of adherence to the facility's policy on skin assessment and documentation.
A resident with dementia, diabetes, and dysphagia was served the incorrect diet due to staff failing to follow the facility's process for verifying diet orders. The resident required a pureed diet but was served mashed potatoes and pasta noodles. The error was identified and corrected, but not before the resident was offered the incorrect food.
Improper Storage of Discontinued Controlled Medications
Penalty
Summary
The facility failed to ensure that discontinued controlled narcotic medications were stored separately from in-use medications, as observed during a survey. Specifically, five residents had discontinued medications stored in two medication carts alongside active medications. For instance, a box of Fentanyl patches sent in error by the pharmacy was left in the medication cart until destruction, and several blister packs of Lorazepam and bottles of Morphine Sulfate belonging to deceased or discharged residents were found in the narcotic box. These medications were not removed from the in-use narcotic storage, contrary to proper procedures. Interviews with nursing staff revealed a lack of awareness regarding the proper storage of discontinued medications. Both a registered nurse and a licensed practical nurse admitted that discontinued medications continued to be counted and stored with active medications until they could be destroyed. The interim director of nursing and the consultant pharmacist were also unaware of this practice, which was not documented in the facility's medication administration policy. The consultant pharmacist confirmed that discontinued medications should not be stored with in-use medications to prevent errors or diversion.
Inconsistent Mail Delivery on Saturdays
Penalty
Summary
The facility failed to ensure consistent delivery of mail to residents on Saturdays, affecting two residents who expressed concerns about this issue. Both residents had intact cognition, as indicated by their Brief Interview for Mental Status (BIMS) scores of 15. One resident reported not receiving mail on Saturdays because the activity staff, responsible for mail delivery, were only present for a limited time on that day. The other resident also noted irregular mail delivery on Saturdays, attributing it to the limited presence of activity staff who left after assisting with noon meals. Interviews with facility staff revealed that mail was typically picked up by the maintenance director and delivered by activity staff from Monday to Saturday, with no delivery on Sundays. However, if mail arrived after the activity staff had left on Saturdays, it was not delivered until Monday. The administrator in training expected that mail delivered by the post office on Saturdays should reach residents the same day. Despite this expectation, the facility lacked a specific policy for mail delivery in long-term care, as the provided policy did not cover this aspect.
Failure to Revise Care Plan for Resident's Meal Preferences
Penalty
Summary
The facility failed to revise the care plan of a resident, identified as R11, to reflect his meal preferences, specifically his dislike for fish. R11, who has a diagnosis of dementia, diabetes, Parkinson's disease, and anxiety disorder, was observed eating a tuna fish sandwich, which he described as tasting like slop. Despite family members informing the staff multiple times about R11's dislike for fish, the care plan did not include this preference. The resident's nutritional assessment also failed to mention his request not to be served fish. Interviews with staff revealed that R11's menu slips were often returned blank to the kitchen, and his dietary preferences, including his dislike for fish, were not communicated effectively. The dietary manager confirmed that R11's dietary card noted 'NO FISH,' yet he still received fish during a meal. The facility did not provide a policy regarding the handling of dietary preferences by the end of the survey, indicating a lack of proper documentation and communication regarding resident meal preferences.
Improper Administration of Levothyroxine with Calcium and Iron
Penalty
Summary
The facility failed to administer levothyroxine according to labeled instructions for a resident. During an observation, an LPN was seen administering levothyroxine along with calcium and iron supplements, despite the medication label advising against taking levothyroxine with these substances. The LPN did not notice the additional instructions on the medication label and had been administering all of the resident's morning medications simultaneously. The instructions to avoid taking levothyroxine with calcium and iron were not included in the electronic medical record (MAR), leading to the oversight. The interim director of nursing (IDON) confirmed that the medications had likely been administered together for the past three days, as documented in the MAR. The facility's policy on medication administration requires staff to follow the Six Rights of medication administration and to avoid significant medication interactions. However, the LPN did not adhere to these guidelines, as she failed to notice the label precaution and did not verify the instructions with the charge nurse or pharmacy. This oversight resulted in the improper administration of levothyroxine, contrary to the facility's medication administration policy.
Failure to Conduct Required AIMS Assessments for Resident on Psychotropic Medication
Penalty
Summary
The facility failed to complete an Abnormal Involuntary Movement Scale (AIMS) assessment for a resident, identified as R12, who was on psychotropic medication. R12 was admitted with diagnoses of dementia, depression, and heart failure, and was prescribed Seroquel and sertraline for these conditions. The facility's policy required an initial AIMS assessment and subsequent assessments every six months to monitor for signs of Tardive Dyskinesia, a potential side effect of psychotropic medications. However, after an initial AIMS assessment in September 2023, there was no evidence of any further assessments being conducted. The interim director of nursing acknowledged during an interview that staff were expected to perform updated AIMS assessments for residents on psychotropic medications as per facility policy. The facility's policy on psychotropic medications required staff to complete these assessments bi-annually and to notify the primary care physician and family if any changes were identified. Despite these requirements, the facility did not adhere to its policy, resulting in a deficiency in monitoring the resident's condition while on psychotropic medication.
Inadequate Infection Control for Urinary Drainage Bag
Penalty
Summary
The facility failed to adhere to proper infection control practices concerning the management of a urinary drainage bag for a resident with a neurogenic bladder. The resident, who was cognitively intact, had a urinary drainage bag due to her condition. Observations revealed that the urinary drainage bag was repeatedly hung from a trash can, which is not an appropriate practice for infection control. This improper placement was noted during multiple observations, including when the resident was seated in her recliner and when assisted by the interim director of nursing. Interviews with various staff members, including registered nurses and a trained medication aide, confirmed that the placement of the urinary drainage bag on the trash can was not acceptable and posed a risk of contamination. Despite being informed of the inappropriate practice, the resident continued to hang the bag from the trash can due to limited options for placement. The facility's policy required that catheters be maintained and properly secured, and any contaminated systems should be replaced immediately. However, the staff and the resident needed further education on proper infection control practices to prevent complications.
Failure to Provide Required Training for New Nursing Assistant
Penalty
Summary
The facility failed to ensure that a newly hired nursing assistant (NA-D) received initial training on Alzheimer's disease or related disorders, assistance with activities of daily living (ADL), problem-solving with challenging behaviors, and communication skills. This deficiency was identified during an interview and document review, which revealed that NA-D, hired on 10/29/24, did not complete the required training. The interim director of nursing confirmed the expectation that all staff caring for vulnerable adults should complete Alzheimer/Dementia training. The facility's August 2024 assessment indicated that staff would be trained on dementia and behavioral health during general orientation, with annual in-services on Federal and State requirements for continuity of care and resident safety. However, the facility failed to provide a copy of NA-D's training policy during the survey.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for a resident with indwelling medical devices, including a urinary catheter and feeding tube. The resident's care plan required staff to don gown and gloves during high contact care activities such as transferring, dressing, and device care. However, during an observation, a registered nurse (RN) and a nursing assistant (NA) entered the resident's room and transferred the resident from a wheelchair to a recliner without wearing the required gown and gloves, despite a magnet on the doorframe indicating the need for EBP. Interviews with the staff revealed a misunderstanding of when EBP should be applied. The NA believed EBP was not necessary during transfers, while the RN acknowledged the need for EBP during device care but not for transfers. The medical doctor emphasized that failing to use EBP could spread infections, especially among residents with indwelling devices. Another RN confirmed that EBP should be worn during all transfers and when working with catheters or feeding tubes. The facility's policy on Standard and Transmission-Based Precautions supports the use of EBP during high contact activities to prevent the transfer of multi-drug resistant organisms.
Failure to Prevent Falls and Implement Care Plans
Penalty
Summary
The facility failed to comprehensively assess falls for root cause, implement appropriate interventions, and follow the care plan to prevent and/or reduce the risk of falls with major injury for two residents with a history of falls. One resident, identified as R2, sustained multiple left rib fractures, a left clavicle fracture, and a subdural hematoma after an unwitnessed fall. The facility did not implement R2's care plan for close supervision, which resulted in R2's fifth unwitnessed fall, a major head injury, and subsequent admission to the intensive care unit. R2 had a history of falls prior to admission and experienced multiple falls with injury since admission. Despite being at medium risk for falls, the facility did not conduct a comprehensive fall analysis to identify root causes and implement effective interventions. R2's care plan lacked a toileting routine, and interventions were not consistently updated or followed. The facility's failure to provide adequate supervision and assess the effectiveness of interventions contributed to R2's repeated falls and injuries. Another resident, identified as R3, was at low risk for falls but experienced multiple unwitnessed falls. The facility did not complete a comprehensive analysis of causal factors or root causes to determine appropriate interventions to prevent falls or reduce the risk of falls with major injury. R3's care plan was not updated with interventions to address the identified risk factors, and staff failed to provide the necessary assistance and supervision, leading to repeated falls.
Deficiency in Continence Care and Toileting Programs
Penalty
Summary
The facility failed to conduct a comprehensive bladder assessment and develop individualized toileting programs for two residents, leading to deficiencies in continence care. Resident 3, who was initially admitted with severe cognitive impairment and was continent of bowel and bladder, experienced a change in mobility and required more assistance with activities of daily living (ADLs) after some falls. Despite these changes, Resident 3 did not have a toileting program, and staff relied on the resident to communicate the need to use the bathroom or observed self-transferring attempts. Interviews with nursing assistants revealed that Resident 3 was not on a scheduled toileting program, and the care plan did not address the resident's toileting needs. Similarly, Resident 2, who had intact cognition and was initially continent, experienced a decline in continence and required assistance with clothing management. The resident's care plan did not include a toileting program, and staff were responsible for changing briefs. Interviews indicated that Resident 2 was frequently incontinent and not on a scheduled toileting or check and change program. The facility's policy on bowel and bladder evaluation did not specify timing for assessments outside of the Care Area Assessment, nor did it provide protocols for changes in condition. The Director of Nursing stated that if a resident was continent, it would not trigger a care plan focus for bowel and bladder, which contributed to the lack of individualized interventions for these residents.
Failure to Accommodate Resident's Drinking Needs
Penalty
Summary
The facility failed to accommodate the needs of a resident (R1) who required a two-handled cup for drinking liquids. R1, diagnosed with quadriplegia, a neck fracture, and dysphagia, had a care plan that specified the need for moderately thick water to be placed in a double-handled cup with a lid on a bedside table within reach. However, observations revealed that R1's bedside table was placed in the middle of the room with a one-handled water pitcher, and a plastic disposable cup with thickened water was placed on the nightstand, both out of R1's reach. R1 confirmed that he could not reach either cup without staff assistance. Nursing assistants (NA-A and NA-B) and other staff members were unaware of the specific requirements outlined in R1's care plan, and the bedside table was not adjusted to be within R1's reach during the observation period. Interviews with various staff members, including nursing assistants, a licensed practical nurse (LPN), a registered nurse (RN), and the director of nursing (DON), confirmed that R1 required thickened liquids in a two-handled cup due to limited arm movement. Despite this, the staff failed to provide the necessary accommodations as specified in the care plan. The facility's policy on individualized, person-centered care plans was not followed, resulting in R1's needs not being met. The deficiency was identified through a combination of observation, interviews, and record reviews, highlighting a failure in communication and adherence to the care plan.
Failure to Monitor and Assess Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure an injury of unknown origin was consistently assessed and monitored for healing progress for a resident with quadriplegia, a neck fracture, and dysphagia. The resident's care plan indicated the need for heel protectors while in bed to prevent pressure ulcers. Despite this, a small brown area was noted on the resident's left heel on 1/21/24, and subsequent documentation on 1/28/24 lacked evidence of the heel's progress. By 2/4/24, the area had developed into a small, scabbed wound. The wound was formally documented on 2/6/24, noting its size and condition, but there was no evidence of new or revised interventions to address the wound or ensure proper use of heel protectors. The Director of Nursing (DON) was informed of the wound by the resident's family on 1/17/24 and assessed it the same day, but was unsure how the wound occurred given the resident's immobility and use of heel protectors. The DON only interviewed staff on shift the evening of 1/17/24 and did not document these interviews. The resident's records lacked evidence of an incident between the physician's assessment on 1/9/24 and the family's report on 1/17/24. Additionally, there was no documentation of new interventions or staff monitoring to prevent further wounds, contrary to the facility's policy on abuse and neglect, which requires thorough investigation and care plan updates following incidents.
Inconsistent Monitoring and Documentation of Resident's Heel Wound
Penalty
Summary
The facility failed to ensure consistent assessment and monitoring of an injury of unknown origin for a resident with quadriplegia, a neck fracture, and dysphagia. The resident's care plan indicated the need for heel protectors while in bed to prevent pressure ulcers. Despite this, the resident developed a small brown area on the left heel, which later scabbed over. Documentation of the wound's progress was inconsistent, with no evidence of assessment on certain dates. Family members and staff reported the wound, but there was a lack of consistent monitoring and documentation by the nursing staff. The wound was eventually noted to be healing, but the initial lack of documentation and monitoring was evident. Interviews with various staff members, including nursing assistants, licensed practical nurses, and the director of nursing, revealed that the wound was not consistently assessed or documented. The facility's policy required weekly monitoring and documentation of any skin impairments, but this was not followed. The director of nursing confirmed that the wound should have been assessed weekly until healed, but there was uncertainty about whether this was done. The deficiency highlights a failure in adhering to the facility's skin assessment and documentation policy, leading to inadequate monitoring of the resident's wound.
Failure to Provide Prescribed Altered Diet
Penalty
Summary
The facility failed to provide an altered diet as prescribed for a resident with dementia, diabetes, and dysphagia. The resident required a pureed textured diet as per physician orders. However, during an observation, the resident was served mashed potatoes and pasta noodles instead of pureed food. The nursing assistant assisting the resident was unaware of the diet requirement and attempted to feed the resident the incorrect food. The error was identified, and the plate was replaced with the correct pureed food, but not before the resident had been offered the incorrect diet. Interviews with various staff members revealed that the facility's process for verifying diet orders was not consistently followed. Dietary staff were expected to reference dietary cards to ensure the correct diet was served, but on the evening in question, the process was chaotic, and the double-check verification was not completed. The facility's policy on diet orders lacked specific directions for the meal delivery process to ensure residents received the correct diet per physician orders.
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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