Pathstone Living
Inspection history, citations, penalties and survey trends for this long-term care facility in Mankato, Minnesota.
- Location
- 718 Mound Avenue, Mankato, Minnesota 56001
- CMS Provider Number
- 245390
- Inspections on file
- 25
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Pathstone Living during CMS and state inspections, most recent first.
Two residents with diabetes received long‑acting insulin at widely varying times across the morning shift rather than at a consistent daily time, despite orders for daily dosing and internal policies and pharmacist guidance that long‑acting insulin should be given at approximately the same time each day. For one resident using a Dexcom CGM, staff relied on CGM readings without consistently confirming low values by fingerstick, did not follow the facility’s hypoglycemia protocol for 15‑minute BG rechecks, and allowed the resident to leave for outside appointments shortly after a documented low BG and glucagon administration without documented monitoring to ensure BG had returned to safe levels. Surveyors also observed this resident eating most of a meal before any BG was obtained, delayed insulin administration until after the meal, and noted that a dislodged CGM sensor had gone unnoticed, while staff interviews revealed uncertainty about CGM use and order transcription that created broad administration windows for insulin.
The facility failed to maintain an effective infection control program, with incomplete documentation and analysis of resident infections. The infection preventionist struggled to access reports and did not include essential data such as signs and symptoms or transmission-based precautions. Additionally, a resident with a nephrostomy tube did not receive proper Enhanced Barrier Precautions (EBP), as a nursing assistant entered the room without wearing the required PPE, despite being aware of the EBP policy.
The facility failed to effectively implement an antibiotic review process, impacting the monitoring of antibiotic use and resistance. The ADON, responsible for tracking infections and antibiotic use, faced challenges in accessing culture results and did not report on MDRO or prophylactic use at meetings. A review showed that many UTIs treated with antibiotics lacked culture results, and not all physicians followed infection testing criteria. The DON confirmed the lack of analysis and monitoring in the antibiotic stewardship program.
A resident with chronic conditions expressed dissatisfaction with the facility's food, which did not align with his cultural preferences. Despite the facility's policy on culturally competent care, the resident's care plan lacked cultural considerations, and staff interviews revealed uncertainty about responsibility for addressing these needs.
The facility failed to ensure cleanliness of ceiling vents in the 3400 wing, affecting three residents. Observations showed vents covered with a black substance due to dust and dirt buildup. The maintenance director admitted that vent cleaning was on a monthly checklist but was only done quarterly. The facility's policy required items to be free of visible soil, yet the vents were visibly dirty.
A resident with a history of cardiovascular issues experienced chest pain, but the facility staff failed to promptly assess and notify the physician, delaying treatment. Despite the resident's symptoms and family member's concerns, staff waited for physician rounds. The resident was eventually sent to the hospital, diagnosed with an acute anterior STEMI, and passed away after complications.
The facility failed to ensure proper infection control practices, including ongoing surveillance, correct PPE usage, and proper storage of PPE. Staff were observed doffing PPE incorrectly, and a meal tray was placed on the floor, posing an infection control risk. These deficiencies had the potential to affect all 56 residents in the facility.
The facility failed to implement a process for antibiotic review, lacking formal tracking and monitoring for residents on antibiotics. The DON and ADON confirmed that while symptoms were monitored and reported, there was no system to track antibiotic use, cultures, or ensure proper prescriptions.
The facility failed to report an allegation of misappropriation of property to the state agency within 24 hours. A resident reported missing cash, and while a police report was filed, the facility did not notify the state agency as required by their policies. The resident later found the cash, but the incident should have been reported within the required timeframe.
The facility failed to ensure accurate MDS assessments for two residents. One resident receiving hospice services was not correctly documented, and another resident with pressure ulcers had an MDS assessment indicating no such injuries. These inaccuracies were confirmed by the MDS coordinators and the DON.
The facility failed to provide a summary of the baseline care plan to newly admitted residents and/or their representatives. This deficiency was identified for three residents, with staff confirming that copies of the care plan were only provided if requested, contrary to the facility's policy.
A resident with moderately intact cognition and specific activity preferences was not offered individualized activities by the facility. Despite documented interests in playing cards, listening to music, and attending religious services, the resident and his family member reported no activities were offered. Staff confirmed the lack of engagement, and the facility did not adhere to its Activity Programs policy.
A resident receiving hospice services experienced missed visits and lack of communication from the hospice agency, leading to confusion and unmet care needs. The facility's director of nursing confirmed the communication issues, and a policy on hospice services was not provided.
A facility failed to implement a ROM program and properly apply a wrist brace and edema glove for a resident with hemiplegia and hemiparesis. Staff inconsistencies and improper application led to the resident's fingers curling and the splint losing its form, indicating a lack of proper care.
A facility failed to properly assess and manage the disposal of cigarettes for a resident with severe cognitive impairment. The resident was observed smoking across the street with the interim director of nursing (IDON) supervising, but the cigarette butt was improperly disposed of and later found inside the facility. The facility lacked a designated receptacle for cigarette disposal, and the IDON admitted to not knowing where the cigarette butt was disposed of, leading to a deficiency in managing the resident's smoking habits and ensuring safety.
The facility failed to maintain a sanitary environment in the kitchen's food preparation and drying areas, with vents, wire mesh, and a printer cord covered in debris. This was confirmed by the cook, maintenance director, and culinary director.
A resident with diabetes received both detemir and glargine insulin simultaneously over six days due to a lapse in the visibility of a hold order, leading to hypoglycemia and hospitalization. Nurses administered both insulins without questioning the orders, and significant changes in the resident's condition were observed.
A resident with a history of Parkinson's Disease, renal insufficiency, neurogenic bladder, seizure disorder, and muscle weakness experienced a significant decline in condition, including decreased appetite, facial pallor, blue lips, increased fatigue, lethargy, and decreased responsiveness. Despite multiple reports from nursing assistants, the licensed nursing staff failed to perform a comprehensive assessment, document observations, or notify a physician. The resident was found in severe respiratory distress and later died from acute respiratory failure.
Inconsistent Insulin Administration and Inadequate Hypoglycemia Management
Penalty
Summary
The deficiency involves the facility’s failure to administer long‑acting insulin at consistent times, failure to appropriately respond to abnormal blood glucose (BG) levels, and failure to monitor and follow up after hypoglycemia interventions for residents with diabetes. One resident with type 2 diabetes mellitus, diabetic retinopathy, and use of a Dexcom continuous glucose monitor (CGM) had a care plan and physician orders directing daily glargine insulin, sliding‑scale Novolog, hypoglycemia treatment, and specific notification parameters for BG values. However, the MAR showed glargine ordered as "every day shift" with an administration window of 6:30 a.m.–1:00 p.m., and actual administration times varied widely from early morning to early afternoon. On multiple days, glargine was given at different times (e.g., between about 9:00 a.m. and 2:45 p.m.), and on some days it was not administered at all with no explanation. Facility staff, including a nursing assistant who transcribed orders and nurses who confirmed them, acknowledged that the order was entered as a broad shift‑range rather than a specific time and that this could affect BG control. The same resident experienced multiple episodes of low BG where staff did not follow the facility’s hypoglycemia protocol or the physician’s orders. On one occasion, the Dexcom alarmed for a low reading in the dining room, and a family member obtained orange juice and notified staff. An LPN reported difficulty locating glucose tablets, did not clearly recall whether a manual fingerstick was obtained, and administered glucagon from the emergency kit based on the CGM reading. Documentation showed BG readings of 54 and 57, administration of orange juice and glucagon, and then the resident leaving the facility for appointments, with instructions to the family member to recheck BG later. There was no comprehensive assessment documented for signs/symptoms of hypoglycemia and no documented monitoring to ensure BG returned to safe levels after glucagon; the next recorded BG was not until several hours later. The van driver and clinic nurse reported they were not informed of the low BG event, and the physician later stated the BG should have been manually checked and that such low levels could lead to coma or death. Additional documentation for this resident showed repeated low BG readings (e.g., in the 50s, 60s, and low 70s) where interventions such as orange juice were given but follow‑up BG checks were delayed or incompletely documented, contrary to the facility’s diabetes and hypoglycemia protocols that called for rechecking every 15 minutes until BG was at least 70 mg/dL and the resident was without symptoms. The Dexcom order initially lacked clear instructions on how to change the sensor, verify readings with fingersticks, or set alarm parameters, and staff reported relying on internet videos to learn sensor changes. During surveyor observation, the resident’s Dexcom displayed a message to start a new sensor, and the resident ate most of his breakfast before any BG was obtained; a TMA later took a manual BG of 153 and then an LPN administered both long‑acting and short‑acting insulin after the meal. Family reported that the Dexcom sensor had fallen off the previous day and staff had not noticed. A second resident with type 2 diabetes and multiple diabetic complications also had glargine ordered daily, but MAR review showed long‑acting insulin administered at widely varying morning times, from just before 7:00 a.m. to after noon, despite staff and the consulting pharmacist stating that long‑acting insulin should be given at approximately the same time each day and BG should be checked before meals and insulin administration. The facility’s own Diabetes‑Clinical Protocol and Insulin Administration policies required assessment of diabetic residents, incorporation of orders and reporting parameters into the MAR and care plan, consistent monitoring of BG, and specific hypoglycemia treatment steps including 15‑minute rechecks and continued monitoring after glucagon. Standing orders for CGM use required setting alarms, verifying initial readings with fingersticks, and performing fingersticks when readings were <100 or >400 or when accuracy was in question. Interviews with nursing staff, the clinical manager, and the pharmacist confirmed that long‑acting insulin should not be administered at random times across a broad shift window and that BG should be checked before meals and insulin dosing. Despite these policies and professional expectations, the facility did not ensure consistent timing of long‑acting insulin for two residents, did not consistently verify or respond to abnormal BG readings according to protocol, and did not document timely reassessment after hypoglycemia interventions for one resident.
Inadequate Infection Control and EBP Implementation
Penalty
Summary
The facility failed to ensure that its infection control program included ongoing surveillance, trending, and analysis of resident infections. The Assistant Director of Nursing (ADON-B), who also served as the infection preventionist, was responsible for tracking and documenting infections and antibiotic use. However, ADON-B experienced difficulties accessing reports and did not include essential information such as signs and symptoms, treatment, or the implementation of transmission-based precautions in the documentation. The facility's monthly resident infection statistics revealed incomplete documentation, with missing data on signs and symptoms, bacteria, outcomes, and whether infections were healthcare-associated. ADON-B acknowledged the challenges in accessing culture and x-ray reports and the lack of adherence to McGeer's criteria by physicians for ordering tests before treating infections. The facility's infection surveillance policy required the infection preventionist to conduct ongoing surveillance for healthcare-associated infections and other significant infections. However, the surveillance flow sheet lacked critical information, and ADON-B did not print out monthly or quarterly reports for infection analysis. Consequently, ADON-B was unable to report on the facility's current or past infection rates during infection control meetings and quality assurance and performance improvement meetings. The Director of Nursing (DON) confirmed that infection surveillance was incomplete and acknowledged the need for improvement in the process. Additionally, the facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a nephrostomy tube, which posed a risk of infection. Despite the presence of a PPE cart and a sign indicating the need for gloves and gown, a nursing assistant (NA-A) entered the resident's room without donning the required PPE. NA-A admitted to being aware of the EBP requirement but did not think it was necessary if not directly handling the tube. The facility had conducted multiple trainings on EBP and created a pocket guide to assist staff, but compliance with the policy was inconsistent. The DON expected staff to adhere to the EBP sign on the door, but the deficiency in implementing EBP was evident in this instance.
Deficiency in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective process for antibiotic review, which is crucial for determining appropriate indications, dosage, duration, and trends of antibiotic use and resistance. During an interview, the Assistant Director of Nursing (ADON), who also serves as the infection preventionist, revealed that while infections and antibiotic use were tracked and documented using a software program, there was difficulty in accessing and printing reports. A review of the facility's monthly antibiotic use data from May 2024 to February 2025 showed that 34 out of 37 urinary tract infections treated with antibiotics lacked culture results and analysis of antibiotic treatment. Additionally, six UTIs were documented as suspected without proper diagnosis, and five residents were on prophylactic antibiotics. The ADON indicated challenges in accessing culture results and noted that not all physicians adhered to the McGeer criteria for infection testing. Furthermore, the ADON did not report on multi-drug resistant organisms (MDRO), prophylactic use, or antibiotic use at infection control or quality assurance performance improvement (QAPI) meetings. The Director of Nursing (DON) confirmed that the antibiotic stewardship program lacked proper analysis and monitoring. The facility's Antibiotic Stewardship policy, last reviewed in October 2024, outlined the need for culture and sensitivity results to be communicated to prescribers to guide antibiotic therapy decisions, but this was not effectively implemented. The Prevention and Control Program policy also emphasized the inclusion of culture reports and antibiotic usage reviews in surveillance activities, which was not adequately followed.
Failure to Include Cultural Aspects in Resident Care Plan
Penalty
Summary
The facility failed to ensure that a resident's care plan included cultural aspects, specifically related to food preferences, for a resident with chronic kidney disease, heart failure, and diabetes. The resident, who was moderately cognitively impaired, expressed dissatisfaction with the food provided, stating it was not prepared in a manner consistent with his cultural preferences. Despite the culinary team offering options within religious and cultural preferences, the resident reported a poor appetite and did not consume the offered supplements. The care plan, developed by a registered nurse, did not address the resident's cultural needs, and the nursing assistant's task sheet and kardex also lacked this information. Interviews with facility staff, including the director of nursing and a licensed social worker, revealed a lack of clarity regarding responsibility for incorporating cultural preferences into care plans. The facility's policy on comprehensive person-centered care plans emphasized culturally competent services, yet this was not reflected in the resident's care plan. The facility assessment indicated a commitment to person-centered care, including cultural and religious aspects, but this was not implemented in practice for the resident in question.
Failure to Maintain Clean Ceiling Vents
Penalty
Summary
The facility failed to maintain cleanliness in the 3400 wing, specifically regarding the ceiling vents in the rooms of three residents. Observations revealed that the vents were covered with a black substance, which was identified as dust and dirt buildup. The maintenance director acknowledged that the vents were dirty and needed cleaning, attributing the buildup to moisture causing dirt to stick. The maintenance director also admitted that although vent cleaning was on a monthly checklist, it was only performed quarterly, contrary to the facility's expectations. Interviews with residents and staff confirmed the presence of the black substance on the vents. One resident expressed uncertainty about whether the substance was dirt or mold. The facility's policy on maintenance of plumbing, HVAC, and related systems indicated that items should be free of visible soil, yet the vents were visibly dirty. The administrator confirmed that vents were expected to be cleaned regularly by maintenance and housekeeping staff, especially before new residents moved in, at resident discharge, and when visibly dirty.
Failure to Address Sudden Change in Condition Leads to Resident's Death
Penalty
Summary
The facility failed to recognize and respond appropriately to a sudden change in condition for a resident, leading to a delay in treatment. The resident, who had a history of cardiovascular issues including non-ST elevation myocardial infarction, atrial fibrillation, and nonrheumatic aortic stenosis, experienced chest pain. Despite the resident's history and the care plan's directive to monitor for cardiac complications, the nursing staff did not conduct a comprehensive assessment or continuous monitoring of the resident's condition. On the morning of the incident, the resident reported chest pain to the nursing staff. However, the staff did not immediately notify the physician or take urgent action. Instead, they planned to wait for the physician's rounds later that morning. The resident's condition included symptoms such as pitting edema, wheezing, and nausea, which were not adequately addressed. The nursing staff's inaction persisted despite the resident's family member expressing concern and urging them to contact the physician. The delay in response resulted in the resident being sent to the emergency room only after the family member insisted on immediate action. Upon arrival at the hospital, the resident was diagnosed with an acute anterior STEMI and underwent a surgical procedure. Unfortunately, the resident suffered complications and passed away later that day. The facility's failure to promptly address the resident's chest pain and notify the physician contributed to the delay in receiving necessary emergency care.
Removal Plan
- re-education on change of condition with nurse management team
- posters of signs/symptoms of cardiac episodes posted at nurses stations and reviewed with all staff
- quiz for each nurse to take asking what do nurses do when a change of condition occurs, what is considered a change of condition
- review of like residents and no one else was at-risk
- nurse meeting scheduled to reiterate presented education
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure the infection control program included ongoing surveillance, trending, and analysis of resident infections. Staff were observed doffing personal protective equipment (PPE) incorrectly for one resident and PPE was stored improperly on the floor for multiple residents placed on enhanced barrier precautions (EBP). Additionally, a meal tray was placed on the floor for one resident, which posed an infection control risk. These deficiencies had the potential to affect all 56 residents in the facility. During observations, it was noted that plastic gowns were stored directly on the floor inside resident rooms, and there was no place to dispose of the gowns before leaving the rooms. Staff confirmed that PPE was donned inside the resident rooms, and it was suggested that mounting the gowns and gloves on the wall would be more efficient. The assistant director of nursing (ADON) and the director of nursing (DON) acknowledged that the current placement of PPE was an infection control risk and that there was no garbage or place to dispose of the gowns readily available next to the door for staff to doff PPE before exiting the rooms. The facility also failed to conduct ongoing infection surveillance. The ADON, who was responsible for infection surveillance, confirmed that tracking of infections was not currently taking place and was not aware of the last infection surveillance. The DON stated that discussions were held at daily meetings about residents showing signs of infection and on antibiotics, but ongoing surveillance had not been completed. The ADON verified that a monthly analysis of illnesses and infections was important to rule out any trends or patterns and that the facility was not currently tracking infection data. Additionally, staff were observed improperly doffing PPE, and a meal tray was placed on the floor, which the ADON acknowledged as an infection control breach.
Failure to Implement Antibiotic Review Process
Penalty
Summary
The facility failed to implement a process for antibiotic review to determine appropriate indications, dosage, duration, and trends of antibiotic use and resistance. This deficiency was identified during an interview with the DON and ADON, who confirmed that while the nursing staff monitored symptoms and reported potential infections to providers, there was no formal tracking or monitoring process for residents placed on antibiotics. The ADON, who was responsible for the infection control program, acknowledged that although he had completed education on infection control and antibiotic stewardship, the facility had not yet implemented a tracking system for antibiotic use. The DON and ADON verified that the facility did not have a formal process to track antibiotics for cultures, source, location of infection, or symptoms when placed on antibiotics. The health unit coordinator received culture results via fax and alerted the nursing staff, who would then contact the doctor if a change in the antibiotic was needed. However, the ADON confirmed that he did not review or track culture results to ensure proper antibiotics were prescribed and did not maintain a tracking log. The facility's Prevention and Control Program policy indicated that antibiotic usage reviews should be included in surveillance activities, but this was not being followed.
Failure to Report Allegation of Misappropriation of Property
Penalty
Summary
The facility failed to report an allegation of misappropriation of property to the state agency within 24 hours as required by their policies and procedures. A resident, who was cognitively intact and independent with most activities of daily living, reported that approximately $70 in cash was stolen from his room. The facility staff were informed of the missing money, and a police report was filed. However, the facility did not report the incident to the state agency within the required timeframe, relying instead on law enforcement to file a report with the Minnesota Adult Abuse Reporting Center (MAARC). The resident's care plan indicated a behavior problem of paranoia related to dementia, which may have influenced the staff's perception of the validity of the report. Despite the resident later finding the cash in his underwear drawer, the facility's regional nurse consultant acknowledged that the incident should have been reported to the state agency within 24 hours. The facility's policy clearly states that any suspected theft or misappropriation of resident property must be reported to the appropriate agencies within 24 hours, which was not adhered to in this case.
Inaccurate MDS Assessments for Hospice and Pressure Ulcers
Penalty
Summary
The facility failed to ensure the accurate identification of resident status in the Minimum Data Set (MDS) assessment for two residents. Resident R52, who was admitted with diagnoses including malignant neoplasms and heart failure, was receiving hospice services. However, the MDS assessment did not reflect this, as section O, K1 under special treatments and programs did not include hospice care services. This discrepancy was confirmed by the MDS coordinator, who acknowledged that the section was not coded correctly despite the resident's indication of receiving hospice services and a provider order for hospice evaluation. Similarly, Resident R21, with diagnoses of hemiplegia, hemiparesis, and diabetes mellitus type 2, had an MDS assessment that incorrectly indicated no pressure ulcers or deep tissue injuries. However, a skin assessment revealed a small open shallow area on the left buttock and a pressure ulcer on the left heel. The MDS coordinator confirmed the inaccuracy and admitted that the MDS would have been submitted incorrectly. The director of nursing also acknowledged that the MDS should have been completed accurately. The facility's policy requires an RN to be responsible for the accuracy of the resident assessment, which was not adhered to in these cases.
Failure to Provide Baseline Care Plan Summary to Residents
Penalty
Summary
The facility failed to offer or provide a summary of the baseline care plan to newly admitted residents and/or their representatives. This deficiency was identified for three residents who were newly admitted. One resident, who was cognitively intact, stated that she never received a copy of her care plan and would like to have one. The social worker confirmed that copies of the care plan were only provided if requested, and the Director of Nursing confirmed that a copy of the baseline care plan was not being offered to the resident or a family member. Another resident's family member also did not recall receiving a copy of the baseline care plan. A registered nurse stated that it was not current facility practice to provide the resident or resident representative a copy of the baseline care plan. The facility's policy and procedure for baseline care plans, dated March 2022, included the requirement to develop a baseline plan of care within 48 hours of admission and to provide a written summary of the baseline care plan to the resident and/or representative. This summary should include the stated goals and objectives of the resident, a summary of the resident's medications and dietary instructions, any services and treatments to be administered by the facility, and any updated information based on the comprehensive care plan. The provision of the summary to the resident and/or representative should be documented in the medical record. However, the facility did not adhere to this policy, resulting in the deficiency noted in the report.
Failure to Provide Individualized Activities for Resident
Penalty
Summary
The facility failed to ensure individualized activities were provided for a resident (R29) who had moderately intact cognition and expressed interest in various activities. Despite the resident's care plan and baseline care plan indicating his preferences for activities such as playing cards, listening to music, and attending religious services, the facility did not offer these activities to him. The resident and his family member both reported that he had not been offered any activities, and the activity calendar posted in his room was not utilized to engage him in the listed activities. The activity coordinators (AC-A and AC-B) and nursing assistant (NA-F) confirmed that they had not offered R29 any activities based on his interests. AC-A stated that the resident's activity preferences were documented, but there was no follow-up to ensure he participated in these activities. AC-C mentioned that staff might have assumed the resident did not want to participate in activities because he had company, but this assumption was not verified with the resident. The director of nursing (DON) confirmed that residents were expected to be offered activities based on their interests and assessments, which did not occur in this case. The facility's Activity Programs policy outlined the importance of providing individualized and group activities based on residents' preferences and needs. However, the facility did not adhere to this policy for R29, as there was no documentation of his participation in activities, and staff did not actively engage him in the activities he enjoyed. This failure to provide individualized activities led to the deficiency identified in the report.
Lack of Coordination with Hospice Services
Penalty
Summary
The facility failed to ensure services were coordinated with the hospice agency for a resident receiving hospice services. The resident required substantial to maximum staff assistance with all activities of daily living and had intact cognition. The resident's care plan indicated the need for coordination with hospice services, but there were discrepancies in the hospice visit schedule. The hospice agency's plan of care indicated visits from a registered nurse and a home health aide, but the facility's hospice binder did not have updated visit dates beyond a certain point. The resident reported missed visits and lack of communication from the hospice agency, leading to confusion and unmet care needs. Interviews with the resident, hospice staff, and the facility's director of nursing confirmed the lack of communication and coordination. The resident expressed frustration over not being informed about visit schedules and having to refuse care from facility staff because hospice was supposed to provide it. The hospice staff admitted to not notifying the resident or the facility in advance of visits, and the director of nursing acknowledged the communication issues. A policy on hospice services was requested but not provided by the facility.
Failure to Implement ROM Program and Properly Apply Splint and Edema Glove
Penalty
Summary
The facility failed to ensure a range of motion (ROM) program for a resident with limited upper extremity mobility, leading to improper application of a wrist brace and edema glove. The resident, who had diagnoses including hemiplegia and hemiparesis following a cerebral infarction, was observed with a hand splint and edema glove incorrectly applied. The resident reported that staff did not perform ROM exercises and often applied the brace incorrectly, causing it to move out of place. Observations confirmed that the splint was not providing the intended support, and the resident's fingers were curled, indicating a lack of proper ROM exercises and splint application. Interviews with staff revealed inconsistencies in the implementation of the resident's care plan. Nursing assistants indicated they did not perform PROM on the resident's left hand due to discomfort and lack of clear instructions. The occupational therapist confirmed that the splint was not in the correct position and had lost its form, making it ineffective in preventing contractures. The therapist also noted that the resident's fingers were tight and required further therapy to regain flexibility. The resident's care plan and provider orders specified the need for ROM exercises and proper application of the splint and edema glove, but these were not consistently followed. The director of nursing acknowledged that the PROM should be performed by nursing assistants and that the hand splint should be applied correctly. However, the facility's documentation and staff interviews indicated a failure to adhere to the care plan, resulting in the resident's condition worsening. The facility's policy emphasized the importance of maintaining ROM and preventing contractures, but the lack of proper implementation and monitoring led to the deficiency observed by the surveyors.
Improper Cigarette Disposal and Supervision
Penalty
Summary
The facility failed to properly assess and manage the disposal of cigarettes for a resident with severe cognitive impairment and multiple health conditions, including aphasia, hemiplegia, and tobacco use. The resident's care plan indicated that he required supervision while smoking and that the facility would store his lighter and cigarettes. However, during an observation, the resident was seen smoking across the street with the interim director of nursing (IDON) supervising. The resident disposed of the cigarette butt improperly, and it was later found inside the facility, indicating a lapse in supervision and proper disposal procedures. The IDON admitted to not knowing where the cigarette butt was disposed of and confirmed that the facility did not have a designated receptacle for cigarette disposal. The director of nursing (DON) also acknowledged the lack of a proper plan or designated area for cigarette disposal, despite the facility's policy requiring metal containers with self-closing covers in smoking areas. The IDON, who was recently hired and still unfamiliar with the facility layout, confirmed that the facility allowed the resident to smoke off-property but did not have a well-thought-out plan for cigarette disposal. Further observations revealed multiple cigarette butts on the ground where the resident commonly smoked, and the DON stated that education would be provided to nursing staff and the resident regarding proper cigarette disposal. The facility's smoking policy emphasized the need for safe smoking practices and designated smoking areas, but the lack of a proper receptacle and supervision led to the deficiency in managing the resident's smoking habits and ensuring safety within the facility.
Unsanitary Conditions in Kitchen Areas
Penalty
Summary
The facility failed to provide a sanitary environment in the kitchen's food preparation and drying areas, potentially affecting all 56 residents. During an initial tour, a vent above the pots and pans dishwashing area was observed to have dark, fuzzy material. Additionally, wire mesh and a printer cord above the food serving area were covered in gray, fuzzy debris. These observations were confirmed by the cook and maintenance director, who acknowledged that the areas were dirty and needed cleaning. The culinary director also confirmed that there should not be any dirt or debris in these areas.
Failure to Administer Insulin Per Physician Orders
Penalty
Summary
The facility failed to ensure insulin was administered per physician orders for a resident (R1) with diabetes, leading to significant medication errors. R1, who was cognitively intact and required insulin daily, had physician orders to switch from detemir insulin to glargine insulin once the detemir was used up. However, due to a lapse in the visibility of the hold order for glargine insulin, R1 received both types of long-acting insulin simultaneously over a six-day period. This resulted in R1 experiencing hypoglycemia and being transported to the hospital after showing symptoms such as increased confusion and agitation. Licensed Practical Nurse (LPN)-A and Registered Nurse (RN)-A both administered the insulins without questioning the orders, despite knowing that both were long-acting insulins. The Director of Nursing (DON) acknowledged that the facility was transitioning from detemir to glargine insulin, and the hold order for glargine was not easily visible. Family members and staff observed significant changes in R1's condition, including increased confusion, agitation, and physical symptoms like being pale and clammy. The facility's Insulin Administration Policy required verification of insulin type, dosage, strength, and method of administration before administration, which was not adhered to in this case.
Failure to Assess and Respond to Change in Condition
Penalty
Summary
The facility failed to comprehensively assess, implement interventions, and provide timely notification for a change in condition to a provider for a resident who was found unresponsive, which delayed care and resulted in death from acute respiratory distress. The resident had a history of Parkinson's Disease, renal insufficiency, neurogenic bladder, seizure disorder, and muscle weakness. Despite several nursing assistants reporting the resident's deteriorating condition, including decreased appetite, facial pallor, blue lips, increased fatigue, lethargy, and decreased responsiveness, the licensed nursing staff did not perform a comprehensive assessment or monitor the resident adequately. On the day of the incident, multiple staff members observed and reported significant changes in the resident's condition, such as very dark urine, red eyes, and lethargy. However, the licensed practical nurse (LPN) and registered nurses (RNs) involved did not take appropriate actions, such as conducting a full set of vital signs, documenting the observations, or notifying a physician. The resident's condition continued to deteriorate throughout the day and evening, with no significant interventions or assessments performed by the nursing staff. By the time the night shift staff assessed the resident, the resident was found to be in severe respiratory distress with critically low oxygen saturation and pulse rates. Emergency Medical Services (EMS) were called, but the resident was not provided with oxygen or other necessary interventions before their arrival. The resident was transported to the hospital, where they were diagnosed with acute respiratory failure and subsequently passed away. The facility's failure to follow protocols for assessing and responding to changes in the resident's condition directly contributed to the resident's death.
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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