Good Shepherd Lutheran Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Sauk Rapids, Minnesota.
- Location
- 1115 4th Avenue North, Sauk Rapids, Minnesota 56379
- CMS Provider Number
- 245269
- Inspections on file
- 22
- Latest survey
- April 17, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Good Shepherd Lutheran Home during CMS and state inspections, most recent first.
The facility did not include required details such as total number and actual hours worked by licensed and unlicensed nursing staff, as well as resident census, on daily posted nurse staffing information. The DON was unaware of these omissions, and there was no policy in place for nurse staffing postings.
The QAPI committee did not maintain effective oversight of a repeat deficiency involving unsafe medication storage, as two medication carts were left unlocked and unattended, and meeting minutes lacked ongoing monitoring data related to this issue.
Surveyors found that food and beverages in facility refrigerators and freezers were not consistently labeled or dated, with some items emitting foul odors, and that ice machines had significant buildup and residue. Staff confirmed these findings and acknowledged that facility policies for food handling and ice machine maintenance were not followed.
A resident with COPD and other chronic conditions, who required extensive assistance and had not been assessed as safe to self-administer medications, was left unsupervised during nebulizer treatments. Staff placed the nebulizer mask and left the room, contrary to physician orders and facility policy, which required staff presence during medication administration unless a self-administration assessment and order were in place.
A resident with COPD and other chronic conditions was administered Budesonide via nebulizer by a medication aide who failed to instruct the resident to rinse her mouth afterward, as required by physician orders and standard practice. Interviews with nursing and pharmacy staff confirmed the omission and the importance of this step to prevent oral infections. The facility's policy required adherence to physician orders, but this was not followed during the observed medication administration.
A resident with paraplegia and a stage 3 pressure ulcer did not receive timely repositioning as required by her care plan, remaining on her back for nearly three hours without assistance. Staff interviews and documentation confirmed the lapse in care, and the facility could not provide a repositioning policy when requested.
Medication carts were observed left unlocked and unattended in two areas, including a memory care unit and another wing. Staff, including an RN and an LPN, walked past the unlocked carts multiple times, leaving them out of direct eyesight for several minutes before securing them. The DON confirmed the expectation that carts should be locked when not in use, especially in areas with residents who have memory impairments. No policy on medication cart security was provided when requested.
Three cognitively intact residents reported that their meals were often served lukewarm or cold, with food temperatures measured below the facility's required 140°F standard. Observations confirmed that items such as meat and vegetables were not at the appropriate temperature when served, and staff were not consistently aware of the required holding temperatures.
Staff did not use required PPE, such as gowns and gloves, while providing high-contact care to a resident on enhanced barrier precautions for a pressure ulcer. Despite being trained and aware of the need for PPE, an LPN and a physical therapy assistant provided care without proper protective equipment, as confirmed by multiple staff interviews and facility policy.
The facility failed to ensure post-dialysis assessment and monitoring for two residents with ESRD. Both residents' care plans lacked specific instructions for post-dialysis care, and staff interviews revealed a lack of training and knowledge regarding dialysis care. The facility's policy did not include guidelines for monitoring residents or training staff, leading to inadequate post-dialysis assessment and monitoring.
The facility failed to maintain records of thorough investigations for four residents related to reported incidents, including missing property, falls, and injuries. Although investigation summaries were provided, evidence of staff interviews was not retained, contrary to the facility's Abuse Prevention Plan.
The facility failed to notify the Ombudsman for LTC of resident transfers to the hospital for two residents. Both residents' Ombudsman Notification of Discharge forms lacked the date and staff signature, indicating they were likely not faxed to the ombudsman as required.
The facility failed to develop comprehensive care plans for two residents requiring dialysis, omitting critical details such as the location of the dialysis graft, dialysis center contact information, and scheduled monitoring post-dialysis. Staff interviews revealed gaps in the care planning process and access to necessary information.
A resident requiring assistance for bathing did not receive a bath for a month, with only one documented refusal and no alternative attempts or documentation of offers. Interviews with staff and the DON confirmed the lack of adherence to the facility's policy on bathing and documentation.
The facility failed to maintain safe storage of medications when medication carts on the 100s and 300s wings were left unlocked and unattended on multiple occasions. Staff confirmed that medication carts should be locked when unattended or out of direct eyesight. The facility policy for medication storage was requested but not provided.
Failure to Post Complete Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that all required data were included on the daily posted nurse staffing information. On multiple consecutive days, the posted nurse staffing information was observed to be missing the total number and actual hours worked by categories of licensed and unlicensed nursing staff directly responsible for resident care per shift. Additionally, the postings did not include the resident census as required. On one occasion, the posted information was also outdated, displaying the previous day's date instead of the current date. Interviews with the Director of Nursing (DON) revealed that she was unaware that the posted nurse staffing information lacked the required details. The DON confirmed that the postings were expected to be updated and accurate so that residents and visitors could know who was providing care. It was also verified that the facility did not have a policy regarding nurse staffing information postings.
Repeat Deficiency in Medication Storage Oversight by QAPI Committee
Penalty
Summary
The facility failed to ensure its Quality Assurance and Performance Improvement Program (QAPI) committee effectively maintained ongoing compliance regarding repeat citations for drug storage. Specifically, the facility was previously cited for unsafe medication storage when two of seven medication carts were observed left unlocked and unattended. Despite this, a review of QAPI meeting minutes showed a lack of ongoing data and monitoring related to this repeat citation. The facility's policy required monitoring the effectiveness of performance improvement activities, but documentation did not reflect sustained oversight of the previously identified deficiency.
Improper Food Storage and Unsanitary Ice Machines
Penalty
Summary
Surveyors identified multiple instances where food and beverages stored in facility refrigerators and freezers were not labeled or dated as required. Specific items such as yogurt, tartar sauce, mayonnaise, sausage, pepperoni, pork Salisbury steak, whip topping, and various soups and muffins were found without open dates, expiration dates, or any notation of when they were placed in storage. Some items, such as mayonnaise, emitted a foul odor when opened. These issues were observed in both the main kitchen storage areas and resident unit refrigerators. Additionally, ice machines in the facility were found to be inadequately maintained, with significant white flaky buildup and orange residue present on the covers and drip trays. The dietary supervisor, dietary manager, and maintenance director all confirmed these findings during interviews, acknowledging that the facility's policies require food to be dated and discarded appropriately and that ice machines should be kept free of buildup. The facility's own policies specify regular cleaning and scale removal for ice machines and proper food handling procedures, which were not followed.
Failure to Supervise Nebulizer Medication Administration
Penalty
Summary
A resident with diagnoses including arthritis, hypertension, and COPD, who required extensive assistance with activities of daily living, was observed self-administering nebulizer treatments without having been assessed as safe to do so. The resident's care plan indicated dependence on staff for medication administration, and a self-administration of medication (SAM) assessment documented that the resident did not wish to self-administer medications. Physician orders directed staff to administer nebulizer medications, and there was no order permitting self-administration. During observation, a trained medication aide prepared and placed the nebulizer mask on the resident, then left the room and was not within visual sight of the resident during the treatment. The aide returned after the treatment period, found the mask removed by the resident, and repeated the process for a second medication. Interviews with staff confirmed that the resident had not been assessed as safe to self-administer medications and that facility policy required staff to remain present unless a SAM assessment and physician order permitted self-administration. The facility failed to ensure safe administration of nebulizer medications by not supervising the resident as required.
Failure to Ensure Proper Post-Inhalation Care for Steroid Medication
Penalty
Summary
A deficiency occurred when staff failed to follow professional standards of practice related to the administration of an inhalation medication for a resident with chronic obstructive pulmonary disease (COPD), arthritis, and hypertension. The resident required extensive assistance with activities of daily living and had a physician's order for Budesonide inhalation suspension via nebulizer, with explicit instructions to rinse and spit after use to prevent oral infections. During a medication administration observation, a trained medication aide prepared and administered the Budesonide nebulizer but did not instruct the resident to rinse her mouth afterward, as required by the physician's order and medication guidelines. The aide confirmed during an interview that she had not seen the order instructions and that it was not her usual practice to instruct the resident to rinse her mouth after using the Budesonide nebulizer. Further interviews with the registered nurse, pharmacy consultant, and director of nursing confirmed the importance of rinsing the mouth after steroid inhalation to prevent infections such as thrush, and all verified that the resident's orders included this instruction. The facility's medication administration policy also required medications to be administered according to physician orders. The failure to instruct and ensure the resident rinsed her mouth after Budesonide administration constituted a failure to meet professional standards and follow physician orders.
Failure to Provide Timely Repositioning for Resident with Pressure Ulcer
Penalty
Summary
A deficiency occurred when a resident with paraplegia, arthritis, and anxiety disorder, who was identified as being at risk for skin breakdown and having a stage 3 pressure ulcer, did not receive timely assistance with repositioning as required by her care plan. The care plan specified that the resident should be repositioned every two hours while in bed to prevent further skin breakdown. Observations showed that the resident remained lying on her back for nearly three hours without being repositioned, despite staff being aware of her need for frequent turning due to her pressure ulcer. Documentation and staff interviews confirmed that the resident had not been repositioned according to the prescribed schedule. The resident required extensive assistance with activities of daily living, including bed mobility and transfers, and had a chronic wound that required daily dressing changes. Staff interviews and documentation indicated that the resident's care plan and physician orders for wound care and repositioning were not followed. The facility was unable to provide a repositioning policy when requested. The deficiency was identified through direct observation, interviews with staff, and review of the resident's medical records and care plan.
Medication Carts Left Unlocked and Unattended
Penalty
Summary
Surveyors observed that medication carts were left unlocked and unattended in two separate areas of the facility. On the locked memory care unit, a medication cart was found in a common area and remained unlocked while staff walked past it multiple times. Similarly, on the 100 wing, another medication cart was observed being left unlocked for an extended period while staff, including a registered nurse and a licensed practical nurse, walked past it and left it out of direct eyesight. The cart was only locked after several minutes had passed. During interviews, the registered nurse confirmed that the medication cart was left unlocked for an unknown amount of time and was not within her direct line of sight. The director of nursing stated that the expectation is for medication carts to be locked any time the nurse is away and out of eyesight, emphasizing the importance of this practice, especially in the dementia unit where residents have memory impairments. The facility was unable to provide a policy regarding medication cart security when requested.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that food was served at a palatable and appetizing temperature for three residents on the North shore unit, all of whom had intact cognition and were able to feed themselves after staff set up their trays. Multiple residents reported that their food was not always hot, with specific complaints about meat and potatoes being served lukewarm or cold. During meal service, food was observed being plated in the main kitchen, placed on a plate warmer, and then transported to the unit. Upon arrival and distribution, food temperatures were measured and found to be below the facility's required holding temperature of 140°F, with items such as hamburger, chicken, potatoes, and cauliflower ranging from 118°F to 131°F. Residents confirmed that their meals were often only lukewarm or cold, and a dietary aide acknowledged the food was not at the expected temperature. The dietary manager stated that the expectation was for hot food to be held at 140°F or higher, as outlined in the facility's policy. The deficient practice was observed to have the potential to affect all 21 residents on the unit.
Failure to Use PPE During Enhanced Barrier Precautions
Penalty
Summary
Staff failed to use proper personal protective equipment (PPE) when providing care to a resident on enhanced barrier precautions (EBP) due to a pressure ulcer. The resident, who had moderate cognitive impairment and diagnoses including COVID-19, depression, and metabolic encephalopathy, was care planned for gown and glove use during high-contact care. Observations showed that an LPN cut the resident's toenails without wearing a gown and leaned on the bed, despite being aware of the EBP requirements. Additionally, a physical therapy assistant assisted the resident with walking, transferring, and adjusting bed covers without wearing PPE, even though she acknowledged having received EBP training and knowing the resident was on EBP. Interviews with staff, including the clinical manager, infection prevention nurse, and director of nursing, confirmed that PPE should have been worn during these high-contact care activities. The facility's infection control manual specified gown and glove use for such activities, and all staff, including therapy, had been trained on EBP. Despite this, staff did not adhere to the required precautions during the observed care events.
Failure to Ensure Post-Dialysis Assessment and Monitoring
Penalty
Summary
The facility failed to ensure post-dialysis assessment and monitoring for two residents who required dialysis services. Resident R48, diagnosed with end-stage renal disease (ESRD) and other related conditions, had no orders for daily monitoring of the dialysis graft, removal of the dressing after dialysis, or post-dialysis assessment requirements. The care plan for R48 also lacked specific instructions for monitoring post-dialysis, including the location of the dialysis center and which arm had the graft. Similarly, Resident R108, also diagnosed with ESRD, had no orders for pre or post-dialysis monitoring, and the care plan did not include scheduled monitoring post-dialysis or details about the dialysis center. Both residents' care plans failed to provide comprehensive instructions for post-dialysis care and monitoring, leading to a lack of proper assessment and documentation by the staff. Interviews with staff revealed a lack of specific training and knowledge regarding the care of residents receiving dialysis. Unlicensed staff (NA)-C admitted to not receiving any training on dialysis care, while LPN-B and RN-B indicated that there were no specific protocols or orders for monitoring dialysis residents upon their return. The Director of Nursing (DON) confirmed that the care plans should have indicated if residents received dialysis and that staff should have looked at the calendar for dialysis appointments. However, the DON acknowledged that there were no specific orders or standard monitoring practices for post-dialysis care unless ordered by the provider. The facility's policy on dialysis procedures did not include guidelines for monitoring residents, training staff, or care plan requirements. Additionally, the facility contract with the dialysis center was requested but not provided. The lack of comprehensive care plans, specific orders, and staff training resulted in inadequate post-dialysis assessment and monitoring for the residents, as evidenced by the observations and interviews conducted during the survey.
Failure to Maintain Records of Thorough Investigations
Penalty
Summary
The facility failed to maintain records of thorough investigations for four residents related to reported incidents. For Resident 29, the facility reported a missing tablet and possible financial exploitation to the Minnesota Department of Health (MDH). Although the facility conducted interviews and submitted a summary, they did not provide evidence of the interviews conducted. Similarly, for Resident 318, who was found on the floor with a skin tear and later diagnosed with a hip fracture, the facility's investigation summary lacked evidence of staff interviews despite indicating that interviews were conducted. Resident 319 was found to have a dislocated right shoulder after a fall, and the facility reported the incident to MDH. The investigation summary noted previous shoulder dislocations and denied any harm by others, but again, the facility did not provide evidence of the staff interviews conducted. Lastly, Resident 50 was found outside the facility with multiple injuries, including a head laceration and fractures, after a fall. The facility's investigation summary mentioned staff interviews, but no evidence of these interviews was provided. The assistant director of nursing and the director of nursing stated that their practice was to summarize the information gathered during investigations and include it in the five-day report to MDH, without retaining the evidence of the interviews conducted. The facility's Abuse Prevention Plan indicated that incidents should be reported, documented, and investigated internally, but the facility did not adhere to this policy by failing to maintain records of the investigations and interviews conducted.
Failure to Notify Ombudsman of Resident Hospital Transfers
Penalty
Summary
The facility failed to notify the Ombudsman for Long Term Care (LTC) of resident transfers to the hospital for two residents. Resident 42, who had intact cognition and diagnoses including heart and renal failure, was hospitalized from February 14, 2024, through February 19, 2024. The Ombudsman Notification of Discharge form for Resident 42, dated February 14, 2024, indicated that the resident would be transferred to the hospital due to an emergent medical need. However, the form lacked the date and staff signature, suggesting it was not faxed to the ombudsman. Similarly, Resident 49, who had severe cognitive impairment and diagnoses including heart failure and quadriplegia, was hospitalized twice. The Ombudsman Notification of Discharge form for Resident 49's hospitalization on December 31, 2023, also lacked the date and staff signature, and a sticky note on the Verification of Receipt of Notice of Bed Hold for the November 2, 2023, hospitalization indicated the ombudsman form could not be located. The nurse case manager (RNCC) confirmed that the facility's procedure required the nurse who received the order to send the resident to the hospital to fax the signed notification to the ombudsman before filing it in the resident's chart. The RNCC stated that staff were expected to make a notation on the form to indicate it was sent to the ombudsman, and if the form lacked such a notation, it was likely not faxed. The facility's Sending a Resident to the ER form indicated that staff were expected to chart discussions with family about ombudsman notification and fax the form to the ombudsman. However, a specific facility policy regarding required ombudsman notification for transfers/discharges was requested but not provided.
Failure to Develop Comprehensive Dialysis Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents requiring dialysis. Resident R48's care plan did not specify which arm had the dialysis graft, the location of the dialysis center, contact information, or scheduled routine monitoring post-dialysis. Similarly, Resident R108's care plan inaccurately included instructions for a graft that the resident did not have and also lacked details on scheduled monitoring post-dialysis, treatment dates, and dialysis center contact information. Both care plans were missing critical information necessary for proper dialysis care management. Interviews with facility staff revealed gaps in the care planning process. The registered nurse case manager admitted that dialysis appointments were not listed on the care plans and was unsure if unlicensed staff had access to the necessary calendar. The director of nursing confirmed that the care plans did not include the location and contact information for the dialysis centers, expecting staff to look up this information if needed. The facility's policy for care plans was requested but not provided, indicating a potential lack of standardized procedures for care planning.
Failure to Provide Bathing Assistance
Penalty
Summary
The facility failed to provide bathing assistance for a resident (R34) who required partial to moderate assistance for showering and bathing. The resident's quarterly minimum data set (MDS) indicated the need for assistance, and the resident's admission record included diagnoses of chronic pain syndrome, major depressive disorder, and generalized anxiety disorder. Over a 30-day period, the bathing task report showed only one instance of the resident refusing a bath, with no other responses documented. The resident confirmed during an interview that it had been a month since she received a bath, often requesting a bath at a later time when she felt unwell, but staff were not available to accommodate her requests. Progress notes also failed to document any offers or refusals of bathing assistance during this period. Interviews with nursing staff revealed that if a resident refused a bath, alternative options or times should have been offered, and any refusals or completed bed baths should have been documented. The Director of Nursing (DON) confirmed that the facility's policy required baths to be offered and completed on scheduled days, with documentation of any refusals and alternative attempts. The DON acknowledged that the documentation did not reflect proper adherence to this policy, indicating that the resident was not offered or provided a bath during the previous 30 days, except for the one documented refusal. This lack of documentation and adherence to policy resulted in the deficiency noted in the report.
Failure to Maintain Safe Storage of Medications
Penalty
Summary
The facility failed to maintain safe storage of medications when medication carts were left unlocked and unattended in two of six facility medication carts. On multiple occasions, medication carts on the 100s and 300s wings were observed to be unlocked and unattended for varying periods. Specifically, on 4/29/24, a medication cart on the 100s wing was left unlocked and unattended from 4:43 p.m. to 4:55 p.m. On 4/30/24, a medication cart on the 300s wing was left unlocked and unattended from 3:35 p.m. to 3:40 p.m. On 5/1/24, a medication cart on the 100s wing was left unlocked and unattended for approximately one minute at 7:22 a.m. Interviews with facility staff, including a registered nurse and the director of nursing, confirmed that medication carts should be locked any time they are unattended or out of direct eyesight. The facility policy for medication storage was requested but not provided.
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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