St Crispin Living Community
Inspection history, citations, penalties and survey trends for this long-term care facility in Red Wing, Minnesota.
- Location
- 213 Pioneer Road, Red Wing, Minnesota 55066
- CMS Provider Number
- 245449
- Inspections on file
- 20
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 15 (1 serious)
Citation history
Health deficiencies cited at St Crispin Living Community during CMS and state inspections, most recent first.
A resident with chronic pain, an amputation, and PTSD was ordered morphine IR 15 mg QID with PRN 7.5 mg doses, but staff failed to secure a timely refill when the supply ran low, resulting in multiple missed scheduled doses and only a single partial PRN dose over roughly a day. A day‑shift RN recognized the impending shortage but did not obtain a new prescription, and an on‑call NP later signed an electronic order without confirming pharmacy receipt, declined to resend it that night, and did not order alternative pain control or monitoring for opioid withdrawal. The resident reported 10/10 pain, remained in bed, had decreased appetite, and increased anxiety, while his spouse observed sweating, confusion, and functional decline, and documentation showed no comprehensive assessment for withdrawal. Review of narcotic records revealed incomplete controlled substance sheets lacking RX numbers, prescriber names, and directions, and discrepancies between documented quantities received and pharmacy packing slips for morphine, compromising accurate tracking and availability of the opioid.
A resident with chronic pain syndrome had scheduled morphine IR 15 mg ordered four times daily, but multiple doses were missed when the medication ran out and was not available. Nursing staff contacted the on-call NP and pharmacy several times, but the NP did not resend the prescription that evening, did not order alternative pain management, and did not direct monitoring for withdrawal or increased pain. The resident reported severe pain, decreased mobility, poor appetite, and increased anxiety during the period without scheduled morphine. The pharmacy later confirmed it had not received the NP’s prescription that night and stated that an emergency verbal order process existed and that the lack of medication constituted an omission medication error, while facility policy required timely practitioner orders and 24-hour physician services for immediate care needs.
A resident with chronic pain had scheduled Morphine IR doses ordered four times daily, along with a PRN Morphine order, but multiple scheduled doses were not administered because the medication was not available, and one dose was given late. Progress notes showed staff repeatedly contacted the on-call provider, triage RN, and pharmacy about the missing prescription, and the NP declined to fax the order until a later time. The DON later acknowledged that the missed doses constituted an allegation of neglect but was unaware of the situation at the time, and the event was not reported to the State Agency as required by the facility’s Abuse Prevention Plan policy.
A resident with chronic pain syndrome, amputation, shrapnel‑related osteoarthritis, and PTSD was on scheduled morphine IR with a PRN order. Staff failed to timely re‑order and ensure availability of the scheduled morphine, resulting in four missed doses and a prolonged gap in full opioid coverage. During this period, the resident reported pain escalating from a baseline 5/10 to 10/10, remained in bed, had decreased appetite, increased anxiety, sweating, and confusion, while his spouse observed him quiet, diaphoretic, and unable to operate the TV remote. Nursing documentation between the missed doses lacked comprehensive pain assessments with pain characteristics, non‑pharmacologic interventions, increased monitoring for escalating pain or opioid withdrawal, or consideration of emergency transfer. One RN recognized in advance that the morphine supply would be insufficient but did not contact the provider due to time constraints, subsequent nurses confirmed the missed doses and significant pain, and the DON was not notified and did not become aware until later. The NP did not verify that the prescription reached the pharmacy, did not provide alternate pain management orders, and did not direct staff to monitor for withdrawal. The facility’s pain management policy required ongoing assessment and reassessment but did not specify when to complete comprehensive assessments, how to document baseline pain, or what steps to take when scheduled pain medications are missed or unavailable, contributing to the deficient pain management.
The facility failed to maintain kitchen equipment, specifically a hotbox used to keep food warm, leading to food being served at unsafe temperatures. The hotbox's top compartment lacked a working thermometer and displayed an error code, which the culinary director could not explain. The environmental services manager found no maintenance records, and the administrator was unaware of the issue, highlighting a lack of oversight and documentation.
The facility failed to properly manage contaminated linen in the 300-unit laundry room, where a yellow-stained bed sheet was left unbagged on the floor beneath clean resident laundry. The room was dirty, with lint scraps and a mildew smell. Staff interviews revealed that NAs were responsible for maintaining cleanliness, but the room remained unclean. The DON and RRN confirmed the issues, and the IP acknowledged that soiled linens sometimes get mixed with residents' clothing, contrary to facility policy.
A resident admitted with multiple fractures and a surgical wound in the left groin area was not properly assessed or treated according to physician orders. The facility failed to transcribe the discharge instructions into the resident's records, leading to a lack of monitoring and documentation of the surgical wound. This oversight resulted in the wound dehiscing and becoming infected, necessitating a five-day hospital stay for surgical intervention and antibiotic therapy.
Failure to Maintain Opioid Availability and Controlled Substance Accountability
Penalty
Summary
The deficiency involves the facility’s failure to ensure effective pharmacy services and continuous availability of prescribed opioid pain medication for a resident with chronic pain and long-term morphine therapy. The resident had diagnoses including chronic pain syndrome, an above-the-knee amputation, post‑traumatic osteoarthritis with contracture, and PTSD, and was cognitively intact but dependent on staff for transfers and toileting. He had MD orders for morphine IR 15 mg four times daily on a scheduled regimen and morphine IR 7.5 mg twice daily PRN. On one day, the day‑shift RN recognized that the resident’s supply of scheduled morphine IR 15 mg tablets would be insufficient but did not contact the provider for a new prescription before the end of the shift, citing time constraints, and only verbally informed the oncoming nurse without verifying that a prescription was obtained. Later that day, the scheduled afternoon and evening 15 mg morphine doses were not administered because the drug was not available, and only a single 7.5 mg PRN dose was given in place of a full scheduled dose. The evening RN attempted multiple times to reach the on‑call NP through a triage nurse and was told by the NP later that she had signed the order in the electronic system but did not verify that the prescription reached the pharmacy and refused to resend it that night, stating she would address it in the morning. The NP did not provide alternative pain management orders, did not order monitoring for opioid withdrawal symptoms, and did not inquire whether doses had already been missed. Pharmacy records confirmed that no morphine prescription from the NP was received that day, and the pharmacy indicated that no calls from the facility were logged during the reported time frame, despite staff documentation that the pharmacy had been contacted multiple times. The following morning, the resident’s early scheduled morphine dose was again not administered due to lack of medication, and the day‑shift RN was not informed by night staff that multiple doses had been missed. She did not contact the on‑call provider until after mid‑morning, when she discovered the resident was out of morphine, at which time the triage RN and a PA became involved to send a new prescription and authorize use of the e‑kit. The resident reported that during the period without his scheduled morphine he experienced pain at 10/10, could not get out of bed, had decreased appetite, and his anxiety worsened; his spouse observed him sweating, unusually quiet, confused, and unable to operate the TV remote as usual. Documentation showed that the resident went approximately 24 hours without a full scheduled 15 mg dose and about 20.5 hours with only a partial 7.5 mg PRN dose instead of his ordered regimen, with no comprehensive assessment for opioid withdrawal symptoms and no enhanced monitoring for increased pain. In addition to the failure to maintain medication availability, the facility failed to ensure proper reconciliation, transcription, and accountability of controlled substances for the same resident’s morphine. Review of the controlled substance book and medication cart revealed incomplete documentation and discrepancies between the narcotic record, bubble packs, and pharmacy packing slips. One controlled substance sheet documented receipt of 24 tablets of morphine 15 mg without listing the RX number, prescriber name, or directions, and the corresponding bubble pack was no longer present for verification. Another sheet documented receipt of 12 tablets for PRN morphine, while the pharmacy packing slip for the same RX and label indicated delivery of only 6 tablets, and the controlled substance sheet again lacked RX number, prescriber, and directions. These inconsistencies and omissions compromised the facility’s ability to accurately track, verify, and ensure availability of the resident’s ordered controlled substances. The DON stated she was unaware that the resident had missed multiple scheduled morphine doses and acknowledged that this represented a significant medication error that could place the resident at risk for acute withdrawal and significant pain. She confirmed that the provider had not been notified about the missed doses at the time, that no medication error report had been completed, and that there were no orders in place during the gap to control the resident’s pain or to monitor for withdrawal symptoms. The consultant pharmacist and medical director both confirmed, based on record review and interviews, that the resident went without morphine for an extended period, that there were no comprehensive assessments or monitoring for pain or acute opioid withdrawal during that time, and that missing scheduled doses of IR morphine would be expected to result in increased pain and potential withdrawal signs such as sweating and nausea. The surveyors determined that these failures in ordering, communication, monitoring, and controlled substance documentation resulted in severe unmanaged pain and possible early opioid withdrawal symptoms for the resident and constituted immediate jeopardy beginning when the facility first failed to ensure the resident’s prescribed morphine was available for administration.
Failure to Obtain Timely Practitioner Orders and Morphine Refill for Pain Management
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely practitioner orders and provision of prescribed narcotic pain medication when a resident’s scheduled morphine was not available. The resident had an order dated 11/28/23 for morphine IR 15 mg to be administered four times daily for chronic pain syndrome at 6:30 a.m., 11:30 a.m., 4:00 p.m., and 8:00 p.m. The February 2026 MAR showed that on 2/2/26 the 4:00 p.m. and 8:00 p.m. scheduled doses were not administered because the medication was not available, and only a single 7.5 mg PRN dose was given at 5:03 p.m. On 2/3/26, the 6:30 a.m. scheduled dose was not administered and the 11:30 a.m. dose was given late at 1:36 p.m., again due to unavailability of the ordered morphine. Progress notes and interviews documented repeated but unsuccessful efforts by nursing staff to obtain a new prescription and supply of morphine. On the evening of 2/2/26, staff contacted the on-call provider and pharmacy multiple times and documented that the medication was not available. The nurse practitioner reported she had sent the morphine prescription to the pharmacy at 7:00 p.m., but the pharmacy could not locate it, and she declined to fax or resend the prescription that night, stating she might do so the following morning. She did not provide alternative pain management orders, did not give instructions to monitor for opioid withdrawal symptoms, and did not direct staff on how to address increased pain. The charge RN confirmed she attempted to reach the NP multiple times between mid-afternoon and late evening, could not use the MAR reorder function because a new prescription was required, and identified the failure to obtain a timely prescription as the root cause of the missed doses. The resident reported that after running out of morphine in the afternoon, he did not receive his scheduled doses for almost a full day, during which he experienced pain rated 10/10, inability to get out of bed, decreased appetite, and worsened anxiety with difficulty swallowing. The pharmacist stated the pharmacy did not receive a morphine prescription from the NP on 2/2/26 and only received a new prescription from a certified physician assistant the following day, which included authorization to obtain a dose from the e-kit. The pharmacist explained that after-hours procedures allowed for emergency verbal prescriptions for controlled substances and characterized the lack of medication in this situation as an omission medication error. The facility’s Physician Services policy required that a physician, NP, or PA provide orders for residents’ immediate care needs, ensure 24-hour availability of physician services in case of emergency, and maintain residents under physician care with timely communication and documentation of orders, which was not met in this case when timely orders and medication were not secured for the resident’s pain management.
Failure to Timely Report Alleged Neglect Related to Missed Pain Medication Doses
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of neglect to the State Agency within the required timeframe after a resident missed multiple scheduled doses of prescribed pain medication. The resident had physician orders for Morphine IR 15 mg four times daily for chronic pain syndrome and an additional PRN order for Morphine IR 7.5 mg twice daily for pain. The February 2026 MAR showed that the 4:00 p.m. and 8:00 p.m. scheduled doses on 2/2/26 and the 6:30 a.m. scheduled dose on 2/3/26 were not administered because the medication was not available in the facility, and the 11:30 a.m. dose on 2/3/26 was administered late at 1:36 p.m. Progress notes documented that staff contacted the on-call provider and pharmacy multiple times regarding the morphine prescription, that the pharmacy had not received or located the prescription, and that the NP declined to fax the prescription that evening, indicating it might be sent the following morning. Further progress notes indicated continued unavailability of the scheduled morphine dose the following morning and additional contacts with the triage RN on-call, who reported sending a renewed order to the pharmacy and contacting an on-call certified physician assistant. During an interview, the DON stated she was not aware that the resident had missed multiple scheduled doses of morphine due to the medication not being available and confirmed that this constituted an allegation of neglect that had not been reported to the State Agency. The facility’s Abuse Prevention Plan policy defined neglect as the failure of the facility, its employees, or service providers to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress, and required immediate reporting of suspected abuse or neglect to the Executive Director or designee and to the Minnesota Department of Health via the online reporting system in accordance with legal timeframes. Despite these policy requirements, the allegation of neglect related to the missed morphine doses was not reported as required.
Failure to Maintain Scheduled Opioid Therapy and Comprehensive Pain Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s scheduled opioid pain medication was re-ordered, available, and administered as ordered, and to provide comprehensive pain assessment and monitoring when doses were missed. The resident had chronic pain syndrome, an above-the-knee amputation of the left leg, post‑traumatic osteoarthritis with contracture of the left hand from shrapnel injury, and PTSD. His MDS showed intact cognition, dependence on staff for transfers and toileting, use of a motorized scooter, and a scheduled pain regimen without PRN or non‑pharmacological pain interventions. The CAA documented frequent moderate pain over five days and directed staff to assess pain each shift, notify the provider of unrelieved pain, and use pharmacologic and non‑pharmacologic interventions. However, the care plan problem statement for pain was left blank, lacked a documented baseline pain level, and did not provide clear guidance for managing chronic pain, scheduled opioid administration, or monitoring when medications were unavailable, despite an intervention requiring a pain scale each shift. The resident had physician orders for morphine IR 15 mg four times daily for chronic pain and morphine IR 7.5 mg twice daily PRN. The MAR showed that on one day the 4:00 p.m. and 8:00 p.m. scheduled 15 mg doses were not administered because the medication was not available, and a 7.5 mg PRN dose was given at 5:03 p.m. as a substitute. The following morning, the 6:30 a.m. scheduled dose was not administered, and the 11:30 a.m. dose was given late at 1:36 p.m., resulting in four missed scheduled doses and a prolonged gap in full opioid coverage. Progress notes documented repeated contacts with the on‑call provider and pharmacy about the morphine prescription and that the medication was not available. The NP reported having sent a prescription to the pharmacy but did not fax it to the facility that evening and did not provide alternate pain management orders or instructions to monitor for increased pain or withdrawal. A triage RN later reported sending a renewed order to the pharmacy and contacting an on‑call PA. The vitals and intake records for the two days of missed doses showed no documented food intake, with improved intake afterward, and resident and family interviews described decreased appetite during the medication gap. During this period, the record lacked comprehensive pain assessments that included pain characteristics, documentation of non‑pharmacological interventions attempted or offered, increased monitoring for escalating pain or opioid withdrawal symptoms, or any offer or suggestion of emergency transfer for pain management. The resident reported that when he receives all scheduled morphine doses his baseline pain is 5/10, but during the gap he experienced pain at 10/10, could not get out of bed, had decreased appetite, and increased anxiety with difficulty swallowing. He stated he tends to shut down and not ask for medication when in severe pain and that staff only asked for a numerical pain rating without exploring specifics. His spouse described him as stoic, noted that he was sweating, quiet, confused, and unable to operate the TV remote, and confirmed that he did not call her as he usually did. Multiple nurses described him as stoic and requiring prodding to report pain; one nurse identified in advance that the morphine supply would be insufficient but did not contact the provider due to time constraints, and subsequent nurses confirmed the missed doses and significant pain. The DON acknowledged unawareness of the missed doses, agreed this represented a significant medication error with no provider notification, no monitoring for withdrawal, and no alternative pain management, and confirmed that the facility’s pain management policy did not specify when to complete comprehensive pain assessments, how to document baseline pain, or what steps to follow when scheduled pain medications are missed or unavailable. The pharmacist and medical director characterized the situation as emergent, explained the pharmacology of IR morphine, and stated that even one missed dose should trigger assessment and monitoring for escalating pain and acute opioid withdrawal, underscoring that the clinical team was responsible for ensuring communication, medication availability, and monitoring when a scheduled opioid dose was missed. The facility’s written pain management policy required evaluation, documentation, and reassessment of pain at regular intervals, with each new report of pain, and after interventions, using an interdisciplinary approach and involving the resident and responsible party. However, the policy did not specify when or where a comprehensive pain assessment must be completed, did not provide guidance for documenting baseline pain, and did not outline steps to follow when scheduled pain medications are missed or unavailable. This lack of detailed procedural guidance, combined with staff failures to timely re‑order morphine, ensure its availability, notify providers of missed doses, and conduct comprehensive assessments and monitoring during the medication gap, led to the resident experiencing unmanaged severe pain, decreased appetite, sweating, confusion, and anxiety during the period when his scheduled opioid therapy was interrupted.
Failure to Maintain Kitchen Equipment for Safe Food Temperatures
Penalty
Summary
The facility failed to maintain kitchen equipment used to keep food warm prior to serving, as observed during a survey. The culinary director (CD) was found using a hotbox with a malfunctioning top compartment that lacked an internal thermometer and displayed an error code 'E00' on the external display. The CD was unable to clarify the meaning of the error code and was uncertain about the last service date of the hotbox. During a meal service, egg rolls stored in the hotbox were found to have an internal temperature of 120 degrees, which was below the safe serving temperature. The CD acknowledged that improper food temperatures could increase the risk of foodborne illness and stated that staff should monitor and log food temperatures, and report malfunctioning equipment to supervisors or maintenance. Further investigation revealed that the environmental services manager (ESM) could not find any service slips or maintenance requests for the hotbox since January. The ESM mentioned that parts from a second hotbox had been used to fix the current one, but could not verify when this occurred. The facility administrator was unaware of the equipment issue and stated that malfunctioning equipment should be taken out of service until repaired. Maintenance logs and equipment information were requested but not provided, indicating a lack of documentation and oversight in maintaining essential kitchen equipment.
Improper Management of Contaminated Linen in Laundry Room
Penalty
Summary
The facility failed to properly manage and contain contaminated linen in the 300-unit laundry room, which had the potential to affect all 15 residents on the unit. During a tour, it was observed that a yellow-stained contaminated bed sheet was left unbagged on the floor, with clean resident laundry placed in a basket on wheels above it. The laundry room was found to be dirty, with used lint scraps, a used paper towel, and a mildew smell present. The detergent compartment on the washer was also dirty with lint scraps and old soap. Interviews with staff revealed that nursing assistants (NAs) were responsible for keeping the laundry room tidy, but the room remained unclean and the contaminated sheet was not properly bagged and removed. The director of nursing (DON) and regional registered nurse (RRN) confirmed the presence of the unbagged contaminated linen and the mildew smell during their observation. The infection preventionist (IP) stated that soiled linens should be bagged at the point of care and taken to the soiled utility room, but acknowledged that sometimes soiled facility linens get mixed up with residents' personal clothing. The facility's policy dated 5/15/24 also stated that dirty linens should be bagged at the point of use and kept separate from clean laundry, which was not adhered to in this instance.
Failure to Monitor and Treat Surgical Wound Leads to Hospitalization
Penalty
Summary
The facility failed to assess, monitor, and treat a surgical wound according to physician orders for a resident who was admitted with multiple fractures and a surgical wound in the left groin area. Upon admission, the facility did not comprehensively assess the surgical wound or transcribe the physician's orders for its monitoring and treatment into the resident's electronic health record. This oversight resulted in the wound dehiscing and becoming infected, leading to a five-day hospital admission for surgical intervention, antibiotic therapy, and wound vacuum-assisted closure. The resident's hospital discharge summary included specific instructions for the care of the left groin incision, which were not transcribed into the facility's records. The facility's staff failed to document the presence, absence, or removal of the Mepilex Ag dressing that was ordered to be in place over the incision. Progress notes and skin assessments did not identify or monitor the left groin incision, and the baseline care plan was incomplete, lacking specific interventions for the resident's surgical wound. Interviews with facility staff revealed a lack of awareness and documentation regarding the resident's surgical incision. Staff members, including licensed practical nurses and registered nurses, did not recall seeing or assessing the incision, and there was no evidence of a comprehensive skin assessment being conducted. The facility's director of nursing and medical director acknowledged the discrepancies in documentation and the failure to follow physician orders, which contributed to the resident's wound dehiscence and subsequent hospitalization.
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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