St Gertrudes Health & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Shakopee, Minnesota.
- Location
- 1850 Sarazin Street, Shakopee, Minnesota 55379
- CMS Provider Number
- 245610
- Inspections on file
- 31
- Latest survey
- January 15, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at St Gertrudes Health & Rehabilitation Center during CMS and state inspections, most recent first.
A resident who required two-person assistance and a mechanical lift for transfers was physically abused by a nursing assistant who attempted to transfer the resident alone and without the required equipment. During the incident, the NA punched the resident in the knee after a verbal altercation, which was witnessed by an RN. The resident reported feeling unsafe and described the abuse, and the facility's investigation confirmed that the NA did not follow the care plan or established protocols.
A facility failed to thoroughly investigate an allegation of physical abuse when a cognitively intact resident was punched by a nursing assistant during care. Although staff interviews were conducted, no residents or families were interviewed about the incident, and the investigation did not include residents from other units where the staff member had worked. The facility's policy requiring comprehensive interviews was not followed.
A resident who required transfer with a Sara Steady lift and care in pairs due to behavioral and physical needs was transferred by staff without the required device and without a second staff member present. Staff interviews revealed confusion and lack of awareness regarding the care plan interventions, and documentation gaps contributed to inconsistent care. The resident had multiple medical conditions and was dependent on staff for daily activities.
Staff did not promptly inform a resident, the resident's doctor, and a family member about important events such as injury, decline, or room changes that affected the resident, as required by regulations.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a failure to meet individualized care requirements.
A resident with multiple health issues, including end-stage renal disease and severe osteoporosis, experienced a fractured clavicle after a transfer using a sit-to-stand lift. The facility failed to report the injury of unknown origin to the State Agency within the required timeframe. Staff interviews revealed inconsistencies in the incident's account, and the facility's administrator acknowledged the reporting failure.
A resident with bilateral amputations expressed feeling unsafe in a shower chair, preferring showers over bed baths. Despite available mechanical lifts and slings, the LTC facility failed to reassess or accommodate the resident's bathing preference, leading to a deficiency in promoting resident self-determination.
The facility failed to provide routine grooming for two residents dependent on staff for personal care. One resident with impaired cognition had unaddressed chin hairs, while another with intact cognition had two-inch throat hairs that were not trimmed or shaved since admission. Staff interviews confirmed that personal care, including shaving, should be offered daily, but these needs were neglected.
A resident with moderate cognitive impairment experienced ongoing constipation issues that were not adequately addressed by the facility. Despite being on medications like Miralax and Senna-S, the resident reported infrequent bowel movements and a lack of proactive management discussions with staff. Medical records were incomplete, and staff interviews revealed a failure to communicate and document the resident's bowel status, leading to a deficiency in bowel management.
A resident with intact cognition and urinary retention had an indwelling catheter since the previous fall, but the facility failed to assess its removal or consult urology. Despite the resident's goal to have the catheter removed, no toileting program or alternative methods were implemented. Interviews revealed a lack of documentation and discussion with the resident and family about the catheter's duration or alternatives, contrary to the facility's policy on catheter use.
A resident with dementia, anxiety, and depression experienced behavioral issues after discontinuing Zoloft. Despite repeated recommendations from the consulting pharmacist to consider restarting Zoloft or using Lexapro, the facility failed to act on these suggestions in a timely manner. The nurse practitioner did not provide a documented rationale for not following the pharmacist's advice, and Lexapro was only started after increased communication from the care team about the resident's symptoms.
A resident in an LTC facility did not receive prescribed medications due to unavailability, resulting in a 7.14% medication error rate. The resident was discharged with orders for droxidopa and metronidazole, but these were not administered as the medications were not in the cart. The LPN did not inform the RN, and the pharmacy was not contacted. The DON noted a lack of clarity on how the orders were missed, and the facility's policy did not define medication errors or actions for unavailable medications.
The facility did not ensure that survey results and the plan of correction for the past three years, including the most recent survey from December 2023, were accessible to residents, families, and visitors. A binder at the main entrance was missing these documents, and the administrator confirmed the oversight. No facility policy on posting survey results was provided.
Failure to Protect Resident from Physical Abuse During Transfer
Penalty
Summary
A deficiency occurred when a nursing assistant (NA) physically abused a resident during care. The resident, who was cognitively intact and dependent on staff for most activities of daily living, required the use of a mechanical lift for transfers and was to receive care from two staff members at all times. Despite these care plan requirements, the NA attempted to transfer the resident alone and without the mechanical lift, leading to an altercation. During this incident, the NA was witnessed by a registered nurse (RN) punching the resident in the left knee after a verbal argument and alleged aggression from the resident. The resident reported feeling unsafe and described being punched by the NA while being transferred from bed to wheelchair. The resident demonstrated the action to interviewers and stated that he retaliated by hitting the NA back. The RN corroborated the resident's account, stating she heard yelling, entered the room, and observed the NA strike the resident. The NA admitted to being alone with the resident, not using the required lift, and not following the care plan, citing lack of time to read care plans and being unfamiliar with the resident's needs. The facility's investigation confirmed that the NA failed to follow the care plan, which required two staff for care and use of the mechanical lift. The NA was alone with the resident and did not adhere to established protocols for managing residents with behavioral concerns. The incident was substantiated as physical abuse, with both the resident and RN providing consistent accounts of the event.
Failure to Thoroughly Investigate Alleged Physical Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of witnessed physical abuse involving a resident who was cognitively intact and dependent on staff for most activities of daily living. The incident occurred when a nursing assistant (NA) was observed by a registered nurse (RN) to punch the resident in the leg during care. The resident confirmed feeling unsafe and described being struck by the NA, and both the NA and RN provided statements regarding the incident. Despite this, the facility's investigation did not include interviews with other residents to determine if they had experienced or witnessed abuse. The investigation process involved interviewing staff members about general experiences with mistreatment but did not include specific questions about the incident or the staff involved. Sixteen staff members were asked if they had ever mistreated a resident or witnessed mistreatment, but there was no documentation of targeted questions regarding the alleged abuse involving the NA and the resident. Additionally, the investigation did not include interviews with residents from other units where the NA had worked, nor were families interviewed. The facility limited its resident assessment to skin and pain checks and baseline emotional and psychological observations, without directly asking residents about abuse or safety concerns. The director of nursing and the administrator indicated that residents on the cognitive unit were not interviewed due to concerns about their ability to provide accurate responses, and residents from other units were not interviewed because the incident was considered isolated. The facility's policy required interviewing all individuals who might have knowledge of the incident, including the alleged victim, perpetrator, witnesses, or others with related contact, but this was not followed in the investigation.
Failure to Implement Care Plan Interventions for Transfer and Supervision
Penalty
Summary
The facility failed to implement the care plan interventions for a resident who required specific transfer and supervision protocols. The resident's care plan indicated that all transfers from bed to chair or toilet were to be performed using a Sara Steady mechanical lift and that care was to be provided in pairs (two staff members present) due to previous behavioral concerns and accusations made by the resident. Despite these documented interventions, staff were observed transferring the resident without the required mechanical device and without a second staff member present. Additionally, there was confusion among staff regarding the specifics of the care plan, with some staff unaware of the need for paired care or the use of the Sara Steady lift. Interviews revealed that staff did not consistently read or follow the care plan, leading to inconsistent application of required interventions. One nursing assistant admitted to transferring the resident alone and without the mechanical lift, stating she had not reviewed the care plan prior to providing care. Other staff members, including nurses and therapy staff, expressed uncertainty about the requirements for paired care and whether these applied to their roles. Documentation and communication gaps were evident, as some staff relied solely on the treatment administration record (TAR) and did not routinely review the full care plan, resulting in missed interventions. The resident involved had a history of sepsis, alcohol-induced chronic pancreatitis, lymphedema, and osteoarthritis, and was dependent on staff for most activities of daily living. The care plan also noted behavioral concerns, including making accusations against staff of different ethnicities, which contributed to the requirement for care in pairs. Despite these needs, the facility did not ensure that all staff were aware of or adhered to the care plan interventions, leading to the observed deficiencies in care delivery.
Failure to Immediately Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors during the review of facility practices and records. The deficiency centers on the facility's failure to ensure that all required parties were promptly informed when significant events impacting the resident occurred, as mandated by regulations.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with established directives or the expressed wishes and objectives of the resident, resulting in noncompliance with required standards for individualized care.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the State Agency within the required timeframe for a resident who was assessed with a fractured clavicle. The incident involved a resident who was cognitively intact and dependent on staff for all transfers. The resident had a history of congestive heart failure, end-stage renal disease, malnutrition, respiratory failure, and morbid obesity. On the evening of the incident, the resident was assisted by staff using a sit-to-stand lift for toileting. During the transfer, the resident's legs became weak, and she was lowered to the toilet. Later, the resident experienced severe pain and was sent to the emergency department, where an x-ray revealed a fractured clavicle. Interviews with staff revealed inconsistencies in the account of the incident. The night nurse reported that the resident had slid in the sit-to-stand lift earlier in the evening, while the evening nurse stated that the resident was weak and requested the use of a ceiling lift due to fear of falling. The nursing assistants involved in the transfer did not recall the resident sliding or bumping her body during the transfer. The facility's assistant director of nursing and the medical director provided possible explanations for the fracture, citing the resident's severe osteoporosis and vulnerability to fractures with slight movements. The facility's administrator acknowledged that the injury should have been reported as an injury of unknown origin within 24 hours, but believed it was reasonable to assume the fracture occurred during the transfer. The facility's policy on abuse prevention required reporting serious bodily injury immediately, but no later than two hours after the event. The report highlights the facility's failure to adhere to this policy, as the injury was not reported to the State Agency within the required timeframe.
Failure to Assess and Facilitate Resident's Bathing Preference
Penalty
Summary
The facility failed to assess and accommodate a resident's preference for bathing methods, specifically showers, after the resident expressed feeling unsafe being transported in a shower chair. The resident, who had undergone bilateral below-knee amputations, was receiving weekly bed baths but preferred showers. The resident felt uncomfortable and unsafe being wheeled through public spaces in a shower chair due to his amputee status. Despite the resident's expressed discomfort, the facility did not reassess or explore alternative options to facilitate the resident's preference for showers. Interviews with staff revealed a lack of communication and assessment regarding the resident's discomfort with the shower chair. A nursing assistant mentioned offering showers, but the resident refused without explaining why. The unit manager acknowledged the resident's discomfort but did not investigate further, believing it was not her place to ask for more information. The director of nursing stated that an assessment should have been conducted to understand the resident's concerns and offer suitable options. The facility had mechanical lifts and slings available that could potentially address the resident's needs, but these were not utilized or considered in the resident's care plan.
Failure to Provide Routine Grooming for Residents
Penalty
Summary
The facility failed to ensure routine grooming was offered or provided to promote good hygiene for two residents who were dependent on staff for their care. Resident 1 (R1) was identified with impaired cognition and multiple diagnoses, including heart disease and diabetes, and was dependent on staff for personal hygiene. Observations revealed that R1 had multiple white hairs on her chin, which had not been addressed by the staff. Interviews with nursing assistants confirmed that personal care, including shaving, should be offered daily, but it appeared that R1's grooming needs had been neglected for at least a couple of weeks. Resident 25 (R25), who had intact cognition and required assistance with personal hygiene, was observed with two-inch white hairs extending from her throat. R25 expressed a desire to have the hairs removed and stated that no one from the facility had offered to trim or shave them since her admission. Interviews with staff, including a licensed practical nurse and the director of nursing, acknowledged that personal hygiene care should include shaving and be performed at least twice per day. However, it was evident that R25's grooming needs had been overlooked, as she had not been asked about the hairs or offered assistance with their removal.
Deficiency in Bowel Management for Resident
Penalty
Summary
The facility failed to adequately address and assess complaints of potential constipation for a resident, leading to a deficiency in bowel management. The resident, identified as having moderate cognitive impairment, reported ongoing issues with constipation despite being on medications like Miralax and Senna-S. The resident expressed that staff had not discussed proactive bowel management options with him, despite his history of colon polyps and repeated complaints to staff about constipation. The resident's medical records, including the Elimination - Bowel evaluation and Medication Administration Record (MAR), were incomplete and lacked comprehensive assessments or interventions for bowel management. The MAR showed multiple refusals or non-administrations of bowel-related medications, and a bowel assessment order was recorded late without further action. Nursing staff, including a nursing assistant and a registered nurse, acknowledged the resident's complaints but failed to ensure appropriate follow-up or documentation in the medical record. Interviews with facility staff, including a licensed practical nurse unit manager and the director of nursing, revealed a lack of communication and documentation regarding the resident's bowel status. The Elimination-Bowel tool was not completed, and standing orders for bowel management were not enacted or charted. The director of nursing confirmed the importance of assessing and acting upon bowel complications to prevent impaction, but the facility's records did not reflect such actions. Additionally, the facility did not provide a policy on bowel management when requested.
Failure to Assess and Remove Indwelling Catheter
Penalty
Summary
The facility failed to assess and remove an indwelling urinary catheter for a resident, identified as R27, who was admitted with intact cognition and required assistance with toileting. Despite having a Foley catheter since the previous fall due to urinary retention, the facility did not attempt to implement a toileting program or consult with urology to evaluate the necessity of the catheter. The resident expressed a desire to have the catheter removed to return home, but no assessment or alternative methods were pursued by the facility. Interviews with the health unit coordinator and the director of nursing revealed that there was no order for a urology consult in the resident's electronic medical record, and no discussion had taken place with the resident or their family regarding the catheter's duration or alternatives. The facility's policy on preventing catheter-associated urinary tract infections emphasized eliminating indwelling catheters whenever possible, yet this was not adhered to in R27's case.
Failure to Act on Pharmacist's Recommendations for Resident's Medication
Penalty
Summary
The facility failed to ensure that the consulting pharmacist's recommendations were fully addressed or acted upon for a resident, identified as R66, who was reviewed for unnecessary medication use. R66's quarterly Minimum Data Set assessment indicated no cognitive impairment, hallucinations, delusions, or behaviors during the seven-day look-back period, but the resident was diagnosed with dementia, general anxiety disorder, and depression. The consulting pharmacist made several recommendations to consider restarting Zoloft or using a different SSRI like Lexapro due to reported behavioral issues after Zoloft was discontinued. However, these recommendations were not acted upon in a timely manner, and there was a lack of documented rationale for not following the pharmacist's advice. The nurse practitioner acknowledged the pharmacist's recommendations but did not make changes to the medication regimen, citing previous side effects and a recent hospitalization for psychic behaviors. Despite repeated recommendations from the pharmacist in August and September, there was no provider response or documented rationale for not acting on the advice to consider Lexapro. It was only after increased communication from the care team about R66's symptoms of anxiety and depression that Lexapro was started at the end of October. Interviews with facility staff, including the director of nursing and the nurse practitioner, revealed that the process for reviewing and acting upon pharmacy recommendations was not followed. The director of nursing confirmed that the pharmacy recommendations should have been reviewed and addressed during the next month's pharmacy review, but this did not occur for R66. The consultant pharmacist also noted the absence of a documented rationale from the provider for disregarding the recommendations, highlighting a breakdown in communication and follow-up within the facility's medication management process.
Medication Unavailability Leads to Errors
Penalty
Summary
The facility failed to ensure medications were available in a timely manner for a resident, resulting in multiple omitted doses and a medication error rate of 7.14%. The resident, who was discharged from an acute care hospital with a diagnosis of orthostatic hypotension, was prescribed droxidopa and metronidazole. However, upon observation, the medications were not available in the medication cart, and the licensed practical nurse (LPN) confirmed that the medications had not been administered since the resident's admission two days prior. The LPN did not notify the unit manager about the unavailability of the medications, and the registered nurse unit manager (RN) confirmed that the pharmacy had not been contacted. The RN acknowledged that the nurse responsible was new and had not participated in recent training. The consulting pharmacist noted that metronidazole should have been readily available, and the dispensing pharmacy technician confirmed that they had not received the orders for the medications. The director of nursing (DON) explained that the health unit coordinator is responsible for faxing orders to the pharmacy, but it was unclear how the orders were missed. The facility's policy on administering medications lacked definitions of what constituted an error or actions to take when medications were unavailable. The deficiency was identified as a failure to provide medications as ordered, which is crucial to prevent negative outcomes for residents.
Failure to Provide Access to Survey Results
Penalty
Summary
The facility failed to ensure that residents, families, and visitors had access to the survey results and the plan of correction (POC) for the past three years, including the most recent survey from December 2023. During an observation at the main entrance, a binder labeled 'St Gertrude's State Survey Results' was found to be missing the survey results and POC from the recertification survey exited on December 14, 2023. The receptionist indicated that the administrator was responsible for maintaining the binder. Upon review, the administrator confirmed that the survey results from December 2023 were not included in the binder at the reception desk or in another binder that was supposed to contain results from the past year. The administrator acknowledged the oversight and the requirement to have three years of survey results available for review. A facility policy on posting survey results was not provided.
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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