Good Samaritan Society - Stillwater
Inspection history, citations, penalties and survey trends for this long-term care facility in Stillwater, Minnesota.
- Location
- 1119 Owens Street North, Stillwater, Minnesota 55082
- CMS Provider Number
- 245207
- Inspections on file
- 24
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Good Samaritan Society - Stillwater during CMS and state inspections, most recent first.
A resident receiving hospice care was administered ten times the prescribed dose of liquid morphine after a hospice nurse incorrectly transcribed the order, and a facility nurse failed to question or verify the unusually large dose before administration. The error was discovered when a new medication bottle arrived with the correct dosage, and the resident required multiple doses of Narcan to reverse the effects. Staff interviews revealed a lack of double-checking for hospice orders and inconsistencies in documentation of the incident.
A resident with severe cognitive impairment was observed in a state of undress with the door open, compromising privacy and dignity. Despite staff presence, the door was often left open, exposing the resident to others. The care plan lacked specific interventions for maintaining privacy, and the room lacked privacy curtains. Staff interviews confirmed the door should remain open for safety, but observations showed it was not partially shut to provide privacy.
A resident with impaired cognition and blindness did not receive necessary assistance with personal hygiene, including nail trimming and shaving, despite expressing a desire for these services. Observations showed long fingernails and facial hair, and interviews revealed a lack of documentation and adherence to facility protocols by nursing staff.
A facility failed to monitor and document bruising for a resident on anticoagulation therapy, as bruises were observed but not recorded in weekly assessments. Additionally, another resident with edema did not receive prescribed Tubi-grips consistently, as care plans and records lacked documentation of their application and removal. Staff interviews revealed inconsistencies in following care protocols, highlighting deficiencies in monitoring and intervention processes.
The facility failed to implement effective fall prevention measures for two residents, leading to multiple falls. One resident with cognitive impairment and a history of falls was left unattended with call lights out of reach, while another resident on multiple psychoactive medications fell due to inadequate supervision and assistance. Staff interviews revealed inconsistencies in care plan adherence and communication, contributing to the deficiencies.
The facility failed to assess and implement appropriate fall prevention interventions for four residents, leading to multiple falls and injuries. One resident sustained a right ankle fracture, and another fell out of bed while trying to turn off an alarm clock, resulting in a head injury and other injuries. The care plans and kardexes lacked evidence of effective interventions to prevent further falls.
The facility failed to employ a full-time RD or a qualified DM, affecting all 39 residents. The interim DS confirmed the absence of a DM and significant kitchen staff turnover. The RD was only on-site twice weekly, and the administrator mentioned a new DM was hired but awaiting a background check.
The facility failed to ensure sufficient support staff with appropriate competencies in food and nutrition services, affecting all 39 residents. The dietary aide lacked required training, and the dietary supervisor struggled to implement necessary processes due to staff shortages and time constraints.
The facility failed to properly store, label, and date food items, and did not maintain clean air vents and ice machines. Observations revealed improperly stored and expired food, moldy items, and significant dust and calcium build-up. The dietary supervisor acknowledged the issues, and the administrator confirmed that policies were not being followed.
The facility failed to follow standard, contact, and droplet precautions, and perform evidence-based hand hygiene for residents with GI symptoms. Staff did not adhere to proper hand hygiene protocols, did not change gloves between tasks, and mishandled soiled linens, leading to deficiencies in infection control practices.
The facility failed to maintain the walk-in freezer, resulting in a large ice dam that impacted frozen food storage. The dietary supervisor and maintenance personnel were aware of the issue but had not resolved it until help from another facility arrived. The administrator was unaware of the problem, and no policy for maintaining equipment was provided.
The facility failed to ensure adequate monitoring for anticoagulant medications for three residents and did not address duplicative prescriptions for one resident. The care plans and medical records lacked documentation of monitoring for bleeding or bruising, and staff interviews confirmed the absence of necessary monitoring and clarification of medication orders. The facility's policy for high-risk medication side effect monitoring did not address anticoagulant side effects, contributing to the deficiencies observed.
The facility failed to ensure that residents were offered or provided updated pneumococcal vaccines per CDC guidelines. Five residents were not appropriately vaccinated upon admission, and the facility's records lacked documentation of shared clinical decision-making regarding the PCV-20 vaccine. Despite residents being agreeable to receiving the vaccine, the pharmacy was out of stock, leading to the deficiency.
The facility failed to ensure the removal of facial hair for a resident with cognitive impairment and multiple sclerosis, despite her expressing discomfort. Staff were unaware of her preference for chin hair removal, and her care plan lacked specific instructions, leading to a deficiency in maintaining her dignity and comfort.
The facility failed to complete baseline care plans within 48 hours for two residents admitted with significant medical conditions, including fractures and a history of falls. Staff interviews revealed confusion about responsibilities, and the care plans lacked essential details and interventions.
The facility failed to comprehensively assess and include dementia in a resident's care plan and did not assess the safety of another cognitively impaired resident using a Keurig coffee maker. Staff interviews revealed inconsistencies and confusion regarding responsibilities for updating care plans, and the DON acknowledged the need for proper assessments.
The facility failed to ensure nail care was completed for a resident with moderately impaired cognition and a diagnosis of TBI. Despite being dependent on staff for personal hygiene, the resident's nails were observed to be long, chipped, and dirty over several days. Staff interviews revealed confusion about responsibility for nail care, and the medical record lacked documentation of nail care or refusals.
The facility failed to ensure weekly skin assessments for a resident who had a fall and sustained bruising and lacerations. Despite the care plan requiring weekly observations, there was no consistent documentation or follow-up by licensed nurses, leading to a deficiency in the resident's care.
The facility failed to perform weekly skin assessments for a resident at risk for pressure injuries. Despite the care plan indicating a potential for pressure ulcer development, there was no documentation of routine skin checks, and staff interviews revealed inconsistent monitoring and documentation practices.
The facility failed to act on the consulting pharmacist's recommendations for a resident on warfarin therapy. Despite the pharmacist's recommendation for monitoring signs and symptoms of bleeding and bruising, the resident's care plan and orders lacked such monitoring, and there was no follow-up on the initial recommendation.
The facility failed to serve menu items as listed and planned for two residents, leading to dissatisfaction with meal options and inconsistency in receiving chosen meals. The dietary supervisor acknowledged the disorganization and difficulty in following the planned menu, while the dietary aide and nursing assistant confirmed the lack of advance menu provision to residents.
Medication Administration Error: Morphine Overdose Due to Transcription Mistake
Penalty
Summary
A medication administration error occurred involving a resident with diagnoses including anemia, heart failure, diabetes mellitus, and seizure disorder, who was receiving hospice care for a terminal prognosis. The resident's physician order specified morphine sulfate concentrate 20 mg/ml, to be given at 0.75 ml every hour as needed for pain or dyspnea. However, a hospice nurse transcribed a new order incorrectly, changing the dose from 0.75 ml to 7.5 ml, which is ten times the intended amount. This transcription error was not identified by the facility nurse, who subsequently administered the excessive dose using multiple syringes. Following the administration of the incorrect morphine dose, the resident exhibited symptoms requiring the use of Narcan (naloxone) to reverse opioid effects. Documentation and interviews revealed inconsistencies in the recording of Narcan administration times and the number of doses given. The error was discovered when a new bottle of morphine arrived from the pharmacy with the correct dosage label, prompting staff to realize the discrepancy and notify appropriate personnel. The facility's medication administration record and staff interviews confirmed that the error was due to the incorrect transcription and lack of verification before administration. Staff interviews indicated that there was no double-checking of hospice orders as is done with new admissions, and the nurse who administered the medication did not question the unusually large volume required for the dose. The director of nursing acknowledged the transcription error but initially did not consider it a facility error, attributing it to the hospice nurse. The facility policy requires medication errors to be reported promptly and defines significant errors as those jeopardizing resident health and safety, which was the case in this incident.
Failure to Maintain Resident Privacy and Dignity
Penalty
Summary
The facility failed to maintain personal privacy and dignity for a resident, identified as R21, who was observed with bare skin and undergarments visible from the hallway. R21, who had severe cognitive impairment and required maximal assistance for activities of daily living, was found lying in bed with the door wide open, exposing him to other residents, visitors, and staff. The care plan for R21 lacked specific interventions to preserve privacy and dignity, despite acknowledging his incontinence and inappropriate sexual behaviors. During multiple observations, R21 was seen in a state of undress with the door open, and staff members, including a social services designee and a nursing assistant, walked past without addressing the situation. Although a trained medication aide eventually closed the door, it was reopened shortly after, leaving R21 exposed again. The room lacked privacy curtains, and the care plan did not provide guidance on maintaining privacy while ensuring safety, as R21 was at risk for falls. Interviews with staff, including the Director of Nursing, confirmed that the door should remain open for safety reasons, but it could be partially shut to provide some privacy. However, the observations indicated that the door was often left wide open, compromising R21's dignity. The facility's policies on resident dignity and fall prevention were not effectively implemented, leading to the deficiency in maintaining R21's privacy and dignity.
Failure to Assist Resident with Personal Hygiene Needs
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADL) for a resident with moderately impaired cognition and blindness. The resident, who had a history of cerebral vascular accident (CVA), required supervision with personal hygiene and had specific physician's orders for weekly skin assessments, nail trimming, and shaving. However, documentation from a weekly skin observation lacked evidence that the resident's nails were trimmed or that he was offered or refused shaving. Observations revealed that the resident's fingernails were approximately half an inch long, and he had several weeks' worth of facial hair, despite expressing a desire to have his nails trimmed and to be clean-shaven. Interviews with nursing assistants and a licensed practical nurse (LPN) confirmed that nursing assistants were responsible for trimming nails and shaving residents once a week on their bath day. However, there was no specific place to document these tasks, and the staff were expected to re-approach residents who refused care and inform the nurse. The director of nursing (DON) reiterated these responsibilities and the need for documentation. Despite these protocols, the resident did not receive the necessary personal hygiene care, indicating a lapse in the facility's adherence to its policy on providing appropriate treatment and services for ADLs.
Deficiencies in Monitoring and Intervention for Residents on Anticoagulation and Edema Care
Penalty
Summary
The facility failed to adequately monitor and document bruising for a resident on anticoagulation therapy. The resident, who had moderate cognitive impairment and was on daily anticoagulation medication, was observed with multiple bruises on their arms and hands. Despite the presence of these bruises, the facility's weekly skin assessments did not document the bruising, and there was no indication of when the bruising was identified or monitored. Interviews with staff revealed that while bruising was common for residents on blood thinners, there was no specific monitoring in place beyond weekly observations, and the bruising was not consistently documented. Additionally, the facility did not implement prescribed interventions for another resident with edema. This resident, who had congestive heart failure and localized edema, was supposed to have Tubi-grips applied to their lower legs daily. However, the care plan did not reflect this requirement, and the medication and treatment administration records lacked documentation of the Tubi-grips being applied or removed as ordered. Observations confirmed that the resident was not consistently wearing the Tubi-grips, and staff interviews indicated a lack of adherence to the prescribed schedule for applying and removing the compression bandages. The facility's policies on skin assessment and edema monitoring did not adequately address the specific needs of these residents, leading to deficiencies in care. The lack of documentation and adherence to care plans for both residents highlights a failure in the facility's monitoring and intervention processes, which are crucial for residents with conditions requiring specific medical management.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to fully assess and implement fall prevention interventions for two residents, leading to multiple falls. One resident, identified as R21, had a history of falls and was at high risk due to cognitive impairment, impulsivity, and other medical conditions such as dementia and Parkinson's disease. Despite these risks, the facility's care plan and interventions were inconsistently applied. Observations revealed that R21's call light was often out of reach, and the resident was left unattended, leading to several falls. The care plan included interventions like moving the resident closer to the nursing station and using a night light, but these were not effectively implemented, as evidenced by the resident's repeated falls and lack of supervision. Another resident, R187, was admitted with a history of falls and was on multiple psychoactive medications, which increased the risk of falls. The facility's pharmacist recommended reviewing and potentially reducing these medications, but the recommendations were not acted upon. R187 experienced a fall while attempting to ambulate independently, despite being identified as needing assistance. The care plan for R187 included keeping the walker within reach and offering toileting assistance, but these measures were not consistently followed, contributing to the resident's fall. Interviews with staff revealed a lack of adherence to care plans and inadequate communication regarding fall risks and interventions. Nursing assistants and other staff members were not consistently using the Kardex to guide care, and there was confusion about the implementation of fall prevention strategies. The facility's failure to effectively assess and address the fall risks for these residents resulted in repeated falls and injuries, highlighting deficiencies in supervision and care planning.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to assess and implement appropriate interventions to decrease the risk of falls for four residents. Resident 189, who had a history of falls and cognitive impairment, was admitted with a diagnosis of open reduction internal fixation (ORIF) of the left femur. Despite being identified as high risk for falls, the care plan and kardex lacked any evidence of a fall care plan or interventions. This led to Resident 189 falling in the bathroom and sustaining a right ankle fracture, which was not promptly addressed by notifying the physician or implementing immediate interventions to prevent further falls. Resident 7, who had mild cognitive impairment and was at high risk for falls due to impaired mobility and psychoactive medication use, experienced multiple falls. The care plan did not include new interventions after each fall, and the facility's risk management reports lacked evidence of immediate interventions to prevent further falls. Despite repeated falls, the care plan and kardex were not updated with effective interventions to mitigate the risk of future falls. Resident 29, with moderate cognitive impairment and a history of falls, was found on the floor at the foot of his bed. The care plan and fall assessment lacked evidence of new interventions to prevent further falls. Similarly, Resident 24, who was cognitively intact but had a history of falls and was on blood thinners, fell out of bed while trying to turn off an alarm clock. The care plan and kardex were not updated with effective interventions, and the grab bars requested by the resident and family were not properly installed, contributing to the fall and subsequent injuries.
Failure to Employ Qualified Dietary Staff
Penalty
Summary
The facility failed to employ either a full-time registered dietitian (RD) or a qualified dietary manager (DM) to carry out the functions of the food and nutrition service, potentially affecting all 39 residents. The facility's list of hires did not include a DM, and the interim dietary supervisor (DS) confirmed there was no DM currently employed. The DS, who was also working at a sister facility, mentioned significant turnover in the kitchen staff and ongoing hiring efforts. The DS had a food safety manager certificate but could not provide it. The RD was only on-site twice weekly. The administrator confirmed the absence of a dietary director for about a month and mentioned a new DM was hired but awaiting a background check.
Insufficient Support Staff in Food and Nutrition Services
Penalty
Summary
The facility failed to ensure sufficient support staff with the appropriate competencies to carry out the functions of the food and nutrition services, potentially affecting all 39 residents. The facility did not have a dietary manager, and the dietary aide (DA-A) lacked the required training for food safety and safe swallowing. On one occasion, DA-A was left alone to serve breakfast due to an ill call from the cook, resulting in a limited breakfast of cold cereal, yogurt, and toast. DA-A, who initially started as a housekeeper, had not received any formal training related to food service and was unsure of the breakfast menu. The dietary supervisor (DS) had been working at the facility for about a month to help due to the absence of a dietary manager. DS noted the lack of processes for labeling, dating foods, and ordering necessary items. Despite efforts to train staff, DS acknowledged the insufficiency of staff and time to implement needed processes. The administrator expected general education for dietary staff to come from the supervisor, but there was no clear policy on kitchen training and requirements. The facility's documentation did not include a dietary manager, and the training records for DA-A were incomplete.
Improper Food Storage and Unsanitary Conditions in Kitchen
Penalty
Summary
The facility failed to ensure proper storage, labeling, and dating of frozen and refrigerated food items, as well as the disposal of expired items. During an initial kitchen observation, surveyors found several improperly stored items in the walk-in freezer, including bags of meat with ice crystals and containers of potato and seafood salad that were not meant to be frozen. The walk-in refrigerator contained moldy strawberries, soup bases without use-by dates, and various other items without proper labeling or dating. The dietary supervisor, who was temporarily helping from a sister facility, acknowledged the issues and admitted there was no effective system for dating, labeling, and storing food in place at the facility. Additionally, the facility failed to maintain clean and sanitary conditions in the kitchen, specifically regarding the air vents and ice machine. Observations revealed large grey clumps of dust in the air vents above the kitchen prep area, which were verified by the dietary supervisor. The dietary supervisor also confirmed that there was no cleaning schedule for the kitchen and that the staff was new and struggling to maintain cleanliness. The ice machine used by residents had a significant build-up of crusty white substance, identified as hard water and calcium deposits, which had not been cleaned since the last quarterly maintenance. The facility's policies on food storage, kitchen cleaning, and ice machine maintenance were not being followed. The administrator confirmed that food should be properly dated and stored, and that cleaning schedules should be adhered to. However, the lack of a dietary manager and the presence of new staff contributed to the deficiencies observed. The facility's failure to comply with its own policies and maintain sanitary conditions had the potential to affect all 39 residents receiving food from the kitchen.
Failure to Follow Infection Control Practices
Penalty
Summary
The facility failed to follow standard precautions, contact precautions, droplet precautions, and perform evidence-based hand hygiene for residents with gastrointestinal (GI) symptoms. For instance, a nursing assistant (NA) did not perform hand hygiene before entering a resident's room, donned gloves, and assisted the resident with toileting and other personal care tasks without changing gloves or performing hand hygiene in between tasks. The NA also failed to wipe the resident's perineal area correctly, which could increase the risk of urinary tract infections (UTIs). The infection preventionist (IP) and other staff confirmed the expected procedures for hand hygiene and perineal care, which were not followed in this instance. Another incident involved a nursing assistant (NA) who assisted a resident on GI and contact precautions without washing hands with soap and water after removing gloves and gown. The NA used hand sanitizer instead, despite the sign on the resident's door indicating the need for soap and water handwashing. The NA admitted to not having enough time to wash hands properly between residents. The nurse manager and other staff confirmed the correct procedures for GI/contact precautions, which were not adhered to in this case. Additionally, a housekeeper failed to perform hand hygiene while cleaning a resident's room and handling soiled linens. The housekeeper carried a dirty bedspread with visible bowel movement without wearing gloves or placing it in a bag, and did not wash hands before handling clean linens. The housekeeping supervisor confirmed that housekeepers should wear gloves and perform hand hygiene when handling soiled items and that extra linens should not be returned to storage after being in a resident's room. These actions and inactions led to deficiencies in infection control practices at the facility.
Failure to Maintain Walk-In Freezer
Penalty
Summary
The facility failed to ensure the walk-in freezer was maintained properly, resulting in a large ice dam that impacted frozen food storage. During an initial kitchen observation, it was noted that one of the two fans in the freezer was not functioning due to a large ice dam. The ice dam extended from the fan down to the shelves and floor, freezing onto several unopened boxes. The dietary supervisor confirmed the ice dam had been present since he started a few weeks ago and that maintenance was aware but had not yet fixed the issue. The maintenance personnel admitted to being aware of the problem for about a week and had been attempting to chip away the ice without success until help from another facility arrived to implement a temporary fix. The administrator was unaware of the ice dam and expected all kitchen equipment to be in good working condition. A policy for maintaining equipment was requested but not provided. The deficiency had the potential to impact all 39 residents residing in the facility, as the ice dam could affect the quality and safety of the stored food.
Failure to Monitor Anticoagulant Medications and Address Duplicative Prescriptions
Penalty
Summary
The facility failed to ensure adequate monitoring for unnecessary medications for three residents. Resident 24, who was on warfarin for anticoagulation, did not have monitoring for signs and symptoms of bleeding or bruising documented in their care plan or nursing and provider orders. Similarly, Resident 91, who was on Eliquis for anticoagulation, also lacked monitoring for bleeding or bruising in their care plan and orders. Additionally, Resident 91 had duplicative medications prescribed, including clotrimazole and nystatin creams, which were not clarified by the staff. Resident 31, who was on Apixaban for anticoagulation, also lacked documentation of monitoring for anticoagulant side effects in their care plan and medical record. Interviews with staff confirmed the absence of necessary monitoring and the presence of duplicative medications for Resident 91. The consulting pharmacist and the Director of Nursing (DON) acknowledged the need for monitoring and clarification of medication orders but noted that these actions were not consistently implemented. The facility's policy for high-risk medication side effect monitoring did not address anticoagulant side effects, contributing to the deficiencies observed. The report highlights the facility's failure to ensure proper monitoring and management of anticoagulant medications, leading to potential risks for the residents involved.
Failure to Ensure Pneumococcal Vaccination per CDC Guidelines
Penalty
Summary
The facility failed to have a method or system to ensure that residents were offered or provided updated pneumococcal vaccines per CDC recommendations. This deficiency was identified for five residents who were not appropriately vaccinated against pneumonia upon admission. The facility's electronic health records lacked documentation of shared clinical decision-making regarding the administration of the PCV-20 vaccine, which should have been offered at least five years after the last pneumococcal vaccine dose for these residents. The infection preventionist (IP) stated that the facility utilized CDC guidelines and the Pneumorex Advisor application to determine vaccine eligibility. However, despite the residents being agreeable to receiving the additional vaccine dose, the pharmacy was out of stock. The facility's policy indicated that residents should receive pneumococcal vaccinations per CDC guidelines, and the process included obtaining consent, a physician's order, and documenting the administration in Point Click Care (PCC). The sampled residents' records showed that they had received previous doses of PPSV-23 and PCV-13 but had not been offered the PCV-20 vaccine as required. The facility's failure to document shared clinical decision-making and ensure the availability of the vaccine led to the deficiency. The policy also required ongoing review of vaccine eligibility and documentation of declination if residents chose not to be vaccinated, which was not adequately followed in these cases.
Failure to Address Resident's Facial Hair Removal Needs
Penalty
Summary
The facility failed to ensure the removal of facial hair for a resident (R6) who had cognitive impairment and diagnoses of multiple sclerosis and dementia. Despite R6's care plan indicating the need for assistance with personal hygiene, there was no specific mention of chin hair removal. Observations revealed that R6 had several white and gray hairs on her chin, which she expressed were bothersome. Interviews with staff indicated a lack of awareness and communication regarding R6's preference for chin hair removal. The nursing assistant (NA-C) and licensed practical nurse (LPN-C) both confirmed that they were unaware of R6's discomfort and did not know if R6 had an electric razor for use. The Director of Nursing (DON) stated that staff were expected to ask about and offer to shave chin hairs on bath days or anytime to ensure resident comfort, but this was not done in R6's case. The facility's policy on resident dignity, which was revised in November 2023, directed staff to maintain dignity by grooming residents according to their wishes. However, the policy was not followed in R6's case, as her care plan and Kardex lacked specific instructions for chin hair removal, and staff did not take the initiative to address her discomfort. This failure to provide appropriate personal hygiene care resulted in a deficiency in maintaining the resident's dignity and comfort.
Failure to Complete Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to ensure a baseline care plan was completed for two residents within 48 hours of their admission. Resident R89, who was admitted with diagnoses including a fracture of the lower end of the right humerus, pain in the right arm, and congestive heart failure, did not have a baseline care plan in her medical record. Interviews with various staff members, including licensed practical nurses and the nurse manager, revealed confusion and inconsistency regarding who was responsible for completing and updating the baseline care plan. The MDS nurse confirmed that R89 did not have a baseline care plan and was unsure why it was missed. Similarly, Resident R189, who was admitted with a history of falls and an open reduction internal fixation of the left femur, also lacked a baseline care plan. The resident's care plan did not include any evidence of a fall care plan, fall history, or interventions to decrease the risk for falls. Additionally, the care plan lacked details on the resident's ADL self-care performance deficit and necessary interventions. The DON confirmed that the facility had 48 hours to complete a baseline care plan and that it was crucial for staff to know how to care for the residents properly.
Failure to Comprehensively Assess and Update Care Plans
Penalty
Summary
The facility failed to comprehensively assess and include dementia in the care plan for a resident with severely impaired cognition and a diagnosis of dementia. Despite the resident's quarterly Minimum Data Set (MDS) indicating severe cognitive impairment and dependence on staff for activities of daily living (ADL) and mobility, the care plan dated 3/28/24 lacked any mention of dementia. Interviews with various staff members, including licensed practical nurses (LPNs), the nurse manager, the MDS nurse, and the director of nursing (DON), revealed inconsistencies and confusion regarding the responsibility for completing and updating the comprehensive care plan. The MDS nurse confirmed that the resident's care plan did not address dementia, which should have been included for the safety and proper care of the resident. Additionally, the facility failed to assess the safety of a cognitively impaired resident using a Keurig coffee maker in their room. The resident's quarterly MDS indicated cognitive impairment and diagnoses of chronic lung disease, kidney disease, and weakness. The medical record lacked evidence of an assessment to ensure the safe use of the coffee maker, and the care plan did not address it. Staff interviews revealed that while some staff were aware of the coffee maker, they were unsure of any safety concerns or assessments conducted. The DON acknowledged that an assessment should have been completed and included in the care plan to ensure safe use of the appliance.
Failure to Provide Adequate Nail Care
Penalty
Summary
The facility failed to ensure nail care was completed for a resident (R19) who was dependent on staff for personal hygiene. R19 had moderately impaired cognition, a diagnosis of traumatic brain injury (TBI), and was known to reject care 1-3 times per week. Despite these conditions, R19's medical record lacked documentation that nail care had been performed. Observations over several days revealed that R19's nails were approximately 1/2 inch long, chipped, jagged, and had brown matter, which R19 expressed dissatisfaction with and a desire to have them cut. Interviews with staff revealed confusion about who was responsible for nail care, with some stating it was the nurses' responsibility and others stating it was the nursing assistants' responsibility. The nurse manager confirmed that R19's nails were very long and had only been trimmed after the surveyor's inquiry. The director of nursing (DON) stated that both nurses and nursing assistants were responsible for cutting residents' nails, with a preference for nurses to cut the nails of diabetic residents. The DON also mentioned that nail care should be performed once a week on bath day and refusals should be documented in the medical record. However, there was no documentation of nail care or refusals in R19's medical record. The facility's policy on activities of daily living (ADLs) indicated that appropriate treatment and services should be provided to maintain or improve residents' abilities, but this was not adhered to in R19's case.
Failure to Conduct Weekly Skin Assessments
Penalty
Summary
The facility failed to ensure weekly skin assessments were completed for a resident (R24) who had a fall and sustained bruising and lacerations. R24's care plan required weekly skin observations by a licensed nurse, but the medical record lacked indication that these assessments were completed since January 2024. Additionally, the care plan did not include continued monitoring of R24's bruising and facial lacerations after the initial 72-hour period post-fall. Observations and interviews revealed that while nursing assistants were aware of the need to monitor skin during baths, there was no consistent documentation or follow-up by licensed nurses as required by the facility's policy. R24, who was cognitively intact and had diagnoses including congestive heart failure and vascular disease, experienced a fall resulting in a grape-sized bump on the forehead, facial bleeding, and a large skin tear on the right deltoid. Despite these injuries and the resident's use of warfarin, which could complicate healing, the facility did not document ongoing assessments or monitoring of the injuries. Interviews with staff, including LPNs and the Director of Nursing, confirmed that the expected weekly monitoring and documentation were not consistently performed, leading to a deficiency in the resident's care.
Failure to Perform Weekly Skin Assessments for At-Risk Resident
Penalty
Summary
The facility failed to ensure weekly skin assessments were completed for a resident (R8) who was at risk for pressure injuries. Despite R8's care plan indicating a potential for pressure ulcer development due to decreased mobility and other risk factors, there was no indication that weekly skin assessments were required or performed. The resident's medical record lacked documentation of routine skin checks, and the active nursing and provider orders did not include a requirement for routine skin assessments. Observations and interviews revealed that while nursing assistants monitored skin during baths and reported issues to nurses, there was no consistent documentation or follow-up by the nursing staff. On one occasion, R8 reported pain and irritation below the nose from oxygen tubing, which was observed as a small reddened area. Although the resident mentioned that staff were aware of the issue, there was uncertainty about any preventive measures being taken. Interviews with nursing staff and the Director of Nursing confirmed that skin monitoring was expected to be done daily by nursing assistants and documented on bath days, but this was not consistently practiced or recorded. The facility's policy on skin assessment and pressure ulcer prevention required accurate documentation and systematic skin inspections, which were not adhered to in R8's case.
Failure to Act on Pharmacist's Recommendations for Anticoagulation Monitoring
Penalty
Summary
The facility failed to ensure that the consulting pharmacist's recommendations were acted upon for a resident (R24) who was taking anticoagulation medication. R24, who was cognitively intact and had diagnoses of congestive heart failure and atrial fibrillation, was on warfarin therapy. The resident's nursing and provider orders did not include monitoring for bleeding, bruising, or other side effects of the anticoagulation medication. Additionally, R24's care plan lacked any indication of monitoring for these side effects. Despite the consulting pharmacist's recommendation in December for monitoring signs and symptoms of bleeding and bruising, there was no follow-up or implementation of this recommendation in the resident's care plan or orders. Interviews with staff revealed that the pharmacy sends recommendations to the nurse practitioner, who then decides on the necessary actions. The Director of Nursing (DON) stated that pharmacy recommendations are received monthly and are either acted upon or delegated. However, the consulting pharmacist acknowledged that there had been no further direction or follow-up on the initial recommendation for anticoagulation monitoring since December. The facility's policy directs the pharmacist to report any irregularities to the attending physician or the DON, and these reports must be acted upon with follow-up documentation maintained. This process was not followed in the case of R24, leading to a deficiency in care.
Failure to Serve Menu Items as Planned
Penalty
Summary
The facility failed to serve menu items as listed and planned for two residents reviewed for nutrition services. Resident 25, who has diagnoses of chronic obstructive pulmonary disease (COPD) and dysphagia, reported not receiving the Salisbury steak and potatoes he selected for dinner, instead receiving a bowl of soup and half a grilled cheese sandwich. Similarly, Resident 8, who has heart disease, kidney disease, and high blood pressure, stated that the food was not always great, there were limited choices, and often received whatever was left rather than the selected option. Both residents expressed dissatisfaction with the meal options and the inconsistency in receiving their chosen meals. The dietary supervisor, who had been at the facility for about a month, acknowledged the difficulty in following the previous dietary manager's menu and the lack of alignment between available food and the planned menu. The dietary supervisor admitted that the facility was supposed to be on a different menu week and that the current situation was disorganized. The dietary aide and nursing assistant confirmed that residents were asked about their meal preferences before each meal, but there was no menu provided to residents ahead of time. The administrator expected the kitchen staff to follow the scheduled menu and consider residents' preferences, but this was not being effectively implemented. Facility policies directed staff to prepare menus in advance and ensure resident preferences were considered, but these policies were not being followed.
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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