Sauer Health Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Winona, Minnesota.
- Location
- 1635 West Service Drive, Winona, Minnesota 55987
- CMS Provider Number
- 245102
- Inspections on file
- 21
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Sauer Health Care during CMS and state inspections, most recent first.
A resident on blood thinners experienced a fall that reopened an existing wound, but the LPN on duty did not perform neurochecks or immediately notify a provider, instead documenting the event in a communication book for review the next day due to lack of on-call coverage. The next morning, an RN reported the resident had a severe headache and altered cognition and expressed concern for a possible brain bleed, confirming that neurochecks and timely provider notification had not occurred. Later, frank blood was noted in the toilet without immediate physician notification, despite the DON’s expectation that such findings, along with the resident’s anticoagulant use and cognitive impairment, should trigger neurochecks, prompt provider contact, and possible ED transfer. The DON and RN reported that the facility had not maintained 24-hour on-call physician services for several years, contrary to facility policy requiring continuous physician availability for emergencies.
A resident with cognitive impairment, multiple comorbidities, a pressure injury, and active warfarin therapy experienced an unwitnessed fall that reopened a coccyx wound, with bleeding noted. Post-fall assessments documented stable VS and no pain, but neuro checks were not initiated and the physician was not actually notified as recorded. Later that night, frank blood in the toilet was observed and documented without neuro checks or provider notification, and a subsequent note attributed the bleeding to a skin tear. The next morning, the resident was lethargic, oriented x2, reporting significant head pain and breakthrough bleeding, and was transferred non-emergently to the ED, where an elevated INR was found and warfarin dosing was adjusted. The care plan lacked anticoagulation management focus, and interviews with nursing staff and the DON confirmed that required neuro assessments and timely provider notification after the fall and subsequent bleeding did not occur, contrary to facility policies on change of condition and fall management.
Two residents who required mechanical lifts for transfers were transferred without comprehensive, documented assessments of sling and harness sizing or consistent use of required safety components. One resident with stroke‑related hemiparesis and impaired balance experienced an incident in a sit‑to‑stand lift when feet were not correctly positioned on the platform and the leg strap was not used, resulting in the resident hanging in the lift until assisted to the floor. Another resident with multiple sclerosis and generalized weakness was dependent on a Hoyer lift, but no individualized sling size assessment based on height, weight, girth, and tailbone‑to‑neck measurements was documented. Care plans and assignment sheets did not specify sling or harness sizes or leg strap use, CNAs reported they did not know how to determine correct sizes and that leg strap use was inconsistent, and the DON and RN acknowledged there was no formal, documented process for sling/harness sizing or monitoring for changes, despite manufacturer instructions and an OT and equipment representative stating that full assessments and leg strap use are required for safe transfers.
A resident with moderately impaired cognition, stroke, CHF, mobility limitations, and documented urinary incontinence was not provided an individualized toileting program despite facility policy requiring comprehensive bladder assessments and tailored interventions. On admission and thereafter, no comprehensive bowel/bladder assessment was completed, the CAA did not identify the type of incontinence, and the care plan lacked specific toileting interventions such as scheduled toileting or prompted voiding. Staff expected the resident to use the call light and did not routinely offer toileting assistance, while the resident reported walking to the bathroom independently, sometimes forgetting to use a walker and experiencing incontinence. Nursing staff and the DON confirmed that comprehensive assessments and individualized toileting plans were not performed, even though the resident was frequently incontinent.
A resident with intact cognition but significant post-stroke physical impairments, including hemiparesis, limited ROM, incontinence, impaired vision, and a history of falls, required extensive assistance from 1–2 staff for transfers and toileting using a gait belt, walker, or EZ Stand lift. Over a 14-day period, call light logs showed this resident’s call light remained active more than 15 minutes on 38 occasions, with an average response time of about 27 minutes and several waits exceeding 40 minutes, especially in early morning and other busy periods. The resident reported frequent waits of about an hour, inconsistent responses, and call lights being turned off without care, and described multiple incontinence episodes related to delayed assistance. NAs stated that call lights ideally should be answered within 5–10 minutes but acknowledged that residents could wait up to 30 minutes during busy times, and the DON confirmed repeated complaints of waits over 20–30 minutes while being unable to provide a facility call light response policy when requested.
A facility failed to ensure proper PPE use when staff moved between rooms of residents with and without COVID-19. A dietary aide entered a COVID-19 positive resident's room with only an N95 mask, then proceeded to other rooms without changing PPE. Staff interviews revealed confusion about PPE requirements, despite facility policies and CDC guidelines mandating full PPE for COVID-19 rooms.
A facility failed to implement person-centered interventions for a resident with a history of falls and cognitive impairment. Despite multiple falls, the care plan was not updated with specific strategies, relying instead on generic reminders. Staff interviews confirmed the absence of individualized interventions, contrary to facility policy requiring updates to care plans based on fall risks.
Failure to Provide 24-Hour On-Call Physician Coverage and Post-Fall Assessment
Penalty
Summary
The deficiency involves the facility’s failure to provide or arrange 24-hour on-call physician services and to ensure timely provider notification and appropriate post-fall assessment for a resident on blood-thinning medication. After the resident, who was new to the facility and taking blood thinners, fell at 7:15 p.m. on 2/4/26, an LPN assessed the resident, noted that an existing wound on the resident’s bottom had reopened, and applied a dressing. However, neurochecks were not performed, and the provider was not notified immediately. Instead, the LPN documented the fall in a communication book for the provider to review during rounds the next day, stating that there was no on-call provider available. The facility’s own policy required 24-hour physician coverage for emergencies, including contacting the primary physician first, then the on-call physician, and, if necessary, the medical director, and transporting the resident to the ED if no physician was reachable and immediate assessment was required. On the following morning, an RN caring for the same resident reported that the resident requested transfer to the ED for a headache rated 7/10 and expressed concern for a possible brain bleed due to the recent fall, use of blood thinners, and altered cognition. The RN confirmed that neurochecks had not been performed after the fall and that the provider had not been notified immediately. The DON stated that, per facility expectations, staff should assess for injury, take vital signs, initiate neurochecks, notify the provider, inform the family, and document in risk management after a fall, and confirmed that these steps were not followed for this resident, who also had moderate cognitive impairment. At 2:05 a.m. on 2/5/26, frank blood was observed in the toilet, but staff still did not notify the physician immediately, despite the DON’s statement that this finding should have prompted an ED transfer due to increased risk of bleeding and that normal vital signs alone could not rule out internal bleeding. The DON and RN both confirmed that the facility had not had 24-hour on-call physician coverage for the past four years, and local providers did not round at the facility, have access to records, or provide on-call coverage, affecting all residents.
Failure to Assess and Notify Provider After Fall in Anticoagulated Resident
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, monitor, and notify the physician of a change in condition for a resident on anticoagulant therapy following a fall. The resident had moderately impaired cognition and multiple diagnoses including stroke, chronic heart failure, gait and mobility abnormalities, and a stage 2 pressure injury on admission. The care plan identified a self-care deficit and moderate fall risk with interventions for assisted ambulation, ADLs, and call light use, but did not include a focus on anticoagulation management with individualized goals and treatment management, despite active warfarin orders. On the evening of the fall, the resident self-reported an unwitnessed fall and was found in a recliner with a reopened coccyx wound and bleeding from the bottom. The post-fall assessment documented normal range of motion, no pain, orientation to person, and the resident’s denial of head strike, with predisposing factors including impaired memory, gait imbalance, and ambulating without assistance. Although documentation indicated multiple notifications, the physician was not actually notified at the recorded time, and neurological checks were not initiated, contrary to facility expectations for unwitnessed falls and residents on anticoagulants. A follow-up note in the early morning hours documented stable vital signs and no new physical findings, stated that the provider did not need to be notified, and lacked any neurological assessment. Later that night, frank blood in the toilet was observed by a nursing assistant, and a progress note recorded this change along with stable vital signs, but again lacked a neurological assessment and provider notification. A subsequent note indicated no blood after toileting and attributed prior bleeding to a skin tear from the fall. Later that morning, the resident was documented as lethargic, oriented x2, with breakthrough bleeding on the right gluteal/thigh region and head pain rated 7/10, and was transferred non-emergently to the ED. In the ED, the resident was noted to have fallen while on blood thinners, complained of head pain, and had an elevated INR of 5.3, with CT scans negative for acute changes and warfarin dosing later adjusted. The DON and nursing staff interviews confirmed that neuro checks were not initiated after the unwitnessed fall, the provider was not notified at the time of the fall or when frank blood was first noted, and that these actions were inconsistent with facility policies on change of condition and fall management, particularly for residents on anticoagulants.
Failure to Assess and Communicate Proper Sling/Harness Sizing and Leg Strap Use for Mechanical Lifts
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess and document appropriate sling and harness sizes, and to consistently use required safety components (leg strap) for mechanical lift transfers, as required by manufacturer instructions. Two residents who depended on mechanical lifts for transfers were affected. One resident had intact cognition with a history of ischemic stroke, left hemiparesis, hemiplegia, unsteadiness on feet, impaired balance, limited mobility, incontinence, impaired vision, and a history of falls. This resident required substantial to maximal assistance for transfers and used a motorized wheelchair. The care plan and group assignment sheet directed staff to use a gait belt and walker or an EZ Stand sit‑to‑stand lift, and later referenced use of a pivot/EZ Stand for transfers, but did not identify the required harness size or whether the leg strap was to be used. For this resident, the clinical record lacked any comprehensive assessment for harness size that incorporated the resident’s weight and torso circumference where the harness is applied, as required by the manufacturer. The record also did not address whether the leg strap should be used. A fall report documented that the resident was elevated in an EZ Stand lift with both feet under him and the leg strap not in use; his feet slipped off the platform, leaving him hanging in the lift until a nurse supported his weight and repositioned his feet so he could be lowered to the floor. The resident reported that his foot did not get all the way on the platform, both feet slipped off because his shoe slipped, and he was hanging on until help arrived. The record did not include a comprehensive assessment identifying the size of sling required for use of a full body mechanical lift. In subsequent interviews, the resident and the RN who responded to the incident both described that the resident’s left foot slipped out of his shoe, both legs were trapped underneath him, he was not strong enough to hold himself up, and the leg strap was not believed to have been used. The second resident had intact cognition with diagnoses of multiple sclerosis, generalized weakness, repeated falls, dependence on a wheelchair, and impaired range of motion in both lower extremities. This resident was dependent on staff for transfers, used a motorized wheelchair, and required assistance of two staff with a Hoyer full body mechanical lift. The care plan did not identify the size of sling required for safe transfers, and the record lacked a comprehensive sling size assessment including height, weight, girth, and the distance from tailbone to base of neck, as required by manufacturer guidelines. The resident reported that two staff transferred her with a Hoyer lift and that she did not know what size sling was used, assuming staff would know. Multiple nursing assistants reported that sling and harness sizes were not identified on care plans, Kardexes, or assignment sheets for residents requiring mechanical lifts. They stated that each resident had a sling or harness in the room, but they were unable or unsure how to determine the correct size, and if a sling became soiled they would obtain another from the supply or linen room without a reliable method to select the appropriate size, especially when tags were worn or unreadable. One nursing assistant reported inconsistent use of the EZ Stand leg strap among staff and expressed concern that the leg strap should be used to prevent legs from slipping out. Another assistant who performed EZ Stand transfers stated she had not received training on use of the leg strap and was unfamiliar with it. The RN and DON confirmed that the facility did not complete formal, documented sling or harness size assessments, relied on a weight‑based reference chart in the linen room, did not document sling/harness size in the medical record, care plan, or assignment sheets, and had no system to monitor weight changes that might require size adjustments. The occupational therapist and the EZ Way lift representative both stated that a full patient assessment is required to determine appropriate accessory size and type, that the leg strap is essential or policy for safe EZ Stand use, and that sizing must be based on manufacturer charts using resident‑specific measurements such as weight, torso circumference, and tailbone‑to‑neck distance.
Failure to Implement Individualized Toileting Program for Incontinent Resident
Penalty
Summary
The deficiency involves the facility’s failure to identify, assess, and implement an individualized toileting program to maintain or improve bladder continence for a resident with urinary incontinence and multiple comorbidities. On admission, the resident’s MDS documented moderately impaired cognition, a history of stroke, chronic systolic and diastolic heart failure, muscle weakness, unsteadiness on feet, fatigue, gait and mobility abnormalities, and a cognitive communication deficit. The resident required partial to moderate assistance with toileting hygiene and dressing, used a walker and wheelchair, and had occasional urinary incontinence while remaining continent of bowel. Despite these findings and the resident’s use of diuretics, no trial of a toileting program such as scheduled toileting, prompted voiding, or bladder training was initiated on admission. The record lacked a comprehensive bowel and bladder assessment, and the CAA identified frequent urinary incontinence with modifiable factors but did not specify the type of incontinence or translate these findings into specific toileting interventions. The resident’s care plan identified a self-care deficit related to congestive heart failure and noted the need for one-person assistance with ambulation, dressing, hygiene, bed mobility, and toileting, as well as frequent bladder incontinence, but it did not address urinary incontinence with individualized interventions or a toileting program. Bladder records showed a mix of continent and incontinent episodes over several weeks. Observation and interview revealed the resident ambulated to the bathroom independently without using the call light, sometimes forgetting to use the walker and experiencing incontinence when trying to reach the bathroom, and reported not receiving staff assistance with toileting. A nursing assistant confirmed staff expected the resident to use the call light and did not routinely check or offer toileting assistance. The RN and DON both acknowledged that comprehensive bowel and bladder assessments, including three-day assessments, were not completed to develop individualized toileting plans, and that although the resident was frequently incontinent, no individualized toileting interventions were in place, contrary to the facility’s urinary incontinence policy requiring comprehensive assessment and individualized toileting programs.
Failure to Provide Timely Call Light Response Due to Insufficient Staffing
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet a resident’s needs, resulting in repeated delayed responses to call lights and delayed care. The resident had intact cognition but significant physical impairments, including a history of cerebral infarction, hemiparesis/hemiplegia, unsteadiness on feet, limited range of motion on one side of the body, incontinence, impaired vision, and a history of falls. The resident’s care plan identified an ADL self-care deficit related to these conditions and specified that the resident required substantial to maximal assistance from one to two staff for transfers using a gait belt and walker or a PRN EZ Stand lift. The resident reported relying on staff assistance for transfers and toileting and stated that call lights were used primarily to get in or out of bed or to use the bathroom. Over a 14-day period, the facility’s call light log for this resident showed that the call light remained active for more than 15 minutes on 38 occasions, with an average response time of approximately 27 minutes and 40 seconds. The longest delays, including multiple waits exceeding 40 minutes, occurred most frequently in the early morning hours between 5:00 a.m. and 9:00 a.m., with additional prolonged waits around midday and late afternoon to early evening. The resident reported that call lights often took about an hour to be answered, that staff had told him lights should be answered within 5–7 minutes, and that this did not occur in practice. He also reported that some call lights were turned off without assistance being provided and that he had experienced multiple episodes of incontinence related to these long response times. Staff interviews further described inconsistent and delayed call light responses. A nursing assistant stated that call lights ideally should be answered within five minutes but acknowledged that during busy times such as early mornings, after lunch, and shift changes, residents might wait up to 30 minutes, and confirmed that this resident frequently complained about long waits. Another nursing assistant reported that staff should aim to answer call lights within 10 minutes but that this did not always happen and confirmed the resident’s frequent complaints. The DON acknowledged that this resident regularly complained of long call light response times, considered waits over 20 minutes to be a problem, and noted that the resident’s complaints typically involved waits over 30 minutes, which she reviewed with him using the call light log. The DON and nursing assistants were unaware that the resident had experienced incontinence episodes due to delayed responses, and the facility was unable to provide a call light response policy when requested.
Inadequate PPE Use During COVID-19 Precautions
Penalty
Summary
The facility failed to ensure the appropriate use of personal protective equipment (PPE) when staff moved between rooms of residents with and without COVID-19 diagnoses. During observations, a dietary aide (DA-A) was seen entering the room of a COVID-19 positive resident, identified as being on enhanced respiratory precautions, wearing only an N95 mask without additional PPE such as gloves, gown, or eye protection. DA-A then proceeded to enter the rooms of other residents, some of whom were not on COVID-19 precautions, without changing the N95 mask or donning additional PPE, despite having contact with potentially contaminated surfaces. Interviews with staff revealed a lack of understanding and training regarding the necessity of full PPE when entering rooms of COVID-19 positive residents. The dietary manager and other staff members, including a registered nurse, expressed uncertainty or incorrect beliefs about PPE requirements, contradicting the facility's COVID-19 Plan and CDC guidelines. The infection preventionist confirmed that all staff were supposed to be trained to use full PPE in such situations, highlighting a gap between policy and practice.
Failure to Implement Person-Centered Fall Prevention Interventions
Penalty
Summary
The facility failed to implement appropriate, person-centered interventions to prevent further falls and potential injury for a resident who was severely cognitively impaired and had a history of repeated falls. The resident's care plan identified risks for falls related to gait and balance problems, incontinence, safety unawareness, use of psychotropic medication, and wandering. Despite these identified risks, the facility did not update the care plan with specific interventions after multiple falls occurred. The resident experienced several falls over a period of months, with each incident being documented in progress notes. However, the interventions following these falls were limited to generic reminders for the resident to use the call light for assistance. The care plan was reviewed multiple times, but no resident-specific interventions were implemented, even after the resident sustained a bruise from a fall. Interviews with facility staff, including a nursing assistant, registered nurse, and the director of nursing, confirmed that the resident only had generic fall interventions in place and lacked person-centered strategies. The facility's policy required that care plans be updated to reflect current fall risks and interventions, but this was not adhered to in the case of the resident. The director of nursing acknowledged that the resident should have had specific interventions due to the high risk for falls, such as physical therapy consults, direct supervision, and proper footwear. The lack of individualized interventions contributed to the ongoing risk of falls and potential injury for the resident.
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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