Sacred Heart Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Austin, Minnesota.
- Location
- 1200 12th Street Southwest, Austin, Minnesota 55912
- CMS Provider Number
- 245447
- Inspections on file
- 21
- Latest survey
- July 25, 2025
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Sacred Heart Care Center during CMS and state inspections, most recent first.
Nursing staff were not adequately trained or educated on the identification and reporting of mechanical lift maintenance concerns, leading to the use of lifts missing essential rubber sling stoppers. Several staff members were unaware of the purpose of these stoppers and continued to use the equipment without proper safety measures, while only a minority had completed the required competency training. Facility policies requiring comprehensive orientation and ongoing training were not consistently followed, and an older, unchecked lift remained in use.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
A resident with multiple mental health diagnoses was admitted without completion of a required Level II PASARR, despite documentation and staff confirmation that the criteria were met. The facility's policy required this screening prior to admission, but it was not conducted as indicated.
A resident with PTSD and other mental health diagnoses was not comprehensively assessed for past trauma, and the care plan lacked individualized, trauma-informed interventions or identification of specific triggers. Staff interviews revealed a lack of awareness regarding the resident's PTSD and related needs, despite facility policy requiring trauma-based care plans.
The facility did not properly track or document employee illnesses, resulting in staff returning to work without clear evidence that their symptoms had resolved or that they were no longer contagious. Incomplete illness logs and inadequate oversight by the infection preventionist led to staff with gastrointestinal and respiratory symptoms working while potentially infectious, affecting the safety of all residents, staff, and visitors.
A resident with dementia and chronic illness receiving hospice care experienced discrepancies in liquid morphine and lorazepam counts. Despite an LPN reporting the issue, nurse managers and the administrator did not initiate an investigation or follow facility policy, attributing the discrepancies to spillage or evaporation. An investigation was only started after an anonymous note alleged narcotic diversion, but the facility could not provide documentation of a proper investigation.
A resident with dementia and chronic kidney disease, receiving hospice care and prescribed narcotics, had a discrepancy in their medication count identified by nursing staff. The RN in charge delayed notifying the administrator and the State Agency about the missing narcotics, contrary to facility policy and regulatory requirements that mandate reporting within 24 hours of an allegation of misappropriation.
The facility did not ensure accurate reconciliation and documentation of controlled substances for two residents receiving narcotic medications. Nursing staff recorded expected rather than actual amounts in narcotic logs, failed to consistently notify administration of discrepancies, and did not follow facility policy for resolving count issues. The consulting pharmacist was not informed of the discrepancies until after medication destruction, and routine reconciliation was not performed.
The facility failed to ensure an RN was on duty for a minimum of 8 consecutive hours on two specific dates. Both the DON and the administrator were unaware of the deficiency until a review of schedules and time card entries confirmed the lack of coverage. A policy for staff scheduling was requested but not provided.
The facility failed to provide comprehensive policies and procedures for their QAPI committee, affecting all 49 residents. The provided QAPI plan lacked details on identifying and correcting quality deficiencies, tracking performance, and other essential processes. Meeting minutes and additional documentation were also insufficient.
The facility failed to ensure appropriate hand hygiene and PPE use for four residents with indwelling catheters, did not complete contact source tracing during norovirus and COVID-19 outbreaks, and neglected to perform hand hygiene and PPE audits. The infection preventionist and director of nursing confirmed these deficiencies.
A resident with intact cognition and multiple medical conditions was found with medications at bedside without a self-administration of medications (SAM) assessment or physician's order. The LPN left the medications at the resident's request, assuming he would not touch them. Interviews with the RN and DON confirmed the lack of necessary documentation and the facility's policy requirements for SAM.
A facility failed to provide a resident with opportunities to participate in outdoor activities, despite her expressed desire and documented preferences. The resident's care plan did not include directions for walking outside, leading to her frustration and feelings of confinement. Staff interviews and activity records revealed limited facilitation of outdoor walks, contributing to the deficiency identified by surveyors.
The facility failed to provide a written bed hold policy to a resident or their representative at the time of hospital transfer. The resident, who had multiple diagnoses and required assistance with all ADLs, was hospitalized and returned to the facility without documentation of a bed hold notice being given. The DON confirmed the lack of communication regarding the bed hold, which was against the facility's policy.
The facility failed to consistently follow orders for the application of hand splints for a resident with limited range of motion. Despite care plans and provider orders, observations revealed that the resident did not have the hand splints on as required. Staff interviews confirmed the resident was supposed to wear the splints, and there were no documented refusals. The facility's policies did not mention the application of hand splints, contributing to the inconsistency in care.
A facility failed to change respiratory equipment weekly for a resident requiring respiratory care, leading to potential infection risks. The resident's care plan and orders lacked specific instructions for changing oxygen tubing and humidifier, and observations showed the equipment was not labeled with change dates. Staff confirmed the absence of required orders and documentation.
The facility failed to develop an antibiotic stewardship program that included protocols and a system to monitor antibiotic use for a resident prescribed prophylactic antibiotics. The resident had multiple diagnoses and was on Bactrim for infection prevention without an end date. The infection preventionist confirmed a lack of monitoring and follow-up, and the issue was not discussed in quality assurance meetings.
The facility failed to ensure the required and complete nurse staffing information was posted and readily available for residents and visitors. Additionally, the facility did not maintain staffing logs for the required 18 months, as confirmed by the RN responsible for scheduling and the DON.
The facility failed to submit accurate direct care staffing information for Quarter 1 of FY 2024, missing RN hours and 24-hour licensed nursing coverage on specific dates. The issue was due to errors in submission and a lack of timely reporting.
The facility failed to incorporate infection control data and performance improvement plans into its QAPI Plan. The provided QAPI document lacked specific details on infection control, and the Facility Assessment did not include documentation on tracking and trending infection control data. The administrator confirmed inconsistent formatting for tracking infection data, and additional requested documentation was not provided.
The facility failed to ensure the Medical Director's routine attendance at QAPI meetings as required. The MD was only present at one out of three reviewed quarterly meetings, despite being in-house weekly. No communication or updates were provided for the missed meetings.
Failure to Ensure Staff Competency and Mechanical Lift Safety
Penalty
Summary
The facility failed to ensure that nursing staff were appropriately trained and educated on identifying and reporting mechanical lift maintenance concerns, specifically regarding the presence and function of rubber sling stoppers on mechanical lifts. Observations and interviews revealed that several mechanical lifts in use were missing these rubber sling stoppers, which are intended to prevent slings from sliding off the support bar during resident transfers. Multiple staff members, including nursing assistants, LPNs, and RNs, demonstrated a lack of understanding about the purpose of the rubber sling stoppers and reported using lifts without them or improvising alternative methods, such as double looping the strap. Only 27 out of 88 nursing staff had completed the required competency checklist for mechanical lift use, and staff were allowed to continue using the lifts for resident transfers even if they had not completed the mandatory training. Further review showed that the facility's policies required comprehensive orientation and ongoing training for safe use of mechanical lifts, but these were not consistently implemented. The administrator was unaware if the facility had contacted the lift manufacturer for service evaluations and acknowledged that an older lift, not routinely checked for maintenance, was still in use. The facility's own assessment and policies emphasized the importance of staff competency and regular training in safe resident handling, but these standards were not met, resulting in staff being unprepared to identify or report equipment maintenance issues.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Complete Required Level II PASARR for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure that a required Level II Pre-admission Screening and Resident Review (PASARR) was completed for a resident with multiple mental health diagnoses. The resident was admitted with diagnoses including Personality Disorder, Suicidal Ideation, Major Depressive Disorder, Generalized Anxiety Disorder, and Post-traumatic Stress Disorder. Documentation, including the Minimum Data Set (MDS) and a Senior LinkAge Line report, indicated the resident had intact cognition, was able to communicate needs, and had a primary diagnosis of severe major depressive disorder. The documentation also confirmed that the resident met criteria for mental illness and required a Level II PASARR evaluation prior to admission. Despite the Level I PASARR being completed and indicating the need for a Level II PASARR, facility staff, including the assistant director of nursing (ADON), director of nursing (DON), and regional consulting registered nurse (RC-RN), confirmed that the Level II PASARR was not completed. The facility's policy required completion of a Level I PASARR for all new admissions and a Level II PASARR as indicated before admission, but this process was not followed for the resident in question.
Failure to Provide Trauma-Informed, Individualized Care Planning for Resident with PTSD
Penalty
Summary
The facility failed to comprehensively assess and implement individualized, trauma-informed care plan interventions for a resident with a diagnosis of post-traumatic stress disorder (PTSD), among other mental health conditions. The resident's Minimum Data Set (MDS) assessment indicated intact cognition and the ability to communicate needs. The care plan identified potential for altered mood related to PTSD, major depressive disorder, generalized anxiety disorder, suicidal ideation, and personality disorder, but interventions were generic and did not address specific trauma triggers or utilize a trauma-informed approach. The care plan lacked identification of triggers to avoid potential re-traumatization and did not include individualized strategies based on the resident's trauma history. Interviews with the resident revealed that she is sensitive to loud noises due to past trauma and prefers staff to knock softly, but facility staff had not inquired about her trauma history or specific triggers. Several staff members, including the infection preventionist and a nursing assistant, were unaware of the resident's PTSD diagnosis or related triggers. The assistant director of nursing, director of nursing, and regional consulting registered nurse confirmed the resident's PTSD diagnosis and acknowledged the absence of a PTSD-specific care plan with related interventions. The facility's policy requires individualized trauma-based care plans to address past trauma, but this was not implemented for the resident in question.
Failure to Track and Document Employee Illnesses for Infection Control
Penalty
Summary
The facility failed to ensure proper tracking and documentation of employee illnesses to determine when staff were safe to return to work, as required by infection prevention and control protocols. Review of employee illness logs from May through July 2025 revealed incomplete documentation, with missing information regarding symptom resolution and clearance for return to work for two staff members: a certified nursing assistant and a dietary aide. Both staff members worked while symptomatic with gastrointestinal and respiratory illnesses, including strep throat and diarrhea, without clear evidence of when their symptoms resolved or if they met criteria for returning to work. The logs did not consistently record necessary details such as symptom resolution dates or confirmation that staff were no longer contagious before resuming duties. Interviews with facility staff, including the registered nurse and director of nursing, confirmed that the process for tracking and monitoring employee illnesses was inadequate. The infection preventionist or designee was expected to oversee employee health practices, including work restrictions and return-to-work criteria, but failed to ensure accurate tracking and surveillance. Facility policy required staff with communicable infections to avoid resident contact until they were no longer contagious, but this was not consistently enforced or documented. No resident outbreaks were identified during the review period, but the lack of proper tracking had the potential to affect all residents, staff, and visitors.
Failure to Investigate Alleged Narcotic Diversion
Penalty
Summary
The facility failed to implement its abuse prohibition policy in response to an allegation of misappropriation of a resident's property, specifically regarding the potential diversion of narcotic medications. A resident with dementia, bipolar disorder, and chronic kidney disease, who was receiving hospice care and prescribed liquid morphine and lorazepam, was found to have discrepancies in the counts of these medications. An LPN reported the morphine count was significantly off at the end of her shift and later noted a similar issue with lorazepam. Despite these reports, the nurse manager did not conduct a facility-wide narcotic count or initiate an investigation, instead attributing the discrepancies to possible spillage or evaporation after speaking with another nurse. The administrator was not informed of the issue until several days later and also did not initiate an investigation at that time, again attributing the discrepancies to spillage or evaporation. An investigation into the missing narcotics was only started after the administrator received an anonymous note several days after the initial report, which specifically alleged narcotic diversion and referenced inaccurate counts at the time of medication destruction. The facility was unable to provide documentation of an investigation into the incident, and the only evidence of follow-up was documentation of nurse training on narcotic counts, which did not include guidance on reconciling discrepancies. The facility's own policy required a thorough investigation into allegations of misappropriation, including interviews, documentation review, and a root-cause analysis, none of which were completed in this case.
Failure to Timely Report Missing Narcotics to State Agency
Penalty
Summary
The facility failed to report a potential misappropriation of a resident's property, specifically missing narcotics, to the State Agency (SA) within the required 24-hour timeframe after the allegation was made. A resident with diagnoses including dementia, bipolar disorder, and chronic kidney disease was prescribed morphine sulfate and lorazepam as part of hospice care. On the evening of 4/11/25, a nurse identified a discrepancy in the narcotic count for this resident and notified the registered nurse (RN)-B via email. RN-B responded to the email but did not initiate further action until the following day and did not inform the facility administrator until the afternoon of 4/14/25, stating she did not initially consider it a concern. The administrator confirmed that she was not made aware of the missing narcotics until 4/14/25 and did not report the incident to the SA at that time, as the investigation was still ongoing and not completed until 4/18/25. Interviews with other nursing staff indicated an understanding that missing medications should be reported to administration immediately and to the SA within 24 hours. The facility's policy also required all alleged violations of misappropriation to be reported to the administrator and appropriate authorities within 24 hours. The delay in reporting the missing narcotics constituted a failure to follow both regulatory requirements and facility policy.
Failure to Accurately Reconcile and Document Controlled Substances
Penalty
Summary
The facility failed to implement and follow policies and procedures to ensure accurate reconciliation of controlled substances, specifically narcotic medications, for two residents who were receiving morphine sulfate and Lorazepam. Documentation showed inconsistencies in the recorded amounts of these medications, with discrepancies between the amounts logged and the actual amounts present in the medication bottles. For one resident, the narcotic record indicated that 13 ml of morphine remained, but only 9 ml was physically present, and the log was adjusted to match the expected rather than the actual amount. Similar inconsistencies were found with Lorazepam, where the amount destroyed did not match the amount recorded as remaining, and no explanation was provided for the difference. Nursing staff, including LPNs and RNs, reported that narcotic counts had been off for some time and that they continued to document the expected amounts rather than the actual amounts present. Staff attributed discrepancies to possible spillage or evaporation and did not consistently notify nurse managers or administration when counts were incorrect. In some cases, staff relied on previous communications or assumptions rather than following the facility's policy, which required immediate notification and resolution of discrepancies before signing off on narcotic records. The consulting pharmacist was not made aware of the discrepancies until after the medications were destroyed, and routine reconciliation of narcotics was not performed by the pharmacist. The facility's own policy required that narcotics be counted at each shift change by two nurses, with immediate notification to supervisors if counts could not be reconciled. However, these procedures were not followed, and staff did not consistently document or address discrepancies as required.
Failure to Ensure RN Coverage for 8 Consecutive Hours
Penalty
Summary
The facility failed to ensure a registered nurse (RN) was on duty for a minimum of 8 consecutive hours per day on 10/7/23 and 10/21/23. A review of the facility schedule for the period from 10/1/23 through 12/31/23 revealed a lack of RN coverage for the required hours on these specific dates. During interviews conducted on 5/2/23, both the Director of Nursing (DON) and the administrator confirmed they were unaware of the deficiency until the review. The DON and the administrator verified the absence of RN coverage for the required hours through schedule and time card entries. A policy for staff scheduling was requested but not provided.
Lack of Comprehensive QAPI Policies and Procedures
Penalty
Summary
The facility failed to provide comprehensive policies and procedures for their Quality Assurance and Performance Improvement (QAPI) committee. During the entrance conference, the director of nursing provided a QAPI plan document that included various statements and guidelines but lacked detailed policies and procedures on the committee's responsibilities and processes. Specifically, the document did not outline how the committee would identify and correct quality deficiencies, track and measure performance, establish goals and thresholds, analyze underlying causes, develop and implement corrective actions, and monitor and evaluate the effectiveness of these actions. This deficiency had the potential to affect all 49 residents currently residing in the facility. During an interview, the administrator stated that QAPI meetings were held monthly and QA meetings quarterly, with various staff members in attendance. However, upon request for meeting minutes and additional documentation, only a handwritten copy of an Orientation Meeting Agenda was provided. The administrator mentioned that infection control information was tracked and trended by the Infection Control Preventionist (ICP) but was not included in the meeting minutes. Additionally, previous performance improvement plans (PIP) were discussed, but no comprehensive documentation was provided to reflect meeting minutes, performance improvement processes, attendance rosters, or the notification process for those not in attendance.
Failure to Implement Infection Control Measures
Penalty
Summary
The facility failed to ensure appropriate hand hygiene and the proper use of personal protective equipment (PPE) for four residents who required enhanced barrier precautions due to having indwelling catheters. Observations revealed that these residents did not have PPE carts or hand hygiene stations in or outside their rooms, nor was there signage indicating the need for enhanced barrier precautions. This failure was confirmed by the infection preventionist (IP) and the director of nursing (DON), who acknowledged that enhanced barrier precautions had not been implemented as required. Additionally, the facility did not complete contact source tracing during two outbreaks of norovirus and COVID-19. The IP admitted that she did not conduct in-depth contact tracing and could not provide documentation of any conversations with staff regarding the infection control process. The DON confirmed that source tracing should have been conducted starting with the resident identified with the infection and extending to all staff and other residents they had contact with. The lack of documentation indicated that these critical steps were not completed. Furthermore, the facility failed to perform hand hygiene and PPE audits to ensure proper technique during the outbreaks. The IP confirmed that these audits had not been conducted, and the DON stated that it was her expectation that such audits would be completed, especially during outbreaks, to ensure proper infection control practices. The facility's policies and procedures for enhanced barrier precautions, infection control audits, and source contact tracing were requested but not provided, further highlighting the deficiencies in their infection control program.
Failure to Complete SAM Assessment for Resident
Penalty
Summary
The facility failed to ensure a self-administration of medications (SAM) assessment was completed for a resident (R32) who was observed with medications at bedside. R32, who had intact cognition and required assistance with all activities of daily living, was found with a bottle of nasal spray and a medicine cup with four unidentified pills on his bedside table. The medications were identified as Quetiapine, Senna, and Sinemet (Carbidopa-Levodopa). The licensed practical nurse (LPN) confirmed that R32 did not have a current order for SAM and that medications should not be left in residents' rooms without the appropriate order and assessment in place. The LPN stated that R32 had asked her to leave the medications on his bedside table while he was in the bathroom, and she assumed he would not touch them despite not knowing him well enough yet. Further interviews with the registered nurse (RN) and the director of nursing (DON) confirmed that residents must have an order and assessment for SAM, and it should be care planned. Both verified that R32 did not have a current order or assessment for SAM, and it was not appropriate for medications to be left at the bedside without the necessary documentation. The facility's Self-Administration of Medications policy indicated that an initial assessment should be conducted before the initial care conference or sooner if requested, and a physician's order should be obtained for self-administration. The policy also required that the resident's ability to self-administer medications be reviewed at the quarterly care conference.
Failure to Facilitate Resident's Choice for Outdoor Activities
Penalty
Summary
The facility failed to provide opportunities for a resident to participate in activities of choice, specifically walking outside, despite the resident's expressed desire and documented preferences. The resident, who had medical diagnoses including coronary artery disease, hypertension, and anxiety, was cognitively impaired but able to express herself and understand others. Her care plan, last reviewed in March, did not include directions or identification of her interest in walking outside, even though it was noted as very important to her. The resident expressed frustration multiple times about not being able to go outside, feeling weaker, and likening her situation to being in a prison. Despite these expressions, the care plan lacked specific directions to address her interest in walking outside, and her activity participation records showed limited opportunities for outdoor walks. Interviews with staff revealed that while they were aware of the resident's desire to go outside, they had not consistently facilitated this activity. The activity aide mentioned that she had only walked with the resident in the gated courtyard and not outside the gated areas. The registered nurse confirmed that the resident could walk around the facility and had gone out on day leaves with family without issues. However, the family had requested that the resident not go beyond the nursing home doors due to concerns about her leaving unattended. Despite these concerns, the resident's care plan did not reflect her desire to walk outside, and her activity attendance records showed only four outdoor walks in a month, none of which corresponded with the times she expressed extreme frustration. The facility's policy on assessment and care plan development directed staff to complete a written assessment and evaluation of the resident before the care conference and to work with the team to initiate, develop, review, and update each individual's plan of care. However, the facility failed to adhere to this policy in the case of the resident, as her care plan did not include her expressed desire to walk outside, leading to her continued frustration and feelings of confinement. The lack of specific directions in the care plan and the limited opportunities for outdoor walks contributed to the deficiency identified by the surveyors.
Failure to Provide Bed Hold Notice at Time of Hospital Transfer
Penalty
Summary
The facility failed to provide a written bed hold policy to a resident or their representative at the time of hospital transfer. Specifically, for one resident who was reviewed for hospitalization, the medical record lacked evidence that a bed hold notice was provided when the resident was transferred to the hospital. The resident, who had intact cognition and required assistance with all activities of daily living, had multiple diagnoses including schizoaffective disorder, heart failure, hypertension, peripheral vascular disease, renal failure, schizophrenia, and chronic obstructive pulmonary disease. The resident was hospitalized and returned to the facility, but there was no documentation of a bed hold notice being given at the time of transfer. During an interview, the Director of Nursing (DON) stated that it was expected for a bed hold to be initiated by the nurse when a resident was transferred out of the facility, and for the case manager or social worker to follow up. The DON confirmed that there was no communication found regarding a bed hold for the resident's hospitalization. The facility's Bed Hold Notice at the Time of Transfer policy required that residents and their responsible parties be fully informed about bed-hold policies and associated costs whenever a resident is hospitalized or on therapeutic leave. The policy also required documentation in the progress notes that the bed hold policy was sent with the resident or given/mailed to a family member, which was not done in this case.
Failure to Consistently Apply Hand Splints
Penalty
Summary
The facility failed to consistently follow orders for the application of hand splints for a resident (R15) with limited range of motion. R15's care plan and provider orders specified that white hand splints should be applied in the morning and removed at 3 pm daily. However, observations on multiple occasions revealed that R15 did not have the hand splints on as required. Interviews with various staff members, including an LPN, RN, and NA, confirmed that R15 was supposed to wear the splints and that there were no documented refusals from R15. Additionally, it was noted that R15's husband, who is also a resident, sometimes removed the splints, but staff would offer to reapply them if R15 was agreeable. The facility's policies on physical devices and activities of daily living did not mention the application of hand splints, contributing to the inconsistency in care. During observations, R15 was noted to have clenched hands with impressions from the thumbnail and powder in the hand creases, indicating a lack of proper splint application. R15's fingernails were also found to be excessively long, which could contribute to skin issues. Despite the care plan and provider orders, the facility staff did not consistently ensure that R15 wore the hand splints as required, leading to a deficiency in the resident's care. The director of nursing confirmed that R15 should have been wearing the hand splints if agreeable, but there was no clear explanation for the lapses in care.
Failure to Change Respiratory Equipment Weekly
Penalty
Summary
The facility failed to ensure respiratory equipment was changed weekly according to professional standards to prevent infection for a resident (R29) who required respiratory care. R29 had intact cognition and was independent with all activities of daily living, with diagnoses including dyspnea, anxiety disorder, depression, PTSD, and slow transit constipation. The care plan for R29 lacked interventions related to oxygen tubing, bubbler, or humidified oxygen, and the orders did not specify the frequency for changing these items. Observations over several days revealed that the oxygen tubing and bubbler lacked labels indicating when they were last changed, and the nasal cannula tubing was discolored and stretched out. R29 confirmed that she did not know when the tubing or humidifier was last changed and had to request staff to change the tubing when it became too loose. Interviews with staff, including a registered nurse and the director of nursing, confirmed that there was no order in the electronic medical record to change R29's oxygen tubing and humidifier bi-weekly. The staff also verified that the facility's policy required the tubing to be changed every two weeks and documented on the treatment administration record, but this was not done for R29. The director of nursing acknowledged the importance of changing the tubing and humidifier to prevent infection and confirmed that there should have been an order for the licensed nursing staff to complete these changes on a scheduled basis. A facility policy on oxygen tubing and humidifier changes was requested but not provided.
Failure to Develop and Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to develop an antibiotic stewardship program that included protocols and a system to monitor antibiotic use. This deficiency was identified for a resident who was prescribed antibiotics prophylactically. The resident, who had intact cognition and required supervision/assistance with all activities of daily living, had multiple diagnoses including type 1 diabetes mellitus, cancer, hypertension, renal failure, anxiety disorder, Waldenstrom macroglobulinemia, encephalitis, and auditory and visual hallucinations. The resident's physician orders indicated the use of Bactrim for infection prevention related to kidney transplant status, but the order lacked an end date for antibiotic use. During an interview, the infection preventionist confirmed that the resident was admitted with orders for prophylactic antibiotics for chronic conditions and that these orders did not have an end date. The infection preventionist also stated that residents on prophylactic antibiotics were not monitored with infection monitoring charting or tracking, and there was no follow-up on the resident's prophylactic antibiotic use with the provider. Additionally, the prophylactic use of antibiotics was not reviewed or discussed at the facility's quality assurance and performance improvement team meetings. The facility's Antibiotic Stewardship Program policy aimed to monitor antibiotic use and ensure appropriate prescribing, but it was not effectively implemented in this case.
Failure to Maintain and Post Accurate Nurse Staffing Information
Penalty
Summary
The facility failed to ensure the required and complete nurse staffing information was posted and readily available for viewing by the residents and visitors. On multiple occasions, the nurse staffing information was either outdated or missing. For instance, on 4/30/24, the nurse staff posting was not updated to reflect the current date until later in the day. Additionally, on 5/1/24, the nurse staffing information posted was dated 4/29/24, and the information for 4/30/24 was missing. This inconsistency in updating the nurse staffing information was confirmed by RN-B, who was responsible for overseeing scheduling. RN-B acknowledged that the current nurse staffing information was not reflective of the actual date and that there had been no updates to reflect staff call-ins or changes for 4/29/24. Furthermore, the facility failed to maintain the staffing logs for the required 18 months. RN-B stated that the staff posting information prior to 12/8/23 was unavailable and had not been retained because the facility was unaware of the need to retain this information for an extended period. The Director of Nursing (DON) also confirmed that she was unaware of the requirement to maintain nurse staff posting information for 18 months. A policy for the retention of staff schedules and nurse staff posting information was requested but not provided.
Failure to Submit Accurate Staffing Information
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information for Quarter 1 of fiscal year 2024. A review of the PBJ Staffing Data Report revealed that there were no registered nurse (RN) hours reported for the period from October 1, 2023, through December 31, 2023. Additionally, the facility was flagged for a lack of licensed nursing coverage 24 hours a day during this period. Upon further investigation, it was found that RN coverage was missing for eight consecutive hours on two specific dates, October 7 and October 21, 2023. The facility's records, including staff schedules and time card logs, were reviewed, and discrepancies were noted, particularly for the period from December 8 to December 31, 2023, as earlier postings had not been retained by the facility. Interviews with the Director of Nursing (DON) and the administrator revealed that the PBJ submission process was not timely and that the person previously responsible for this task was no longer on staff. Both the DON and the administrator were unaware of any days where there was a lack of RN coverage for eight consecutive hours or a lack of licensed nursing coverage for the entire 24-hour period. The administrator acknowledged that there was no official facility policy for PBJ submission, and the process was completed as outlined on the CMS website. The deficiency was primarily due to errors in submission and a lack of timely and accurate reporting of staffing information.
Inadequate Incorporation of Infection Control Data into QAPI Plan
Penalty
Summary
The facility failed to ensure that infection control data and performance improvement plans were incorporated into the facility-wide Quality Assurance and Performance Improvement (QAPI) Plan. During the entrance conference, the facility provided a QAPI plan document that was last updated in 2021, which included various statements and principles but lacked specific details on infection control data and performance improvement plans. The Facility Assessment, last updated in 2022, mentioned preadmission screening and protocols for infection control but did not provide documentation on tracking and trending of infection control data or performance improvement processes. The administrator confirmed that QAPI meetings were held monthly and QA meetings quarterly, but the documentation provided did not reflect consistent tracking, trending, or contact tracing for infections and illnesses. During an interview, the administrator stated that infection control information was tracked and trended by the Infection Control Preventionist (ICP) during meetings, but there was no consistent formatting for this data. Additional documentation, such as meeting minutes, performance improvement processes, attendance rosters, and notification processes, was requested but not provided for review. This deficiency had the potential to affect all 49 residents currently residing in the facility.
Failure to Ensure Medical Director's Routine Attendance at QAPI Meetings
Penalty
Summary
The facility failed to demonstrate routine attendance and participation in the Quality Assurance Performance Improvement (QAPI) process by the Medical Director (MD). The QAPI Plan required the MD to be present at quarterly meetings. However, a review of the attendance rosters for meetings held on 6/28/23, 10/25/23, and 1/31/24 revealed that the MD was only present at the meeting on 10/25/23. The administrator confirmed that QAPI meetings were held monthly and Quality Assurance meetings quarterly, and that the MD was in-house weekly. Despite this, there was no evidence of the MD's attendance at the other two required meetings, nor was there any provided communication regarding the MD's absence or updates from the missed meetings.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
