Mayo Clinic Health System - Lake City
Inspection history, citations, penalties and survey trends for this long-term care facility in Lake City, Minnesota.
- Location
- 500 West Grant Street, Lake City, Minnesota 55041
- CMS Provider Number
- 245218
- Inspections on file
- 28
- Latest survey
- December 4, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Mayo Clinic Health System - Lake City during CMS and state inspections, most recent first.
Two residents who required mechanical lifts for transfers did not receive comprehensive assessments to determine the correct sling or harness size, as required by manufacturer instructions. Instead, staff relied on weight-based charts and informal judgment, with no formal documentation or inclusion of sling size in care plans or Kardex. Multiple staff interviews confirmed the absence of a standardized assessment process and unclear responsibility for determining sling/harness size.
A resident with a history of stroke, cognitive impairment, and impulsivity experienced multiple unwitnessed falls, including one after being left unsupervised on the commode, resulting in two thoracic spinal fractures and hospitalization. The facility did not consistently analyze fall trends, update care plans with individualized interventions, or assess the required level of supervision, leading to actual harm.
A resident in a LTC facility was mistakenly given lisinopril, intended for another resident, by a new nurse on their first independent medication pass. The resident, with chronic kidney disease and hyponatremia, experienced dizziness, weakness, and hypotension, requiring emergency treatment. The facility's medication administration policy was not followed, leading to this significant error.
The facility failed to provide the required written SNFABN and NOMNC forms to three residents whose Medicare A coverage ended. The NOMNC and SNFABN for these residents lacked signatures from their representatives acknowledging receipt and understanding of the notices. The CSM confirmed responsibility for providing these notices but did not remember obtaining written signatures. The facility's policy requires these notices to be signed and dated to demonstrate receipt and understanding.
A facility failed to accurately complete the MDS for a resident with severe cognitive impairment and wandering behavior. The resident's quarterly MDS did not document wandering, despite a history of elopement attempts and increased wandering during delusional episodes. The MDS coordinator admitted to overlooking progress notes indicating the resident's attempts to leave the facility. The DON confirmed the importance of accurate MDS assessments for resident care and Medicare reimbursement.
A resident with chronic heart conditions did not receive Metoprolol Tartrate according to physician's orders, as staff failed to consistently check and document blood pressure and pulse before administration. Interviews with facility staff confirmed the oversight, highlighting the importance of these checks to prevent adverse effects. The facility did not provide a Medication Administration/Monitoring policy when requested.
A resident with a stage three pressure ulcer was not repositioned every two hours as required by their care plan, leading to a deficiency in care. Despite the resident's inability to reposition themselves and their preference to remain seated for activities, staff interviews and observations confirmed that the necessary repositioning was not consistently provided, contributing to stalled healing of the ulcer.
A resident with moderate cognitive impairment and dementia exhibited wandering and aggressive behaviors, but the facility failed to investigate and analyze the underlying causes. Despite interventions like verbal reminders and a wanderguard, the behaviors persisted. Staff interviews revealed a lack of documented analysis or comprehensive assessment, contrary to the facility's policy on behavioral health management.
A resident with dementia and delusional disorders experienced elopement attempts and behavioral issues. Despite provider orders for a psychiatric consult, the facility failed to schedule the appointment. Staff interviews revealed a lack of awareness and follow-up on the order, leading to a delay in securing necessary psychiatric care.
A resident with C-Diff was not properly managed during therapy sessions, as the therapist failed to change gloves after potential contamination and did not use PPE when entering the resident's room. Additionally, laundry staff did not wear gowns while handling soiled laundry, contrary to facility policy, increasing the risk of cross-contamination.
A resident was not offered the PCV20 vaccine despite being eligible, as the facility failed to ensure shared clinical decision-making and proper documentation. The resident, who had previously received PPSV23 and PCV13, was unaware of the PCV20 vaccine and expressed interest in receiving it. Interviews revealed that the facility's process for reviewing and offering vaccines was not followed in this case.
The facility failed to deliver mail to residents on weekends, affecting all residents who receive mail. Interviews revealed that mail was held until Monday due to the absence of staff to receive it on weekends. The activities director and receptionist confirmed the lack of weekend delivery, and the administrator noted that mail was delivered to an attached hospital, which stopped weekend delivery. No alternative arrangements were made, and a mail delivery policy was not provided.
Failure to Assess and Document Proper Sling/Harness Size for Mechanical Lift Transfers
Penalty
Summary
The facility failed to comprehensively assess and document the appropriate sling or harness sizes for residents requiring mechanical lifts for transfers, as required by manufacturer instructions. For two residents who utilized sit-to-stand and full-body mechanical lifts, there was no evidence of a formal assessment that included necessary measurements such as height, weight, distance from tailbone to base of neck, or torso circumference. Instead, staff relied primarily on the resident's weight and a laminated chart in the tub room to estimate sling or harness size, without documenting the specific size in the care plan or Kardex. Interviews with various staff members, including RNs, LPNs, nurse managers, and nursing assistants, revealed a lack of clarity and consistency regarding responsibility for assessing sling/harness size. Staff reported that there was no formal assessment process, and that the size was not routinely updated or included in care plans. Some staff indicated that therapy might be responsible for the assessment, while others believed it was the responsibility of nursing. The process described by staff involved using judgment and trial-and-error to determine if a sling or harness fit properly, rather than following a standardized assessment protocol. Manufacturer instructions for the mechanical lifts and slings used in the facility specify that a full patient assessment must be conducted to determine the appropriate accessory size and type prior to each use. The facility was unable to provide a policy or procedure for mechanical lift equipment, and documentation for the two residents reviewed did not include a Mechanical Lift Sling Assessment. The lack of a comprehensive and documented assessment process for determining sling/harness size led to the deficiency identified by surveyors.
Failure to Assess and Prevent Falls Resulting in Resident Harm
Penalty
Summary
The facility failed to assess or analyze trends in falls to determine causal factors or root causes and did not implement individualized interventions to prevent or reduce the risk of falls with major injuries for a resident who experienced multiple falls. The resident had a complex medical history, including a recent stroke with left-sided hemianopsia, hemiparesis, cognitive impairment, poor safety awareness, and impulsivity. Despite being identified as at moderate risk for falls and requiring extensive assistance with activities of daily living, the facility did not consistently update or revise the care plan with new interventions after each fall, nor did they conduct comprehensive assessments to determine the appropriate level of supervision needed, particularly during toileting and transfers. The resident experienced several unwitnessed falls, including incidents where he slid out of his wheelchair, attempted to self-transfer from bed to wheelchair, and was left unsupervised on the commode. Documentation revealed that after some falls, interventions were noted in progress notes but not incorporated into the care plan. There was also a lack of assessment regarding whether the resident could be left alone on surfaces other than the wheelchair, such as the commode or other chairs. Staff interviews indicated that therapy and nursing staff were aware of the resident's impulsivity and cognitive deficits, but there was no clear assessment or documentation regarding the level of supervision required during toileting tasks. Incident reports and fall scene investigations were incomplete or missing for several falls, and the facility's post-fall investigation process was not consistently followed. The director of nursing and nurse manager confirmed that fall huddle forms were not completed for all incidents, and root cause analyses were lacking, particularly regarding whether the resident's basic needs were met at the time of the falls. As a result of being left unsupervised on the commode, the resident suffered two thoracic spinal fractures and required hospitalization. The facility's failure to assess, analyze, and implement individualized interventions contributed to actual harm for the resident.
Medication Error Leads to Resident Harm
Penalty
Summary
The facility failed to ensure medications were administered to the correct resident, resulting in a significant medication error for one resident. The resident, who had intact cognition and diagnoses of chronic kidney disease stage 3b and hyponatremia, was mistakenly given lisinopril, a medication intended for another resident. This error occurred on the first day a new nurse was independently passing medications. The resident experienced immediate adverse effects, including dizziness, weakness, and hypotension, which required emergency medical treatment. The resident's blood pressure dropped significantly after receiving the incorrect medication, leading to symptoms such as dizziness, nausea, and blurred vision. The resident was sent to the emergency department for further evaluation and treatment, where they received intravenous fluids and albumin to address the hypotension. The resident's condition was closely monitored, and they experienced ongoing symptoms, including weakness and leg pain, following the incident. Interviews with staff revealed that the nurse responsible for the error was new and had not realized the mistake until the resident exhibited symptoms of hypotension. The facility's director of nursing confirmed that the error was significant due to the adverse effects experienced by the resident. The facility's medication administration policy requires that medications be administered as prescribed, with proper resident identification and adherence to the five rights of medication administration, which were not followed in this instance.
Removal Plan
- the facility completed an investigation and causal analysis
- RN-B was immediately re-educated and supervised
- provided education to licensed and unlicensed staff regarding giving medications as ordered and medication administration policy
Failure to Provide Required Medicare Notices
Penalty
Summary
The facility failed to provide the required written Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) and Notice of Medicare Non-Coverage (NOMNC) forms to three residents whose Medicare A coverage ended. For Resident 2, the NOMNC indicated that the community support manager (CSM) called the family member, who was also the power of attorney, to notify them of the end of skilled services and the beginning of financial liability. However, the NOMNC lacked the signature of the family member acknowledging the notification. The SNFABN also lacked a signature, and the family member stated they did not receive or sign any written notice. Resident 2's payer source changed from Medicare Part A to Private Pay, and they remained in the facility. Similarly, for Resident 162, the NOMNC and SNFABN lacked signatures from the power of attorney acknowledging receipt and understanding of the notices. The family member stated they never received or signed the notices and were unaware of the care level and associated costs. Resident 258's NOMNC also lacked a signature, and the resident was discharged from the facility. The CSM confirmed that she was responsible for providing these notices and acknowledged that she did not remember offering or obtaining written signatures for these residents. The facility's Medicare A Denial policy requires that the NOMNC and SNFABN be signed and dated by the resident or their representative to demonstrate receipt and understanding of the notices.
Inaccurate MDS Completion for Resident with Wandering Behavior
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) for a resident reviewed for wandering. The resident, identified as R26, had an admission MDS indicating severe cognitive impairment, physical and verbal behaviors, and wandering with no significant risk, with a Wanderguard in place. However, the quarterly MDS did not document wandering, despite the resident's history of elopement attempts and increased wandering during episodes of delusional thoughts. Progress notes from 3/20/24 to 3/27/24 indicated that on 3/22/24, the resident attempted to leave the facility multiple times, refused medications, and required redirection and 1:1 care. During an interview, the MDS coordinator acknowledged using a reference sheet to confirm assessment dates and stated that she referenced task documentation and progress notes during the assessment period. She admitted to overlooking the progress note dated 3/22/24, which documented the resident's multiple attempts to exit the facility. The director of nursing confirmed the importance of accurate MDS assessments for appropriate resident care and Medicare reimbursement. The facility's policy on the MDS/Careplan Process emphasized the need for comprehensive assessments to identify care needs and develop a plan of care.
Failure to Administer Medication Per Physician's Orders
Penalty
Summary
The facility failed to administer medications according to the physician's orders for a resident with multiple health conditions, including chronic heart failure, atrial fibrillation, hypertension, obstructive sleep apnea, and chronic obstructive pulmonary disease. The resident's physician had ordered Metoprolol Tartrate to be administered daily, with specific instructions to hold the medication if the resident's heart rate was below 50 or systolic blood pressure was below 100. However, the Medication Administration Record and Treatment Administration Record lacked documentation of the required blood pressure and pulse checks prior to administering the medication from May 17, 2024, to the present. Interviews with facility staff, including a trained medication aide, a registered nurse clinical manager, a consultant pharmacist, and the director of nursing, confirmed that the necessary monitoring was not consistently performed as per the physician's orders. The staff acknowledged the importance of these checks to prevent potential adverse effects, such as dizziness or dangerously low blood pressure, which could lead to life-threatening situations. Despite the expectation that these parameters be followed, the facility did not provide a Medication Administration/Monitoring policy and procedure when requested.
Failure to Reposition Resident with Pressure Ulcer
Penalty
Summary
The facility failed to provide timely assistance with repositioning for a resident, identified as R4, who had a stage three pressure ulcer. R4's care plan required repositioning every two hours while in bed or a wheelchair to promote healing and prevent further skin breakdown. However, observations revealed that R4 was left seated in a Broda chair for extended periods without repositioning, from 9:42 a.m. to 12:57 p.m., during which time R4 was moved only for lunch and toileting. Interviews with staff, including nursing assistants and a registered nurse, confirmed that R4 was unable to reposition herself and required staff assistance every two to three hours, as per the care plan. Despite this, R4 frequently refused to lay down, preferring to watch television and participate in activities, which contributed to the lack of repositioning. The report highlights that R4 had multiple medical conditions, including moderately impaired cognition, non-traumatic brain dysfunction, atrial fibrillation, heart failure, renal insufficiency, diabetes mellitus, non-Alzheimer's dementia, seizure disorder, depression, and muscle weakness. These conditions, along with the presence of a stage three pressure ulcer, increased R4's risk for further skin breakdown. The facility's failure to adhere to the care plan for repositioning, as confirmed by staff interviews and observations, resulted in a deficiency in providing appropriate pressure ulcer care for R4.
Failure to Investigate and Analyze Resident's Behavioral Health Needs
Penalty
Summary
The facility failed to adequately investigate, review, and analyze the underlying causes of a resident's anxiety and agitation. The resident, identified as R24, exhibited behaviors such as wandering, exit-seeking, and aggression, which were potentially harmful to himself and others. Despite these behaviors being documented in progress notes, there was a lack of comprehensive assessment and analysis to determine the triggers or underlying causes of these behaviors. R24 had a significant change in their Minimum Data Set (MDS), indicating moderate cognitive impairment and diagnoses including dementia, repeated falls, and malignant neoplasm of the prostate. The care plan identified R24 as at risk for wandering and elopement, with interventions such as verbal reminders and a wanderguard. However, these interventions were often ineffective, as evidenced by multiple incidents of wandering, exit-seeking, and aggression documented between 5/15/24 and 6/11/24. Interviews with staff revealed that while behaviors were discussed in interdisciplinary team (IDT) meetings, there was no documented analysis of the behaviors to identify potential causes. The facility's policy required individualized behavioral care plan interventions and regular reviews by the IDT team, but the medical record lacked evidence of such reviews or analyses. The deficiency highlights a failure to adhere to the facility's policy on mood and behavior management.
Failure to Follow Up on Psychiatric Consult for Dementia Resident
Penalty
Summary
The facility failed to follow up on provider orders for a resident diagnosed with dementia, delusional disorders, and anxiety. The resident, identified as R26, had a history of severe cognitive impairment, elopement attempts, and behavioral issues such as verbal aggression and threats. Despite having a care plan in place that included a wanderguard and medication adjustments, the facility did not ensure a psychiatric consult was scheduled as ordered by the provider. Interviews with staff revealed a lack of awareness regarding the psychiatric appointment, and the unit secretary admitted to not documenting or following up on the appointment scheduling process. The resident's progress notes indicated ongoing behavioral episodes, yet there was no documentation of an increase in these behaviors. The unit secretary recalled attempting to make the psychiatric appointment but was unable to do so due to the order being in review. No follow-up actions were taken until prompted by a nurse manager, leading to a delay in securing the necessary psychiatric consultation. The director of nursing acknowledged the importance of following up on provider orders for the proper healthcare of residents, but a policy for provider orders was not provided upon request.
Infection Control Deficiencies in Therapy and Laundry Handling
Penalty
Summary
The facility failed to ensure proper hand hygiene and use of personal protective equipment (PPE) during therapy sessions for a resident diagnosed with Clostridium difficile (C-Diff). The resident, who required moderate assistance with grooming and hygiene and was frequently incontinent of bowel, was observed in a therapy session where the physical therapist did not change gloves after touching potentially contaminated items. The therapist continued to assist the resident without changing gloves and did not adhere to contact precautions when entering the resident's room, despite clear signage indicating the need for gown and gloves. Additionally, the facility did not properly manage the sorting of soiled and potentially contaminated laundry, increasing the risk of cross-contamination. During a laundry tour, it was observed that laundry staff did not wear gowns while handling soiled laundry, including isolation gowns, which were frequently found loose in storage carts. The facility's policy required the use of gloves and gowns when handling contaminated laundry, but this was not followed, and there were no gowns available in the area for staff to use. Interviews with staff, including the infection preventionist and the director of nursing, confirmed that the observed practices were breaches in infection control. The infection preventionist acknowledged the need for staff to wear isolation gowns during laundry sorting to prevent contamination, and the director of nursing emphasized the importance of following infection control practices to prevent the spread of infection.
Failure to Offer Pneumococcal Vaccine to Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as R40, was offered and/or provided the pneumococcal vaccine series as recommended by the CDC. R40, who was over the age of 65, had previously received the PPSV23 vaccine in 2012 and the PCV13 vaccine in 2015. However, there was no evidence of shared clinical decision-making with the physician regarding the administration of the PCV20 vaccine, which should have been considered at least five years after the last pneumococcal dose. The immunization record lacked documentation of offering or providing education about the PCV20 vaccine to R40. Interviews with the infection preventionist and the registered nurse clinical manager revealed that the facility's process involved reviewing immunization records upon admission and discussing eligible vaccines with residents. However, in R40's case, the PCV20 vaccine was not addressed, and the resident was not informed about its availability. R40 confirmed that she was unaware of the third pneumonia vaccine and expressed interest in receiving it. The facility's policy indicated that residents should be offered pneumococcal vaccines according to CDC guidelines, but this was not adhered to in R40's case.
Failure to Deliver Resident Mail on Weekends
Penalty
Summary
The facility failed to ensure timely delivery of mail to residents on weekends, which has the potential to affect all residents who receive mail. Interviews with residents revealed uncertainty about mail delivery on Saturdays, with one resident stating that mail was delivered by the activities staff, and another indicating that mail was delivered to family members. The activities director confirmed that her department was responsible for mail delivery, but mail was not delivered on weekends as her staff occasionally worked on weekends and the mail was held until the following Monday. Further interviews revealed that the receptionist stated mail was not delivered on weekends due to the absence of staff at the desk to receive it, and the decision was made to hold mail to safeguard protected health information. The administrator explained that mail was delivered to an attached hospital and sorted by activities staff, but the hospital stopped weekend mail delivery, and the mailroom was locked on Saturdays. No alternative arrangements were made for weekend mail delivery, and a policy regarding resident mail delivery was requested but not provided.
Latest citations in Minnesota
A resident with dry eye syndrome and degenerative eye disease had orders for cyclosporine ophthalmic emulsion and Refresh Tears, both scheduled at the same time. Medication records and direct observation showed a TMA instilled cyclosporine drops in both eyes and immediately followed with Refresh Tears in both eyes without waiting between medications. This practice conflicted with referenced professional guidance recommending several minutes between multiple eye drops and with the medical provider’s recommendation to wait fifteen minutes between the two ophthalmic medications. No facility policy on ophthalmic medication administration was provided when requested.
A resident with severe cognitive impairment, impaired mobility, and high fall risk was care planned to have wheelchair footrests in place at all times, with staff ensuring proper positioning and monitoring for leaning during transport. A NA transported the resident in a manual wheelchair from the shower without the footrests, and while going through the doorway the wheelchair struck the door frame, causing the resident, who was leaning forward, to fall out. The resident sustained a T12 fracture, head injury with concussion, abrasions and contusions, and multiple right-hand lacerations requiring sutures, and the DON confirmed the care plan had not been followed.
A high‑risk, immobile resident with MS and prior heel DTI developed an avoidable unstageable coccygeal pressure ulcer after staff failed to consistently assess and document skin status, did not transfer or timely provide ordered pressure‑relieving mattresses, and did not reliably perform q2h repositioning. The resident was repeatedly left on a bedpan for prolonged periods despite early reports of this issue, and the toileting care plan was not revised to a bedside commode until after the coccygeal wound had significantly worsened. Wound assessments lacked complete measurements and staging, changes in wound size and color were not promptly recognized as deterioration or reported to providers, and recommended interventions from a wound NP (including an air mattress and offloading) were not promptly implemented. As a result, the coccygeal ulcer rapidly progressed to a large, necrotic, malodorous wound requiring hospital transfer and surgical debridement.
A resident with spastic hemiplegia, muscle weakness, and moderate cognitive impairment was observed using bilateral bed grab bars for bed mobility and transfers, but the care plan did not address grab bar or side rail use. Review of the EMR showed no completed bed mobility device or side rail assessment to determine the necessity or safety of the grab bars, and no documentation that risks and benefits were discussed or that informed consent was obtained. An LPN and the ADON stated that a bed mobility device assessment is required before grab bars are installed and confirmed that no such assessment existed for this resident.
A resident with bilateral heel pressure ulcers and multiple comorbidities received wound care during which an RN removed dressings from both heels, cleansed both wounds, and wiped each heel without changing gloves or performing hand hygiene between wounds or after disposing of soiled dressings. This practice conflicted with the facility’s written wound care procedure, which requires glove removal and hand hygiene after dressing removal and after wound cleansing. In interviews, the RN, NP, and DON/IP acknowledged that hand hygiene and glove changes are expected between dirty and clean tasks and between separate wounds to prevent infection.
A resident with MS, neurogenic bladder, mobility limitations, and existing pressure injuries was identified as dependent for toileting hygiene and at risk for pressure ulcers, yet the care plan lacked an individualized toileting/incontinence plan and a defined repositioning schedule. Despite a new coccyx pressure ulcer and documentation that interventions such as increased repositioning and incontinent care were needed, the care plan was not revised for a period of time to reflect these changes. During this time, the resident sometimes fell asleep on a bedpan and remained on it until staff removed it, and staff were not initially informed that the bedpan should no longer be used. The DON later acknowledged that the care plan revisions for turning, repositioning, and toileting were delayed until after the resident’s coccyx ulcer had significantly worsened.
A resident with diabetes, Crohn’s disease, bowel incontinence, and a history of MASD on the right gluteus developed an open, painful lesion on the right gluteal area that was documented over time without complete wound characteristics, clear etiology, or timely provider notification. Wound care orders were written for a stage 3 pressure ulcer on the left buttocks, while staff reported the wound was only on the right side and applied the left‑sided orders to the right gluteal wound in the absence of specific right‑side treatment orders. The DON acknowledged discomfort with staging the wound, lack of early physician notification, and confusion over wound classification, despite a facility policy requiring comprehensive wound assessment, consistent measurement, and provider notification when treatment orders are absent.
A resident with diabetes, chronic leg ulcer, kidney transplant, and a documented gluteal wound was care-planned for Enhanced Barrier Precautions (EBP), with posted instructions requiring gown and gloves for high-contact care such as transfers and wound care. During a telehealth wound assessment, the DON donned a gown and initially performed hand hygiene but then applied gloves without hand hygiene, removed a soiled dressing from the resident’s gluteal area, discarded it, removed gloves, and applied new gloves again without performing hand hygiene between glove changes. On another occasion, during use of a sit-to-stand lift, an NA wore gown and gloves, but the DON handled the lift harness, the resident’s clothing, and assisted with the transfer and repositioning while wearing a gown but no gloves, despite EBP requirements for transfers. The DON stated EBP was only needed for catheter or wound care and not for transfers, contradicting the posted EBP instructions and facility policy.
A resident with severe dementia, psychiatric disorders, and high dependence for ADLs was verbally abused during evening care when a NA, frustrated with the resident’s crying and resistance, loudly ridiculed her as acting like a two-year-old, threatened to hit her back if struck, told her she would be sent to a locked unit, and questioned who would want to care for her when she cried like a baby. Multiple staff witnessed the loud, stern, and intimidating tone and reported it to an LPN, who recognized it as verbal abuse but did not immediately remove the NA from duty or promptly report the allegation per policy, allowing the NA to continue working on the unit. Following this incident, the resident demonstrated increased crying, combativeness, resistance to care, wandering, self-isolation, and refusal of food, fluids, and medications above baseline, with documentation of significant emotional distress and subsequent ED evaluation for aggressive behaviors and poor intake.
A resident with dementia, bilateral above‑knee amputations, vascular disease, and severe protein‑calorie malnutrition developed a wound on an amputation stump that had a dressing dated several days before any documentation or treatment orders appeared in the record. Although bath audits and nursing notes initially reported no skin issues, a later assessment described a full‑thickness stage 4 ulcer/diabetic ulcer on the stump with exposed bone, erythema/edema, slough, and moderate serosanguineous drainage. Nursing staff interviews showed no one could identify who first discovered the wound or applied the initial dressing, and there was no evidence that the wound was assessed, the provider notified, or standing orders implemented when it was first present, despite facility expectations that new wounds be promptly evaluated and reported.
Failure to Follow Professional Standards for Ophthalmic Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice for administering ophthalmic medications to a resident with dry eye syndrome and degenerative eye disease. The resident was cognitively intact, required assistance with ADLs, and had physician orders for cyclosporine ophthalmic emulsion 0.05% one drop in both eyes twice daily and Refresh Tears ophthalmic solution one drop in both eyes four times daily for dry eyes. The administration summary showed that both eye medications were scheduled for the same time and were documented as being given at the same time on multiple dates. During a medication pass observation, a trained medication aide administered the ordered oral medications, then applied gloves and instilled one drop of cyclosporine in each eye, immediately followed by one drop of Refresh Tears in each eye, without any waiting period between the two medications. The surveyors referenced guidance from the American Academy of Allergy, Asthma, and Immunology stating that when more than one eye drop is ordered, three to four minutes should be allowed between drops in the same eye, and five to fifteen minutes should be allowed between different eye medications to prevent dilution. Interviews with the DON, pharmacy consultant, and medical provider confirmed that best practice and the provider’s recommendation were to wait between administration of cyclosporine and Refresh Tears, with the medical provider specifying a fifteen-minute interval. The facility did not provide a policy on ophthalmic medications when requested. The observed practice and documented administration times demonstrated that staff did not follow these professional standards or the medical provider’s recommended interval between the two eye medications.
Failure to Follow Wheelchair Transport Care Plan Leads to Fall With Injuries
Penalty
Summary
The deficiency involves the facility’s failure to implement care-planned fall prevention interventions for a resident at high risk for falls, resulting in a fall with injury. The resident had diagnoses including aphasia, dysphagia, muscle weakness, traumatic brain injury, and impaired mobility, with severe cognitive impairment documented on the MDS and dependence on staff for transfers and wheelchair transport. A care plan addressing wheelchair transport safety and positioning directed staff to ensure the resident was fully positioned and supported in the wheelchair prior to transport, verify footrests were in place prior to transport, and monitor for leaning, sliding, or unsafe positioning. An additional care-planned approach required wheelchair pedals to be on at all times. On the date of the incident, a nursing assistant transported the resident in a manual wheelchair from the shower room to the resident’s room without the foot pedals in place, contrary to the care plan. While being wheeled through the doorway, the wheelchair struck the door frame, causing the chair to stop and the resident, who had begun leaning forward, to fall out of the wheelchair onto the floor. Progress notes and ED documentation identified that the resident sustained a T12 vertebral fracture, a head injury with concussion, an abrasion and contusion to the head, a bruise to the left knee, and multiple lacerations to the right hand requiring sutures. The nursing assistant later acknowledged awareness that the foot pedals should have been on but did not apply them because the transport was only from the shower to the room. The DON confirmed that the resident’s care plan had not been followed when the fall occurred.
Failure to Implement and Update Pressure Ulcer Prevention and Treatment Led to Avoidable Unstageable Coccygeal Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, monitor, and implement individualized pressure ulcer prevention and treatment interventions for multiple high‑risk residents, resulting in an avoidable, unstageable coccygeal pressure ulcer for one resident that required surgical debridement and hospitalization. The resident had primary progressive multiple sclerosis, hereditary spastic paraplegia, obesity, and pre‑existing pressure‑related deep tissue injury to the left heel, and was identified as high risk for pressure ulcers on the Braden Scale due to constant moisture, chairfast status, very limited mobility, inadequate nutrition, and friction/shear risk. Hospital records on readmission documented irritant contact dermatitis of the bilateral gluteal cleft with specific cleansing and barrier cream orders, and facility documentation showed the resident could not reposition in bed or chair and required assist of two and a full‑body mechanical lift for transfers. Despite this, the admission/readmission skin assessment and weekly skin checks lacked measurements and detailed wound characteristics for the heel ulcer and gluteal dermatitis, and the care plan did not include comprehensive, individualized interventions beyond generic repositioning and wound care orders. After a new coccyx pressure ulcer was identified and documented as a stage 2 lesion, the facility failed to promptly and accurately update the care plan and implement recommended pressure‑relieving interventions. The wound nurse practitioner on 3/5 ordered coccyx wound care, an air mattress, pressure offloading, and a dietician consult, but the care plan was not revised and there was no evidence that an air mattress was placed on the bed for nearly two weeks. The environmental services director later confirmed that when the resident was moved to a new room, the gel mattress was not transferred, and the air mattress requested on 3/17 was not actually placed until the following day, despite being marked as completed. During this period, TAR documentation showed gaps in the every‑2‑hour repositioning order, and staff interviews revealed that CNAs were unaware of which residents were on repositioning programs, were not consistently repositioning residents, and had not received recent education on pressure ulcer prevention. The DON and RN case manager acknowledged that the coccyx wound increased in size and changed color between assessments, that the bed lacked the ordered gel mattress, and that the physician was not notified of the wound’s deterioration at that time. The facility also failed to timely modify toileting and incontinence care practices despite knowledge that the resident was being left on a bedpan for extended periods. The DON reported hearing before an IDT meeting that the resident had fallen asleep on a bedpan for an undetermined amount of time, but the care plan was not revised to discontinue bedpan use and implement a bedside commode until after the coccyx wound had significantly worsened. CNAs confirmed that the resident sometimes fell asleep on the bedpan and that they were not informed she should no longer use it until after the sore had worsened. Subsequent wound assessments documented rapid progression of the coccyx wound from a small stage 2 ulcer to a large, malodorous, necrotic wound with eschar, slough, erythema, and purulent drainage, ultimately classified as an unstageable pressure ulcer. The DON, NP, PA, and medical director all indicated that the lack of a pressure‑relieving mattress, failure to adjust pressure‑reducing interventions, and prolonged time on a bedpan likely contributed to the development and deterioration of the resident’s pressure ulcer, which was determined to be avoidable and resulted in hospitalization and surgical debridement. Additional documentation and interviews showed systemic assessment and communication failures related to pressure ulcer management. Weekly skin checks and wound assessments often omitted complete measurements, staging, and wound characteristics, and changes in wound size and appearance were not consistently recognized as deterioration or communicated to providers. The DON acknowledged that a 3/12 assessment showing increased wound size and purple discoloration should have been identified as a deep tissue injury and reported to the physician, but this did not occur. When nursing later documented foul odor, increased pain, and expanding necrotic tissue, telemedicine and PA responses deferred in‑person evaluation and ED transfer despite earlier recommendations that the resident be sent to the ED if an in‑person provider could not assess the wound. The NP ultimately found a large, malodorous, purulent wound with expanding eschar and ordered transfer to the hospital, where imaging and surgical findings confirmed a large necrotic sacral wound requiring extensive debridement. Throughout this sequence, the facility did not consistently follow its own pressure ulcer protocols, did not ensure ordered pressure‑relieving equipment was in place, and did not promptly revise care plans or interventions in response to known risk factors and documented wound changes. The report also notes that other residents reviewed for pressure ulcers were affected by similar failures in monitoring and individualized intervention, though detailed narratives focus primarily on this resident. Staff interviews revealed that CNAs relied on paper care guides that did not clearly identify residents on repositioning programs or at risk for skin breakdown, and that they were unaware of some residents’ special mattress orders or toileting restrictions. The DON and medical director stated that residents at risk for pressure ulcers should have immediate pressure‑relieving interventions and that existing ulcers require ongoing evaluation to prevent deterioration, but the documented practices for this resident did not align with those expectations. These combined actions and inactions—insufficient assessment detail, delayed or missing care plan revisions, failure to implement ordered support surfaces and repositioning, and delayed response to wound deterioration—constituted the deficiency in providing appropriate pressure ulcer care and preventing new ulcers from developing.
Failure to Assess, Care Plan, and Obtain Consent for Bed Grab Bar Use
Penalty
Summary
The deficiency involves the facility’s failure to follow required procedures before installing and using bed grab bars for a resident. The resident had diagnoses including spastic hemiplegia affecting the left side and muscle weakness, and an admission MDS indicating moderate cognitive impairment. During observation, the resident was seen in a power chair with bilateral grab bars on the bed and reported using them to roll in bed and for transfers. The resident’s care plan, dated 1/23/26, documented a need for assistance with bed mobility and independence with transfers but did not mention or address the use of grab bars or side rails. Review of the electronic medical record showed no completed grab bar/side rail or bed mobility device assessment to determine the necessity of the grab bars or whether the resident could safely use them. There was also no evidence that the resident or the resident’s representative had been educated on the risks of having a grab bar on the bed or that informed consent had been obtained. In interviews, an LPN and the ADON both stated that a bed mobility device assessment was required to determine need and safety prior to installing grab bars, and both confirmed that no such assessment was present in the resident’s record.
Failure to Perform Hand Hygiene and Change Gloves During Wound Care
Penalty
Summary
Surveyors observed that a registered nurse (RN) and a nurse practitioner (NP) did not follow the facility’s established infection control practices during wound care for one resident. During a wound treatment, the RN wore gloves while removing the dressing from the resident’s left heel, then removed the dressing from the right heel, sprayed both wounds with wound cleanser, wiped the left heel with gauze, and then used a clean gauze pad to wipe the right heel. The RN did not remove her gloves or perform hand hygiene after disposing of the soiled dressings or between cleaning the left and right heel wounds, contrary to the facility’s written wound care procedure, which requires glove removal and hand hygiene after removing the previous dressing and again after cleaning the wound. The resident’s admission MDS documented diagnoses including multiple rib fractures, heart failure, dementia, anxiety, and the presence of a pressure ulcer, and indicated the resident was cognitively intact and required staff assistance with care and transfers. The resident’s care plan identified pressure ulcers on both heels requiring wound care. In interviews, the RN, NP, and the DON/infection prevention nurse each stated that gloves should be changed when moving from dirty to clean areas and that hand hygiene is expected after glove removal and between wounds to prevent infection, confirming that the observed practice did not align with facility policy or expected infection control standards.
Failure to Timely Revise Care Plan for Toileting and Skin Integrity
Penalty
Summary
The deficiency involves the facility’s failure to timely revise and individualize a resident’s care plan to address toileting and incontinence needs in relation to impaired skin integrity. The resident had diagnoses including primary progressive multiple sclerosis, hereditary spastic paraplegia, obesity, and a pressure-induced deep tissue injury to the left heel. A Significant Change MDS identified the resident as dependent for toileting hygiene, with lower extremity range-of-motion limitations, wheelchair use, dependence for transfers, occasional urinary incontinence, intact cognition, and at risk for pressure ulcers with existing unhealed pressure injuries and MASD. The resident’s skin-focused care plan, revised on various dates, included skin inspections, wound care orders, weekly skin checks, pressure ulcer care to the left heel, nutritional supplements, and a gel mattress, but did not include an individualized toileting or incontinence plan. On a weekly skin check dated 3/3/26, nursing staff identified a new Stage 2 pressure ulcer on the coccyx and contact dermatitis on both gluteal folds. An IDT Final Post Review Follow Up dated 3/10/26 (signed 3/23/26) documented that a new skin issue had occurred and that interventions after the incident included wound care treatment orders, increased repositioning, and increased incontinent care. However, the resident’s care plan from 3/3/26 through 3/16/26 did not show revisions reflecting increased incontinence care or a repositioning schedule, and the care plan was not updated to include these elements until 3/17/26. During this period, the care plan still lacked an individualized toileting plan despite the resident’s identified incontinence and new coccyx pressure ulcer. Progress notes on 3/17/26 documented that the resident’s coccyx wound had declined, with an evaluation describing a deteriorating wound characterized as a Kennedy terminal ulcer/End of Life, staged as a Stage 4 pressure ulcer, in-house acquired, with increased size, exudate, odor, pain, and surrounding erythema. On that same date, the skin focus care plan was revised to include prompt incontinence care and keeping the skin clean and dry, and the elimination focus care plan was revised to address incontinence due to neurogenic bladder with use of a bedside commode offered every 2–3 hours. A nursing assistant reported that when working with the resident, the resident would sometimes fall asleep on the bedpan and forget to ask staff to remove it, and that she was not aware the resident was not supposed to use the bedpan until after the sore had worsened. The DON stated that the resident’s care plan had not been revised earlier to include a turning and repositioning schedule or toileting changes, and that it should have been revised as soon as staff learned the resident was falling asleep on the bedpan, rather than waiting until after the pressure ulcer worsened.
Failure to Assess and Notify Provider for Right Gluteal Wound
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess and appropriately manage a non‑pressure skin issue on a resident’s right gluteal area, and to notify the physician in a timely manner. The resident had diagnoses including diabetes, Crohn’s disease, and a kidney transplant, and the MDS indicated occasional bowel incontinence, no pressure ulcers, and no moisture‑associated skin damage at that time. Earlier documentation identified a resolved MASD to the right gluteus, and a progress note later described a sacral wound with creams applied, noting that sores were still open and painful during application, but without any measurements, wound characteristics, or evidence of physician notification. Subsequent wound assessments documented an open lesion on the right gluteus with specific measurements on multiple dates, but did not identify the wound type or other characteristics, and the record did not show physician notification or treatment orders for the right gluteal lesion. Provider orders in place initially addressed cleansing the buttocks and applying barrier cream, and later included a detailed wound care order for a stage 3 pressure ulcer documented on the left buttocks. However, the resident’s record did not contain a specific treatment order for the right gluteal wound, despite the ongoing documentation of an open lesion in that area. Interviews revealed confusion and inconsistency in wound identification and classification. The DON stated that the right gluteal wound was documented as an open lesion because she did not feel comfortable determining the wound type, and acknowledged that the physician should have been notified when the wound was first identified. The DON was unaware that the NP had documented the wound as being on the left buttocks and as a stage 3 pressure ulcer, while the RN reported that the wound had never been on the left buttocks and that she had been applying the left‑sided wound orders to the right gluteal area because there was no open area on the left. The resident reported a recurring painful area on the right buttocks and chronic stool leakage since prior anal fistula surgery. The facility’s own wound treatment policy required comprehensive assessment of wound etiology and characteristics, consistent measurement and documentation, and provider notification in the absence of treatment orders, which were not followed for this resident’s right gluteal wound. The deficiency centers on the lack of a comprehensive wound assessment for the right gluteal lesion, incomplete documentation of wound characteristics, failure to clearly determine and document the wound etiology, and failure to notify the physician and obtain appropriate treatment orders when the wound was identified and remained open. These actions and inactions resulted in a discrepancy between the documented wound location and type and the actual clinical presentation, as well as a period during which the right gluteal wound had no specific, clearly ordered treatment despite being open and painful.
Failure to Perform Hand Hygiene and Implement Enhanced Barrier Precautions During Wound Care and Transfers
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper hand hygiene during wound care and to consistently implement Enhanced Barrier Precautions (EBP) for a resident requiring such measures. The resident had diagnoses including diabetes, a non-pressure chronic ulcer of the right lower leg, and a kidney transplant, and a wound assessment documented an open lesion on the right gluteal area. The resident’s care plan and a sign posted outside the room specified that EBP, including gown and gloves, were required for high-contact care activities such as dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, catheter care, and wound care. During one observation, the DON performed hand hygiene and donned a gown before entering the resident’s room for a telehealth wound assessment. Inside the room, the DON went into the bathroom, applied gloves without performing hand hygiene, removed the resident’s brief, and removed a foam dressing from the right gluteal area that had stool on one corner. After discarding the soiled dressing, the DON removed gloves and then applied new gloves without performing hand hygiene between glove changes. When questioned, the DON stated that hand hygiene should be done when hands or gloves are visibly soiled and before and after removing or applying gloves, and acknowledged that hand hygiene had not been performed each time gloves were removed and reapplied. In a separate observation, the resident was transferred using a sit-to-stand mechanical lift while EBP requirements were not fully followed. An NA entered the room wearing a gown and gloves with the lift, and the DON applied the lift harness under the resident’s arms and cinched the waist strap, encountering the resident’s clothing, while not wearing gloves. After the transfer to bed, the DON pulled down the resident’s pants and removed the harness while touching the resident’s clothes. Following wound care by a CNP-WOC, the DON again assisted the resident by sitting the resident on the edge of the bed, applying the lift harness, and adjusting the resident’s pants and shirt while wearing a gown but no gloves. The DON stated that EBP was only needed for catheter or wound care and not for transfers, and only upon reading the posted EBP sign acknowledged that EBP was required for all high-contact resident care activities, including transfers.
Failure to Protect Resident From Verbal Abuse and Delay in Removing Alleged Perpetrator
Penalty
Summary
The deficiency involves the facility’s failure to protect a vulnerable resident from mental abuse and to respond appropriately to an allegation of abuse. The resident had severe cognitive impairment, Alzheimer’s disease, dementia, anxiety, depression, psychotic disorder, and significant functional dependence, including frequent incontinence and the need for extensive assistance with ADLs and transfers. Her care plan identified behavioral and mood issues such as wandering, yelling, combative behavior, and calling staff names, with interventions including calm approaches, emotional support, redirection, and monitoring for emotional distress and mood/behavior changes. She was identified as a vulnerable adult, with instructions to monitor for signs of emotional distress and to follow the facility’s abuse reporting policy. On the evening in question, while the resident was crying on the phone with her son and expressing a desire to leave, NA-A and NA-B entered to provide evening care using an EZ stand lift. After the resident ended the phone call, multiple staff reported that NA-A spoke to the resident in a loud, stern, and frustrated tone, telling her to stop crying and that she was acting like a two-year-old. When the resident swatted at NA-A, NA-A stated, “If you hit me, I’m going to hit you back,” and later told the resident she was “in trouble now.” Staff reported that NA-A told the resident she would be sent to a locked unit so she could not get out, and questioned who would want to care for her when she cried like a baby, and that nobody would want to keep working with her. NA-C described NA-A yelling commands such as “HOLD ON!” and “Stop crying! Where would you be if you were not here? Probably lying on the floor,” and felt NA-A was obviously upset and overwhelmed. These statements were made in the presence of the resident while she was already distressed and crying. Following this interaction, the resident exhibited crying, yelling, combativeness, resistance to care, wandering into other residents’ rooms, self-isolation, and refusal of food, fluids, and medications above her prior baseline, as documented in behavior charts, target behavior monitoring, and nursing progress notes. Staff documented that she cried most of the morning, was very restless, difficult to redirect, hit and pinched staff, called staff names, and refused care and meals. She required repeated redirection, 1:1 attention, and non-pharmacological interventions, and was ultimately sent to the ED for evaluation of combativeness and emotional distress, where she was treated for dementia with aggressive behavior and hypoglycemia related to poor intake. The report identifies that the resident’s actual response and the reasonable person concept showed serious psychosocial harm, including increased crying and combative behavior above baseline, fear/anxiety manifested as combativeness, resistance to care and social interaction, and self-isolation. The facility also failed to immediately remove the alleged perpetrator from resident care and to promptly report and investigate the allegation in accordance with its abuse policy. After NA-B and NA-C reported to LPN-A that NA-A had yelled at and threatened the resident, LPN-A acknowledged it as verbal abuse but did not initiate immediate protective measures or timely reporting. LPN-A stated she believed she had 24 hours to report because there was no injury, despite facility policy requiring reporting within two hours. NA-A remained on the unit and continued working until the end of her shift, including after staff had clearly communicated their concerns to LPN-A. TMA and NA staff described uncertainty about their authority to remove NA-A and reliance on the nurse to act, while the DON later informed LPN-A that NA-A should have been removed from the floor to prevent further danger to residents. The Immediate Jeopardy was determined to have begun when NA-A’s derogatory, intimidating, and threatening statements were made and continued while she remained on duty with access to the resident and other vulnerable residents.
Failure to Timely Assess and Treat Newly Discovered Stump Wound
Penalty
Summary
The deficiency involves the facility’s failure to provide timely treatment and care for a newly discovered wound on a resident’s above‑knee amputation stump. The resident was admitted with diagnoses including unspecified dementia with behavioral disturbances, vascular dementia, bilateral above‑knee amputations, vascular disease, reduced mobility, and severe protein‑calorie malnutrition, and had no documented ulcers or skin problems on admission or on the most recent MDS. A weekly bath audit on 3/17/26 documented only non‑tender lymph nodes on the right upper hip and did not identify any open areas. However, when the wound was later assessed, the dressing on the stump was dated 3/16/26, indicating that a wound and dressing existed at that time, even though no corresponding assessment, provider notification, or treatment orders were documented. On 3/23/26, nursing staff documented a new skin issue above the resident’s knee at the amputation site, describing a stage 4 pressure ulcer/injury with full‑thickness skin and tissue loss, exposed bone, erythema/edema, and moderate serosanguineous exudate. The wound measured 1.56 cm by 1.64 cm, with 20–29% granulation tissue and 80% slough. A progress note and skin issues assessment on that date confirmed the wound characteristics and staging, and the NP, after reviewing a picture, determined the wound to be a diabetic ulcer with peripheral vascular disease and severe protein‑calorie malnutrition as contributing factors. On that same date, the NP was notified, antibiotic therapy (doxycycline) was ordered for possible cellulitis, and specific wound care orders were initiated, with documentation on the MAR that these treatments were carried out beginning 3/23/26. Multiple interviews with nursing staff revealed that no one could identify who discovered the wound or who applied the initial dressing dated 3/16/26, and there was no documentation of a wound assessment, provider notification, or interim treatment between 3/16/26 and 3/22/26. Several RNs and LPNs who worked shifts from 3/16/26 through 3/20/26 stated they did not notice a wound on the stump and that, per their usual practice, they would have contacted the provider and initiated treatment if they had found one. One LPN recalled seeing a band‑aid with a date on the stump but could not recall the date, and another LPN stated she did not see the wound because she was not looking for one. The facility’s standing orders required staff to assess all wounds daily, change dressings every three days and as needed, treat with normal saline or non‑cytotoxic cleanser and appropriate dressings, and notify the provider the next business day when a new wound or injury was found. Despite these expectations, the wound identified by the dated dressing on 3/16/26 was not assessed, reported, or treated according to orders and facility policy until 3/23/26.
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