The Gardens At Winsted Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Winsted, Minnesota.
- Location
- 551 Fourth Street North, Winsted, Minnesota 55395
- CMS Provider Number
- 245459
- Inspections on file
- 27
- Latest survey
- August 15, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at The Gardens At Winsted Llc during CMS and state inspections, most recent first.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact circumstances or individuals involved.
A deficiency was cited when a resident's care plan did not address all identified needs and lacked measurable timetables and specific actions, resulting in incomplete planning and documentation.
Surveyors found that a resident did not receive appropriate care for bowel/bladder continence or incontinence, catheter management, and UTI prevention. The care provided did not meet required standards, resulting in a deficiency.
A resident with paraplegia and no cognitive impairment reported that a nursing assistant inserted a finger into her anus during care, which she found painful and distressing. The allegation was not reported to the charge nurse or State Agency within the required two-hour window, despite staff being aware of the reporting policy.
A resident reported a painful and upsetting incident involving a contracted NA during care, where the NA inserted a finger into the resident's anus. Investigation revealed that the contracted NA had not received the facility's required abuse training, including education on sexual abuse and reporting requirements. The facility's policy did not address how contracted staff would be included in abuse prevention training, and documentation from the agency lacked evidence of sexual abuse education.
A resident with severe cognitive impairment and an indwelling catheter received personal care from a CNA who failed to change gloves or perform hand hygiene between multiple care tasks, despite facility policy and enhanced barrier precautions. The CNA also handled personal items and equipment with contaminated gloves. Additionally, the facility did not track or trend symptoms of illness for residents not on antibiotics, as infection logs only included cases treated with antibiotics and did not document other types of illnesses.
Two residents' rooms had persistent, strong odors due to limited staff access for personal care and cleaning, as both individuals often refused assistance and housekeeping. Despite care plans indicating the need for staff support, the odors continued to permeate surrounding areas. Additionally, a resident's missing clothing item was not thoroughly investigated or tracked, as facility staff were unaware of the established policy and did not consistently follow the grievance process.
Two residents reported during Resident Council that mail was not delivered to them on Saturdays, and staff confirmed that mail was only collected and distributed on Mondays due to the absence of a receptionist and lack of a policy. The post office verified that mail was delivered to the facility on Saturdays, but the facility failed to ensure timely distribution, affecting all residents.
Surveyors found that the facility did not consistently identify or address residents' individual activity preferences, failed to develop or update resident-specific activity care plans, and did not coordinate or document activities of interest. Several residents reported boredom and a lack of meaningful activities, with activity calendars lacking variety and scheduled weekend or evening options. Staff confirmed that activity records were incomplete and that some activities listed were not actually provided.
A resident with chronic pain and multiple diagnoses was found with several OTC medications at bedside without a complete self-administration of medications (SAM) assessment or provider orders for each medication. While the care plan and assessment addressed only one of the bedside medications, the facility failed to follow its policy requiring individual SAM evaluations and orders for all medications kept at bedside.
Residents repeatedly voiced concerns about limited activities and lack of follow-up on their requests during council meetings. Despite ongoing grievances related to Therapeutic Recreation, such as requests for more crafts, games, and the return of popular programs, the facility did not provide feedback or resolutions. Activity calendars showed minimal offerings, and no policies for program development or council grievance follow-up were available.
A resident filed multiple grievances over several months, but the facility failed to consistently follow up, document, and resolve these complaints as required by policy. Some grievances lacked any documented resolution or follow-up, and the process for timely investigation and communication of outcomes was not adhered to, as confirmed by staff interviews.
A resident with severe cognitive impairment and multiple medical conditions was enrolled in hospice, but the facility failed to integrate the hospice plan of care with its own care plan. The facility's documentation did not specify the hospice services provided or include the hospice plan of care, leaving staff without necessary reference information, despite requirements outlined in the hospice agreement.
A resident with end stage renal disease and other comorbidities did not consistently receive Midodrine at the correct time before dialysis due to unclear medication orders and inconsistent communication between facility staff and the dialysis center. Required documentation was missing for some dialysis sessions, and staff were unclear about the timing of medication administration, leading to deviations from the dialysis center's instructions.
A resident who had previously received PPSV23 and PCV13 vaccines had a physician order for PCV20, but the vaccine was not administered despite being available and consented. Review of the MAR showed no documentation of administration, and staff confirmed the immunization was not given as required by facility policy.
A resident with cognitive impairment and elopement risk did not have consistent or clearly documented monitoring of their Wanderguard device, with staff unclear on procedures and missing manufacturer guidance. Another resident was observed using e-cigarettes in their room despite policy requiring use only in designated areas, and staff did not effectively enforce this rule. Additionally, a resident with dysphagia and a modified diet was left unsupervised in the dining room while eating, including being served food not prepared according to dietary orders, contrary to facility policy requiring supervision during meals.
Two residents with significant medical and behavioral health needs experienced persistent room odors that permeated surrounding areas, with no documented social services interventions or evidence that social workers addressed or were aware of the issue. Both residents were cognitively intact and had care plans noting behavioral and psychosocial risks, but progress notes and care conferences failed to address the odor concerns.
The facility did not ensure that required survey results and complaint investigation documentation, including CMS 2567 forms for complaint investigations and revisits, were available for review. Interviews confirmed staff were aware of the posting requirements, but the necessary documents were missing from the survey binder, and no policy for posting survey results was in place.
A resident with multiple chronic conditions and a wound requiring daily care did not receive proper Enhanced Barrier Precautions (EBP) during a wound care procedure, as the DON failed to wear a gown as required by physician orders and the care plan. The DON acknowledged the omission, and the facility could not provide an EBP policy when requested.
The facility failed to maintain cleanliness in a resident's room and the dining room, affecting the living environment. Brownish stains, soiled tissues, and uncleaned plates were found in the dining room, and a housekeeper cleaned without gloves and did not wash hands. A white powder-like substance was also found in a resident's room, which was not cleaned promptly. The DON expected these areas to be cleaned before and after meals, as per facility policy.
The facility failed to ensure proper use of PPE and EBP for residents with Foley catheters, leading to infection control deficiencies. A resident with a urinary tract infection lacked EBP signage, and staff did not wear gowns and gloves during high-contact care. Another resident with a bladder disorder had EBP signage, but staff were observed not using PPE. A third resident with acute kidney failure also lacked EBP signage, and staff failed to use PPE during care activities.
A facility failed to communicate a resident's medication orders to the pharmacy, resulting in delayed delivery. The resident, with multiple health conditions, missed doses of critical medications, including insulin, due to ineffective use of the E-Kit by pool staff. The pharmacy received incomplete orders, and the facility's policy for handling missing medications was not adequately communicated to temporary staff.
A resident with severe cognitive impairment and multiple medical conditions was hospitalized due to an infected ulcer. The facility failed to notify the resident's representative of changes in the resident's condition and treatment, including new orders for antibiotics and pain medications. Interviews revealed that staff did not consistently communicate these changes, despite facility policy requiring notification of the resident's representative.
A resident with severe cognitive impairment and multiple medical conditions developed worsening pressure ulcers due to inadequate monitoring and documentation by the facility. Despite having a care plan, staff failed to consistently document wound conditions, leading to a lack of communication and the resident's hospitalization for sepsis from an infected wound.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the facility's failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This deficiency was based on observations and review of the care planning process, which did not meet regulatory standards for comprehensive and measurable care planning.
Deficient Bowel/Bladder and Catheter Care Leading to UTI Risk
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not consistently provided to residents in these areas. Specific failures included inadequate attention to the needs of residents with continence or incontinence issues, improper catheter care, and insufficient measures to prevent UTIs. These deficiencies were observed through direct surveyor findings, indicating lapses in the standard of care required for residents' bowel and bladder management, catheter maintenance, and infection prevention.
Failure to Timely Report Alleged Sexual Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of sexual abuse to the State Agency (SA) within the required two-hour timeframe. A cognitively intact resident with paraplegia, neurogenic bowel, and major depressive disorder reported that, during assistance with a brief change, a nursing assistant inserted a finger into her anus in a manner the resident described as painful and upsetting. The resident reported the incident to a nursing assistant, who delayed reporting the allegation to the charge nurse, citing that no other nurse was available at the time. The nursing assistant eventually reported the allegation to the registered nurse at approximately 8:30 a.m., who then spoke with the resident and subsequently reported the incident to the administrator and the SA. Interviews and document review revealed that staff were aware of the expectation to report abuse allegations immediately to the charge nurse and to the SA within two hours, as outlined in the facility's policy. Despite this, there was a delay in reporting the incident, as the allegation was not communicated to the appropriate personnel and the SA within the required timeframe. The deficiency was identified for one of three residents reviewed for abuse reporting.
Failure to Train Contracted Staff on Facility Abuse Policy and Sexual Abuse Reporting
Penalty
Summary
The facility failed to ensure that contracted agency staff received training on the facility's abuse policy and annual abuse training, which had the potential to affect all 37 residents. A resident reported an incident involving a contracted nursing assistant (NA) who, during care, inserted a finger into the resident's anus, which the resident described as painful and upsetting. The incident was reported to a registered nurse, and subsequent review of the contracted NA's training records revealed that while the agency provided some abuse training, it did not include education on sexual abuse or the facility's specific reporting requirements. The NA confirmed that he had not received any abuse training from the facility itself, only from his agency, and that his last agency training was several months prior. Further review of the facility's policies indicated that orientation and annual in-service training on abuse and reporting were required for all new employees, but there was no evidence or process to ensure that contracted staff were included in this training. The facility's policy did not specify how contracted staff would be trained or who was responsible for ensuring their compliance with abuse prevention and reporting education. Documentation from the contracted agency also lacked evidence of sexual abuse training and did not meet the facility's requirements.
Failure to Perform Hand Hygiene and Track Non-Antibiotic Illnesses
Penalty
Summary
The facility failed to ensure proper hand hygiene and glove changes during personal care for a resident with enhanced barrier precautions due to an indwelling catheter. During an observed care episode, a certified nursing assistant (CNA) donned gloves and a gown before entering the resident's room and proceeded to provide a range of personal care activities, including washing, dressing, pericare, and catheter care, without changing gloves or performing hand hygiene between tasks. The CNA also touched personal items, used a walkie talkie, and handled objects in the room while wearing the same gloves, only removing them at the end of the care episode. Interviews with the CNA and supervisory staff confirmed that gloves were not changed unless visibly soiled, and hand hygiene was not performed as required by facility policy and standard infection control practices. The resident involved had significant cognitive impairment and was dependent on staff for activities of daily living. The care plan specified the use of enhanced barrier precautions and outlined the need for staff to don and doff personal protective equipment appropriately and to perform hand hygiene during care. Despite these directives, the observed care did not follow the expected sequence of clean-to-dirty care, nor did it include necessary glove changes and hand hygiene at appropriate intervals, as confirmed by both the CNA and the director of nursing (DON) during interviews. Additionally, the facility did not have a system in place to track and trend symptoms of illness among residents who were not on antibiotics. Review of infection control logs revealed that only infections treated with antibiotics were recorded, with no documentation or tracking of viral, fungal, or other illnesses not requiring antibiotic therapy. The infection prevention and control policy referenced surveillance tools for recognizing infections and spotting trends, but did not address the need to track symptoms or illnesses that did not result in antibiotic use. Interviews with the DON confirmed that symptom tracking for potential infections not requiring antibiotics was not maintained in a spreadsheet or log, and infection logs were only completed for identified infections at the end of each month.
Failure to Maintain Odor-Free Environment and Properly Investigate Missing Personal Items
Penalty
Summary
The facility failed to ensure that resident living areas were free from persistent odors, specifically in the rooms of two residents. One resident, with diagnoses including morbid obesity and diabetes, was noted to have a strong, foul odor emanating from his room on multiple occasions. Despite being cognitively intact and generally independent with self-care, this resident often refused staff assistance with personal hygiene, particularly with pericare and cleaning of abdominal folds, which contributed to the ongoing odor. Staff interviews confirmed that the resident's room had a persistent odor, and housekeeping efforts, including deep cleaning and use of odor-blocking products, only temporarily alleviated the issue. The care plan indicated staff were to assist with personal hygiene, but the resident's refusals limited their ability to do so. Another resident, diagnosed with neuromuscular dysfunction of the bladder, spina bifida with hydrocephalus, and morbid obesity, also had a room with a strong urine odor that extended into adjacent areas. This resident, while cognitively intact, required supervision and some assistance with ADLs but often refused staff and housekeeping entry, preferring to manage personal care independently. Staff interviews revealed that the odor had been present for a long time, and the resident's reluctance to allow cleaning or assistance contributed to the problem. The care plan specified assistance with personal hygiene and elimination, but the resident's refusals limited staff intervention, resulting in persistent odors. Additionally, the facility failed to fully investigate and track missing personal items for a resident who reported a missing clothing item for approximately two months. The resident, who was alert and oriented, reported the missing item to housekeeping, but the facility's follow-up was inconsistent. The housekeeping director was initially unaware of the missing item and lacked knowledge of the facility's tracking system and policy for lost items. Although a policy and grievance process existed, it was not consistently followed, and there was no established tracking log in use. The facility's grievance log showed other missing items, some of which were replaced, but the process for investigating and resolving missing items was not systematically implemented.
Failure to Deliver Resident Mail on Saturdays
Penalty
Summary
The facility failed to ensure that residents received their mail on Saturdays, as required, affecting all 37 residents. During a Resident Council meeting, two residents reported that mail was not delivered to them on Saturdays, and this concern was confirmed by other residents. The mail was delivered by the post office to a locked box outside the facility, but it was not distributed to residents until Monday, as the key was secured and the receptionist position responsible for mail delivery was vacant. The business office manager confirmed that mail was only collected and distributed on Mondays, and there was no current policy addressing Saturday mail delivery. Interviews with facility staff, including the interim administrator and corporate nurse, revealed a lack of awareness regarding the requirement for Saturday mail delivery. The facility initially believed that Saturday delivery was at the discretion of the community, but confirmation from the local Post Master established that mail was indeed delivered to the facility on Saturdays. Despite this, the facility did not provide any additional information or a policy regarding Saturday mail delivery, resulting in a failure to provide residents with reasonable access to their mail.
Failure to Individualize and Document Resident Activity Programs
Penalty
Summary
The facility failed to identify and address the personal activity preferences of all residents reviewed for activities, resulting in a lack of individualized activity care planning and coordination. For five residents, care plans either did not reflect their current interests or lacked evidence of implementation of interventions targeting their stated preferences. Documentation was inconsistent or missing, with activity attendance records not found in the electronic medical record and only handwritten records available upon request. In several cases, residents' care plans listed interests such as crafts, cards/games, and reading, but there was no documentation of participation in these activities, nor evidence that staff facilitated or supported these interests. Residents interviewed expressed dissatisfaction with the activity program, noting a lack of variety, insufficient weekend and evening activities, and limited options beyond watching TV or playing Bingo. Some residents specifically requested additional activities such as exercise or newspaper readings, which were not reflected in the activity calendar or care plans. The activity calendars reviewed lacked scheduled weekend activities, with only 'Independent Leisure' noted, and did not include certain activities that residents had expressed interest in, such as crafts or outings. The activities director confirmed that some activities listed on the calendar, such as virtual reality sessions, were no longer being offered despite being advertised, and that documentation of one-to-one visits and activity participation was not consistently entered into the electronic medical record. For one resident, there was no activity plan of care created at all, despite documented interests in painting, music, and outings. Staff interviews revealed that activity calendars were often copied from previous months with little variety, and that some activities were not communicated to residents in advance or included on the calendar. The facility did not have a policy for activity program development and implementation available for review. These findings demonstrate a systemic failure to assess, plan, and document activities in accordance with residents' individual needs and preferences.
Failure to Complete Self-Administration Assessment and Orders for Bedside Medications
Penalty
Summary
The facility failed to ensure that a complete self-administration of medications (SAM) assessment was performed and appropriate orders were obtained for all medications kept at bedside for one resident. The resident, who was alert, oriented, and largely independent in activities of daily living, was observed with three bottles of over-the-counter (OTC) medications at her bedside, including Hair, Skin, and Nail Vitamins, Elderberry Gummies, and Glucosamine/Chondroitin and MSM supplement. While the care plan and medical record documented a SAM assessment for elderberry chews, there was no assessment or provider order for the other OTC medications at bedside. The care plan directed staff to monitor bedside medication usage and assess the resident's capability to self-administer, but this was only documented for the elderberry chews. The resident had a complex medical history, including chronic pain, osteoporosis, and a recent femur fracture, and was receiving multiple prescribed medications for pain management. The DON confirmed that she was unaware of the additional medications at bedside and acknowledged that each medication kept at bedside required a separate SAM assessment and provider order, as per facility policy. The facility's policy required interdisciplinary team determination and documentation for safe self-administration, with periodic reassessment, but this process was not followed for all medications observed at the resident's bedside.
Failure to Address Resident Council Concerns Regarding Activities
Penalty
Summary
The facility failed to address and resolve concerns raised by residents during resident council meetings in a timely manner. Over several months, meeting minutes documented repeated requests and grievances related to Therapeutic Recreation, including requests for more activities, crafts, games, and the reinstatement of previously offered programs such as Bingocize and exercise sessions. Residents also requested daily newspaper readings and more weekend activities. Despite these ongoing concerns, there was no evidence that the facility provided feedback or resolutions to the residents regarding their requests. Additionally, the activity calendars for March and April showed limited offerings, with several days listing only 'Independent Leisure' and minimal craft activities. During a resident council meeting held during the survey, multiple residents confirmed that their grievances and recommendations had not been addressed or communicated back to them. The facility was unable to provide policies for Therapeutic Program Development or for managing and following through on resident council grievances and recommendations. The lack of documented follow-up and absence of relevant policies contributed to the deficiency, affecting all residents who participated in the council meetings over the past two months.
Failure to Follow Up and Resolve Resident Grievances
Penalty
Summary
The facility failed to follow up and resolve grievances for a resident who had filed multiple complaints over a specified period. Documentation showed that while some grievances had resolution forms completed, there was a lack of follow-through, particularly when the resident indicated dissatisfaction with the outcome. For several grievances, there was no documentation of resolution or follow-up, and some issues were not addressed at all, despite being logged. The facility's grievance log and forms revealed gaps in timely investigation and communication of outcomes to the resident, as required by facility policy. Interviews confirmed that the process for handling grievances was not consistently followed, with the corporate licensed social worker acknowledging that grievances had not been addressed in a timely manner and that some had not been addressed at all. Facility policies required prompt investigation and communication of grievance outcomes, but these procedures were not adhered to, resulting in unresolved concerns and incomplete documentation for several grievances filed by the resident.
Failure to Integrate Hospice Plan of Care with Facility Care Plan
Penalty
Summary
The facility failed to ensure that the hospice plan of care was integrated with the facility care plan for a resident receiving hospice services. The resident, who had severe cognitive impairment and was dependent on staff for activities of daily living, was enrolled in hospice with multiple diagnoses including anemia, hypertension, arthritis, neuropathy, and urinary retention. The facility's care plan noted the resident was on hospice but did not specify what hospice services were being provided or include the hospice plan of care or visit schedule for staff reference. The medical record lacked this essential information, and staff interviews confirmed that the hospice care plan could not be located in the designated binder or within the electronic care plan system. Further review revealed that the hospice nurse described a detailed hospice service plan, including nursing and aide visits, as well as monthly therapy and support services, but this information was not reflected in the facility's documentation. The director of nursing and corporate nurse acknowledged that the hospice care plan was not available as required for staff reference. The facility's agreement with the hospice provider specified that the hospice plan of care should be established, maintained, and accessible, including details on services, frequency, and measurable outcomes, but this was not implemented in practice for the resident in question.
Failure to Ensure Timely and Accurate Dialysis Medication Administration and Communication
Penalty
Summary
The facility failed to consistently communicate with the dialysis department and follow through on specific medication administration instructions for a resident requiring dialysis. The resident, who was cognitively intact and had diagnoses including end stage renal disease, congestive heart failure, diabetes, and recent post-surgical treatment, was admitted following a hospitalization that included complications related to dialysis such as hypotension and hypoglycemia. The care plan identified the need for a diabetic diet and highlighted the risk for dialysis complications, directing staff to send a communication folder with the resident for each dialysis session. Despite these directives, there were lapses in the communication process. The Dialysis Center Communication Record, which was supposed to accompany the resident to and from dialysis, was missing for some sessions, and the facility was unable to account for all records since admission. Additionally, the communication record from the dialysis center specifically instructed that the resident's Midodrine medication be administered one hour before dialysis. However, the medication administration record (MAR) only indicated "AM" dosing without specifying the required timing, leading to confusion among staff. Interviews revealed that staff sometimes gave the medication with breakfast or at the time of departure, rather than the specified one hour prior, and the order was not clearly written to reflect the dialysis center's instructions. Further, the facility lacked a clear policy beyond the undated communication record document, and the process for reviewing and implementing new orders from the dialysis center was not consistently followed. The director of nursing acknowledged that the medication order should have been more precise and that the review process for dialysis communication records was not fully implemented. The care coordination agreement with the dialysis provider required the facility to ensure residents received necessary medications before dialysis, but this was not reliably achieved for this resident.
Failure to Administer Ordered Pneumococcal Vaccine
Penalty
Summary
The facility failed to ensure that a resident was offered and/or provided the recommended pneumococcal vaccine series as outlined by the Centers for Disease Control (CDC). Specifically, the resident's immunization record showed that she had previously received PPSV23 and PCV13 vaccines, and there was a physician order for the administration of PCV20. However, a review of the medication administration record (MAR) revealed no evidence that the PCV20 vaccine was administered to the resident, despite the vaccine being ordered and delivered to the facility. Further document review and staff interview confirmed that the consent for immunization had been obtained and the vaccine was available, but the administration had not occurred. The facility's own policy required that consent be obtained and the pneumococcal vaccination be administered per physician order, with documentation in the resident's medical record. This process was not completed for the resident in question, resulting in a failure to follow established immunization protocols.
Failure to Monitor Wanderguard, Enforce Smoking Policy, and Supervise Dining Room
Penalty
Summary
The facility failed to implement appropriate monitoring and supervision in several areas, resulting in deficiencies related to accident hazards and resident safety. For one resident with moderate cognitive impairment and a history of elopement, the facility did not provide clear or consistent procedures for monitoring the function and placement of a Wanderguard device. Staff were unclear on how to check the device's function, and documentation lacked specific instructions. The care plan and facility policies did not provide adequate guidance, and the manufacturer's manual was not available. There was also a lapse in interdisciplinary team review documentation for residents at risk of elopement. Another deficiency involved a resident who was permitted to store and use e-cigarettes independently. Despite a care plan and assessment indicating the resident was aware of the rules, the resident was observed using an e-cigarette in her room on multiple occasions, contrary to facility policy requiring use only in designated areas. The resident kept e-cigarettes on her bedside table and admitted to using them indoors due to difficulty moving, indicating a lack of effective monitoring and enforcement of the smoking policy. Additionally, the facility failed to provide adequate supervision in the dining room for a resident with a history of dysphagia and pocketing food, who required a modified diet. The resident was repeatedly observed eating alone without staff present, including while consuming foods not properly prepared according to dietary orders. Staff interviews confirmed that supervision was expected for residents with altered diets due to choking risk, and the facility's policy required dining room supervision during meals, which was not consistently provided.
Failure to Provide Behavioral Health and Social Services for Residents with Odor Issues
Penalty
Summary
The facility failed to provide necessary behavioral health care and social services for two residents whose room odors were significant enough to permeate surrounding halls, affecting other residents, visitors, and staff. For one resident with diagnoses including morbid obesity, alveolar hypoventilation, and type 2 diabetes, there were repeated observations of strong, foul odors emanating from the room. The resident was cognitively intact and required varying levels of assistance with self-care and toileting. Documentation showed a history of refusing care and treatments, and the care plan included psychosocial monitoring and interventions. However, social services progress notes lacked evidence that the social worker was aware of or addressed the odor issue, and there was no documentation of interventions related to this matter until after it was brought to their attention during the survey. Another resident, diagnosed with neuromuscular bladder dysfunction, lumbar spina bifida with hydrocephalus, and morbid obesity, was also found to have a strong urine odor in and around the room. This resident was cognitively intact and required supervision and assistance with ADLs. The resident admitted to soiling the bed and only requesting assistance when necessary, and preferred minimal disturbance. The care plan noted risks related to mood and behavior, with interventions for monitoring and emotional support, but social services documentation did not show awareness of or action on the odor issue. The quarterly care conference also failed to mention the odor, focusing only on routine bathing. Interviews with the corporate and covering licensed social workers revealed that the facility did not have a dedicated social worker or designee at the time, and the two were sharing responsibilities. Both residents had declined certain behavioral health referrals, but there was no evidence of further social services interventions or documentation addressing the ongoing odor issues. Requested policies for social services assessment and intervention were not provided.
Failure to Post Required Survey and Complaint Investigation Results
Penalty
Summary
The facility failed to ensure that both recertification survey results and documentation of complaint investigations were readily available for review by residents, families, visitors, and staff. During the recertification survey, it was observed that the survey binder near the main entrance contained only the recertification surveys from the past three years, but lacked the required CMS 2567 forms for complaint investigations and revisits conducted during those years. Specific complaint investigations and revisits were missing from the binder, including those completed on several dates, and there was no documentation of certain desk audits or revisits. Interviews with the interim administrator and corporate nurse confirmed that the facility was aware of the requirement to post the last three years of all annual survey and complaint investigation results, including the CMS 2567 forms. However, upon review, it was verified that this information was not present in the binder as required. Additionally, the facility did not have a policy in place for the posting of survey results.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented during wound care for a resident with multiple diagnoses, including cancer, anemia, hypertension, renal insufficiency, dementia, multiple sclerosis, and depression. The resident had a physician order and care plan in place requiring EBP, specifically the use of gloves and a gown during high contact care activities such as wound care. During an observed wound care procedure, the DON performed hand hygiene and donned gloves but did not wear a gown as required by the EBP order and care plan. The DON acknowledged this omission immediately after the procedure and confirmed the expectation to follow EBP guidelines. Additionally, the facility was unable to provide a policy for EBP when requested.
Failure to Maintain Cleanliness in Dining and Resident Areas
Penalty
Summary
The facility failed to maintain cleanliness and sanitary conditions in both a resident's room and the dining room, affecting the living environment of the residents. During an observation, brownish stains were found on the floor under a table in the dining room, along with soiled tissues and uncleaned plates with leftover food. A resident expressed discomfort with the cleanliness of the area. The housekeeping supervisor was observed cleaning the stains without wearing gloves and subsequently did not wash hands before interacting with a resident, which is against the facility's training protocols. Additionally, a white powder-like substance was observed scattered on the floor in a resident's room, which was identified by a housekeeper as coming from the resident's skin. The housekeeper admitted to being too busy to clean it up earlier. The Director of Nursing stated that the expectation was for the dining room and resident rooms to be cleaned before and after meals. The facility's policy indicated that housekeeping is assigned to clean these areas daily, but this was not adhered to, leading to unsanitary conditions.
Infection Control Deficiencies in PPE and EBP Usage
Penalty
Summary
The facility failed to ensure proper use of personal protective equipment (PPE) and enhanced barrier precautions (EBP) for residents with indwelling Foley catheters, leading to infection control deficiencies. Resident 1, diagnosed with urinary tract infection and sepsis, had a Foley catheter but lacked EBP signage on her door. Staff did not wear gowns and gloves during high-contact care activities, such as transferring the resident, which was acknowledged by RN-A. Resident 2, with a bladder disorder and neuromuscular dysfunction, also had an indwelling Foley catheter and EBP signage on the door. However, staff were observed not wearing gowns and gloves during transfers and other high-contact activities. Nursing Assistant A admitted to not using PPE and handling soiled linens without gloves, despite being aware of the EBP requirements. Resident 4, diagnosed with acute kidney failure and infection due to an indwelling urethral catheter, did not have EBP signage on the door. Staff failed to wear PPE during transfers and high-contact care, and one nursing assistant touched the Foley catheter without gloves, then proceeded to handle clean items and touch surfaces without washing hands. The Director of Nursing, also the infection preventionist, was unaware of the need for EBP for Resident 1 and acknowledged the lack of PPE use, indicating a need for reeducation on infection control practices.
Medication Communication and E-Kit Utilization Deficiency
Penalty
Summary
The facility failed to ensure that a resident's ordered medications were fully communicated to the pharmacy, resulting in a delay in medication delivery. The resident, who was admitted with diagnoses including acute and chronic congestive heart failure, type 2 diabetes, asthma, and morbid obesity, did not receive several physician-ordered medications immediately following admission. The facility's process involved checking and clarifying orders before entering them into the electronic medication record, but some orders were not communicated effectively to the pharmacy, leading to a delay in medication delivery. The facility also failed to ensure that all licensed staff, including pool agency staff, understood and utilized the emergency medication kit (E-Kit) effectively. The Director of Nursing (DON) and Resident Care Manager (RCM) were aware of the missing medications on the day following the resident's admission and attempted to rectify the situation by contacting the pharmacy. However, the pool agency staff did not have access to the PIXUS medication dispensing system or the refrigerated E-Kit, which contained some of the missing medications, including insulin. This oversight resulted in the resident missing doses of insulin, which were critical for managing their diabetes. The pharmacy confirmed that they had only received part of the medication orders and could have delivered the medications within four hours if a STAT order had been placed. The facility's policy for dealing with missing medications was not effectively communicated to the pool staff, leading to the oversight. Despite the missed doses, the pharmacist and physician assistant did not consider the omission a significant error due to the resident's historically high blood sugar levels and the subsequent clarification and adjustment of insulin orders by the physician assistant.
Failure to Notify Resident's Representative of Condition Change
Penalty
Summary
The facility failed to notify a resident's representative following a change in the resident's condition, which resulted in hospitalization. The resident, who had severe cognitive impairment and multiple medical diagnoses including diabetes, morbid obesity, anemia, edema, heart failure, altered mental status, and end-stage renal disease, experienced a decline in condition. The resident was dependent on staff for daily activities and had multiple pressure ulcers, including two stage 2, three stage 3, and one unstageable ulcer. Despite physician orders for pain management and wound infection treatment, there was no documentation of notification to the resident's responsible party about changes in the resident's condition or treatment on specific dates. Interviews with the resident's family member and facility staff revealed a lack of communication regarding the resident's condition and treatment changes. The family member, who was the primary contact, was unaware of the deterioration of the resident's wounds and the new orders for antibiotics and pain medications until contacted for the interview. Facility staff, including LPNs and RNs, admitted to not notifying the family about medication changes, citing various reasons such as chronic medical issues and unclear policy directives. The facility's policy required sharing changes in a resident's condition or treatment with the resident and/or their representative, but this was not adhered to in this case.
Inadequate Wound Monitoring and Documentation
Penalty
Summary
The facility failed to effectively monitor and communicate the wound status of a resident with severe cognitive impairment and multiple medical conditions, including diabetes, morbid obesity, and end-stage renal disease. The resident had several pressure ulcers, including stage 2, stage 3, and unstageable ulcers. Despite having a care plan that directed staff to monitor and document skin conditions and inform medical professionals of any changes, there was a lack of consistent documentation and communication regarding the resident's wound status. The resident's condition worsened, leading to hospitalization for sepsis due to an infected perianal wound. Interviews with facility staff revealed that while nurses performed wound treatments and visualized the wounds, there was no consistent process for documenting the condition of the wounds unless there were noticeable changes. This lack of documentation made it difficult to track the progression of the wounds and communicate effectively with the wound care agency. The facility's policy required evaluation and documentation of wounds during dressing changes, but this was not consistently followed, contributing to the deficiency in care.
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.
