Johnson Memorial Hosp & Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Dawson, Minnesota.
- Location
- 1290 Locust Street, Dawson, Minnesota 56232
- CMS Provider Number
- 245485
- Inspections on file
- 25
- Latest survey
- February 20, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Johnson Memorial Hosp & Home during CMS and state inspections, most recent first.
A facility failed to ensure that all licensed nurses were trained and competent in insulin administration, leading to a resident receiving the wrong type of insulin. The error was reported, and the resident was monitored without adverse effects. The DON admitted to a lack of formal training records and audits, despite policy requirements for ongoing education.
The facility did not meet its own assessed staffing requirements for RNs, LPNs/TMAs, and NAs on multiple weekend shifts, with documented shortfalls in nursing assistant hours and inconsistencies in LPN/TMA coverage. The DON confirmed that the facility assessment was outdated and that required staffing levels were not maintained as specified.
The facility did not submit complete and accurate direct care staffing data to CMS, as required, due to failures in tracking and reporting hours worked by contracted and on-call RNs. The DON confirmed that some RN hours were omitted from the PBJ report, and the payroll coordinator did not verify the accuracy of submitted data. No policy was in place for PBJ reporting.
The facility did not ensure that the infection preventionist maintained complete and accurate surveillance of employee illness, as multiple department heads failed to report required data and return-to-work dates, and illness tracking logs lacked individual staff identifiers, hindering effective oversight and exposure tracking.
Facility staff failed to label insulin pens with required open and discard dates for multiple residents, as observed during medication administration and storage checks. Nursing staff and the DON confirmed that facility policy and manufacturer guidelines require such labeling, but several insulin pens in use lacked this information.
A resident with severe cognitive impairment eloped from the facility without staff knowledge, despite wearing a WanderGuard bracelet. The door failed to lock, and the alarm did not sound. The care plan was not updated to include new interventions to prevent future elopements, and staff were unaware of the incident.
A resident with diabetes was mistakenly given the wrong type of insulin due to a failure in following medication administration protocols. The facility lacked a formal process to verify nurse competency in insulin administration, relying on on-the-job training without documented audits or competency checks.
A resident with significant cognitive and physical impairments experienced a fall that was not properly assessed or monitored by staff. Despite displaying and reporting severe pain for several hours after the fall, the resident did not receive a comprehensive pain assessment, pain relief, or timely physician notification. Inadequate communication and documentation among staff led to a delay in identifying a hip fracture, resulting in delayed medical attention and pain management.
The facility failed to notify the county (SMHA) when a resident had a new onset of mental illness since admission. The resident's diagnoses included delusional disorders, paranoid schizophrenia, obsessive-compulsive disorder, depression, and anxiety. The medical record lacked any indication that the SMHA had been notified of these new diagnoses. Interviews revealed no process in place to ensure notification, despite the facility's policy requiring it.
The facility failed to revise the care plan for a resident with peripheral edema and cardiomyopathy. Despite significant edema and weight gain, the care plan lacked interventions for managing edema. Observations showed the resident with 4+ edema, often seated with feet on the floor, and not using support stockings or a foot stool. Interviews confirmed non-compliance with recommended interventions, and the DON acknowledged the care plan should have been updated.
Insulin Administration Training Deficiency
Penalty
Summary
The facility failed to ensure that all licensed nurses, including both regular and agency staff, were appropriately trained and deemed competent in administering insulin according to facility policy and manufacturer's instructions. This deficiency was identified through observation, interviews, and document reviews, revealing that none of the 14 nurses who administered or had the potential to administer insulin had documented training or competency assessments. The incident involved a resident who was mistakenly given 36 units of Fiasp, a short-acting insulin, instead of the prescribed 36 units of Basaglar, a long-acting insulin. The error was reported to the resident's primary provider, and the resident was monitored for any adverse effects, though none were reported. The director of nursing (DON) acknowledged the lack of a formal checklist or accessible records to verify that insulin administration training or competencies had been completed. Training was reportedly conducted on the job by nurse managers, but no audits were performed to ensure compliance. The facility's in-service education policy required continuing education and training to meet regulatory and licensing requirements, with initial and annual training based on departmental needs. However, the absence of documented training and competency assessments for insulin administration highlighted a significant gap in the facility's adherence to its own policies and procedures.
Failure to Maintain Required Staffing Levels per Facility Assessment
Penalty
Summary
The facility failed to implement and maintain a facility-wide assessment that accurately determined and provided the necessary staffing resources to care for residents competently during both regular operations and emergencies. Document review showed that the facility's assessment identified specific staffing requirements for RNs, LPNs/TMAs, and NAs for each shift on both weekdays and weekends. However, a review of six sampled weekend dates revealed that the actual staffing hours for nursing assistants (NAs) consistently fell short of the required hours as outlined in the facility assessment. Additionally, there were discrepancies in LPN/TMA hours on some shifts, and night shift NA hours were also below the required levels on multiple occasions. During an interview, the DON acknowledged that the staffing needs had been determined by a previous interim administrator and confirmed that the facility assessment required review and revision, as the staffing hours should be consistent across weekdays and weekends. The DON also agreed that the required staffing hours identified in the facility assessment were not met on the sampled weekend shifts. No additional policy related to staffing was provided by the facility at the end of the survey.
Failure to Accurately Report Direct Care Staffing Data to CMS
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to CMS for Quarter 4 of 2024, as required. Review of the Payroll Based Journal (PBJ) report revealed that excessively low weekend staffing had triggered a concern. Further examination of staff schedules and timecards showed that a contracted RN worked a 12-hour shift on 7/6/24 but did not clock in using the facility's system, resulting in those hours not being included in the PBJ report. Additionally, an on-call hospital RN worked an 8-hour shift on 8/17/24, but there was uncertainty about whether those hours were properly recorded and allocated to the nursing home. The DON confirmed the omission of the contracted RN's hours and was unsure about the process for on-call hospital staff. The payroll coordinator stated he submitted PBJ hours without running verification reports and only checked for the presence of an RN each day. The facility did not have a policy on PBJ reporting.
Failure to Ensure Effective Infection Surveillance and Reporting
Penalty
Summary
The facility failed to ensure proper oversight by the infection preventionist (IP) in managing the infection prevention and control program, specifically regarding the tracking and documentation of employee illness. Over a three-month period, multiple department heads did not consistently report required surveillance data, resulting in incomplete records for 33 out of 60 staff and missing return-to-work dates for numerous staff who called in sick. The surveillance logs only included department information and not individual staff identifiers, making it impossible to determine specific areas of exposure or to track potential transmission to residents. Interviews revealed that the IP was aware of the ongoing issue with department heads not submitting information timely and had raised these concerns in interdisciplinary team meetings. The administrator was also aware of the problem and had discussed it in QAPI meetings, expecting the IP to retrain department heads if necessary. The facility's policy required supervisors to report detailed illness information, but the policy did not specify that the IP should identify individual staff, limiting the ability to provide comprehensive oversight and exposure tracking.
Failure to Label Insulin Pens with Open and Discard Dates
Penalty
Summary
Surveyors observed that facility staff failed to properly label insulin pens with both open and discard dates for six residents who were prescribed insulin. During medication administration, registered nurses were seen removing insulin pens from medication cupboards and administering insulin without ensuring that the pens were labeled according to manufacturer instructions. In several instances, insulin pens in active use lacked either an open date, a discard date, or both. This was confirmed through direct observation of medication administration and inspection of medication storage areas, where multiple insulin pens for different residents were found without the required labeling. Interviews with nursing staff and the director of nursing revealed that the facility's protocol required staff to label insulin pens with both open and discard dates once removed from refrigeration, in accordance with manufacturer guidelines. Staff acknowledged that insulin pens not properly dated should be discarded and replaced, and that it was not appropriate to administer insulin without verifying expiration dates. Review of the facility's Medication Administration Protocol further confirmed the expectation that medications, including insulin, be labeled with open and discard dates and checked for expiration prior to administration.
Failure to Revise Care Plan After Resident Elopement
Penalty
Summary
The facility failed to revise the care plan for a resident who experienced an actual elopement event. The resident, who had severe cognitive impairment due to Alzheimer's dementia, delirium, and disorientation, was observed exiting the building without staff knowledge. Although the resident was wearing a WanderGuard bracelet, the door did not lock, and the alarm did not sound as expected. The resident was found approximately 10 feet from the door after another resident notified the staff. Despite the incident, the care plan was not updated to include new interventions to prevent future elopements. Interviews with facility staff revealed a lack of awareness regarding the resident's elopement. A registered nurse and a nursing assistant both reported measures they typically take to monitor the resident, such as keeping doors closed and offering diversions, but neither was aware of the actual elopement event. The director of nursing acknowledged that the care plan should have been updated to reflect the elopement and implement new preventive measures, but it was not done. The facility's policy requires care plan revisions when a resident's condition changes, which was not adhered to in this case.
Insulin Administration Error Due to Lack of Competency Verification
Penalty
Summary
The facility failed to administer insulin according to physician orders and manufacturer instructions for a resident who was administered the wrong insulin. The incident involved a resident with a medical history of Alzheimer's, dementia with psychotic disturbance, depression, and diabetes. The resident was scheduled to receive 36 units of Basaglar, a long-acting insulin, but was mistakenly given 36 units of Fiasp, a short-acting insulin. The error was identified by the staff nurse during documentation, who then reported the incident to the resident's primary provider. The provider instructed the staff to monitor the resident's blood sugar levels. The resident did not experience any side effects from the incorrect insulin administration. The facility's Medication Administration Protocol policy requires nursing staff to follow medication rights, including verifying the right medication, dose, route, time, and ensuring the medication has not expired. However, the facility lacked a formal checklist to ensure licensed nurses were deemed competent in insulin administration upon hire or annually. The Director of Nursing acknowledged that there were no accessible records of employee training or competencies related to insulin administration, and training was conducted on the job by nurse managers. Although in-service training sessions on insulin administration were held, the facility did not conduct audits to ensure compliance with the protocol.
Failure to Assess, Monitor, and Treat Pain After Resident Fall
Penalty
Summary
A resident with diagnoses including parkinsonism, dementia, and primary progressive aphasia experienced a fall that was not witnessed by staff. The resident was found on the floor and initially assessed by staff, who noted a red area on the right lower back but did not identify or document any pain at that time. The resident was dependent on staff for all activities of daily living and was at high risk for falls due to balance problems and poor communication abilities. Following the fall, there was no further monitoring or assessment for injuries for nearly 14 hours. During the night following the fall, the resident began to display and report severe pain, including vocal complaints and facial grimacing, particularly during personal care activities. Despite these clear indicators of pain, the night shift LPN did not reassess the resident, provide pain relief, or notify the physician. Communication between staff was inadequate, as the night shift nursing assistant was not informed of the fall, and the LPN failed to document or report the incident and the resident's pain to the oncoming shift. The resident's pain was not comprehensively assessed, and no additional pain medication was administered beyond the scheduled dose of Tylenol prior to the fall. It was not until the following morning that the day shift LPN was notified of the resident's pain and conducted an assessment, which led to physician notification and subsequent hospital transfer. The resident was diagnosed with a right hip fracture requiring surgical repair. The facility's policies on pain management, fall assessment, and notification of changes in condition were not followed, as evidenced by the lack of timely assessment, documentation, and communication after the fall and during the period when the resident was experiencing significant pain.
Failure to Notify SMHA of New Mental Illness Diagnoses
Penalty
Summary
The facility failed to notify the county (designated state mental health authority (SMHA)) when a resident had a new onset of mental illness since admission. The resident's annual Minimum Data Set (MDS) assessment identified diagnoses of delusional disorders, paranoid schizophrenia, obsessive-compulsive disorder, depression, and anxiety. The pre-admission screen (PAS) initially identified that the resident did not have a major mental disorder diagnosable under the Diagnostic and Statistical Manual of Mental Disorders (DSM). However, the resident's current diagnosis list showed new diagnoses of schizophrenia and obsessive-compulsive disorder, and a new delusional disorder. The medical record lacked any indication that the SMHA had been notified of these new diagnoses. Interviews with the social service designee and the administrator revealed that there was no process in place to ensure notification of new mental illness diagnoses, despite the facility's policy requiring the social worker or director of nursing to contact Senior Linkage for a new PASARR referral.
Failure to Revise Care Plan for Resident with Peripheral Edema
Penalty
Summary
The facility failed to revise the care plan for a resident with peripheral edema and a diagnosis of cardiomyopathy. The resident was admitted with multiple diagnoses including diabetes, an implantable cardiac defibrillator, and hypertensive heart disease. Despite observations and documentation indicating significant edema and weight gain potentially related to fluid retention, the care plan did not include interventions for managing edema. The resident's psychosocial note indicated she had agreed to try some interventions for her leg edema, but these were not reflected in the care plan. Observations over several days showed the resident with 4+ edema in her feet and ankles, often seated with her feet on the floor and not using support stockings or a foot stool, which she reportedly refused to use due to fear of falling. Interviews with nursing staff confirmed the resident's non-compliance with recommended interventions such as leg elevation and wearing compression stockings. The Director of Nursing acknowledged that the care plan did not address the problem of peripheral edema, a known side effect of cardiomyopathy, and confirmed that it should have been updated to include monitoring and interventions for edema and weight changes. The facility's policy required care plans to be individualized, comprehensive, and reviewed monthly, with revisions made as needed to address current problems, which was not adhered to in this case.
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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