Madison Healthcare Services
Inspection history, citations, penalties and survey trends for this long-term care facility in Madison, Minnesota.
- Location
- 900 Second Avenue, Madison, Minnesota 56256
- CMS Provider Number
- 245382
- Inspections on file
- 24
- Latest survey
- January 27, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Madison Healthcare Services during CMS and state inspections, most recent first.
A resident with malnutrition, Parkinson’s disease, and a feeding tube had provider orders for scheduled tube feedings and free water flushes to maintain weight within a target range. Over multiple days, staff documented that tube feedings and flushes could not be administered because the MIC-KEY extension tubing had been thrown away or was otherwise unavailable, and supplies were not in stock. Despite repeated notes that feedings were not given and that the G-tube was not utilized, there was no timely documentation that a provider was notified of this significant interruption in ordered treatment or of the resident’s associated weight loss. The resident’s weight declined from a previously stable range around 110–112 lbs to approximately 101 lbs and then 100.5 lbs, and the resident reported feeling weak and very unwell. Interviews with staff, the DON, the dietician, the physician, and the resident’s family confirmed that tube feedings had been missed for an extended period due to missing equipment and that the physician was not informed until after the resident was evaluated in clinic and the weight loss was identified, in contrast to facility policy requiring prompt physician and family notification when treatment is significantly altered.
A resident with severe protein-calorie malnutrition, weight loss, and a feeding tube had provider orders for regular diet, scheduled enteral formula, free water flushes, and frequent weights, but staff repeatedly failed to administer ordered tube feedings and flushes and did not consistently obtain ordered weights. For an extended period, MIC-KEY tube extensions needed for feeding were missing after being discarded, and no replacements were available, yet the dietitian and providers were not promptly notified that enteral feedings could not be given. During this time, the resident’s oral intake was poor, breakfast was consistently refused, and staff observations showed limited encouragement of fluid intake. Central supply reported that MIC-KEY connectors were not routinely stocked and depended on nurses requesting orders, and nursing staff acknowledged they should have contacted the on-call provider and nursing leadership when they realized supplies were unavailable. The resident’s weight dropped from the previously stable range to below 100 lbs, and documentation and interviews linked this decline, malnutrition, and weakness to the lack of ordered tube feedings, inadequate monitoring of intake and weights, and failure to follow facility policies for change in condition and tube feeding management.
A resident who required maximum assistance and had limited mobility was left without access to a call light while seated in a wheelchair during breakfast. Staff failed to follow the care plan and facility policy, resulting in the resident being unable to request help for over an hour. Family members and the resident reported this was a recurring issue, and staff were unaware of the oversight.
A resident with heart failure and a hip fracture, who required significant assistance and had contractures affecting nutrition, experienced persistent dry mouth. Despite recommendations from a dentist and documentation in progress notes, staff did not contact the provider or obtain medication for xerostomia. Interviews with the resident, family, RN, and DON confirmed the lack of follow-up, and the facility lacked a policy for notifying providers of such recommendations.
A resident with a surgical hip incision did not receive ongoing wound monitoring and care as ordered, particularly after returning from a hospital stay for an abscess. Nursing staff failed to document or perform dressing changes and wound assessments according to provider orders, and the DON was unaware of the missed care. Facility policy requiring regular skin assessments was not followed.
The facility failed to ensure annual Alzheimer's training for key staff, including the administrator, DON, RNs, and a TMA, and did not provide initial training for a newly hired NA. This oversight was acknowledged by the DON, who noted the facility's plans to address the issue with new education software.
A resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's and depression, was prescribed olanzapine, an antipsychotic medication. The facility failed to conduct the required AIMS assessment to monitor for involuntary movements, as per their policy. Interviews with staff confirmed the oversight, highlighting a lapse in following the facility's Psychotropic Drug Monitoring policy.
A resident's room contained an unsecured oxygen tank, contrary to facility protocol. The resident, who had multiple health conditions, was unaware of the issue. Staff interviews confirmed that oxygen tanks should be secured, and the DON acknowledged the oversight. The facility lacked a current policy for oxygen use.
Failure to Notify Physician of Prolonged Interruption in Enteral Nutrition
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician in a timely manner when ordered enteral nutrition and water flushes were not administered due to missing MIC-KEY extension tubing, resulting in multiple missed tube feedings for a resident. The resident was cognitively intact and had diagnoses including anemia, malnutrition, depression, Parkinson’s disease, and chronic vascular intestinal disorders. The resident’s care plan and provider orders directed that tube feedings and free water flushes be administered on specific days of the week, with daily or scheduled weights and provider notification of notable changes. Despite these orders, the EMAR/TAR showed that seven scheduled tube feedings and associated 30 ml water flushes were not given between late December and early January. Progress notes documented that on multiple dates staff were unable to administer tube feedings, water flushes, or check residuals because the MIC-KEY extension tubing was missing or had been thrown away and no replacement was available. Entries on several days indicated there were no MIC-KEY extensions in the room, no supplies available, and that supplies were on order, with repeated notations that tube feedings could not be given. During this period, the G-tube was not utilized, and staff documented ongoing inability to administer enteral feeds due to lack of equipment. The facility’s central supply process required nurses to write needed supplies on a tablet in the medication room, and MIC-KEY connections were a special-order item not kept in stock, requiring staff notification to the purchasing nurse. During this same timeframe, the resident experienced weight loss from previously documented weights around 110–112 lbs to approximately 101 lbs and then 100.5 lbs, and the resident reported feeling freezing cold, weak, and like she was dying, leading to an ER visit. The record lacked evidence of provider notification about the missed tube feedings and associated weight loss until a clinic visit with an NP, when it was reported that the resident had not received tube feedings for about 10 days due to the missing connector. Interviews with the DON and LPN staff confirmed that the MIC-KEY connector had been thrown out on Christmas Day, that the written request on the order tablet was missed, that supplies were not received until early January, and that staff would have been expected to notify a provider when unable to administer tube feedings. The facility’s “Change in Condition of Resident” policy required physician and family notification when treatment needed to be significantly altered, with documentation of such notifications in the medical record, but the resident’s record did not show timely physician notification of the missed enteral nutrition. Interviews with the resident, family member, dietician, and physician further described the circumstances leading to the deficiency. The family member reported being informed by staff that the resident had not received tube feedings since Christmas due to a missing connector and that a similar issue had occurred previously for 10 days. The dietician stated the resident’s oral intake was not adequate and that the feeding tube was needed to keep the resident nourished. The physician later learned that a part had been thrown out, that tube feedings could not be administered, and that the resident’s weight had dropped below 100 lbs, and stated she would have expected immediate notification so that additional orders could be given. Despite these conditions and repeated documentation of missed feedings due to lack of equipment, there was no timely documentation of physician notification as required by facility policy, leading to the cited deficiency for failure to notify the physician of a significant change in treatment and missed enteral nutrition. The facility’s own policy on change in condition emphasized that nursing judgment must be applied on a case-by-case basis and that staff must contact the physician and notify family when there is a need to significantly alter treatment, including discontinuation of an existing treatment. The ongoing inability to provide ordered tube feedings and water flushes due to missing MIC-KEY extension tubing constituted a significant alteration in treatment, yet the medical record did not reflect timely physician or family notification during the period when feedings were not administered. Only later, after the resident’s weight loss was identified at an outside appointment and after the family raised concerns, was the provider formally notified of the missed tube feedings. This sequence of events, combined with the documented missed feedings and lack of timely notification, formed the basis of the deficiency.
Failure to Provide Ordered Tube Feedings and Hydration Due to Missing Equipment and Poor Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to recognize, evaluate, and address a resident’s nutrition and hydration needs, including failure to administer ordered enteral feedings and water flushes due to missing equipment. The resident had intact cognition, severe protein-calorie malnutrition, abnormal weight loss, muscle weakness, and intestinal disorder, and was care planned to receive tube feedings, free water flushes, and regular diet with monitoring of caloric and fluid intake and weekly weights. Provider orders specified a regular easy-to-chew diet, scheduled tube feedings with a calorically dense formula several times per week, and free water flushes, with later updates increasing tube feeding frequency and initiating daily weights due to weight loss. Despite these orders, the electronic MAR/TAR showed multiple missed doses of the tube feeding formula and free water flushes, as well as some refusals, and the facility did not consistently document or obtain weights as ordered. From late December through early January, the resident’s tube feedings were not administered for an extended period because MIC-KEY tube extensions needed for feeding were thrown away and no replacements were available. Progress notes documented that from 12/25 through 1/8, the MIC-KEY tube extensions were missing, and on 1/8 it was noted that the extension was still not available and the resident would not drink the supplement orally. During this same period, the resident’s oral intake was poor, with breakfast consistently refused and variable intake at lunch and supper, and the resident experienced significant weight loss, with weights dropping from around 108–109 lbs in mid-December to approximately 99–100 lbs by early January. Weights ordered three times weekly and later daily were not consistently obtained, with several dates lacking documented weights despite active orders related to malnutrition and weight loss. Staff interviews and documentation revealed that the dietitian, MD, and NP were not promptly informed that tube feedings could not be given due to the missing MIC-KEY connection, and the dietitian was unaware that staff were unable to locate the proper equipment. The dietitian stated that the resident’s oral intake alone had not met nutritional needs for several months and that tube feedings were needed to maintain weight, and that staff should have notified her or the providers if the connection piece was unavailable for more than two days. The MD and NP both stated they would have expected nursing staff to notify a provider immediately when tube feedings could not be administered or were repeatedly refused, and the MD noted that the resident’s weight became concerning when it dropped below 100 lbs. Central supply reported that MIC-KEY connections were not routinely stocked, that ordering depended on nurses notifying purchasing, and that she had not been informed they were out of the connection piece. Nursing staff acknowledged that they should have contacted the on-call provider and nursing leadership when they realized on 12/25 that they lacked the proper supplies to administer tube feedings, especially given the resident’s poor oral intake, shingles, UTI, and noticeable weight loss. Observations further showed that staff did not consistently promote or assist with fluid intake. During one observation, a nursing assistant placed a 450 ml mug of water next to the resident without offering a drink and left the room. The resident reported being unable to remember if she had received tube feedings, acknowledged sometimes refusing them, and stated she wanted to continue receiving them because she could not eat enough to maintain her weight. The dietitian described that when the resident was well nourished, her mood and participation improved, and that when her weight dropped under 100 lbs, outcomes such as quality of life, longevity, muscle mass, and health were affected. Facility policies required notification of providers for significant changes in treatment and specified that tube feedings be flushed with 30 ml sterile water before and after each feeding, but the facility did not follow these policies in relation to the resident’s missed tube feedings, missing equipment, and declining nutritional status. The resident’s clinical course during this period included an ER visit for generalized weakness, with findings of tachycardia, weight of 105 lbs, and urinalysis abnormalities suggestive of infection, followed by a diagnosis of generalized weakness and instructions to follow up with the primary provider. Subsequent provider evaluation documented weight loss since the ER visit and revealed that tube feedings had not been given for 10 days due to the missing connector. The NP documented concern about weight changes, inability to provide tube feedings due to the lost connection part or refusals, and lack of timely notification to the provider. Family reported being told that the resident had previously missed tube feedings for 10 days in an earlier month for the same reason and that the resident’s primary source of nutrition and fluids was the tube feeding because she could not eat or drink enough by mouth to meet her needs. Throughout this time, the facility failed to ensure the availability of necessary enteral feeding equipment, failed to administer ordered tube feedings and water flushes, failed to consistently monitor and document weights and intake as ordered, and failed to promptly notify the dietitian and providers of the inability to carry out the ordered nutrition and hydration regimen, resulting in significant weight loss, malnutrition, and weakness as documented in the record.
Failure to Ensure Call Light Accessibility for Resident Requiring Maximum Assistance
Penalty
Summary
The facility failed to ensure that a resident's call light was accessible as required by the care plan and facility policy. The resident, who was cognitively intact and required maximum assistance with bed mobility, transfers, and toileting due to diagnoses including heart failure and a hip fracture, was observed sitting in a wheelchair during breakfast without access to her call light. The call light was attached to the bedside railing, out of the resident's reach, and the resident reported being unable to find it. The resident stated that staff often forgot to provide her with the call light when she was in her wheelchair, and she sometimes had to yell for help. Family members also reported multiple occasions where they had to provide the call light to the resident because staff did not do so, specifying that the call light should be placed across the resident's chest in bed and attached to the wheelchair handle when seated. Staff interviews revealed that nursing assistants were unaware they had not provided the call light to the resident during breakfast, believing they had done so after assisting her into the wheelchair. The director of nursing was also unaware that the resident had been without her call light for over an hour. Facility policy required that the call light be within easy reach of residents when in bed or confined to a chair, but this was not followed in the observed instance, resulting in the resident being unable to summon assistance as needed.
Failure to Follow Up on Provider Recommendations for Xerostomia
Penalty
Summary
A deficiency occurred when the facility failed to ensure that provider recommendations were followed up on in a timely manner for a resident with significant medical needs. The resident, who was cognitively intact and had diagnoses including heart failure and a hip fracture, required maximum assistance with mobility and toileting. The resident's care assessments identified contractures and limited range of motion that could impact nutritional status. Progress notes documented that the resident experienced a very dry mouth, which was noted as potentially contributing to dental decay and discomfort. Recommendations were made to assist with oral care and to have the medical doctor address the resident's xerostomia (dry mouth). Despite these recommendations, there was no documentation that the resident received any medication for xerostomia, and interviews with the resident, family members, and staff confirmed that no action had been taken to address the dentist's recommendation. The registered nurse acknowledged that the provider had not been contacted regarding the recommendation, and the director of nursing was unaware of the dentist's input. The facility did not have a specific policy for notifying providers of such recommendations, contributing to the lack of follow-up.
Failure to Perform Ongoing Wound Monitoring and Care
Penalty
Summary
A resident with a history of heart failure and hip fracture, who was cognitively intact and required maximum assistance with mobility and toileting, was admitted with a surgical incision on the left hip. The care plan did not include documentation regarding wound care, despite physician orders specifying Mepilex dressing changes every two to three days. The electronic health record (EHR) and treatment administration record indicated dressing changes were performed every three days, but there was a lack of ongoing wound assessment documentation, particularly after the resident returned from a hospital stay for an abscess and active drainage at the surgical site. Interviews revealed that nursing staff did not assess or change the dressing as ordered after the resident's hospital readmission, and the director of nursing was unaware of this lapse. Observations confirmed that wound assessments and dressing changes were not consistently documented or performed according to provider orders. Facility policy required head-to-toe skin assessments upon admission and readmission, with weekly follow-up, but these were not documented for the resident after their return from the hospital.
Deficiency in Alzheimer's Training for Staff
Penalty
Summary
The facility failed to ensure that five out of eight staff members, including the administrator, DON, two RNs, and a TMA, received annual training on Alzheimer's disease and related disorders. Additionally, a newly hired nursing assistant did not receive initial training on Alzheimer's disease or related disorders. The personnel files of these staff members showed that while they had completed training on ADL care, communication needs, and behaviors, there was no record of annual training on Alzheimer's disease and related disorders. This deficiency had the potential to affect all residents in the facility. The facility's July 2024 assessment indicated a commitment to providing necessary training and verifying staff competencies upon orientation, annually, and as needed. However, during an interview, the DON acknowledged the lapse in training, noting that the facility had previously received a grant to facilitate training but had not purchased the course on an annual basis. The facility was in the process of acquiring new education software for the upcoming year. Despite a request, the facility did not provide a copy of its In-service Training policy.
Failure to Conduct AIMS Assessment for Resident on Antipsychotic
Penalty
Summary
The facility failed to complete an Abnormal Involuntary Movement Scale (AIMS) assessment for a resident who was administered an antipsychotic medication. The resident, who had diagnoses of non-traumatic brain dysfunction, Alzheimer's disease, and depression, was identified as having severely impaired cognition and required assistance with daily activities. On a specific date, the resident received a new diagnosis of severe recurrent major depressive disorder with psychotic features and was prescribed olanzapine, an antipsychotic medication. Despite the facility's policy requiring an AIMS assessment upon the initiation of an antipsychotic, no such assessment was completed for the resident. Interviews with the MDS coordinator and the pharmacist consultant revealed that the facility's policy mandated an AIMS assessment at the start of antipsychotic medication, with subsequent assessments scheduled 30 days later and with any dosage changes. The MDS coordinator confirmed that the resident's chart lacked an AIMS assessment, and the pharmacist consultant emphasized the importance of the assessment in monitoring for extrapyramidal side effects. The facility's Psychotropic Drug Monitoring policy outlined the need for AIMS assessments at baseline, with new medications or dosage changes, and at six-month intervals, none of which were adhered to in this case.
Unsecured Oxygen Tank in Resident Room
Penalty
Summary
The facility failed to ensure the safety of a portable oxygen tank for a resident, identified as R21, who was alert and oriented. During an observation, it was noted that one of the two oxygen tanks in R21's room was unsecured and resting on the floor. R21, who had been admitted to the facility in August 2024 with multiple diagnoses including pulmonary fibrosis and COPD, reported that the oxygen tanks were routinely left in his room for use when needed. He was unaware that the unsecured tank posed a problem. Interviews with facility staff, including an LPN and the DON, confirmed that oxygen tanks should not be left unsecured in resident rooms. The LPN stated that tanks not in use should be stored in the oxygen supply closet or secured in a cart or wheelchair holder. The DON acknowledged the unsecured tank in R21's room and confirmed it was against facility protocol. Additionally, the facility did not have a current policy for oxygen use in the LTC setting.
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 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 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 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 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 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 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 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 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 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 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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