Pioneer Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Fergus Falls, Minnesota.
- Location
- 1131 South Mabelle Avenue, Fergus Falls, Minnesota 56537
- CMS Provider Number
- 245463
- Inspections on file
- 24
- Latest survey
- August 6, 2025
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Pioneer Care Center during CMS and state inspections, most recent first.
Surveyors found that multiple medications, including eye drops, insulin pens, inhalers, and nitroglycerin, were not properly labeled or dated, and some were missing administration instructions or resident identifiers. Staff often relied on the EMAR for directions instead of ensuring medication containers were labeled, and medications brought in by families frequently lacked pharmacy labels. These deficiencies were confirmed through staff interviews and observations, revealing a failure to follow facility policy for medication labeling and storage.
Surveyors identified that food items in the kitchen refrigerators and freezers were not consistently labeled with opened dates or expiration dates, and some items were not discarded by their expiration dates. Both the cook and dietary manager confirmed that these practices did not meet facility policy, which requires all opened food to be dated and discarded appropriately.
The facility did not properly implement self-administration of medication assessments and procedures for two residents. One resident had lidocaine patches left unsecured in their room despite not being able to apply them independently, while another had topical antifungal medications left at the bedside without authorization for self-administration. Staff and pharmacy consultants confirmed that medications should have been secured and that proper assessments were not followed.
A resident with severe cognitive impairment and a history of falls was placed in a low bed to prevent further falls, but staff did not complete a restraint assessment or identify the low bed as a potential restraint. Interviews and observations showed that the low bed restricted the resident's ability to stand independently, and staff were uncertain about its classification as a restraint, despite facility policy requiring assessment.
A resident with complex medical needs and a history of falls was not accurately coded on the MDS for the use of bed and chair alarms, despite care plans, physician orders, and staff observations confirming their use. The MDS coordinator did not perform a visual assessment or fully review care documentation, resulting in the omission of this critical information from the assessment.
A resident did not receive appropriate care to maintain or improve ROM and mobility, and the facility did not ensure that necessary interventions were provided or documented, except when decline was medically unavoidable.
The facility did not consistently post up-to-date nurse staffing information as required, with outdated postings and incorrect resident census numbers observed. The DON and scheduler confirmed that postings were often prepared in advance and not always updated to reflect current census or staffing changes, leading to inaccurate information being displayed.
A resident with severe cognitive impairment was found with multiple bruises of unknown origin on her inner thighs and knee. Although the administrator and DON were notified, the physician was not informed until five days later, contrary to facility expectations for immediate notification. This delay prevented timely medical evaluation and intervention.
A resident with severe cognitive impairment and high care needs was found with multiple unexplained bruises on her inner thighs and knees, described as fingerprint-sized and in a straight line. The facility's investigation did not include comprehensive staff interviews about possible abuse or suspicious behavior, and staff who observed the bruising were not questioned about abuse. Leadership acknowledged that the investigation did not follow policy requirements for injuries of unknown origin.
A resident with severe cognitive impairment and multiple medical conditions developed several greenish, fingerprint-sized bruises on the inner thighs. Although there was an order to monitor the bruises, it lacked clear instructions and was not entered into the TAR, resulting in inconsistent monitoring and missing documentation over several days. Staff interviews confirmed a lack of awareness and follow-through regarding the monitoring order, and the medical provider was not notified at the time of the incident.
A resident with cognitive impairment and limited mobility was left unsupervised on a secured outdoor patio for several hours in hot weather, without access to water or sun protection. Staff failed to provide adequate supervision or communicate the resident's status during shift changes, resulting in the resident being found unresponsive and requiring emergency treatment for heat exhaustion and dehydration.
A resident with COPD was allowed to self-administer nebulizer medication without a proper assessment or order in place. The facility's staff, including a TMA and RN, failed to follow the process for evaluating and documenting the resident's ability to self-administer medication safely. The resident's care plan and electronic health record lacked necessary documentation, and the pharmacy consultant expected these assessments and orders to be completed to ensure safe medication administration.
A resident with severe cognitive impairment and a preference for no facial hair was not assisted with facial hair removal, despite requiring substantial assistance with hygiene. Observations showed the resident had facial hair, and interviews revealed staff failed to follow the facility's policy of offering daily assistance for facial hair removal to maintain dignity.
A resident with severe cognitive impairment developed a stage two pressure ulcer behind the left ear due to nasal cannula tubing. The facility failed to assess, document, and implement interventions for the ulcer, despite the resident being at moderate risk. Nursing staff were unaware of the ulcer, and required procedures for pressure ulcer management were not followed, leading to inadequate care.
Medication Labeling and Storage Deficiencies
Penalty
Summary
Surveyors identified multiple deficiencies related to the labeling and storage of medications for nine residents. Medications, including eye drops, insulin pens, inhalers, and nitroglycerin, were found without proper labeling, such as missing resident names, administration directions, or dates of opening. In several cases, medications brought in by families lacked pharmacy labels, and staff relied on electronic medication administration records (EMAR) for instructions rather than ensuring the medication containers themselves were properly labeled. Some medications, such as eye drops and insulin pens, were not dated when opened, making it difficult to determine if they were still within the manufacturer’s recommended usage period. Observations revealed that staff did not consistently follow procedures for labeling medications upon opening or for maintaining medications in their original packaging with pharmacy labels. For example, eye drops and insulin pens were found undated, and some medications were stored outside of their labeled boxes, resulting in missing instructions and resident identifiers. Staff interviews confirmed that the expectation was to label medications with the date opened and to dispose of them after the recommended period, but this was not consistently practiced. In some instances, staff removed and destroyed improperly labeled or expired medications during the survey. The facility’s own policy required that all medications be labeled with the medication name, prescribed dose, strength, expiration date, resident’s name, route of administration, and instructions. However, the survey found that this policy was not followed for several medications, including those for dry eyes, glaucoma, diabetes, and chest pain. The lack of proper labeling and storage was confirmed by nursing staff, the clinical coordinator manager, the consultant pharmacist, and the director of nursing during interviews and observations.
Improper Food Labeling and Storage in Kitchen Refrigerators and Freezers
Penalty
Summary
Surveyors observed that the facility failed to ensure proper labeling, dating, and discarding of food items stored in the kitchen refrigerators and freezers. During a kitchen tour, it was found that a half container of sour cream in the walk-in cooler lacked an opened date and had an expiration date that had already passed. In the kitchen fridge, a quarter container of mustard was found with an expired date, and a half bottle of barbeque sauce was missing both an opened date and an expiration date. The cook confirmed these findings and stated that all opened food should be dated and discarded by the expiration date. The dietary manager also confirmed that food should be dated when opened and discarded after the shelf life or expiration date. Facility policy requires leftover foods to be stored in covered containers, clearly labeled, dated, and monitored to ensure consumption by safe use-by dates or frozen.
Failure to Implement and Secure Self-Administration of Medication Procedures
Penalty
Summary
The facility failed to properly implement self-administration of medication (SAM) assessments and procedures for two residents. One resident, who was cognitively intact and had diagnoses including diabetes, heart failure, and arthritis, had a physician's order for a lidocaine patch to be applied at bedtime and removed in the morning. Although the SAM assessment indicated the resident could self-administer medications after nurse setup, observations showed that nursing staff applied and removed the patch daily, and left an open box of lidocaine patches unsecured on the resident's dresser. Staff confirmed that the patches should have been secured in a locked medication drawer and that the resident was not able to apply the patch independently, only remove it. The pharmacy consultant and clinical coordinator both stated that only one patch should be left out at a time and that medications should be stored securely according to the SAM assessment. Another resident, with mild cognitive impairment and diagnoses including an indwelling urinary catheter, heart failure, and hypertension, had orders for topical antifungal medications. The care plan and SAM assessment indicated the resident was not able to self-administer medications. However, observations revealed that tubes of Clotrimazole cream and Nystatin powder were left on the nightstand in the resident's room. The resident reported that staff left the medications out for application, and if not left out, staff would not apply them as only one person could access the locked medications. Staff confirmed there was no order for self-administration and subsequently locked the medications away. Facility policy required that the interdisciplinary team assess each resident's cognitive and physical abilities to determine if self-administration is safe and appropriate, and that self-administered medications be stored securely. The policy also stated that any medications found at the bedside without authorization for self-administration should be turned over to the nurse in charge. The facility did not follow these procedures, resulting in unsecured medications at residents' bedsides and improper implementation of SAM assessments.
Failure to Assess Low Bed as Potential Physical Restraint
Penalty
Summary
The facility failed to comprehensively assess the use of a low bed as a potential physical restraint for a resident with severe cognitive impairment, Parkinson's disease, hypertension, arthritis, and a history of falls. The resident required extensive assistance with activities of daily living, including bed mobility, transfers, and toileting, and used a wheelchair for mobility. Despite the resident's ability to stand independently, staff placed the bed in the lowest position as an intervention following a fall, with the intention of preventing further falls. However, there was no documentation of a restraint assessment being completed prior to implementing this intervention, and the resident's care plan and assessments did not identify the low bed as a restraint. Observations and staff interviews revealed that the low bed made it difficult for the resident to stand up independently, and staff were unsure whether the low bed constituted a restraint. The facility's policy defined a physical restraint as any device that restricts freedom of movement and cannot be easily removed by the resident. Despite this, the low bed was not evaluated as a potential restraint, and the required assessment was not performed before its use. The director of nursing confirmed that a restraint assessment should have been completed but was not done in this case.
Failure to Accurately Code MDS for Resident Safety Alarms
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment was accurately coded to reflect the use of safety alarms for a resident with medically complex conditions, including hypertension, anxiety, and depression, who required extensive assistance with activities of daily living. Despite the resident's care plan and physician orders indicating the use of bed, recliner, and wheelchair alarms as fall interventions, the MDS assessment did not document the presence of these alarms. Multiple observations confirmed the resident was consistently using bed and chair alarms, and staff interviews verified that these alarms had been in place for an extended period. The MDS coordinator acknowledged that the alarms were not coded on the MDS and stated that the standard process involved reviewing assessments, care plans, and care conference notes, but a visual assessment was not performed for this resident at the time of the MDS completion. Both the MDS coordinator and nursing staff confirmed that the alarms should have been included in the MDS coding. The facility's policy required that MDS assessments consistently reflect information from progress notes, care plans, and resident observations, which was not followed in this instance.
Failure to Maintain or Improve Resident Range of Motion
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide appropriate care to maintain and/or improve a resident's range of motion (ROM), limited ROM, and/or mobility. The facility did not ensure that care and services were provided to prevent avoidable decline in ROM or mobility, except in cases where a decline was medically unavoidable. The report notes that the necessary interventions to maintain or improve the resident's physical abilities were not implemented or documented as required.
Failure to Consistently Post Accurate Daily Nurse Staffing Information
Penalty
Summary
The facility failed to consistently post required nurse staffing information on a daily basis as mandated. On the day of observation, the staff posting displayed was outdated, showing information from two days prior and an incorrect resident census. The current day's posting was found behind previous days' postings and also contained an incorrect census. The DON confirmed these discrepancies and explained that the process was to update the nurse staff posting daily, with the scheduler responsible for creating the postings and the charge nurse responsible for updating them with census or staffing changes. Interviews revealed that the scheduler typically prepares postings for upcoming days in advance, especially before weekends, and places them behind the current posting. Updates to the census or staffing changes occurring on weekends are expected to be made by the charge nurse. However, the process did not ensure that the most current and accurate information was consistently displayed, as required by facility policy. The policy specifies that daily postings must include the facility name, current date, resident census at the beginning of the shift, shift schedule, type and category of nursing staff, actual time worked, and totals for licensed and non-licensed staff.
Failure to Timely Notify Physician of Resident Injury
Penalty
Summary
The facility failed to notify a physician in a timely manner regarding a change in condition for a resident who was found with multiple bruises of unknown origin on her inner thighs and knee. The resident had severely impaired cognition, inattention, and disorganized thinking, making her unable to communicate how the bruises occurred or whether she felt safe. Documentation showed that the incident was discovered by staff in the morning, and while the administrator and DON were notified, the section of the incident report regarding physician notification was left blank. Progress notes indicated that the resident's family was informed, but there was no documentation of immediate provider notification. The physician was not notified until five days after the bruises were discovered, via fax, and was unaware of the incident during a routine visit that occurred in the interim. Interviews with staff confirmed that the expectation was for immediate provider notification, especially given the potential for abuse or injury. The lack of timely communication prevented the physician from evaluating the resident promptly and determining if further medical assessment or interventions were necessary.
Failure to Thoroughly Investigate Injury of Unknown Source
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown source for a resident with severe cognitive impairment and multiple physical dependencies. The resident, who had diagnoses including Parkinson's disease, dementia, and anxiety, was non-ambulatory, required substantial to maximal assistance with all activities of daily living, and was unable to communicate about her safety or the cause of her injuries. On assessment, staff identified multiple bruises of varying sizes and colors on the resident's inner thighs and knees, which were described as fingerprint-sized and arranged in a straight line. The resident's care plan directed staff to use caution during transfers and to monitor and report any suspected abuse or neglect, but the source of the bruising was not observed, and the resident could not explain the injuries. The facility's documentation and investigation into the incident were incomplete. Progress notes indicated that the resource manager was notified and the resident's family was informed, but did not specify what actions were taken. The state agency report and facility records showed that previous skin assessments did not note any discoloration or bruising, and that the bruising could have been related to the process of changing the resident's brief. However, there was no evidence that staff interviews included questions about possible abuse, aggressive care, or suspicious behavior by staff or other residents. Staff who discovered or observed the bruising confirmed they were not interviewed about abuse or the incident itself. Interviews with facility leadership and the medical director confirmed that the investigation did not follow policy requirements for injuries of unknown origin, which called for comprehensive interviews with all staff who had contact with the resident during the relevant period, including questions about abuse. The director of nursing acknowledged that staff were only asked about skin changes, difficulties with repositioning, and care challenges, and not about abuse. The medical director stated that he was not notified of the incident and would have expected a more thorough investigation, including an examination to determine if the injuries were suspicious.
Failure to Monitor and Document Bruising for Cognitively Impaired Resident
Penalty
Summary
The facility failed to properly assess and monitor bruises for a resident with severely impaired cognition, Parkinson's disease, dementia, and significant physical limitations. The resident was dependent on staff for all activities of daily living and had an order for weekly skin monitoring, as well as a specific order to monitor bruising to the inner thighs after staff observed multiple greenish, fingerprint-sized bruises. Documentation showed that the order to monitor the bruises lacked clear directions and frequency, and was not entered into the Treatment Administration Record (TAR), resulting in inconsistent monitoring and documentation. Progress notes were missing for several days following the discovery of the bruises, and staff interviews confirmed a lack of awareness and follow-through regarding the monitoring order. The incident report and progress notes indicated that the medical provider was not notified at the time of the incident, and the order to monitor the bruises was not effectively communicated or implemented among nursing staff. The DON and other staff acknowledged that the order should have been placed in the TAR with a specified frequency to ensure consistent monitoring, but this was not done. As a result, there was no documented evidence that the resident's bruises were assessed every shift or daily as would have been expected, leading to a failure in providing appropriate treatment and care according to orders and the resident's needs.
Resident Left Unsupervised Outdoors Resulting in Heat Exhaustion
Penalty
Summary
A deficiency occurred when a resident with mild neurocognitive disorder, impaired mobility, and a history of delusions and agitation was left unsupervised on an outdoor patio. The resident was dependent on staff for transfers, had impaired balance, and required supervision with all decision-making. According to the care plan, the resident was at risk for falls and required prompt response to requests for assistance, as well as supervision when outside. Despite these needs, the resident was brought outside by staff and left alone for an extended period in hot weather, without access to water or sun protection. Staff interviews and documentation revealed that the resident was placed on the patio around early afternoon and checked on intermittently. Multiple staff members noted that the resident refused to return inside when offered, but she was not provided with water or adequate sun protection, and there was no way for her to independently alert staff if she needed help. The patio door required a code to re-enter the building, which the resident could not operate due to her physical limitations. Staff were unclear about the frequency of required checks and did not consistently communicate the resident's location or status during shift changes. The resident was found unresponsive after being left outside for several hours in temperatures reaching 90 degrees Fahrenheit. She exhibited signs of heat exhaustion and dehydration, including confusion, elevated vital signs, and sunburn. Emergency services were called, and the resident was treated in the emergency department for heat exposure, dehydration, and hyperkalemia before being returned to the facility. The facility's policy required supervision based on individual assessment and environmental hazards, but staff failed to provide adequate supervision and did not follow established procedures for monitoring residents outside.
Failure to Ensure Safe Self-Administration of Nebulizer Medication
Penalty
Summary
The facility failed to ensure the safe administration of nebulizer medication for a resident who was observed to self-administer without being assessed as safe to do so. The resident, who was cognitively intact and had diagnoses including COPD, heart failure, and anxiety disorder, required assistance with activities of daily living. Despite this, the resident's care plan did not include interventions for self-administration of medication, and there was no documented self-administration medication (SAM) assessment or order for the resident to self-administer the nebulizer medication. During observations, a trained medication aide set up the nebulizer for the resident and left the room, allowing the resident to self-administer the medication unsupervised. The aide assumed the resident had been assessed for self-administration, but upon review, it was confirmed that no such assessment or order existed. Interviews with the unit manager RN and the DON revealed that the facility's process for SAM assessments and obtaining orders was not followed, and the resident's care plan and electronic health record lacked the necessary documentation. The pharmacy consultant also expected a SAM assessment and order to be in place to ensure safe medication administration.
Failure to Assist Resident with Facial Hair Removal
Penalty
Summary
The facility failed to ensure that a resident, who required assistance with hygiene, had her facial hair removed, despite her preference for no facial hair. The resident, who was severely cognitively impaired with diagnoses including dementia, coronary artery disease, and hypertension, required substantial assistance with bathing and dressing but was noted to be independent with personal hygiene. However, observations revealed that the resident had multiple white facial hairs on her cheeks, chin, and around her mouth, which she was unable to remove herself. Interviews with nursing assistants and the clinical manager revealed that the usual practice was to assist residents with facial hair removal to maintain their dignity. However, the staff failed to check and assist the resident with facial hair removal as per her care plan and facility policy. The director of nursing confirmed that staff were expected to offer facial hair removal daily and document any refusals. A family member also confirmed the resident's preference for no facial hair. The facility's policy emphasized promoting cleanliness and skin care, yet the staff did not adhere to these guidelines, leading to the deficiency.
Failure to Assess and Manage Pressure Ulcer
Penalty
Summary
The facility failed to comprehensively assess, monitor, and implement interventions for a resident with a stage two pressure ulcer. The resident, who had severe cognitive impairment and required extensive assistance with activities of daily living, developed a pressure ulcer behind the left ear due to nasal cannula tubing. Despite being at moderate risk for pressure ulcer development, the resident's care plan and assessments lacked documentation of the pressure ulcer, and no interventions were implemented to prevent further skin breakdown. Observations and interviews revealed that nursing staff were unaware of the pressure ulcer and had not completed necessary assessments or documentation. A registered nurse discovered the ulcer during an observation and noted that it had not been assessed or measured previously. The facility's policy required a wound checklist to be completed when a new pressure ulcer was identified, but this was not done, leading to a lack of monitoring and intervention. Interviews with nursing staff and the director of nursing confirmed that the facility's procedures for pressure ulcer management were not followed. The resident's care plan was not updated to reflect the presence of the ulcer, and the necessary steps to promote healing and prevent further deterioration were not taken. The facility's policies on skin assessment and wound treatment documentation were not adhered to, resulting in inadequate care for the resident's pressure ulcer.
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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