Stewartville Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Stewartville, Minnesota.
- Location
- 120 Fourth Street Northeast, Stewartville, Minnesota 55976
- CMS Provider Number
- 245349
- Inspections on file
- 26
- Latest survey
- December 4, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Stewartville Care Center during CMS and state inspections, most recent first.
The facility did not identify alternatives or complete and document comprehensive assessments before installing grab bars on beds for two residents. For one resident with intact cognition and another with severe cognitive impairment, required assessments and informed consents were missing from the records, and staff interviews confirmed inconsistent documentation practices. The facility's policy requiring assessment, risk review, and consent prior to grab bar use was not followed or documented.
Surveyors found that discontinued medications, including insulin pens, IV antibiotics, and other drugs belonging to residents who had passed away or been discharged, were not returned to the pharmacy or destroyed in a timely manner. Staff interviews confirmed that these medications were left in the medication room for extended periods, with inconsistent adherence to facility policy requiring prompt disposal or return.
Two residents received cold, unappetizing breakfast meals after significant delays in meal service, with food items such as eggs, ham, and toast left out for extended periods before being served. Staff confirmed the food was cold and soggy, and facility policy on time and temperature control was not followed.
Surveyors found that food items in the kitchen, including prepared and dry goods, were not consistently labeled, dated, or discarded according to facility policy. Dietary staff confirmed that all are responsible for removing expired foods, but several items remained past their required discard dates or were undated, contrary to established procedures.
Staff failed to consistently wear required PPE, specifically gowns, when providing high-contact care to residents with conditions such as wounds, catheters, and feeding tubes who were under Enhanced Barrier Precautions. Despite EBP signage and prior staff education, multiple staff members either did not wear gowns or were unclear about the requirements, and PPE was not always readily accessible outside resident rooms. Facility leadership was unaware of the noncompliance until it was identified during the survey.
The facility did not maintain the kitchen plate warmer in safe working order, with only one side functioning and no maintenance logs or tracking system in place. Staff communicated the issue verbally, but no formal records or policy existed, resulting in some plates remaining cold and affecting meal temperatures for residents.
A resident with multiple medical conditions and significant weight loss did not receive a physician-ordered nutritional supplement due to a breakdown in order entry and communication among staff. The supplement, recommended by the RD and ordered by the provider, was not implemented because the order was misplaced and not entered into the system, resulting in the resident not receiving the additional calories needed for weight gain.
The facility failed to revise comprehensive care plans for diabetic management for two residents, leading to deficiencies in their care. One resident's care plan lacked a communication plan for a glucose monitoring app and did not address blood sugar goals or insulin refusals. Another resident's care plan did not include blood sugar range goals or interventions for hypo/hyperglycemia, despite frequent high readings. Staff interviews confirmed the lack of diabetic management in the care plans.
A resident with dementia and a history of falls experienced an unwitnessed fall due to the failure of a motion sensor alarm, resulting in significant injuries. The facility did not investigate the alarm's failure or update care plans, contributing to inadequate supervision and intervention.
A resident with dementia and a history of falls experienced an unwitnessed fall resulting in injuries, including rib fractures and a hematoma. The facility failed to report the incident to the state agency, despite the motion sensor alarm not functioning and the resident wearing compression stockings that should have been removed. The director of nursing believed the care plan was followed, and the incident was not reported as required by the facility's procedures.
A resident with dementia and a history of falls suffered serious injuries from an unwitnessed fall when the motion sensor alarm failed to sound. The resident was found with rib fractures and facial contusions, and the incident was not reported to the state agency. Staff interviews indicated the alarm did not activate, and the reason for its failure was unknown.
A resident with Lewy body dementia, who was easily startled and at risk for falls, had a pressure sensor alarm added to her bed without an assessment of its appropriateness. The alarm, which sounded in her room, was implemented despite the resident's sensitivity to environmental sounds, potentially increasing her fall risk. The facility did not provide evidence of a person-centered care plan tailored to the resident's needs.
The facility did not employ a full-time RD or qualified DM, affecting all 45 residents. The previous DM left, and the RD has not been providing support. The facility's dietary staff are contracted, and there has been a lack of communication about a replacement DM. A new DM was hired but delayed due to a pending background check.
The facility failed to maintain safe food storage and kitchen cleanliness, affecting all residents receiving meals. Observations included soiled areas in the kitchen, unlabeled and undated food items in storage, and expired juices in the dining room. The facility's dietary policies on labeling, dating, and equipment maintenance were not followed.
A resident with chronic kidney disease was not provided with the prescribed renal diet due to the unavailability of appropriate protein substitutes and lack of action by the cook to seek guidance. The resident received a meal that included items not compliant with her dietary restrictions, and a box of condiments, including salt, was observed in front of her, which she stated was not part of her diet.
Failure to Assess, Document, and Obtain Consent for Bed Grab Bar Use
Penalty
Summary
The facility failed to identify and attempt alternatives prior to installing or using grab bars on beds for two residents. For one resident with intact cognition and diagnoses including Type 2 diabetes and chronic heart failure, the care plan indicated independent bed mobility and use of bilateral grab bars. Although an informed consent form was signed, there was no evidence in the electronic health record (EHR) that a grab bar assessment had been completed to determine necessity or safety. The resident confirmed using the grab bars and recalled signing paperwork but could not remember the details. For another resident with severely impaired cognition, dementia, and a history of stroke, the care plan required assistance of two staff for bed mobility and transfers but lacked information about grab bars. The EHR for this resident also lacked evidence of a grab bar assessment, education on risks, or a signed consent form. The resident's wife was unaware of any discussion about risks or paperwork regarding the grab bars. Staff interviews revealed inconsistent documentation practices. Registered nurses and LPNs stated that a nurse manager was responsible for completing grab bar assessments, which were reportedly done on paper and placed in the resident's paper chart. However, neither the assessments nor the consents could be located in the EHR or paper records for the two residents. The facility's policy required assessment of alternatives, risk of entrapment, discussion of risks and benefits, and informed consent prior to grab bar installation, but these steps were not documented or verifiable for the affected residents.
Failure to Timely Dispose of Discontinued Medications
Penalty
Summary
The facility failed to ensure that discontinued medications were returned to the pharmacy or destroyed in a timely manner, as observed during a survey of the medication room. On inspection, 108 cards of various oral medications, creams, bulk powdered medications, bottled liquids, insulin pens, and IV antibiotics were found stored on a shelf and in bins. These included unopened boxes of insulin pens and IV antibiotics for residents who had either passed away or been discharged, as well as medications that had been discontinued. Some medications were undated or unlabeled. Interviews with staff confirmed that these medications were from residents who were no longer in the facility or whose medication orders had changed, and that the medications were awaiting return to the pharmacy or destruction. Staff interviews revealed that all nursing shifts were responsible for handling discontinued medications, but the process was not consistently followed. The consultant pharmacist stated that medications eligible for credit should be returned to the pharmacy within 30 days, while others should be destroyed as soon as possible. However, the administrator and DON acknowledged that medications often remained in the medication room for extended periods, sometimes up to a month, before being destroyed or returned. Facility policy required discontinued medications to be destroyed or returned in accordance with established procedures, but observations and staff statements indicated that this was not being done in a timely manner.
Failure to Serve Palatable and Appropriately Heated Meals
Penalty
Summary
The facility failed to ensure that meals were served at a warm or hot and palatable temperature, as required to promote quality of life and nutritional intake. Observations showed that breakfast items such as toast, eggs, and ham were prepared early and left sitting for extended periods before being served. Specifically, toast was cooked at 7:07 a.m. and was still being served to residents nearly two hours later. During meal service, food was plated and delivered to different wings in sequence, resulting in significant delays for some residents. Staff confirmed that the food, including eggs, ham, and toast, was cold and the toast was soggy by the time it reached the last residents. Two residents who received their trays last reported that their meals were cold and unappetizing, with one resident eating only a quarter of the portion and the other leaving the meal uneaten due to the poor quality. Staff interviews corroborated that breakfast foods can be difficult to keep warm and that toast left out for two hours should not have been served. The facility's policy required safe food handling procedures for time and temperature control during food transportation and delivery, which was not followed in this instance.
Improper Food Labeling and Storage Practices Identified
Penalty
Summary
Surveyors observed that the facility failed to ensure proper labeling, dating, and discarding of food items stored in refrigerators and dry storage areas. During a kitchen tour, multiple food items, including hot dogs, bratwurst, tuna salad, clam chowder, cranberry, celery, corn, ground all spice, and ground cloves, were found either undated or kept past their expiration or preparation dates. The dietary manager confirmed that the facility's policy requires foods to be labeled with the date they were opened or prepared and discarded after one week, but several items did not meet this standard. Interviews with dietary staff, including a cook and a dietary aide, revealed that all staff are responsible for discarding expired foods, and they acknowledged the foods should be thrown out one week after the date marked. The dietary district manager verified that several items were not discarded as required by policy, including items with expired manufacturer dates. The facility's food storage policy also requires storage areas to be neat, arranged for easy identification, and date marked as appropriate, which was not consistently followed.
Failure to Ensure Proper PPE Use for Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure proper use of personal protective equipment (PPE) for residents requiring Enhanced Barrier Precautions (EBP). Multiple residents with conditions such as chronic pain, artificial joints, urinary catheters, open wounds, and feeding tubes were identified as needing EBP, as indicated by signage on their room doors. Despite this, staff members, including nursing assistants and an LPN, were observed providing direct care activities such as toileting, hygiene, wound care, and device management without wearing gowns, as required by EBP protocols. Staff interviews revealed inconsistent understanding and application of EBP requirements, with some staff acknowledging awareness of the need for gowns but choosing not to wear them, while others were unsure of the meaning of EBP signage or the specific PPE required. Observations documented that staff entered rooms with EBP signage and performed high-contact care activities—such as assisting with toileting, changing briefs, wound care, and managing feeding tubes—without donning gowns. In several cases, staff stated they were aware of the EBP signage and the expectation to wear gowns but did not comply. Some staff expressed confusion about the location of PPE supplies or the specific requirements for EBP, and one staff member incorrectly believed that only gloves were required. PPE carts were found in central locations rather than immediately accessible outside resident rooms, contributing to inconsistent PPE use. Interviews with facility leadership, including the DON, infection preventionist, and administrator, confirmed that staff had received education on EBP and were expected to follow the protocols. However, leadership was unaware that staff were not consistently using proper PPE in EBP rooms. The facility's posted EBP signage clearly outlined the requirement for both gloves and gowns during high-contact care activities, and the facility's infection control policy emphasized the importance of preventing disease transmission. Despite these policies and education efforts, the lack of adherence to EBP protocols was observed and confirmed through staff interviews and documentation review.
Failure to Maintain Kitchen Equipment in Safe Operating Condition
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe operating condition, specifically the left side of the plate warmer, which was not functioning for an extended period. The cook reported that only the right side of the plate warmer worked, resulting in some plates remaining cold and causing dissatisfaction among residents when their food cooled quickly. The issue had been communicated verbally to the dietary manager, but no maintenance logs or tracking systems were in place for the plate warmer, and the administrator confirmed that no such records existed. The dietary district manager also stated that maintenance issues were communicated by word of mouth and could not specify when the facility became aware of the malfunction. No equipment maintenance policy was provided when requested.
Failure to Provide Ordered Nutritional Supplement for Weight Loss
Penalty
Summary
A resident with a history of traumatic brain injury, digestive system surgery, vascular intestinal disorder, ischemic colitis, intestinal obstruction, and dysphagia experienced significant weight loss over several months. The resident was on a pureed diet with thickened liquids and required substantial assistance with daily activities. The care plan identified risks for dehydration and aspiration, and the nutritional assessment documented an 11% weight loss in six months. The registered dietician recommended a nutritional supplement three times daily to address the weight loss, and a physician's telephone order for the supplement was issued. Despite the provider's order for a nutritional supplement, the order was not entered or implemented. The director of nursing was unaware that the order had not been processed, attributing the failure to a lack of an effective system for order entry and the order being misplaced among paperwork. As a result, the resident did not receive the prescribed supplement intended to increase calorie intake and support weight gain, contrary to the provider's instructions and the resident's care needs.
Deficient Diabetic Management in Care Plans
Penalty
Summary
The facility failed to revise the comprehensive care plans for diabetic management for two residents, R1 and R2, which led to deficiencies in their care. R1, diagnosed with type 1 diabetes mellitus, had a care plan that did not address a communication plan for the Dexcom smart phone application used to monitor blood sugars. The care plan also lacked specific blood sugar goal ranges and did not include individualized interventions to manage hypo/hyperglycemia or address R1's refusals to take insulin. Despite having blood sugar readings as low as 47 and as high as 600, the care plan did not adequately address these issues. R2, diagnosed with type 2 diabetes and diabetic chronic kidney disease, also had a care plan that was insufficient in managing their diabetic condition. The care plan did not include blood sugar range goals, management of the Dexcom sensor, or interventions for hypo/hyperglycemia. R2 frequently had blood sugar readings above 200, yet the care plan did not reflect a focus on diabetic management. During an observation, it was confirmed that R2's care plan lacked diabetic management details. Interviews with facility staff, including an LPN and the DON, revealed that the care plans for both residents did not clearly address diabetic management. The DON acknowledged the deficiencies and expressed an expectation for care plans to include diabetic management. The facility's policy on comprehensive care plans emphasized the need for personalized plans based on the nature of the illness and treatment prescribed, which was not adhered to in these cases.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement care-planned fall interventions for a resident with dementia, anxiety, and depression, resulting in actual harm. The resident, who had a history of falls and was at high risk due to cognitive deficits, experienced an unwitnessed fall while self-transferring. The motion sensor alarm, intended to alert staff of such movements, did not sound, and the facility did not investigate the reason for this failure. The resident sustained significant injuries, including rib fractures and facial contusions, and was admitted to the emergency department. The resident's care plan included several fall prevention measures, such as using a call light for assistance, keeping the bed low and locked, and employing a motion sensor alarm to alert staff of self-transfers. However, the nursing assistant care sheet did not reflect these interventions, and the staff failed to ensure the alarm was functioning. Interviews with staff revealed that the motion sensor alarm was not operational at the time of the fall, and there was confusion about the resident's alarm system, with some staff unaware of its status or the reasons for its failure. The facility did not update the care plan or staff instructions following the incident, nor did they assess the impact of adding a second pressure sensor alarm, which could potentially startle the resident due to her condition. The lack of investigation into the alarm's failure and the absence of updated care planning contributed to the deficiency, as the facility did not provide adequate supervision and intervention to prevent avoidable accidents and injuries.
Failure to Report Unwitnessed Fall with Injury
Penalty
Summary
The facility failed to report an unwitnessed fall with injury to the state agency for a resident who was at risk for falls due to dementia and other cognitive impairments. The resident, who had a history of falls and was on antipsychotic medication, was found on the floor with a large hematoma above the left eye and upper lip. The fall was unwitnessed, and the resident was later admitted to the emergency department with rib fractures and a urinary tract infection. The care plan included measures such as using a call light for assistance, keeping the bed low and locked, and using a motion sensor alarm, but the alarm did not activate during the incident. Interviews with staff revealed that the motion sensor alarm was not functioning at the time of the fall, and the resident was found wearing compression stockings that should have been removed before bed. Despite these issues, the director of nursing did not report the fall to the state agency, believing that the care plan was followed and the staff adhered to it. The facility's procedure for reporting suspected maltreatment of vulnerable adults was not followed, as the incident was not reported to the Minnesota Department of Health Office of Health Facility Complaints.
Failure to Investigate Unwitnessed Fall with Serious Injury
Penalty
Summary
The facility failed to thoroughly investigate an unwitnessed fall involving a resident with dementia, anxiety, and depression, who suffered serious injuries including rib fractures and facial contusions. The resident, who was at risk for falls due to cognitive decline and poor decision-making, was found on the floor with a large hematoma above the left eye and upper lip. The motion sensor alarm, which was part of the resident's fall prevention program, did not sound to alert staff of the movement, and the fall was unwitnessed. The resident was subsequently admitted to the emergency department with rib fractures and a urinary tract infection. Interviews with staff revealed that the motion sensor alarm did not activate, and the fall was not reported to the state agency. The director of nursing believed the care plan was followed, as the sensor alarm was present in the room, and the bed was low and locked. However, the reason for the alarm's failure to sound was unknown. The facility's vulnerable adult procedure required an internal investigation with written statements from involved staff, but there is no indication that this was completed following the incident.
Failure to Implement Person-Centered Dementia Care Plan
Penalty
Summary
The facility failed to assess, develop, and implement a person-centered dementia care treatment plan for a resident diagnosed with Lewy body dementia. The resident, who was easily startled and at risk for falls, had a pressure sensor alarm added to her bed, which sounded in her room. This intervention was implemented without evidence of an assessment process to determine its appropriateness given the resident's diagnosis and sensitivity to environmental sounds. The resident's care plan included measures such as using a call light for assistance, keeping the bed low and locked, and using a motion sensor alarm, but did not account for the potential negative impact of the pressure sensor alarm. Observations and interviews revealed that the resident was easily startled by noises, which could increase her risk of falls. Nursing assistants noted that the resident could be startled by moderate noises, such as a mop bucket or someone speaking to her unexpectedly. Despite this, the facility added a pressure sensor alarm that sounded in the resident's room, potentially exacerbating her startle response and fall risk. The facility did not provide evidence that this intervention was tailored to the resident's specific needs, highlighting a deficiency in person-centered care planning for dementia patients.
Failure to Employ Qualified Dietary Staff
Penalty
Summary
The facility failed to employ a full-time registered dietitian (RD) or a qualified dietary manager (DM) to oversee the food and nutrition services, potentially affecting all 45 residents. The previous DM left earlier in the month, and the regional manager quit in April 2024. Since then, an untrained staff member, C-A, has been handling orders and scheduling without formal training for the DM position. The facility's RD, who is contracted, has not been providing support or visiting the kitchen since the DM's departure, and C-A could not recall the last visit by the RD. The facility's dietary staff are contracted through an outside company, and there has been a lack of communication regarding the replacement of the DM, who has not been present since May 10, 2024. The administrator confirmed the absence of a DM and stated that the RD, also contracted, last visited in April 2024. The dietary company was aware of the situation, and a new DM was hired but could not start due to pending background check results. The facility's policy requires a qualified dietitian or clinically qualified nutrition professional to provide guidance and oversight, which was not being fulfilled.
Deficiencies in Food Storage and Kitchen Cleanliness
Penalty
Summary
The facility failed to ensure safe food storage and kitchen cleanliness, which could potentially affect all 45 residents who receive meals from the kitchen. During a kitchen tour, several issues were observed, including a black thick dry substance around the legs of prep tables and cabinets, and adhered dry substances of varying sizes and colors on the wall, floor, and piping underneath the dishwasher. The cook, C-B, confirmed the presence of these soiled areas and was unsure when they were last cleaned. Additionally, the cabinets containing clean pans had a white substance and food crumbs, and the ice machine had a white thick substance along the bottom with several towels underneath, indicating a possible leak. C-B was unaware of the last maintenance of the ice machine. In the walk-in cooler, pasteurized egg flats and a bag of carrots were found without received or open dates, with the carrots showing signs of mold. In the walk-in freezer, opened and unopened bags of food were not labeled or dated, and C-B confirmed that some items had been there for at least three months. In dry storage, a box of snack bars and a large bag of flour were stored directly on the floor, contrary to policy. Additionally, expired juices were found in the dining room, with C-A unaware that the juices were only good for seven days after opening. The facility's dietary policies require proper labeling, dating, and storage of food items, as well as regular cleaning and maintenance of equipment, which were not adhered to in these instances.
Failure to Follow Therapeutic Diet for Resident
Penalty
Summary
The facility failed to ensure that a therapeutic diet prescribed by the attending physician was followed for a resident with chronic kidney disease, functional dyspepsia, and moderate protein-calorie malnutrition. The resident was on a renal dialysis diet, which included specific restrictions on sodium, protein, potassium, and phosphorus intake. During a kitchen observation, it was found that the facility did not have the appropriate protein substitute for the renal diet, as the pork chops were unavailable, and no alternative was prepared. The cook, who was not trained on different diet types, did not seek guidance from the registered dietitian available for questions. The resident received a meal that did not comply with the prescribed renal diet, including Hawaiian baked ham, which was not part of the diet. The resident acknowledged the discrepancy but did not request an alternative meal. Additionally, a box of condiments, including salt, was observed in front of the resident, which she stated was not supposed to be part of her diet. The regional director of operations confirmed that diet exchanges were available and expected the ordered diets to be followed, as per the facility's dietary policy.
Latest citations in Minnesota
A resident with dry eye syndrome and degenerative eye disease had orders for cyclosporine ophthalmic emulsion and Refresh Tears, both scheduled at the same time. Medication records and direct observation showed a TMA instilled cyclosporine drops in both eyes and immediately followed with Refresh Tears in both eyes without waiting between medications. This practice conflicted with referenced professional guidance recommending several minutes between multiple eye drops and with the medical provider’s recommendation to wait fifteen minutes between the two ophthalmic medications. No facility policy on ophthalmic medication administration was provided when requested.
A resident with severe cognitive impairment, impaired mobility, and high fall risk was care planned to have wheelchair footrests in place at all times, with staff ensuring proper positioning and monitoring for leaning during transport. A NA transported the resident in a manual wheelchair from the shower without the footrests, and while going through the doorway the wheelchair struck the door frame, causing the resident, who was leaning forward, to fall out. The resident sustained a T12 fracture, head injury with concussion, abrasions and contusions, and multiple right-hand lacerations requiring sutures, and the DON confirmed the care plan had not been followed.
A high‑risk, immobile resident with MS and prior heel DTI developed an avoidable unstageable coccygeal pressure ulcer after staff failed to consistently assess and document skin status, did not transfer or timely provide ordered pressure‑relieving mattresses, and did not reliably perform q2h repositioning. The resident was repeatedly left on a bedpan for prolonged periods despite early reports of this issue, and the toileting care plan was not revised to a bedside commode until after the coccygeal wound had significantly worsened. Wound assessments lacked complete measurements and staging, changes in wound size and color were not promptly recognized as deterioration or reported to providers, and recommended interventions from a wound NP (including an air mattress and offloading) were not promptly implemented. As a result, the coccygeal ulcer rapidly progressed to a large, necrotic, malodorous wound requiring hospital transfer and surgical debridement.
A resident with spastic hemiplegia, muscle weakness, and moderate cognitive impairment was observed using bilateral bed grab bars for bed mobility and transfers, but the care plan did not address grab bar or side rail use. Review of the EMR showed no completed bed mobility device or side rail assessment to determine the necessity or safety of the grab bars, and no documentation that risks and benefits were discussed or that informed consent was obtained. An LPN and the ADON stated that a bed mobility device assessment is required before grab bars are installed and confirmed that no such assessment existed for this resident.
A resident with bilateral heel pressure ulcers and multiple comorbidities received wound care during which an RN removed dressings from both heels, cleansed both wounds, and wiped each heel without changing gloves or performing hand hygiene between wounds or after disposing of soiled dressings. This practice conflicted with the facility’s written wound care procedure, which requires glove removal and hand hygiene after dressing removal and after wound cleansing. In interviews, the RN, NP, and DON/IP acknowledged that hand hygiene and glove changes are expected between dirty and clean tasks and between separate wounds to prevent infection.
A resident with MS, neurogenic bladder, mobility limitations, and existing pressure injuries was identified as dependent for toileting hygiene and at risk for pressure ulcers, yet the care plan lacked an individualized toileting/incontinence plan and a defined repositioning schedule. Despite a new coccyx pressure ulcer and documentation that interventions such as increased repositioning and incontinent care were needed, the care plan was not revised for a period of time to reflect these changes. During this time, the resident sometimes fell asleep on a bedpan and remained on it until staff removed it, and staff were not initially informed that the bedpan should no longer be used. The DON later acknowledged that the care plan revisions for turning, repositioning, and toileting were delayed until after the resident’s coccyx ulcer had significantly worsened.
A resident with diabetes, Crohn’s disease, bowel incontinence, and a history of MASD on the right gluteus developed an open, painful lesion on the right gluteal area that was documented over time without complete wound characteristics, clear etiology, or timely provider notification. Wound care orders were written for a stage 3 pressure ulcer on the left buttocks, while staff reported the wound was only on the right side and applied the left‑sided orders to the right gluteal wound in the absence of specific right‑side treatment orders. The DON acknowledged discomfort with staging the wound, lack of early physician notification, and confusion over wound classification, despite a facility policy requiring comprehensive wound assessment, consistent measurement, and provider notification when treatment orders are absent.
A resident with diabetes, chronic leg ulcer, kidney transplant, and a documented gluteal wound was care-planned for Enhanced Barrier Precautions (EBP), with posted instructions requiring gown and gloves for high-contact care such as transfers and wound care. During a telehealth wound assessment, the DON donned a gown and initially performed hand hygiene but then applied gloves without hand hygiene, removed a soiled dressing from the resident’s gluteal area, discarded it, removed gloves, and applied new gloves again without performing hand hygiene between glove changes. On another occasion, during use of a sit-to-stand lift, an NA wore gown and gloves, but the DON handled the lift harness, the resident’s clothing, and assisted with the transfer and repositioning while wearing a gown but no gloves, despite EBP requirements for transfers. The DON stated EBP was only needed for catheter or wound care and not for transfers, contradicting the posted EBP instructions and facility policy.
A resident with severe dementia, psychiatric disorders, and high dependence for ADLs was verbally abused during evening care when a NA, frustrated with the resident’s crying and resistance, loudly ridiculed her as acting like a two-year-old, threatened to hit her back if struck, told her she would be sent to a locked unit, and questioned who would want to care for her when she cried like a baby. Multiple staff witnessed the loud, stern, and intimidating tone and reported it to an LPN, who recognized it as verbal abuse but did not immediately remove the NA from duty or promptly report the allegation per policy, allowing the NA to continue working on the unit. Following this incident, the resident demonstrated increased crying, combativeness, resistance to care, wandering, self-isolation, and refusal of food, fluids, and medications above baseline, with documentation of significant emotional distress and subsequent ED evaluation for aggressive behaviors and poor intake.
A resident with dementia, bilateral above‑knee amputations, vascular disease, and severe protein‑calorie malnutrition developed a wound on an amputation stump that had a dressing dated several days before any documentation or treatment orders appeared in the record. Although bath audits and nursing notes initially reported no skin issues, a later assessment described a full‑thickness stage 4 ulcer/diabetic ulcer on the stump with exposed bone, erythema/edema, slough, and moderate serosanguineous drainage. Nursing staff interviews showed no one could identify who first discovered the wound or applied the initial dressing, and there was no evidence that the wound was assessed, the provider notified, or standing orders implemented when it was first present, despite facility expectations that new wounds be promptly evaluated and reported.
Failure to Follow Professional Standards for Ophthalmic Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice for administering ophthalmic medications to a resident with dry eye syndrome and degenerative eye disease. The resident was cognitively intact, required assistance with ADLs, and had physician orders for cyclosporine ophthalmic emulsion 0.05% one drop in both eyes twice daily and Refresh Tears ophthalmic solution one drop in both eyes four times daily for dry eyes. The administration summary showed that both eye medications were scheduled for the same time and were documented as being given at the same time on multiple dates. During a medication pass observation, a trained medication aide administered the ordered oral medications, then applied gloves and instilled one drop of cyclosporine in each eye, immediately followed by one drop of Refresh Tears in each eye, without any waiting period between the two medications. The surveyors referenced guidance from the American Academy of Allergy, Asthma, and Immunology stating that when more than one eye drop is ordered, three to four minutes should be allowed between drops in the same eye, and five to fifteen minutes should be allowed between different eye medications to prevent dilution. Interviews with the DON, pharmacy consultant, and medical provider confirmed that best practice and the provider’s recommendation were to wait between administration of cyclosporine and Refresh Tears, with the medical provider specifying a fifteen-minute interval. The facility did not provide a policy on ophthalmic medications when requested. The observed practice and documented administration times demonstrated that staff did not follow these professional standards or the medical provider’s recommended interval between the two eye medications.
Failure to Follow Wheelchair Transport Care Plan Leads to Fall With Injuries
Penalty
Summary
The deficiency involves the facility’s failure to implement care-planned fall prevention interventions for a resident at high risk for falls, resulting in a fall with injury. The resident had diagnoses including aphasia, dysphagia, muscle weakness, traumatic brain injury, and impaired mobility, with severe cognitive impairment documented on the MDS and dependence on staff for transfers and wheelchair transport. A care plan addressing wheelchair transport safety and positioning directed staff to ensure the resident was fully positioned and supported in the wheelchair prior to transport, verify footrests were in place prior to transport, and monitor for leaning, sliding, or unsafe positioning. An additional care-planned approach required wheelchair pedals to be on at all times. On the date of the incident, a nursing assistant transported the resident in a manual wheelchair from the shower room to the resident’s room without the foot pedals in place, contrary to the care plan. While being wheeled through the doorway, the wheelchair struck the door frame, causing the chair to stop and the resident, who had begun leaning forward, to fall out of the wheelchair onto the floor. Progress notes and ED documentation identified that the resident sustained a T12 vertebral fracture, a head injury with concussion, an abrasion and contusion to the head, a bruise to the left knee, and multiple lacerations to the right hand requiring sutures. The nursing assistant later acknowledged awareness that the foot pedals should have been on but did not apply them because the transport was only from the shower to the room. The DON confirmed that the resident’s care plan had not been followed when the fall occurred.
Failure to Implement and Update Pressure Ulcer Prevention and Treatment Led to Avoidable Unstageable Coccygeal Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, monitor, and implement individualized pressure ulcer prevention and treatment interventions for multiple high‑risk residents, resulting in an avoidable, unstageable coccygeal pressure ulcer for one resident that required surgical debridement and hospitalization. The resident had primary progressive multiple sclerosis, hereditary spastic paraplegia, obesity, and pre‑existing pressure‑related deep tissue injury to the left heel, and was identified as high risk for pressure ulcers on the Braden Scale due to constant moisture, chairfast status, very limited mobility, inadequate nutrition, and friction/shear risk. Hospital records on readmission documented irritant contact dermatitis of the bilateral gluteal cleft with specific cleansing and barrier cream orders, and facility documentation showed the resident could not reposition in bed or chair and required assist of two and a full‑body mechanical lift for transfers. Despite this, the admission/readmission skin assessment and weekly skin checks lacked measurements and detailed wound characteristics for the heel ulcer and gluteal dermatitis, and the care plan did not include comprehensive, individualized interventions beyond generic repositioning and wound care orders. After a new coccyx pressure ulcer was identified and documented as a stage 2 lesion, the facility failed to promptly and accurately update the care plan and implement recommended pressure‑relieving interventions. The wound nurse practitioner on 3/5 ordered coccyx wound care, an air mattress, pressure offloading, and a dietician consult, but the care plan was not revised and there was no evidence that an air mattress was placed on the bed for nearly two weeks. The environmental services director later confirmed that when the resident was moved to a new room, the gel mattress was not transferred, and the air mattress requested on 3/17 was not actually placed until the following day, despite being marked as completed. During this period, TAR documentation showed gaps in the every‑2‑hour repositioning order, and staff interviews revealed that CNAs were unaware of which residents were on repositioning programs, were not consistently repositioning residents, and had not received recent education on pressure ulcer prevention. The DON and RN case manager acknowledged that the coccyx wound increased in size and changed color between assessments, that the bed lacked the ordered gel mattress, and that the physician was not notified of the wound’s deterioration at that time. The facility also failed to timely modify toileting and incontinence care practices despite knowledge that the resident was being left on a bedpan for extended periods. The DON reported hearing before an IDT meeting that the resident had fallen asleep on a bedpan for an undetermined amount of time, but the care plan was not revised to discontinue bedpan use and implement a bedside commode until after the coccyx wound had significantly worsened. CNAs confirmed that the resident sometimes fell asleep on the bedpan and that they were not informed she should no longer use it until after the sore had worsened. Subsequent wound assessments documented rapid progression of the coccyx wound from a small stage 2 ulcer to a large, malodorous, necrotic wound with eschar, slough, erythema, and purulent drainage, ultimately classified as an unstageable pressure ulcer. The DON, NP, PA, and medical director all indicated that the lack of a pressure‑relieving mattress, failure to adjust pressure‑reducing interventions, and prolonged time on a bedpan likely contributed to the development and deterioration of the resident’s pressure ulcer, which was determined to be avoidable and resulted in hospitalization and surgical debridement. Additional documentation and interviews showed systemic assessment and communication failures related to pressure ulcer management. Weekly skin checks and wound assessments often omitted complete measurements, staging, and wound characteristics, and changes in wound size and appearance were not consistently recognized as deterioration or communicated to providers. The DON acknowledged that a 3/12 assessment showing increased wound size and purple discoloration should have been identified as a deep tissue injury and reported to the physician, but this did not occur. When nursing later documented foul odor, increased pain, and expanding necrotic tissue, telemedicine and PA responses deferred in‑person evaluation and ED transfer despite earlier recommendations that the resident be sent to the ED if an in‑person provider could not assess the wound. The NP ultimately found a large, malodorous, purulent wound with expanding eschar and ordered transfer to the hospital, where imaging and surgical findings confirmed a large necrotic sacral wound requiring extensive debridement. Throughout this sequence, the facility did not consistently follow its own pressure ulcer protocols, did not ensure ordered pressure‑relieving equipment was in place, and did not promptly revise care plans or interventions in response to known risk factors and documented wound changes. The report also notes that other residents reviewed for pressure ulcers were affected by similar failures in monitoring and individualized intervention, though detailed narratives focus primarily on this resident. Staff interviews revealed that CNAs relied on paper care guides that did not clearly identify residents on repositioning programs or at risk for skin breakdown, and that they were unaware of some residents’ special mattress orders or toileting restrictions. The DON and medical director stated that residents at risk for pressure ulcers should have immediate pressure‑relieving interventions and that existing ulcers require ongoing evaluation to prevent deterioration, but the documented practices for this resident did not align with those expectations. These combined actions and inactions—insufficient assessment detail, delayed or missing care plan revisions, failure to implement ordered support surfaces and repositioning, and delayed response to wound deterioration—constituted the deficiency in providing appropriate pressure ulcer care and preventing new ulcers from developing.
Failure to Assess, Care Plan, and Obtain Consent for Bed Grab Bar Use
Penalty
Summary
The deficiency involves the facility’s failure to follow required procedures before installing and using bed grab bars for a resident. The resident had diagnoses including spastic hemiplegia affecting the left side and muscle weakness, and an admission MDS indicating moderate cognitive impairment. During observation, the resident was seen in a power chair with bilateral grab bars on the bed and reported using them to roll in bed and for transfers. The resident’s care plan, dated 1/23/26, documented a need for assistance with bed mobility and independence with transfers but did not mention or address the use of grab bars or side rails. Review of the electronic medical record showed no completed grab bar/side rail or bed mobility device assessment to determine the necessity of the grab bars or whether the resident could safely use them. There was also no evidence that the resident or the resident’s representative had been educated on the risks of having a grab bar on the bed or that informed consent had been obtained. In interviews, an LPN and the ADON both stated that a bed mobility device assessment was required to determine need and safety prior to installing grab bars, and both confirmed that no such assessment was present in the resident’s record.
Failure to Perform Hand Hygiene and Change Gloves During Wound Care
Penalty
Summary
Surveyors observed that a registered nurse (RN) and a nurse practitioner (NP) did not follow the facility’s established infection control practices during wound care for one resident. During a wound treatment, the RN wore gloves while removing the dressing from the resident’s left heel, then removed the dressing from the right heel, sprayed both wounds with wound cleanser, wiped the left heel with gauze, and then used a clean gauze pad to wipe the right heel. The RN did not remove her gloves or perform hand hygiene after disposing of the soiled dressings or between cleaning the left and right heel wounds, contrary to the facility’s written wound care procedure, which requires glove removal and hand hygiene after removing the previous dressing and again after cleaning the wound. The resident’s admission MDS documented diagnoses including multiple rib fractures, heart failure, dementia, anxiety, and the presence of a pressure ulcer, and indicated the resident was cognitively intact and required staff assistance with care and transfers. The resident’s care plan identified pressure ulcers on both heels requiring wound care. In interviews, the RN, NP, and the DON/infection prevention nurse each stated that gloves should be changed when moving from dirty to clean areas and that hand hygiene is expected after glove removal and between wounds to prevent infection, confirming that the observed practice did not align with facility policy or expected infection control standards.
Failure to Timely Revise Care Plan for Toileting and Skin Integrity
Penalty
Summary
The deficiency involves the facility’s failure to timely revise and individualize a resident’s care plan to address toileting and incontinence needs in relation to impaired skin integrity. The resident had diagnoses including primary progressive multiple sclerosis, hereditary spastic paraplegia, obesity, and a pressure-induced deep tissue injury to the left heel. A Significant Change MDS identified the resident as dependent for toileting hygiene, with lower extremity range-of-motion limitations, wheelchair use, dependence for transfers, occasional urinary incontinence, intact cognition, and at risk for pressure ulcers with existing unhealed pressure injuries and MASD. The resident’s skin-focused care plan, revised on various dates, included skin inspections, wound care orders, weekly skin checks, pressure ulcer care to the left heel, nutritional supplements, and a gel mattress, but did not include an individualized toileting or incontinence plan. On a weekly skin check dated 3/3/26, nursing staff identified a new Stage 2 pressure ulcer on the coccyx and contact dermatitis on both gluteal folds. An IDT Final Post Review Follow Up dated 3/10/26 (signed 3/23/26) documented that a new skin issue had occurred and that interventions after the incident included wound care treatment orders, increased repositioning, and increased incontinent care. However, the resident’s care plan from 3/3/26 through 3/16/26 did not show revisions reflecting increased incontinence care or a repositioning schedule, and the care plan was not updated to include these elements until 3/17/26. During this period, the care plan still lacked an individualized toileting plan despite the resident’s identified incontinence and new coccyx pressure ulcer. Progress notes on 3/17/26 documented that the resident’s coccyx wound had declined, with an evaluation describing a deteriorating wound characterized as a Kennedy terminal ulcer/End of Life, staged as a Stage 4 pressure ulcer, in-house acquired, with increased size, exudate, odor, pain, and surrounding erythema. On that same date, the skin focus care plan was revised to include prompt incontinence care and keeping the skin clean and dry, and the elimination focus care plan was revised to address incontinence due to neurogenic bladder with use of a bedside commode offered every 2–3 hours. A nursing assistant reported that when working with the resident, the resident would sometimes fall asleep on the bedpan and forget to ask staff to remove it, and that she was not aware the resident was not supposed to use the bedpan until after the sore had worsened. The DON stated that the resident’s care plan had not been revised earlier to include a turning and repositioning schedule or toileting changes, and that it should have been revised as soon as staff learned the resident was falling asleep on the bedpan, rather than waiting until after the pressure ulcer worsened.
Failure to Assess and Notify Provider for Right Gluteal Wound
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess and appropriately manage a non‑pressure skin issue on a resident’s right gluteal area, and to notify the physician in a timely manner. The resident had diagnoses including diabetes, Crohn’s disease, and a kidney transplant, and the MDS indicated occasional bowel incontinence, no pressure ulcers, and no moisture‑associated skin damage at that time. Earlier documentation identified a resolved MASD to the right gluteus, and a progress note later described a sacral wound with creams applied, noting that sores were still open and painful during application, but without any measurements, wound characteristics, or evidence of physician notification. Subsequent wound assessments documented an open lesion on the right gluteus with specific measurements on multiple dates, but did not identify the wound type or other characteristics, and the record did not show physician notification or treatment orders for the right gluteal lesion. Provider orders in place initially addressed cleansing the buttocks and applying barrier cream, and later included a detailed wound care order for a stage 3 pressure ulcer documented on the left buttocks. However, the resident’s record did not contain a specific treatment order for the right gluteal wound, despite the ongoing documentation of an open lesion in that area. Interviews revealed confusion and inconsistency in wound identification and classification. The DON stated that the right gluteal wound was documented as an open lesion because she did not feel comfortable determining the wound type, and acknowledged that the physician should have been notified when the wound was first identified. The DON was unaware that the NP had documented the wound as being on the left buttocks and as a stage 3 pressure ulcer, while the RN reported that the wound had never been on the left buttocks and that she had been applying the left‑sided wound orders to the right gluteal area because there was no open area on the left. The resident reported a recurring painful area on the right buttocks and chronic stool leakage since prior anal fistula surgery. The facility’s own wound treatment policy required comprehensive assessment of wound etiology and characteristics, consistent measurement and documentation, and provider notification in the absence of treatment orders, which were not followed for this resident’s right gluteal wound. The deficiency centers on the lack of a comprehensive wound assessment for the right gluteal lesion, incomplete documentation of wound characteristics, failure to clearly determine and document the wound etiology, and failure to notify the physician and obtain appropriate treatment orders when the wound was identified and remained open. These actions and inactions resulted in a discrepancy between the documented wound location and type and the actual clinical presentation, as well as a period during which the right gluteal wound had no specific, clearly ordered treatment despite being open and painful.
Failure to Perform Hand Hygiene and Implement Enhanced Barrier Precautions During Wound Care and Transfers
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper hand hygiene during wound care and to consistently implement Enhanced Barrier Precautions (EBP) for a resident requiring such measures. The resident had diagnoses including diabetes, a non-pressure chronic ulcer of the right lower leg, and a kidney transplant, and a wound assessment documented an open lesion on the right gluteal area. The resident’s care plan and a sign posted outside the room specified that EBP, including gown and gloves, were required for high-contact care activities such as dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, catheter care, and wound care. During one observation, the DON performed hand hygiene and donned a gown before entering the resident’s room for a telehealth wound assessment. Inside the room, the DON went into the bathroom, applied gloves without performing hand hygiene, removed the resident’s brief, and removed a foam dressing from the right gluteal area that had stool on one corner. After discarding the soiled dressing, the DON removed gloves and then applied new gloves without performing hand hygiene between glove changes. When questioned, the DON stated that hand hygiene should be done when hands or gloves are visibly soiled and before and after removing or applying gloves, and acknowledged that hand hygiene had not been performed each time gloves were removed and reapplied. In a separate observation, the resident was transferred using a sit-to-stand mechanical lift while EBP requirements were not fully followed. An NA entered the room wearing a gown and gloves with the lift, and the DON applied the lift harness under the resident’s arms and cinched the waist strap, encountering the resident’s clothing, while not wearing gloves. After the transfer to bed, the DON pulled down the resident’s pants and removed the harness while touching the resident’s clothes. Following wound care by a CNP-WOC, the DON again assisted the resident by sitting the resident on the edge of the bed, applying the lift harness, and adjusting the resident’s pants and shirt while wearing a gown but no gloves. The DON stated that EBP was only needed for catheter or wound care and not for transfers, and only upon reading the posted EBP sign acknowledged that EBP was required for all high-contact resident care activities, including transfers.
Failure to Protect Resident From Verbal Abuse and Delay in Removing Alleged Perpetrator
Penalty
Summary
The deficiency involves the facility’s failure to protect a vulnerable resident from mental abuse and to respond appropriately to an allegation of abuse. The resident had severe cognitive impairment, Alzheimer’s disease, dementia, anxiety, depression, psychotic disorder, and significant functional dependence, including frequent incontinence and the need for extensive assistance with ADLs and transfers. Her care plan identified behavioral and mood issues such as wandering, yelling, combative behavior, and calling staff names, with interventions including calm approaches, emotional support, redirection, and monitoring for emotional distress and mood/behavior changes. She was identified as a vulnerable adult, with instructions to monitor for signs of emotional distress and to follow the facility’s abuse reporting policy. On the evening in question, while the resident was crying on the phone with her son and expressing a desire to leave, NA-A and NA-B entered to provide evening care using an EZ stand lift. After the resident ended the phone call, multiple staff reported that NA-A spoke to the resident in a loud, stern, and frustrated tone, telling her to stop crying and that she was acting like a two-year-old. When the resident swatted at NA-A, NA-A stated, “If you hit me, I’m going to hit you back,” and later told the resident she was “in trouble now.” Staff reported that NA-A told the resident she would be sent to a locked unit so she could not get out, and questioned who would want to care for her when she cried like a baby, and that nobody would want to keep working with her. NA-C described NA-A yelling commands such as “HOLD ON!” and “Stop crying! Where would you be if you were not here? Probably lying on the floor,” and felt NA-A was obviously upset and overwhelmed. These statements were made in the presence of the resident while she was already distressed and crying. Following this interaction, the resident exhibited crying, yelling, combativeness, resistance to care, wandering into other residents’ rooms, self-isolation, and refusal of food, fluids, and medications above her prior baseline, as documented in behavior charts, target behavior monitoring, and nursing progress notes. Staff documented that she cried most of the morning, was very restless, difficult to redirect, hit and pinched staff, called staff names, and refused care and meals. She required repeated redirection, 1:1 attention, and non-pharmacological interventions, and was ultimately sent to the ED for evaluation of combativeness and emotional distress, where she was treated for dementia with aggressive behavior and hypoglycemia related to poor intake. The report identifies that the resident’s actual response and the reasonable person concept showed serious psychosocial harm, including increased crying and combative behavior above baseline, fear/anxiety manifested as combativeness, resistance to care and social interaction, and self-isolation. The facility also failed to immediately remove the alleged perpetrator from resident care and to promptly report and investigate the allegation in accordance with its abuse policy. After NA-B and NA-C reported to LPN-A that NA-A had yelled at and threatened the resident, LPN-A acknowledged it as verbal abuse but did not initiate immediate protective measures or timely reporting. LPN-A stated she believed she had 24 hours to report because there was no injury, despite facility policy requiring reporting within two hours. NA-A remained on the unit and continued working until the end of her shift, including after staff had clearly communicated their concerns to LPN-A. TMA and NA staff described uncertainty about their authority to remove NA-A and reliance on the nurse to act, while the DON later informed LPN-A that NA-A should have been removed from the floor to prevent further danger to residents. The Immediate Jeopardy was determined to have begun when NA-A’s derogatory, intimidating, and threatening statements were made and continued while she remained on duty with access to the resident and other vulnerable residents.
Failure to Timely Assess and Treat Newly Discovered Stump Wound
Penalty
Summary
The deficiency involves the facility’s failure to provide timely treatment and care for a newly discovered wound on a resident’s above‑knee amputation stump. The resident was admitted with diagnoses including unspecified dementia with behavioral disturbances, vascular dementia, bilateral above‑knee amputations, vascular disease, reduced mobility, and severe protein‑calorie malnutrition, and had no documented ulcers or skin problems on admission or on the most recent MDS. A weekly bath audit on 3/17/26 documented only non‑tender lymph nodes on the right upper hip and did not identify any open areas. However, when the wound was later assessed, the dressing on the stump was dated 3/16/26, indicating that a wound and dressing existed at that time, even though no corresponding assessment, provider notification, or treatment orders were documented. On 3/23/26, nursing staff documented a new skin issue above the resident’s knee at the amputation site, describing a stage 4 pressure ulcer/injury with full‑thickness skin and tissue loss, exposed bone, erythema/edema, and moderate serosanguineous exudate. The wound measured 1.56 cm by 1.64 cm, with 20–29% granulation tissue and 80% slough. A progress note and skin issues assessment on that date confirmed the wound characteristics and staging, and the NP, after reviewing a picture, determined the wound to be a diabetic ulcer with peripheral vascular disease and severe protein‑calorie malnutrition as contributing factors. On that same date, the NP was notified, antibiotic therapy (doxycycline) was ordered for possible cellulitis, and specific wound care orders were initiated, with documentation on the MAR that these treatments were carried out beginning 3/23/26. Multiple interviews with nursing staff revealed that no one could identify who discovered the wound or who applied the initial dressing dated 3/16/26, and there was no documentation of a wound assessment, provider notification, or interim treatment between 3/16/26 and 3/22/26. Several RNs and LPNs who worked shifts from 3/16/26 through 3/20/26 stated they did not notice a wound on the stump and that, per their usual practice, they would have contacted the provider and initiated treatment if they had found one. One LPN recalled seeing a band‑aid with a date on the stump but could not recall the date, and another LPN stated she did not see the wound because she was not looking for one. The facility’s standing orders required staff to assess all wounds daily, change dressings every three days and as needed, treat with normal saline or non‑cytotoxic cleanser and appropriate dressings, and notify the provider the next business day when a new wound or injury was found. Despite these expectations, the wound identified by the dated dressing on 3/16/26 was not assessed, reported, or treated according to orders and facility policy until 3/23/26.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
