Good Samaritan Society - Pipestone
Inspection history, citations, penalties and survey trends for this long-term care facility in Pipestone, Minnesota.
- Location
- 1311 North Hiawatha, Pipestone, Minnesota 56164
- CMS Provider Number
- 245591
- Inspections on file
- 16
- Latest survey
- January 7, 2026
- Citations (last 12 mo.)
- 1 (1 serious)
Citation history
Health deficiencies cited at Good Samaritan Society - Pipestone during CMS and state inspections, most recent first.
A resident with moderately impaired cognition and a recent hospitalization for pneumonitis due to aspiration returned with a physician order for an IDDSI Level 5 minced and moist diet with slightly thick liquids. Despite updated care plan and diet notification specifying minced and moist texture, direct supervision, and assisted-side seating, the resident was served a tuna melt on a regular bun with sweet potato tots instead of the ordered minced and moist meal. The cook believed a soggy bun met minced and moist criteria, and an NA, unaware of the new diet order, delivered the meal after the cook prepared and the NA cut the sandwich. During the meal, dietary staff observed the resident eating the sandwich, then making abnormal breathing sounds, turning gray, and actively choking; an LPN found the resident cyanotic and not breathing, performed the Heimlich maneuver multiple times, and the resident was transferred to the ED, where large pieces of bread and cheese and a food bolus were documented. The DON later clarified that the LPN had not verified the diet texture against the physician order and had relied on the cook’s assurance that the meal was correct, contributing to the failure to provide the ordered texture-modified diet.
The facility did not consistently document the resolution of staff illnesses before allowing them to return to work, and failed to ensure a newly hired dietary aide completed the required two-step TB testing. These lapses in infection control and employee health monitoring had the potential to affect all residents.
A resident with a history of acute respiratory failure and hypoxia returned from the hospital with new physician orders for oxygen therapy, but the care plan and medical records were not updated to reflect the revised flow rates. Staff continued to administer oxygen at higher rates than ordered, did not verify the actual flow rate against the updated order, and failed to document the amount of oxygen administered as required. The facility's policy lacked guidance on documentation, and the administrator was unaware of the order change.
A resident with a history of acute respiratory failure and hypoxia received oxygen therapy at incorrect flow rates, as staff failed to follow the most recent physician order and did not update the care plan or MAR. Observations showed oxygen was administered at 3 L/min instead of the ordered 1-2 L/min during the day and 2 L/min at night, and staff did not verify or document the actual flow rate as required.
A resident receiving oxygen therapy did not have their physician orders accurately reconciled or updated in the electronic medical record after returning from the hospital. Staff continued to administer oxygen at a flow rate inconsistent with both the previous and updated orders, and documentation in the care plan and MAR was not revised to reflect the new instructions. Staff did not verify the correct flow rate, and the facility lacked a policy for reconciling physician orders.
A resident was prescribed Bactrim for a UTI following an outpatient visit and completed the antibiotic course without adverse effects. However, the facility did not perform a required antibiotic time-out (ATO) within 48-72 hours after starting the medication, as outlined by CDC guidelines and facility policy. The DON confirmed the omission, noting that the antibiotic was not initiated by facility staff, but acknowledged the responsibility for antibiotic stewardship.
A resident with multiple chronic conditions, including diabetes, heart failure, and pneumonia, consented to receive an updated pneumococcal vaccine but did not receive it. Nursing staff and the DON confirmed the vaccine was not administered, despite facility policy and CDC guidelines requiring it.
Failure to Follow IDDSI Level 5 Diet Order Leads to Choking Event
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s order for a texture‑modified diet for one resident with dysphagia-related risk, resulting in the resident being served an inappropriate regular‑texture meal. The resident had moderately impaired cognition, diagnoses including epilepsy, COPD, and right lower lobe lung cancer, and had recently been hospitalized for pneumonitis due to inhalation of food and vomit. Upon discharge from the hospital, the physician ordered an IDDSI Level 5 minced and moist diet with slightly thick liquids. The resident’s care plan and Diet Notification Form were revised on the same day to reflect a Level 5 minced and moist texture, slightly thick liquids, direct supervision in the dining room, and placement on the assisted side of the dining room, with interventions to monitor and report signs of chewing or swallowing difficulties, coughing, or choking. Despite these updated orders and care plan revisions, on the evening in question the resident was served a tuna melt sandwich on a regular hamburger bun and sweet potato tots, rather than a properly prepared minced and moist meal. The facility’s own IDDSI guidelines specified that Level 5 minced and moist foods require no biting, minimal chewing, and that no regular dry bread is allowed due to high choking risk, with food pieces not to exceed 4 mm in size. The facility’s alternate menu for Level 5 diets indicated that residents on this diet should receive minced tuna salad with minced or pureed bread, minced sweet potato puffs, and pureed dessert, not a regular bun. The cook reported that he prepared tuna melts by placing tuna with mayo and pickle relish on a hamburger bun, wrapping it in foil, baking it, and holding it in the steam table, and believed that a “soggy” bun was acceptable for a minced and moist diet. He gave the plate to a nursing assistant, who cut the sandwich in half and served it to the resident. Multiple staff interviews confirmed that the resident was served and had eaten part of a sandwich on a bun with sweet potato tots. A nursing assistant stated she handed the resident’s dietary card to the cook and received a tuna melt on a bun with sweet potato tots, and that she was unaware of the resident’s new diet change since his recent hospital return. Dietary aides described seeing the resident with a sandwich between buns and sweet potato tots on his plate, with part of the sandwich already eaten, and observed the resident making abnormal breathing noises, turning gray, and then actively choking. The resident was brought to the nurse’s station, where an LPN found him cyanotic, not breathing, non‑responsive, with food debris around his mouth and on his clothing, and performed the Heimlich maneuver multiple times before the resident began agonal breathing and was sent to the ED. ED documentation noted copious solid food removed from the resident’s mouth, large pieces of bread and cheese in the material expelled, and a chest x‑ray showing a food bolus. The DON later clarified that the LPN had not actually verified the diet texture against the physician order at the time of the incident and had relied on the cook’s statement that the meal was correct, contributing to the failure to provide the ordered minced and moist diet. The situation was determined to be an Immediate Jeopardy beginning when the resident was served the regular‑texture tuna melt on a bun and sweet potato tots, which did not meet the IDDSI Level 5 minced and moist requirements and directly conflicted with the physician’s diet order and the facility’s own diet guidelines and menus for texture‑modified diets.
Removal Plan
- Educate all staff regarding IDDSI modified texture and physician ordered diets with competencies
- Review dietary policy and procedure
- Validate resident diets
- Update care plans
- Audit all meals to assure residents on special textured diets receive the proper diet texture foods
Failure to Track Employee Illness Resolution and Complete TB Testing
Penalty
Summary
The facility failed to properly track and document employee illnesses to ensure staff were only returning to work after symptoms had resolved, as required by policy. Specifically, three staff members (a nursing assistant, a trained medication aide, and a dietary aide) were absent from work due to symptoms such as diarrhea, vomiting, and fever, but there was no documentation indicating when or if their symptoms had resolved prior to their return. The absence reports and timecards did not consistently record the resolution of symptoms, and the process for monitoring staff illnesses was identified as inconsistent and in need of improvement by facility leadership. Additionally, the facility did not ensure that a newly hired dietary aide completed the required two-step tuberculosis (TB) testing upon hire. The employee health file showed that only the first step of the TB test was documented, with no evidence of the second step being completed as required by the facility's TB control policy. Facility leadership confirmed that the necessary documentation for the second TB test was missing.
Failure to Update Care Plan and Medical Records After New Oxygen Therapy Orders
Penalty
Summary
The facility failed to revise the care plan for a resident receiving oxygen therapy when new physician orders were received following a hospital discharge. The resident, who had a history of acute respiratory failure with hypoxia and intact cognition, was observed on multiple occasions with oxygen flow rates set at 3 L/min, despite a new physician order specifying oxygen at 1-2 L/min during the day and 2 L/min at night. The care plan and medical records, including the Order Summary Report and Medication Administration Record, were not updated to reflect the new order, and staff continued to administer oxygen at the previous rate of 2 L/min or higher. Staff did not verify the actual flow rate against the updated physician order, nor did they document the amount of oxygen being administered as required. Interviews revealed that direct care staff were not permitted to adjust the oxygen flow rate and only switched the tubing between devices, while a registered nurse was unaware of the updated order and did not ensure the MAR matched the current physician instructions. The administrator confirmed that the medical record was not consistent with the most recent physician order and was unaware of the change. The facility's oxygen administration policy required a physician order and licensed nurse oversight but did not specify documentation procedures for the amount of oxygen administered. No care plan policy was provided during the survey.
Failure to Follow and Update Physician Orders for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that the correct physician order for oxygen therapy was followed and appropriately monitored for a resident with a history of acute respiratory failure and hypoxia. The resident was observed on multiple occasions with oxygen flow rates set at 3 L/min, despite the most recent physician order specifying 1-2 L/min during the day and 2 L/min at night. The care plan and medication administration record (MAR) were not updated to reflect the new order, and staff continued to document and administer oxygen based on outdated instructions. Additionally, there was no evidence that staff were verifying the actual flow rate or reconciling the MAR with the current physician order. Direct care staff were observed switching the resident between an oxygen concentrator and a portable tank, both set at incorrect flow rates. Interviews revealed that staff were unaware of the updated order and did not verify the accuracy of the MAR. There was also no documentation that the resident's family, who may have adjusted the oxygen flow, had been educated not to do so. The facility's oxygen administration policy did not specify procedures for documenting the amount of oxygen administered, contributing to the lack of oversight and consistency in care.
Failure to Reconcile and Update Oxygen Therapy Orders After Hospital Discharge
Penalty
Summary
The facility failed to accurately reconcile and update physician orders for a resident receiving oxygen therapy following a hospital discharge. Despite a new physician order specifying oxygen at 1-2 L/min during the day and 2 L/min at night, the electronic medical record, care plan, and medication administration record (MAR) continued to reflect the previous order of 2 L/min at rest and overnight. Multiple observations showed the resident receiving oxygen at 3 L/min from both the concentrator and portable tank, which did not match either the old or new physician orders. Staff did not verify or adjust the flow rate according to the updated order, and there was no documentation that the MAR had been reconciled with the most recent physician instructions. Interviews revealed that direct care staff were not permitted to change the oxygen flow rate and only switched the tubing between devices. The registered nurse was unaware of the updated order and did not verify the MAR against the new physician order. The administrator also confirmed that the order summary report had not been updated to reflect the change. Additionally, the facility lacked a policy for reconciling physician orders, and the existing oxygen administration policy did not address documentation of the amount of oxygen administered. The resident's oxygen saturation levels were monitored, but there was no evidence that staff checked or documented the actual flow rate as required by the updated physician order.
Failure to Complete Antibiotic Time-Out for Resident on Bactrim
Penalty
Summary
The facility failed to complete a comprehensive assessment for continued use of antibiotics for one resident who was reviewed for antibiotic stewardship. According to the Centers for Disease Control (CDC) guidelines, facilities are required to evaluate residents within 48-72 hours after starting an antibiotic to ensure the medication is effective, a process known as an antibiotic time-out (ATO). In this case, a resident was prescribed Bactrim for a urinary tract infection (UTI) following an outpatient appointment, and the medication was administered as ordered. Documentation showed the resident took the antibiotic as prescribed and completed the course without adverse effects. However, the resident's medical record did not contain evidence that an ATO was performed within the required 48-72 hour window after the initiation of antibiotic therapy. The director of nursing (DON) confirmed that, although the resident did not exhibit signs or symptoms of infection while at the facility and the antibiotic was prescribed externally, the facility did not conduct the ATO as per their usual process. Facility policy requires ongoing infection surveillance and documentation of antibiotic use, but this was not followed in this instance.
Failure to Provide Updated Pneumococcal Vaccination After Consent
Penalty
Summary
The facility failed to ensure that one sampled resident was offered and/or provided updated pneumococcal vaccinations in accordance with CDC guidelines. The resident, who was of advanced age and had diagnoses including diabetes, heart failure, and pneumonia, had previously received PCV13 and PPSV23 vaccines. Documentation showed that the resident consented to receive an updated pneumococcal vaccine dose, but the vaccine was not administered after consent was obtained. Both the registered nurse and the director of nursing confirmed that the updated vaccine had not been given, despite facility policy requiring provision of the vaccine per CDC recommendations.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
