Sandstone Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Sandstone, Minnesota.
- Location
- 109 Court Avenue South, Sandstone, Minnesota 55072
- CMS Provider Number
- 245454
- Inspections on file
- 20
- Latest survey
- April 8, 2026
- Citations (last 12 mo.)
- 12 (1 serious)
Citation history
Health deficiencies cited at Sandstone Health Care Center during CMS and state inspections, most recent first.
The facility failed to include Enhanced Barrier Precautions (EBPs) in the care plan and Kardex for a dependent resident with Alzheimer’s disease and a stage IV pressure ulcer, and staff did not consistently use required PPE during high-contact care. An agency NA assisted an RN with repositioning the resident during coccyx wound care while wearing only gloves and a mask, despite an EBP sign on the door and a PPE cart outside the room. The RN wore a gown but did not instruct the NA to don one. The NA reported receiving only verbal instructions, not being shown how to access care plans, and not recognizing the EBP signage or PPE cart as applying to that resident. The ADON/infection control nurse acknowledged that EBPs, including gown and gloves, should have been used and that EBPs had been omitted from the resident’s care plan, contrary to facility policies requiring care plans to reflect current standards of practice and targeted gown and glove use for MDRO control.
Staff failed to follow hand hygiene, PPE, and Enhanced Barrier Precautions (EBPs) during high-contact care for three residents on EBPs. A resident with multiple stage III–IV pressure ulcers and a Foley catheter received wound and catheter care from the DON, who repeatedly changed gloves without performing hand hygiene, did not change gloves between different wounds, and placed soiled paper tape measures on bedside and supply surfaces that were not disinfected afterward. Another resident with a stage IV pressure ulcer and severely impaired cognition had an EBP sign and PPE cart outside the room, yet an NA assisted an RN with repositioning during wound care wearing only gloves and a mask, with no gown, and reported not being aware of the EBP requirements or how to access the care plan. A third resident with stage III and IV wounds had wound measurements taken with paper tape measures that were placed on the bedside table and later on the treatment cart after contacting wound drainage, while the DON again failed to perform hand hygiene between glove changes and the bedside table was not disinfected.
A resident who was fully dependent on staff for transfers and had osteoporosis and intellectual disabilities was injured during a transfer with an EZ Way smart lift when two underage nursing assistants failed to follow policy and manufacturer instructions. One assistant left the area before all sling straps were secured, and the other operated the lift without verifying strap placement or having required adult supervision, resulting in the resident falling and sustaining a scalp contusion and T4 vertebral fracture.
The facility failed to ensure weekend mail delivery for residents, affecting all 41 residents. While mail and packages were delivered to the facility, they were not distributed to residents on weekends. Staff interviews revealed that the activities staff only delivered mail already in their department and did not retrieve new mail from the office, leading to delays. The activities director acknowledged the issue and planned to address it.
The facility used a non-alcohol-based hand sanitizer in dispensers, contrary to policy requiring at least 62% alcohol content. Staff were unaware of this discrepancy. Additionally, a resident with COPD had oxygen tubing that was not changed weekly as required, increasing infection risk.
The facility failed to maintain a surety bond to protect the resident trust fund, potentially affecting 23 residents. The office manager could not locate the bond, and the administrator provided a document that did not cover resident trust accounts. Despite requests, no specific bond documents were received, violating the facility's policy on managing resident finances.
The facility failed to properly store temperature-controlled medications, affecting several residents and any needing medications from the emergency kit. The medication refrigerator at station three recorded temperatures out of the safe range multiple times from October 2024 to February 2025. Despite adjustments, staff did not notify maintenance, and the consultant pharmacist expressed concerns about medication viability. Medications like insulin and vaccines were stored improperly, contrary to CDC guidelines.
The facility failed to follow provider orders for medication administration and fluid management for two residents. One resident received furosemide despite low blood pressure, contrary to orders, while another resident's fluid restriction and daily weight monitoring were not properly documented or communicated. Staff interviews revealed a lack of awareness and documentation, leading to inconsistencies in care delivery.
A resident with a history of stroke and dysphagia was observed with a straw in their water cup, contrary to speech therapy instructions to avoid straws. The resident confirmed the regular use of straws, and an RN verified the risk of aspiration. The facility did not provide a policy on aspiration precautions.
A resident with COPD was not administered oxygen as ordered, receiving higher flow rates than prescribed. The treatment record showed multiple instances of oxygen being set at three liters per minute, contrary to the order of two liters at bedtime. Staff confirmed the discrepancy, acknowledging the potential risk of carbon dioxide retention. The DON emphasized the importance of adhering to medical orders, especially for residents with COPD.
A facility failed to limit the use of a PRN psychotropic medication, lorazepam, to a 14-day period or ensure it was re-evaluated for a resident receiving palliative care. Despite multiple recommendations from the pharmacist to document the rationale for extending the PRN order, no response was received from the physician. Interviews revealed confusion about the need for a stop date, and the issue was discussed in a quality meeting without resolution.
The facility failed to ensure that call lights in multi-resident bathrooms were accessible from the floor, affecting three residents. Observations showed cords were either looped and attached high on the wall or too short, making them difficult to reach. Maintenance confirmed the issue, and a resident stated the call light was always hooked to the wall. The administrator noted that lower cords would improve accessibility in emergencies.
Failure to Include and Implement Enhanced Barrier Precautions in Resident Care Planning
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement care plans that included Enhanced Barrier Precautions (EBPs) for residents requiring such precautions, and failure of staff to use required personal protective equipment (PPE) during high-contact care. Surveyors observed an EBP sign on the door of a resident’s room and a PPE cart outside the door, indicating that EBPs were required. During wound care to the resident’s coccyx, a nursing assistant (NA), who was an agency aide, assisted a registered nurse (RN), also an agency nurse, while wearing only gloves and a mask. The RN entered the room wearing a mask, gloves, and a gown but did not instruct the NA to don a gown, even though the NA was performing high-contact care by turning and holding the resident in position. The resident did not participate in bed mobility and was dependent on staff for all care and mobility. The resident’s admission MDS documented diagnoses of Alzheimer’s disease and a stage IV pressure ulcer, with severely impaired cognition and total dependence on staff. The resident’s care plan directed assistance of one to two staff for all care but did not include directions for EBPs during high-contact care. The NA reported receiving only verbal instructions about resident care upon starting work and stated she had not been shown how to access residents’ care plans or the Kardex. She did not see the EBP sign on the door and did not know the PPE cart was intended for that resident, although she was aware of EBP practices in general. The ADON/infection control nurse acknowledged that EBPs, including gown and gloves, should be used for identified residents during high-contact care, that NAs are to reference the Kardex for required precautions, and that EBPs had been missed in the resident’s care plan. Facility policies on EBPs and comprehensive person-centered care plans required incorporation of identified problems, risk factors, and current standards of practice, including targeted gown and glove use for MDRO control, which were not reflected in this resident’s care plan or consistently implemented by staff.
Failure to Follow Hand Hygiene, PPE, and EBP Protocols During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its own infection prevention and control practices, including hand hygiene, glove use, surface disinfection, and Enhanced Barrier Precautions (EBPs), for three residents on EBPs during high-contact care. For one resident with multiple pressure injuries and a Foley catheter, the DON repeatedly failed to perform hand hygiene between glove changes and between care of different wounds. During wound care to the left foot, the DON removed soiled dressings, discarded gloves, and applied new gloves without hand hygiene, then cleansed and dressed a stage II heel wound and a stage III lateral foot wound without changing gloves or performing hand hygiene between steps until later in the procedure. The DON also attempted Foley catheter insertion multiple times, changing to sterile gloves and opening new catheter kits without performing hand hygiene between attempts. When providing care to the resident’s stage IV coccyx and left gluteal fold wounds, the DON removed dressings without changing gloves and performing hand hygiene, handled paper tape measures between the wounds and the bedside table without hand hygiene, and did not change gloves or perform hand hygiene between cleansing the two separate wounds. The same resident’s care involved additional infection control lapses related to contaminated items and environmental surfaces. The DON placed used paper tape measures on the bedside table and on top of an open box of facial tissues, then later on the flap of an open box of ostomy bags, after the tape measures had been in contact with the resident’s wounds and the bedside table. The nurses did not disinfect the over-bed table where the soiled tape measures had been placed before exiting the room. This resident’s quarterly MDS documented diagnoses including Type 2 diabetes mellitus, paraplegia, encephalopathy, and multiple pressure ulcers (two stage III, one stage IV, and one deep tissue injury). The resident’s care plan indicated she was on EBPs per CDC recommendations for wounds, with a goal to remain free of multidrug-resistant organisms (MDRO), and that she was cognitively intact but dependent on staff for all care and mobility. For a second resident on EBPs with a stage IV pressure ulcer and severely impaired cognition, staff failed to implement required gown use during high-contact care. An EBP sign and PPE cart were present outside the room, but an NA entered wearing only gloves and a mask while an RN, an agency nurse, entered with a mask, gloves, and gown and did not instruct the NA to don a gown. The NA assisted with positioning the resident for coccyx wound care, with her scrubs in contact with the resident’s bedding and handrail, and had been providing care for this resident for weeks without using a gown. The NA reported she did not see the EBP sign, did not know the PPE cart was intended for that resident, and had not been shown how to access residents’ care plans, while the ADON later acknowledged EBPs had been missed on this resident’s care plan. For a third resident on EBPs with stage III coccyx and stage IV left gluteal wounds, the DON again failed to follow infection control practices during wound care. The DON used a paper measuring tape on the coccyx wound, wrote measurements on it, and placed the tape directly on the bedside table where red liquid was observed on the back of the tape, and it touched the resident’s water mug. The DON changed gloves but did not perform hand hygiene before measuring the left gluteal wound with a new paper tape measure. At the end of the procedure, the DON picked up the marker and soiled tape measures with bare hands, placed them in her scrub pocket, and later placed them on the treatment cart next to a laptop in the hallway. The nurses did not disinfect the bedside table after wound care. Facility policies on hand hygiene, PPE, and EBPs required hand hygiene before and after glove use, between contaminated and clean body sites, after handling used dressings or contaminated equipment, and after glove removal, and directed that gloves do not replace handwashing and that gowns and gloves be used for high-contact care for residents with wounds or indwelling devices under EBPs.
Failure to Ensure Safe Mechanical Lift Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to ensure a safe transfer of a resident using an EZ Way smart lift, resulting in the resident falling from the sling and sustaining a scalp contusion and a closed wedge compression fracture of the T4 vertebra. The resident, who had diagnoses of intellectual disabilities and osteoporosis and was fully dependent on staff for transfers, required two staff members and the use of a mechanical lift for all transfers according to her care plan. On the day of the incident, two nursing assistants, both under the age of eighteen, attempted to transfer the resident without following facility policy or the manufacturer's instructions. During the transfer, one nursing assistant attached only the upper right sling strap and was distracted by another resident's needs, leaving the area. The other assistant, also underage, began operating the lift without verifying that all straps were secured and without the required adult supervision. As a result, the resident leaned forward and fell out of the lift onto the floor. Interviews confirmed that both staff members were aware that at least one adult should have been present and that all straps needed to be checked before operating the lift, but these procedures were not followed. The EZ Way representative confirmed that the lift and sling were functioning properly and that the incident was due to improper use. The facility's policies and the manufacturer's instructions both required two staff to be present, with one being at least eighteen years old, and for all four sling straps to be checked before lifting. The medical director confirmed that the injuries were acute and directly resulted from the fall during the transfer.
Removal Plan
- Reviewed policies on use of mechanical lifts.
- Re-assessed R1 and all residents who utilize a mechanical lift.
- Re-educated all staff who use the mechanical lift on the policy and procedure and did competency testing.
- Completed audits observing staff transferring residents with mechanical lifts; results would be brought to Quality Assurance and Performance Improvement (QAPI) committee.
- Developed an ongoing plan for safe transfer education in QAPI meeting.
Failure in Weekend Mail Delivery for Residents
Penalty
Summary
The facility failed to ensure weekend mail delivery for residents, impacting all 41 residents residing at the facility. During interviews, residents confirmed that while mail and packages were delivered to the facility on weekends, they were not distributed to them. Some residents noted that mail and packages were left unattended in the facility over the weekend. The facility's policy requires mail to be delivered to residents within 24 hours, unopened and unread, unless assistance is requested. Interviews with staff revealed a lack of clarity and consistency in the mail delivery process on weekends. The activities staff, responsible for mail delivery, only distributed mail that was already in the activities department and did not retrieve newly delivered mail from the office on weekends. This resulted in residents not receiving their mail until the following week. The activities director acknowledged the inconsistency in mail delivery and indicated plans to address the issue.
Non-Alcohol Hand Sanitizer and Delayed Oxygen Tubing Change
Penalty
Summary
The facility failed to ensure the use of alcohol-based hand sanitizer in the hand hygiene dispensers throughout the facility. Observations revealed that the hand sanitizer dispensed from the hallway and resident room dispensers felt watery and was odorless. Housekeeping staff were responsible for refilling the dispensers and used a product provided by Ecolab, which was benzalkonium chloride 0.89% and water, a non-alcohol-based sanitizer. The facility's policy required the use of an alcohol-based hand rub containing at least 62% alcohol, but the staff, including the administrator and the director of nursing, were unaware that the product in use did not meet this requirement. Additionally, the facility failed to change the oxygen tubing timely for a resident receiving oxygen therapy. The resident, who had a diagnosis of COPD and used oxygen, had oxygen tubing dated 2/2, which was not changed weekly as required by the facility's infection control policy. The tubing was verified by an LPN to be overdue for a change, and the director of nursing confirmed that the tubing should be replaced weekly to minimize infection risk.
Failure to Maintain Surety Bond for Resident Trust Funds
Penalty
Summary
The facility failed to maintain a surety bond to protect the account balance of the resident trust fund, which had the potential to affect 23 of 41 residents with trust accounts managed by the facility. During an interview, the office manager, responsible for the resident trust funds, was unable to locate a copy of the surety bond and indicated a need to follow up with the corporate office. The administrator later provided a document titled 'Erisa Dishonesty Bond Edition of 10/1/17' from Spring Valley Mutual Insurance Company, which covered employees insured by employee benefit plans but did not include coverage for residents with trust accounts. Despite additional requests, no further documents specific to the resident trust accounts were received. The facility's policy on handling resident finances and property requires that any party responsible for managing residents' personal funds be bonded or insured in sufficient amounts to cover losses of resident funds and provide proof of such bond or insurance.
Improper Storage of Temperature-Controlled Medications
Penalty
Summary
The facility failed to ensure that temperature-controlled medications were properly stored, affecting six residents and any resident needing medications from the pharmacy-provided emergency kit, stock vaccine, and tuberculin testing medication. During a tour of station three's medication room, it was observed that the medication refrigerator temperature log recorded temperatures out of the safe range. The refrigerator contained insulins, neurontin, vaccines, and other medications, and the temperatures were noted to be 48 degrees Fahrenheit in the morning and 53 degrees Fahrenheit in the afternoon. Despite adjusting the temperatures, the staff did not notify anyone about the issue. The temperature records for the medication refrigerator showed multiple instances of temperatures being out of the safe range from October 2024 to February 2025. The safe range was identified as 36 degrees Fahrenheit to 46 degrees Fahrenheit, but the records revealed several dates where the temperatures were either below or above this range. The medications stored in the refrigerator included liquid gabapentin, Trulicity, Semglee, Copaxone, Novolog, Lantus, Arexvy kit, and Aplisol, all of which required storage between 36 degrees and 46 degrees Fahrenheit according to the manufacturer's guidelines. Interviews with the director of nursing, consultant pharmacist, and maintenance staff revealed that there was an expectation for staff to notify maintenance if the medication refrigerator was out of the temperature range. However, maintenance staff could not recall being notified, and the consultant pharmacist expressed concern about the viability of medications stored out of the safe range for months. The facility's medication guidelines required that medications needing refrigeration be stored within standard temperature parameters based on CDC recommendations, which was not adhered to in this case.
Failure to Follow Provider Orders for Medication and Fluid Management
Penalty
Summary
The facility failed to adhere to provider orders for medication administration and fluid management for two residents, leading to deficiencies in care. Resident R18, who had moderately impaired cognition and diagnoses of hypertension and repeated falls, was prescribed furosemide with specific parameters to hold the medication if the systolic blood pressure (SBP) was below 110. However, the medication was administered on two occasions when R18's SBP was below the threshold, potentially risking further health complications. Interviews with nursing staff revealed an expectation that provider orders should be followed, and failure to do so could result in adverse effects such as lower blood pressure and electrolyte imbalance. For Resident R142, the facility did not follow provider orders for a fluid restriction and daily weight monitoring. R142, diagnosed with heart failure, stomach cancer, anemia, and hypertension, had orders for a fluid restriction of 64 ounces daily and daily weight monitoring due to ascites. The care plan did not include the fluid restriction, and the Kardex used by staff to guide care was not updated with this critical information. Interviews with nursing assistants and registered nurses indicated a lack of awareness and documentation regarding the fluid restriction and daily weights, leading to inconsistencies in care delivery. The facility's policy on medication administration emphasized the importance of following provider orders and ensuring the six rights of medication administration. Despite this, the facility's failure to document and communicate essential care instructions for R142, such as fluid restrictions and daily weights, resulted in a lack of adherence to prescribed care plans. This oversight in communication and documentation contributed to the deficiencies observed during the survey, highlighting the need for accurate and timely updates to care plans and staff awareness of resident-specific care requirements.
Failure to Follow Aspiration Precautions for a Resident
Penalty
Summary
The facility failed to ensure aspiration precautions were followed for a resident reviewed for accidents. The resident, who had a history of cerebral infarction and dysphagia, was identified as cognitively intact and had specific instructions to avoid using straws, as per speech therapy recommendations. Despite these instructions, the resident was observed with a large plastic cup containing a straw. The resident confirmed that they always had a straw in their water cup. A registered nurse verified that the resident was not supposed to have straws and acknowledged that the use of a straw would increase the risk of aspiration. The facility did not provide a policy on aspiration precautions when requested.
Failure to Administer Oxygen as Ordered for Resident with COPD
Penalty
Summary
The facility failed to ensure that oxygen was administered as ordered for a resident with chronic obstructive pulmonary disease (COPD). The resident, who was moderately cognitively intact, had an active order for oxygen at two liters per nasal cannula at bedtime. However, the treatment record for the past three months showed that the resident had been receiving oxygen at three liters per minute on multiple occasions. Additionally, observations revealed that the resident's oxygen flow meter was set at 2.5 liters per minute, which was higher than the prescribed amount. Interviews with staff confirmed that the oxygen flow rate was not being maintained as per the medical provider's order. A licensed practical nurse acknowledged that the oxygen should have been set at two liters per minute and expressed concern that a higher flow rate could lead to the resident retaining carbon dioxide, potentially causing respiratory failure. The director of nursing stated that staff were expected to check the oxygen flow meter daily and document oxygen saturations, emphasizing the importance of following the medical provider's orders, especially for residents with COPD.
Failure to Limit PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that the use of a PRN psychotropic medication, specifically lorazepam, was limited to a 14-day period or re-evaluated by the provider for ongoing need and efficacy for a resident. The resident, who was moderately cognitively intact, had multiple diagnoses including anxiety disorder and was receiving palliative care. Despite the resident's active order for lorazepam being valid through end of life, the facility did not receive a documented rationale from the physician for extending the PRN order beyond 14 days, as required by policy. The pharmacist had made multiple recommendations to the providers in November, December, and February to document the rationale for the PRN order extension, but no response was received. Interviews with the hospice RN and the DON revealed a lack of clarity regarding the need for a stop date for the PRN lorazepam order, with the DON unsure if the medical director had communicated with the hospice physician about this issue. The consultant pharmacist confirmed that the request for a stop date had been discussed in a quality meeting, but no action was taken to address the deficiency.
Inaccessible Call Lights in Resident Bathrooms
Penalty
Summary
The facility failed to ensure that resident call lights were accessible from the bathroom floor in multi-resident bathrooms for three residents. During observations, it was noted that the call light cords in the shared bathrooms of these residents were not within reach from the floor. Specifically, one resident's call light was looped and attached to a hook approximately four feet from the floor, while the other two residents had call light cords that were 10 and 14 inches from the floor, respectively. Further investigation revealed that the maintenance staff confirmed the call lights were not easily accessible, with measurements showing cords at 17 to 18 inches from the floor when unhooked. A resident confirmed that the call light had always been hooked to the wall, and no request was made for it to be looped. The facility administrator acknowledged that having the call light cords reach closer to the floor would increase the likelihood of residents being able to reach them in case of a fall. Despite a request, the facility did not provide a policy on call lights.
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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