Kittson Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Hallock, Minnesota.
- Location
- 1010 South Birch Ave, Hallock, Minnesota 56728
- CMS Provider Number
- 245247
- Inspections on file
- 22
- Latest survey
- June 11, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Kittson Healthcare during CMS and state inspections, most recent first.
A resident with blindness and multiple comorbidities, identified as a fall risk and care planned for contact guard assist, was ambulating with a cane and staff supervision when she lost balance and fell, resulting in a left arm fracture. Staff did not use a gait belt or maintain close proximity as required by the care plan, and interviews confirmed confusion about assistance levels. The facility's policy did not explicitly require gait belt use for all transfers or ambulation, contributing to the incident.
A resident identified as DNR in facility records and who verbally confirmed their DNR preference did not have a signed advanced directive in their medical record. The DON confirmed the required documentation was missing and could not provide the facility's policy on advanced directives.
A resident who was independent with bed mobility and transfers was observed using half bed rails, but the facility did not complete a comprehensive assessment or obtain informed consent for their use. Staff interviews confirmed that no assessment was performed, as the rails were considered adaptive equipment rather than restraints, despite facility policy requiring documentation and assessment.
A resident with diabetes did not receive insulin according to manufacturer instructions when an LPN failed to prime the insulin pen with 2 units before administration. The LPN attached a new needle but did not perform the required priming step, contrary to facility policy and manufacturer guidelines. This was confirmed through observation, staff interviews, and review of the facility's insulin administration policy.
The facility did not provide the latest CDC education on vaccine risks and benefits or offer the most recent pneumococcal vaccines to several residents. Documentation was lacking regarding whether residents received required vaccine information or were offered the newer PCV20 or PCV21 vaccines, and staff interviews confirmed there was no process to re-evaluate vaccination status outside of annual reviews.
The facility did not include the daily resident census on the nurse staffing posting, despite displaying other required staffing information. The census was omitted on nearly all reviewed days, and staff confirmed they were not trained or instructed to include it. The census was only recorded in a non-public area, making it inaccessible to residents and visitors.
The facility failed to implement timely transmission-based precautions and confirmatory testing for COVID-19 for residents displaying symptoms, as per CDC guidelines. Additionally, enhanced barrier precautions were not used for a resident with an indwelling catheter. The facility's infection control log lacked details on test types and isolation measures, and staff were not instructed on proper PPE use for catheter care.
The facility failed to ensure unlicensed personnel did not administer injectable medications, violating state requirements, and omitted medications during medication pass for several residents. A CCMA administered insulin injections, which should have been done by licensed professionals. Additionally, medications were not administered as ordered, with some remaining in the medication cart despite being signed off. The DON acknowledged these as medication errors and was attempting to improve medication tracking.
The facility failed to date opened prescription eye drops, risking the use of expired products for three residents. During a review, it was found that the open vials of latanoprost on a medication cart lacked recorded open dates. The RN acknowledged that staff often forget to date medications, and the DON confirmed that not all staff were following the policy. The facility's policy required discarding latanoprost 42 days after opening, but without open dates, compliance was not possible.
A facility failed to implement antibiotic stewardship protocols for a resident with a UTI. The infection control log did not specify the organism identified in urine cultures, and the resident's medical record lacked evidence of culture results to ensure the correct antibiotic was prescribed. Staff interviews revealed gaps in processes, including lack of orientation for an RN and inadequate documentation of culture results. The facility's Antibiotic Stewardship Policy was not followed in this case.
A resident with severe cognitive impairment was left exposed in their room, visible from the hallway, due to staff inaction. Despite multiple staff members passing by, the resident remained uncovered for several minutes. The facility's policy emphasizes maintaining resident dignity and privacy, which was not upheld in this instance.
A resident with severe cognitive impairment was improperly restrained in a recliner by a nursing assistant to prevent wandering. The resident's wheelchair was moved out of reach, restricting self-transfer, which violated the facility's restraint-free policy. Video evidence and staff interviews confirmed the incident, revealing a misunderstanding of restraint use among staff.
The facility failed to report an incident where a resident with cognitive impairment was handled roughly and restrained by a nursing assistant. Additionally, an injury of unknown origin on another resident was not reported, despite being in a suspicious location. The facility's policy requires immediate reporting of such incidents, but these were not reported to the appropriate authorities.
A facility failed to investigate allegations of rough treatment and the use of a recliner as a restraint for a resident with severe cognitive impairment. Additionally, the facility did not report or investigate an injury of unknown origin for another resident, violating its own policies on abuse and injury investigation.
A resident with severe cognitive impairment and bladder cancer experienced a skin tear on the scrotum, which the facility failed to properly assess and address. Despite being at risk for pressure ulcers and frequently incontinent, the resident's care plan was not updated, and staff were unaware of the injury. Observations showed improper handling during transfers, and interviews revealed a lack of communication and follow-through in wound care, leading to inadequate interventions and oversight of the resident's condition.
A resident with severe cognitive impairment and hemiplegia was at risk for pressure ulcers, yet the facility failed to consistently implement prescribed interventions. Observations showed the resident wearing fuzzy slippers instead of heel protectors, and their heels were not properly offloaded. Staff interviews confirmed the care plan was not followed, and a policy on pressure ulcer care was not provided.
A nursing assistant improperly transferred a resident with severe cognitive impairment, using a recliner as a restraint and failing to use a gait belt, leading to unsafe conditions. Additionally, another resident with severe cognitive impairment was not adequately supervised, resulting in aimless wandering and potential safety risks. Staff failed to intervene appropriately in both cases, highlighting deficiencies in the facility's transfer and supervision practices.
A resident with dementia became agitated and aggressive when a nursing assistant attempted to remove a banana from his wheelchair, contrary to his care plan directives. The incident, captured on video, showed the assistant's approach escalated the situation, leading to physical aggression from the resident. The facility lacked a policy on dementia care.
A resident with multiple diagnoses, including cancer and Parkinson's disease, did not have a physician-prescribed Tramadol taper order implemented, leading to continued urinary retention issues. Despite a pharmacy consultant's recommendation and the physician's signed order, the medication dosage was not reduced due to communication and system issues within the facility.
Failure to Use Gait Belt During Ambulation Results in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to use a transfer (gait) belt during ambulation for a resident identified as being at risk for falls. The resident, who was blind and had diagnoses including type 2 diabetes and hypertension, required partial to moderate assistance for walking and was care planned for contact guard assist (CGA) or stand by assist (SBA) with one staff for all mobility. Documentation and care plans indicated that a gait belt was to be used during ambulation, particularly when walking to dine. On the day of the incident, the resident was ambulating in a hallway with a cane and a nursing assistant providing SBA. The resident lost balance and fell, landing on her left side and sustaining a left arm fracture. Multiple staff interviews and a review of surveillance video confirmed that the resident was not wearing a gait belt and the nursing assistant was not in close proximity at the time of the fall, contrary to care plan directives and facility expectations. Staff interviews revealed confusion regarding the meaning of CGA and SBA, and it was acknowledged that a gait belt should have been used for safety. The facility's fall prevention policy outlined universal fall precautions and the need for individualized care plans for residents at risk of falls, but did not specifically direct staff to use a gait belt with all transfers or ambulation. The lack of adherence to the care plan and failure to use a gait belt directly contributed to the resident's fall and subsequent injury.
Failure to Maintain Signed Advanced Directive for DNR Status
Penalty
Summary
The facility failed to ensure that a signed copy of an advanced directive, specifically indicating whether to perform cardiopulmonary resuscitation (CPR) or to implement a do not resuscitate (DNR) order, was present in the medical record for one resident. Documentation including the resident's face sheet, care plan, and admission checklist identified the resident as DNR, and the resident verbally confirmed their wish for DNR status during an interview. However, the medical record did not contain a signed advanced directive by the resident or their representative and the provider. The DON confirmed that the process required a signed provider order and advanced directive upon admission, and that the resident was not listed as wanting CPR, but was unable to locate the required signed document. Additionally, a policy related to advanced directives was requested but not provided.
Failure to Assess and Document Bed Rail Use
Penalty
Summary
The facility failed to ensure that a resident with attached bed rails was comprehensively assessed for their use. The resident in question had no cognitive impairment and was independent with bed mobility and transfers, according to the quarterly Minimum Data Set (MDS), which also indicated that bed rails were not used. However, observations on two separate occasions showed that the resident had half bed rails up and locked on both sides of the upper half of the bed. The resident reported using the rails to reposition and assist with getting out of bed, and stated that the rails did not restrain movement. A review of the resident's medical record revealed a lack of assessment regarding entrapment risk, risk versus benefits, informed consent, bed dimensions in relation to the resident's height and weight, and documentation of alternatives attempted or contraindicated before installation. Interviews with facility staff, including the MDS coordinator and the DON, confirmed that no assessment was performed because the bed rails were considered adaptive equipment for mobility and transfers, not restraints. The facility's policy required documentation and assessment for bed rail use, but this was not completed in this case.
Failure to Prime Insulin Pen Prior to Administration
Penalty
Summary
A deficiency occurred when a licensed practical nurse (LPN) failed to administer insulin according to the manufacturer's instructions for a resident with diabetes. The resident, who was cognitively intact and had a diagnosis of diabetes, was prescribed Lantus and Novolog insulin at specific times throughout the day. During an observation of medication administration, the LPN prepared the Novolog insulin pen by attaching a new sterile needle but did not prime the pen with 2 units of insulin before administering the dose, as required by the manufacturer's instructions. The LPN stated she had been instructed that priming was only necessary on the initial use and had never primed the pen before subsequent injections. Further review revealed that the facility's policy, as well as the manufacturer's instructions for the insulin pen, required priming with 2 units before each injection to ensure accurate dosing. Another nurse confirmed that she always primed the pen by wasting 2 units before drawing up the prescribed dose. The director of nursing also stated that staff are instructed to always prime insulin pens prior to administration. The failure to follow these procedures resulted in the resident not receiving insulin in accordance with the manufacturer's instructions.
Failure to Provide Updated Pneumococcal Vaccine Education and Offer New Vaccines
Penalty
Summary
The facility failed to provide the most recent Centers for Disease Control (CDC) education regarding the risks and benefits of vaccinations and did not offer the most recent pneumococcal vaccines to three out of five residents reviewed for immunizations. Specifically, the medical records for these residents did not document whether they received the Vaccine Information Statements (VIS) or education about the risks and benefits of the pneumococcal vaccine. Additionally, there was no documentation indicating that these residents were offered or had accepted or declined the newer pneumococcal vaccines (PCV20 or PCV21), despite having received earlier versions of the vaccine in previous years. Interviews with nursing staff and the Director of Nursing revealed that while vaccination status is reviewed upon admission and annually during care conferences, there was no established process to re-evaluate current residents' pneumococcal vaccination status outside of these times. The facility's standing orders and policies referenced the use of older pneumococcal vaccines and did not address the newer recommendations. As a result, the facility did not ensure that current residents were consistently offered the most up-to-date pneumococcal vaccines or provided with the latest CDC educational materials as required.
Failure to Post Daily Resident Census on Nurse Staffing Information
Penalty
Summary
The facility failed to include the daily resident census on the nurse staffing posting, as required. Observations on multiple days showed that the nurse staff posting, displayed across from the nurse's station, included the date, shift hours, and the number of RNs, LPNs, and NAs with their total and actual hours worked, but consistently omitted the daily census. Review of postings from over a month revealed that the census was missing on 37 out of 38 days. Interviews with the health unit coordinator (HUC) and the director of nursing (DON) confirmed that neither had been documenting the census on the posting, as the HUC was not trained to do so and the DON had not enforced this requirement. The census was only recorded on a white board in the nurse's area, which was not visible to residents or visitors. No nurse staff posting policy was provided upon request.
Inadequate Infection Control and Precautions in LTC Facility
Penalty
Summary
The facility failed to implement timely transmission-based precautions and testing for COVID-19 according to CDC guidelines for four residents who were displaying COVID-19 symptoms. These residents exhibited symptoms such as cough, shortness of breath, and fever, yet were not placed in isolation after initial negative antigen tests. The facility's infection control log did not specify the type of COVID-19 test used, whether confirmatory tests were conducted, or if isolation was implemented. The Director of Nursing (DON) confirmed that symptomatic residents were not placed in isolation, as the facility did not want to isolate residents based on initial negative antigen tests. Additionally, the facility failed to implement enhanced barrier precautions for a resident with an indwelling catheter. The care plan for this resident did not include instructions for using personal protective equipment (PPE) during catheter care. A nursing assistant was observed performing catheter care without wearing a gown, and the DON admitted that staff had not been instructed on enhanced barrier precautions related to catheter care. The facility's policy on catheter care did not provide specific guidance on PPE use. The facility's policies and procedures were not aligned with CDC guidelines, which recommend confirmatory testing following a negative antigen test for symptomatic individuals and the use of enhanced barrier precautions for residents with indwelling medical devices. The DON and staff were unaware of these guidelines, leading to inadequate infection prevention and control measures for both COVID-19 and catheter care.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to ensure that unlicensed personnel did not administer injectable medications, which is inconsistent with state requirements. This deficiency was identified for four residents who received insulin injections. The certified clinical medical assistant (CCMA) administered insulin to these residents, despite state statutes requiring that injectable medications be administered only by licensed professionals such as physicians, physician's assistants, registered nurses, nurse practitioners, or licensed practical nurses. The CCMA believed that administering injections was within her scope of practice, as she was supervised by a registered nurse who was available in the building. Additionally, the facility failed to ensure medications were administered as ordered for three residents whose medications were omitted during medication pass. For instance, one resident's levothyroxine tablets were found in the medication cart, indicating they were not administered as signed off by the licensed practical nurse. Another resident's medication card was missing a tablet without any documentation of wastage, and a third resident's medication was not administered despite being signed off by the CCMA. These omissions were identified during observations of the medication cart and interviews with nursing staff. The facility's director of nursing acknowledged that extra or missing medications from resident medication cards constituted medication errors. The facility was aware of the issues with medication administration and was attempting to improve tracking of resident medications. The director of nursing had implemented a policy for nurses to initial and date each bubble on the medication cards when administering medications, but inconsistencies remained. The facility's policy on medication pass delivery emphasized the importance of following the six rights of medication administration, yet these standards were not consistently met.
Failure to Date Opened Eye Drops Leads to Potential Expired Medication Use
Penalty
Summary
The facility failed to ensure that prescription eye drops were dated when opened, which could lead to the administration of expired products. During an observation of the medication carts, it was found that the open vials of latanoprost for three residents did not have the date of opening recorded. This oversight was noted on one of the two medication carts reviewed. The registered nurse (RN-A) acknowledged that staff often forget to date the medications when opened, and was unsure when the eye drops had been opened, suggesting that new vials should be ordered. The director of nursing (DON) confirmed that the expectation was for staff to record open dates on medication bottles, but acknowledged that not all staff were complying with this policy. The facility had a significant number of new staff members, and efforts were being made to ensure they were properly trained. The facility's policy stated that latanoprost eye drops should be discarded 42 days after opening, and the manufacturer's guidelines indicated that once opened, the drops could be stored at room temperature for six weeks. However, the lack of recorded open dates on the medication vials meant that these guidelines could not be followed accurately.
Failure to Implement Antibiotic Stewardship Protocols
Penalty
Summary
The facility failed to implement antibiotic stewardship protocols for a resident identified as R4, who was taking an antibiotic for a urinary tract infection (UTI). The Nursing Home Infection Control Log, updated in April 2022, identified three residents diagnosed with UTIs in May 2024, including R4. However, the log did not specify the organism identified in the urine cultures. R4's medical record lacked evidence of the urine culture results to ensure the correct antibiotic was prescribed, and the facility was unable to provide a copy of these results. R4, who had a history of bladder cancer and chronic kidney disease, experienced recurring blood and blood clots in his urine. On May 3, 2024, R4 complained of pain, and a registered nurse (RN) obtained a verbal order for a urinalysis. The following day, R4 was confirmed to have a UTI, and an antibiotic, Augmentin, was prescribed and administered. However, the culture and sensitivity results, which confirmed sensitivity to Augmentin, were not documented in R4's medical record. Interviews with staff revealed gaps in the facility's processes. RN-A, who did not receive proper orientation, learned the facility's processes from travel nurses. The Director of Nursing (DON) stated that the infection control log did not include organisms due to lack of access to the clinic's electronic medical record system. The campus-wide Infection Preventionist (IP) followed the urine culture results but did not share them with the DON. The facility's Antibiotic Stewardship Policy, reviewed in February 2023, outlined the need for tracking and documenting antibiotic use, but these procedures were not followed in R4's case.
Resident Privacy Violation Due to Staff Inaction
Penalty
Summary
The facility failed to ensure the privacy and dignity of a resident, identified as R19, who was observed exposed from the hallway. R19, who had severe cognitive impairment and diagnoses including Alzheimer's disease and anxiety, was dependent on staff for all abilities. The care plan for R19 did not include measures to maintain his privacy. During an observation, R19 was seen lying in bed with his room door wide open, and his back, legs, and incontinent brief were visible due to bunched-up blankets and gown. Multiple staff members, including nursing assistants, walked past R19's room without addressing his exposure, although one eventually covered him after a delay. Interviews with staff revealed that it was expected for staff to check on residents and ensure their privacy by covering them if exposed. However, staff admitted to being preoccupied with other tasks or not noticing R19's condition. The Director of Nursing acknowledged the importance of care planning interventions to prevent such exposure and stated that staff had been educated on maintaining resident privacy. The facility's Quality of Life policy emphasized the importance of maintaining resident dignity and privacy, including keeping residents covered when outside their rooms.
Inappropriate Use of Recliner as Restraint for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as R13, was free from physical restraints. R13, who had severe cognitive impairment and exhibited wandering behaviors, was observed being placed into a recliner by a nursing assistant (NA-C) without consent. NA-C removed R13's wheelchair out of reach, effectively using the recliner as a restraint to prevent R13 from wandering. This action was witnessed by a registered nurse (RN-A) and was reported to the director of nursing (DON). The incident was corroborated by video surveillance, which showed NA-C placing R13 in a recliner and moving the wheelchair away, preventing R13 from self-transferring. Despite the facility's policy to keep residents restraint-free, staff, including NA-C, admitted to routinely placing wandering residents in recliners to prevent them from entering other residents' rooms. The DON acknowledged that moving the wheelchair out of reach constituted a restraint. Interviews with staff revealed a misunderstanding or disregard for the facility's restraint policy. The DON initially did not consider the recliner as a restraint and did not review the surveillance footage until later. The facility's policy defined physical restraints as any item that confined a person, including recliners, if the resident could not remove themselves independently. This incident highlighted a failure to adhere to the policy, resulting in the inappropriate use of a recliner as a restraint for R13.
Failure to Report Abuse and Injury of Unknown Origin
Penalty
Summary
The facility failed to report an allegation of rough treatment and the use of a recliner as a restraint for a resident identified as R13. R13, who had severe cognitive impairment and exhibited wandering behaviors, was reportedly handled roughly by nursing assistant NA-C. NA-C was observed grabbing R13 by the underarms and placing her into a recliner against her will, with the intent to prevent her from wandering. Despite witnessing the incident, RN-A did not ensure the incident was reported to the appropriate authorities, and the Director of Nursing (DON) did not investigate further, believing it to be a personal issue between staff members. Additionally, the facility failed to report an injury of unknown origin for another resident, R4, who had severe cognitive impairment and was at risk for pressure ulcers. R4 was found to have a skin tear in a sensitive area, which was not documented thoroughly in the medical record. The DON acknowledged that the injury should have been reported as it was in a suspicious location and the resident could not explain how it occurred. However, the injury was not reported to the State Agency as required by the facility's policy. The facility's policy on abuse, neglect, and injuries of unknown origin mandates immediate reporting of such incidents to the administrator and the Minnesota Department of Health. Despite this policy, the incidents involving R13 and R4 were not reported in a timely manner, highlighting a failure in the facility's adherence to its own procedures for ensuring resident safety and compliance with federal and state laws.
Failure to Investigate Allegations of Rough Treatment and Injury
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of rough treatment and the use of a recliner as a restraint for a resident with severe cognitive impairment. The incident involved a nursing assistant (NA-C) who was observed placing the resident into a recliner against her will to prevent wandering, which was witnessed by a registered nurse (RN-A). Despite RN-A's concerns and communication with the Director of Nursing (DON), no immediate investigation was initiated, and NA-C continued to work without any intervention. The facility did not review available video surveillance that captured the incident, which showed NA-C handling the resident roughly and not using proper transfer techniques. Additionally, the facility failed to report and investigate an injury of unknown origin for another resident who had a severe cognitive impairment. The resident was found to have a significant skin tear in a sensitive area, which was not documented or explained in the medical records. The injury was discovered during routine care, and staff were unable to determine how or when it occurred. The facility's policy required such injuries to be reported and investigated, but this was not done. The facility's lack of action in both cases violated its own policies on abuse and injury investigation. There was no evidence of staff interviews or protective measures taken for the residents involved. The DON acknowledged the oversight and the need for an investigation but failed to act promptly, leaving the residents without the necessary protection and care.
Failure to Address Skin Tear in Resident with Cognitive Impairment
Penalty
Summary
The facility failed to properly identify, assess, and implement interventions to promote skin integrity and healing for a resident with a skin tear on the scrotum. The resident, who had severe cognitive impairment and a diagnosis of bladder cancer, was at risk for pressure ulcers and frequently incontinent. Despite these risks, the care plan and interventions were not adequately followed or updated to address the resident's skin condition. Observations revealed that the resident was transferred using a standing lift, during which the removal of a soaked incontinent brief caused discomfort and potentially contributed to the skin tear. The brief was soaked with bloody urine and blood clots, which may have obscured the presence of the skin tear. Staff members, including nursing assistants and a licensed practical nurse, were unaware of the skin tear's existence or its cause, and the resident's medical record lacked comprehensive documentation of the injury. Interviews with staff indicated a lack of communication and follow-through regarding the resident's wound care. The Director of Nursing acknowledged that the incident slipped through the cracks, and the resident was not added to wound rounds or provided with appropriate interventions. The facility's Skin Breakdown Prevention Protocol was not adhered to, as weekly skin checks and documentation were not consistently performed, leading to the oversight of the resident's skin tear and inadequate care planning.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to implement appropriate interventions for preventing pressure ulcers for a resident identified as being at risk. The resident, who had severe cognitive impairment and conditions including hemiplegia and Alzheimer's disease, was noted to have a healing unstageable pressure injury on the left heel. Despite the care plan directing staff to use heel protectors while the resident was in bed, observations revealed that the resident was wearing fuzzy slippers instead of the prescribed heel protectors. Additionally, the resident's heels were observed resting on the mattress rather than being offloaded with a pillow as required. Staff interviews confirmed that the fuzzy slippers were incorrectly used as heel protectors, and the resident's care plan was not consistently followed. The LPN acknowledged that the resident should always wear heel protectors in bed to maintain skin integrity, especially given the resident's limited mobility. The director of nursing emphasized the importance of adhering to the care plan to prevent the recurrence of pressure injuries. A policy on pressure ulcer care and interventions was requested but not provided, indicating a potential gap in the facility's documentation and adherence to care protocols.
Deficiencies in Resident Transfer and Supervision Practices
Penalty
Summary
The facility failed to ensure safe resident transfer practices for a resident with severe cognitive impairment, identified as R13. The incident involved a nursing assistant, NA-C, who improperly transferred R13 by lifting her under the arms and placing her into a recliner against her will. This action was taken to prevent R13 from wandering in her wheelchair, which was used as a restraint. The transfer was conducted without the use of a gait belt, and the wheelchair brakes were not locked, posing a risk of falls. The incident was witnessed by RN-A, who intervened by asking another nursing assistant, NA-D, to transfer R13 back to her wheelchair. However, NA-C, visibly upset, proceeded to transfer R13 back to her wheelchair without proper technique, dragging R13's feet on the floor. The facility also failed to provide a safe environment and adequate supervision for a resident identified as R19, who had severe cognitive impairment and a history of wandering. R19 was observed moving aimlessly in his wheelchair in the common area, coming into close contact with a family member, FM-A, who had to push R19 away multiple times. Staff did not intervene during these interactions, and R19's movements were not redirected to prevent potential harm. Observations showed that R19's wheelchair bumped into furniture and other residents, yet staff did not take action to ensure R19's safety or the safety of others. The facility's policies on safe lifting and movement of residents, as well as elopement and wandering, were not adequately followed. The policy on safe lifting did not specify when gait belts should be used, and the wandering policy did not address maintaining safety for wandering residents within the facility. The Director of Nursing acknowledged the deficiencies, noting that staff failed to communicate effectively and did not intervene appropriately to safeguard the residents involved.
Failure to Follow Dementia Care Plan Leads to Resident Agitation
Penalty
Summary
The facility failed to provide appropriate dementia care interventions for a resident diagnosed with Alzheimer's disease and dementia with behavioral disturbances. The resident, identified as having moderate cognitive impairment, required assistance with daily activities and had a history of agitation and aggression, particularly when personal items were removed from his sight. The care plan for the resident included specific interventions to manage these behaviors, such as keeping the resident in line of sight when out of his room and removing items only when he was not present to prevent agitation. However, these interventions were not followed during an incident where a nursing assistant attempted to remove a banana from the resident's wheelchair, leading to the resident becoming agitated and physically aggressive. The incident was captured on video surveillance, showing the nursing assistant's inappropriate approach, which escalated the situation. The nursing assistant attempted to take the banana, which the resident perceived as a threat to his personal belongings, resulting in the resident grabbing and squeezing the assistant's arm. The assistant's response, including loud verbal exchanges, further aggravated the resident. The director of nursing acknowledged that the approach was not appropriate and that the care plan's directives were not followed. The facility did not provide a policy on caring for residents with dementia when requested.
Failure to Implement Physician-Prescribed Medication Taper Order
Penalty
Summary
The facility failed to ensure that a resident's physician-prescribed medication taper order was implemented, which did not meet professional standards of quality. The resident, who was moderately cognitively impaired and had multiple diagnoses including cancer, Parkinson's disease, and diabetes mellitus, was prescribed Tramadol for chronic back pain. Despite a pharmacy consultant's recommendation to taper the Tramadol dosage to address urinary retention issues, the order was not executed. The resident's pain was identified as mild and rarely impacted his daily activities, yet the medication taper was not implemented as prescribed by the physician. The pharmacy consultant recommended a reduction in Tramadol from three times a day (TID) to twice a day (BID) to potentially alleviate urinary retention, a side effect of the medication. This recommendation was documented and signed by the physician but was not acted upon. The physician expected the order to be processed, but it was not, leading to the resident continuing on the higher dosage of Tramadol. The Director of Nursing (DON) confirmed that the signed order was not processed and attributed the delay to a system glitch and communication issues between the medical staff. Interviews with the pharmacy consultant, the physicians involved, and the DON revealed that there was a lack of follow-through on the medication taper order. The DON acknowledged that the pharmacy review forms should have been returned and acted upon more promptly. The facility's policy on medication and treatment review was not adhered to, resulting in the resident continuing to receive a medication dosage that potentially contributed to his urinary retention issues.
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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