Traverse Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Wheaton, Minnesota.
- Location
- 303 Seventh Street South, Wheaton, Minnesota 56296
- CMS Provider Number
- 245638
- Inspections on file
- 24
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Traverse Care Center during CMS and state inspections, most recent first.
A resident with a neurogenic bladder and indwelling Foley catheter was discharged from the hospital with orders for a urology follow-up, but the LTC facility failed to schedule or complete this appointment. The resident experienced multiple catheter-related complications, including bleeding and a UTI, leading to an ER visit and further hospitalization. Staff interviews confirmed the urology follow-up was not arranged, and family members were not informed, resulting in a deficiency related to failure to follow discharge orders.
A long-term care facility failed to ensure proper PPE use and infection control, leading to potential infection risks. Staff did not consistently wear required PPE for residents under enhanced barrier precautions and COVID-19 precautions. Observations showed improper handling of catheter care and inadequate hand hygiene. The facility's infection control program lacked comprehensive surveillance and analysis of resident infections.
A resident with moderate cognitive impairment and multiple diagnoses reported feeling scared of a nursing assistant due to alleged abusive behavior. Despite the resident informing the assistant director of nursing, the facility failed to report the allegation to the administrator and the State Agency within the required two-hour timeframe. Interviews revealed that the director of nursing and assistant director of nursing were aware of the incidents but did not classify them as abuse requiring immediate reporting, resulting in a deficiency finding.
A resident with severe cognitive impairment and multiple diagnoses received medications that were crushed against physician orders, potentially altering their efficacy. The facility's staff failed to notify the physician or pharmacist about the resident's medication administration issues, leading to a deficiency in adhering to professional standards of practice.
A resident with Alzheimer's and dementia, at high risk for pressure ulcers, was not repositioned for over two hours, contrary to their care plan. Despite having an unhealed pressure ulcer on the coccyx, the resident remained in the same position for an extended period, as staff attended to other residents. The facility's policy required repositioning every two hours to prevent skin breakdown, which was not adhered to, as confirmed by staff interviews.
Two residents at high risk for falls did not receive appropriate interventions as outlined in their care plans. One resident's wheelchair cushion slipped due to the absence of a Dycem mat, and another resident did not receive 30-minute safety checks, leading to multiple self-transfers to the floor. Staff were unaware of these interventions, contributing to the deficiency.
The facility failed to date insulin pens for three residents and did not discard a Tubersol solution after 30 days as recommended. Insulin pens were found undated, and the Tubersol solution exceeded the manufacturer's usage timeframe. Interviews with staff confirmed the expectation for proper dating and discarding of these medications, which was not followed, leading to this deficiency.
A facility failed to prevent drug diversion involving a Fentanyl patch for a resident with osteoarthritis. The patch was found to be tampered with, and a TMA was suspected of reapplying the old patch and forging nurse signatures. The facility's policy requiring two staff to verify and destroy controlled substances was not followed, and the administration did not adequately investigate or address the issue.
A facility failed to report a suspected drug diversion involving a resident's Fentanyl patch. Discrepancies were noted by an LPN, including mismatched dates and forged signatures. Despite internal findings and the TMA's admission of reapplying an old patch, the incident was not reported to the State Agency as required. The facility's policy lacked specific guidance on reporting suspected diversions, leading to non-compliance with state requirements.
A facility failed to prevent further drug diversion after a resident's Fentanyl patch was found to be suspicious. The patch lacked expected markings, and required verification protocols were not followed, with evidence of forged signatures. Despite reporting the incident, no staff education or retraining on controlled substance procedures occurred, and the Director of Nursing did not investigate further upon returning to the facility.
Failure to Schedule and Complete Urology Follow-Up After Hospital Discharge
Penalty
Summary
The facility failed to ensure that a hospital physician's discharge order for a follow-up appointment with urology was scheduled and completed for a resident who was readmitted from the hospital. Upon re-entry, the resident had a history of severely impaired cognition, impaired mobility, neurogenic bladder, renal failure, diabetes mellitus, and was dependent on an indwelling urinary catheter. Hospital discharge instructions specifically directed that the Foley catheter was to remain in place until a follow-up with urology, and that the catheter should be changed every four weeks. However, review of the resident's medical records did not identify that a urology appointment was scheduled or completed as ordered. Progress notes and interviews revealed ongoing complications with the resident's urinary catheter, including episodes of no urine output, unsuccessful irrigation, bleeding at the catheter insertion site, and eventual trauma during catheter removal that resulted in an emergency room visit and hospital admission for catheter complications and UTI. The hospital discharge summary after this event noted a fissure caused by the catheter and provided specific instructions for catheter care, including a referral to urology for possible supra-pubic catheter placement. Despite these ongoing issues, staff interviews confirmed that the resident had not been scheduled for a urology appointment after the initial hospital discharge, and the last known urology visit was several years prior. Multiple staff members, including the assistant director of nursing and the director of nursing, acknowledged that the follow-up with urology was not completed and that the facility did not ensure the appointment was scheduled as ordered. Family members also expressed concern and were unaware of any urology follow-up. The deficiency was attributed to a lack of follow-through on discharge orders and inadequate documentation and communication regarding specialist appointments.
Inadequate PPE Use and Infection Control in LTC Facility
Penalty
Summary
The facility failed to ensure appropriate personal protective equipment (PPE) was worn to prevent the spread of infection for residents under enhanced barrier precautions (EBP) and COVID-19 transmission-based precautions (TBP). Observations revealed that a nursing assistant did not maintain proper PPE protocol while providing catheter care to a resident with a Foley catheter. The catheter bag was observed lying on the floor, and the nursing assistant removed her gown prematurely during the care process, acknowledging the mistake afterward. The clinical manager confirmed that catheter bags should not be on the floor and that PPE should be worn during catheter care. Additionally, the facility did not adhere to proper PPE protocols for residents with COVID-19. Observations showed that staff, including the infection preventionist and nursing assistants, did not consistently wear the required PPE, such as N95 masks, gowns, gloves, and eye protection, when entering rooms of COVID-19 positive residents. There were instances where staff wore surgical masks over N95 masks, which compromised the seal and effectiveness of the N95 masks. Staff also failed to perform hand hygiene between resident interactions, increasing the risk of cross-contamination. The facility's infection control program was inadequate, lacking comprehensive surveillance and analysis of resident infections. The infection control logs did not include assessments of residents on EBP or those with active infections, such as urinary tract infections or wound infections. The infection preventionist admitted that the facility's tracking system was a work in progress and that not all infections were being monitored. The director of nursing confirmed the expectation for staff to follow CDC guidelines for PPE use and infection prevention, but the facility was not conducting audits to ensure compliance.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to report an allegation of staff-to-resident abuse within the required timeframe of two hours to the administrator and the State Agency (SA). The incident involved a resident with moderate cognitive impairment and multiple diagnoses, including heart failure, diabetes mellitus, and anxiety disorder, who required extensive assistance with activities of daily living. The resident reported feeling scared of a nursing assistant (NA-C) due to two incidents where NA-C allegedly raised his fist and voice at the resident. Despite the resident informing the assistant director of nursing (ADON) about these incidents, the facility did not document the report to the SA, and the ADON did not consider it necessary to report the allegation to the administrator or the SA. Interviews with staff revealed that the ADON and the director of nursing (DON) were aware of the resident's fear of NA-C and the verbal incident but did not classify it as abuse requiring immediate reporting. The facility's policy on abuse, neglect, and exploitation mandates reporting all alleged violations to the administrator and the SA within two hours if the events involve abuse. However, the DON and ADON did not adhere to this policy, as they believed the situation was resolved by ensuring NA-C did not work with the resident alone. The administrator was unaware of the allegation, and the facility's failure to report the incident as per policy resulted in a deficiency finding.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure medications were administered in accordance with physician orders and standards of practice for a resident, identified as R210, who was observed to receive medication. R210 had severe cognitive impairment and multiple diagnoses, including type two diabetes, chronic kidney disease stage four, bipolar disorder, anxiety, borderline personality disorder, depression, congestive heart failure, hypertension, and anemia. The resident required extensive assistance with daily activities and was at risk for adverse reactions to medications. The care plan specified that medications should be administered as ordered and monitored for side effects and effectiveness. During an observation, a registered nurse (RN-C) was seen preparing medications for R210 outside the resident's room. Another nurse (RN-B) advised RN-C to crush the medications as R210 was not feeling well. RN-C proceeded to crush the medications, mixed them with applesauce, and handed them to RN-B, who then administered them to R210. It was later confirmed that the medications were labeled 'do not crush' and were intended to be given whole, as indicated in R210's electronic health record. The physician had not been notified that R210 was receiving medications crushed or chewing them, which could affect the medication's absorption and efficacy. Interviews with RN-C, RN-B, the consultant pharmacist, and the director of nursing (DON) confirmed that the medications should not have been crushed, as this could alter their delivery and effectiveness. The facility's policy on medication administration required that medications be given as ordered by the physician and in accordance with professional standards. The failure to adhere to these standards resulted in the resident potentially not receiving the correct dose of medication, as the medications were altered by being crushed.
Failure to Reposition Resident Leads to Pressure Ulcer Risk
Penalty
Summary
The facility failed to provide timely assistance with repositioning for a resident, identified as R206, who had a history of pressure ulcers and was at high risk for further development. R206's quarterly Minimum Data Set (MDS) indicated diagnoses of Alzheimer's disease, dementia, and anxiety, requiring assistance for bed mobility and transfers. The resident had an unhealed pressure ulcer on the coccyx and was assessed with a Braden scale score of 14, indicating high risk for pressure ulcers. The care plan required skin preparation twice daily and as needed, along with the use of an air mattress overlay. Observations on a specific day revealed that R206 was not repositioned for over two hours and thirty-five minutes, despite being in isolation precautions and having a care plan that required repositioning every two hours. The resident was observed in the same position multiple times between 7:25 a.m. and 10:40 a.m. A registered nurse (RN-B) confirmed the presence of a pressure ulcer on the coccyx, measuring 2 x 1.4 cm, with serosanguinous drainage. The RN acknowledged that the resident should have been repositioned every two hours, as per the care plan, but was not due to attending to other residents. Interviews with nursing assistants and the director of nursing (DON) confirmed the failure to reposition R206 as required. Nursing assistants admitted to not having been in the resident's room for repositioning due to attending to other residents' call lights. The DON was unaware of the lapse in repositioning and reiterated the expectation for staff to reposition residents every two hours to prevent skin breakdown. The facility's policy on pressure injury prevention emphasized the importance of redistributing pressure to prevent and manage pressure injuries.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement effective interventions to prevent falls for two residents, R53 and R206, who were at high risk for falls. R53, who was cognitively intact and had a history of falls with major injury, was found on the floor after her wheelchair cushion slipped out. Despite the care plan specifying the use of a Dycem non-slip mat under the cushion to prevent such incidents, it was not in place during an observation. Staff interviews revealed a lack of awareness and implementation of this intervention, contributing to the deficiency. R206, diagnosed with Alzheimer's disease, dementia, and anxiety, had a history of self-transferring to the floor. The care plan included 30-minute safety checks as a fall prevention measure. However, documentation showed numerous missed checks, and continuous observation confirmed that staff did not perform these checks over a two-hour and 35-minute period. Interviews with staff and the DON revealed a lack of awareness and adherence to the care plan, leading to the deficiency. The facility's Fall Prevention Program Policy required individualized care and monitoring of interventions for effectiveness, which was not adhered to in these cases. The failure to implement and monitor fall prevention interventions as outlined in the care plans for R53 and R206 resulted in deficiencies in ensuring a safe environment free from accident hazards.
Failure to Date Insulin Pens and Discard Tubersol Solution
Penalty
Summary
The facility failed to ensure that insulin pens were accurately dated when opened for three residents who received insulin injections. During an observation, it was found that insulin pens for these residents were not dated when opened, which is against the manufacturer's specifications that require insulin pens to be discarded after a certain period once opened. The residents involved had various medical conditions, including diabetes mellitus, hypertension, and other health issues, and required assistance with activities of daily living. Additionally, the facility did not discard a Tubersol solution after 30 days as recommended by the manufacturer. The Tubersol solution, used for tuberculosis testing, was found in the medication refrigerator with an open date that exceeded the 30-day usage recommendation. The LPN verified the undated insulin pens and the Tubersol solution, acknowledging that they should have been dated and discarded according to the manufacturer's guidelines. Interviews with the pharmacy consultant and the director of nursing revealed that there was an expectation for insulin pens to be dated upon opening to ensure they were used or discarded within the recommended timeframe. The pharmacy consultant initially believed the Tubersol solution was acceptable to use until the expiration date but later confirmed it should have been discarded after 30 days. The facility's policies on insulin pen usage and medication storage were not adhered to, leading to this deficiency.
Failure to Prevent Drug Diversion of Fentanyl Patch
Penalty
Summary
The facility failed to adhere to its policy and procedure to prevent drug diversion, specifically concerning the administration and management of a Fentanyl Transdermal Patch for a resident. The resident, who was receiving the patch every 72 hours for osteoarthritis, was found to have a patch that did not match the expected appearance, raising suspicions of drug diversion. The facility's policy required two nurses or a licensed nurse and a trained medical assistant (TMA) to verify the administration and destruction of controlled substances, but this protocol was not followed. During the investigation, it was discovered that a TMA was suspected of not removing the old Fentanyl patch and instead reapplying it, while also forging the signatures of nurses in the narcotic book. The TMA admitted to reapplying the old patch but claimed it was unintentional. The incident was reported to the director of nursing (DON), but there was a lack of awareness and follow-up from the administration, as the DON was out of the office and did not conduct further investigation or implement preventive measures upon returning. The report highlights multiple failures in the facility's controlled substance management, including improper verification and destruction of the Fentanyl patch, lack of immediate action from the administration, and inadequate communication among staff. The investigation revealed that the facility's policy was not followed, and there was no conclusive evidence to prove drug diversion, although the circumstances strongly suggested it. The lack of adherence to protocol and insufficient administrative response contributed to the deficiency.
Failure to Report Suspected Drug Diversion
Penalty
Summary
The facility failed to report a suspected drug diversion incident involving a resident who was prescribed a Fentanyl Transdermal Patch for osteoarthritis. The issue was identified when a Licensed Practical Nurse (LPN) noticed discrepancies with the patch, including mismatched dates and signatures that did not match her own. The facility's policy required two nurses to verify the removal and application of Fentanyl patches, but the process was not followed, leading to suspicions of drug diversion by a Trained Medical Assistant (TMA). The internal investigation revealed that the TMA was suspected of reapplying an old patch and forging signatures, which was reported to the Director of Nursing (DON). Despite these findings, the facility did not report the incident to the State Agency (SA) as required. The Clinical Services Manager from a contracted agency confirmed that the TMA admitted to reapplying the old patch but claimed it was unintentional. The TMA's contract was terminated, but the facility's administrators were not fully aware of the incident or the need to report it to the SA. The facility's Controlled Substance Administration and Accountability policy required immediate reporting of unresolved discrepancies to various authorities, including the SA. However, the policy lacked specific guidance on when to report suspected drug diversion to the SA. The administrators assumed that since the investigation did not conclusively prove diversion, reporting was unnecessary. This oversight led to a failure in compliance with state reporting requirements, as the facility did not report the suspected drug diversion incident to the SA.
Failure to Prevent Drug Diversion in LTC Facility
Penalty
Summary
The facility failed to implement appropriate interventions to prevent further drug diversion after an incident involving a resident's Fentanyl patch. The resident, who was receiving a Fentanyl Transdermal Patch every 72 hours for osteoarthritis, was found with a patch that did not appear to be authentic. The patch lacked the expected green writing indicating it was Fentanyl, and there were discrepancies in the signatures required for verification. The facility's procedure required two nurses or a nurse and a trained medical assistant to verify the application and removal of the patch, but this protocol was not followed. Additionally, there was evidence of forged signatures in the medication destruction log, suggesting a breach in the controlled substance handling process. Despite the incident being reported to the Director of Nursing (DON) and other administrators, there was no evidence of staff education or retraining on the controlled substance procedure following the event. The DON, who was out of the office at the time, did not conduct further investigation or implement measures to prevent recurrence upon returning. The internal investigation by a registered nurse confirmed that the facility's policy was not adhered to, but there was no conclusive evidence of tampering with the patch. The lack of follow-up actions and staff education contributed to the deficiency in handling the suspected drug diversion.
Latest citations in Minnesota
A resident with dry eye syndrome and degenerative eye disease had orders for cyclosporine ophthalmic emulsion and Refresh Tears, both scheduled at the same time. Medication records and direct observation showed a TMA instilled cyclosporine drops in both eyes and immediately followed with Refresh Tears in both eyes without waiting between medications. This practice conflicted with referenced professional guidance recommending several minutes between multiple eye drops and with the medical provider’s recommendation to wait fifteen minutes between the two ophthalmic medications. No facility policy on ophthalmic medication administration was provided when requested.
A resident with severe cognitive impairment, impaired mobility, and high fall risk was care planned to have wheelchair footrests in place at all times, with staff ensuring proper positioning and monitoring for leaning during transport. A NA transported the resident in a manual wheelchair from the shower without the footrests, and while going through the doorway the wheelchair struck the door frame, causing the resident, who was leaning forward, to fall out. The resident sustained a T12 fracture, head injury with concussion, abrasions and contusions, and multiple right-hand lacerations requiring sutures, and the DON confirmed the care plan had not been followed.
A high‑risk, immobile resident with MS and prior heel DTI developed an avoidable unstageable coccygeal pressure ulcer after staff failed to consistently assess and document skin status, did not transfer or timely provide ordered pressure‑relieving mattresses, and did not reliably perform q2h repositioning. The resident was repeatedly left on a bedpan for prolonged periods despite early reports of this issue, and the toileting care plan was not revised to a bedside commode until after the coccygeal wound had significantly worsened. Wound assessments lacked complete measurements and staging, changes in wound size and color were not promptly recognized as deterioration or reported to providers, and recommended interventions from a wound NP (including an air mattress and offloading) were not promptly implemented. As a result, the coccygeal ulcer rapidly progressed to a large, necrotic, malodorous wound requiring hospital transfer and surgical debridement.
A resident with spastic hemiplegia, muscle weakness, and moderate cognitive impairment was observed using bilateral bed grab bars for bed mobility and transfers, but the care plan did not address grab bar or side rail use. Review of the EMR showed no completed bed mobility device or side rail assessment to determine the necessity or safety of the grab bars, and no documentation that risks and benefits were discussed or that informed consent was obtained. An LPN and the ADON stated that a bed mobility device assessment is required before grab bars are installed and confirmed that no such assessment existed for this resident.
A resident with bilateral heel pressure ulcers and multiple comorbidities received wound care during which an RN removed dressings from both heels, cleansed both wounds, and wiped each heel without changing gloves or performing hand hygiene between wounds or after disposing of soiled dressings. This practice conflicted with the facility’s written wound care procedure, which requires glove removal and hand hygiene after dressing removal and after wound cleansing. In interviews, the RN, NP, and DON/IP acknowledged that hand hygiene and glove changes are expected between dirty and clean tasks and between separate wounds to prevent infection.
A resident with MS, neurogenic bladder, mobility limitations, and existing pressure injuries was identified as dependent for toileting hygiene and at risk for pressure ulcers, yet the care plan lacked an individualized toileting/incontinence plan and a defined repositioning schedule. Despite a new coccyx pressure ulcer and documentation that interventions such as increased repositioning and incontinent care were needed, the care plan was not revised for a period of time to reflect these changes. During this time, the resident sometimes fell asleep on a bedpan and remained on it until staff removed it, and staff were not initially informed that the bedpan should no longer be used. The DON later acknowledged that the care plan revisions for turning, repositioning, and toileting were delayed until after the resident’s coccyx ulcer had significantly worsened.
A resident with diabetes, Crohn’s disease, bowel incontinence, and a history of MASD on the right gluteus developed an open, painful lesion on the right gluteal area that was documented over time without complete wound characteristics, clear etiology, or timely provider notification. Wound care orders were written for a stage 3 pressure ulcer on the left buttocks, while staff reported the wound was only on the right side and applied the left‑sided orders to the right gluteal wound in the absence of specific right‑side treatment orders. The DON acknowledged discomfort with staging the wound, lack of early physician notification, and confusion over wound classification, despite a facility policy requiring comprehensive wound assessment, consistent measurement, and provider notification when treatment orders are absent.
A resident with diabetes, chronic leg ulcer, kidney transplant, and a documented gluteal wound was care-planned for Enhanced Barrier Precautions (EBP), with posted instructions requiring gown and gloves for high-contact care such as transfers and wound care. During a telehealth wound assessment, the DON donned a gown and initially performed hand hygiene but then applied gloves without hand hygiene, removed a soiled dressing from the resident’s gluteal area, discarded it, removed gloves, and applied new gloves again without performing hand hygiene between glove changes. On another occasion, during use of a sit-to-stand lift, an NA wore gown and gloves, but the DON handled the lift harness, the resident’s clothing, and assisted with the transfer and repositioning while wearing a gown but no gloves, despite EBP requirements for transfers. The DON stated EBP was only needed for catheter or wound care and not for transfers, contradicting the posted EBP instructions and facility policy.
A resident with severe dementia, psychiatric disorders, and high dependence for ADLs was verbally abused during evening care when a NA, frustrated with the resident’s crying and resistance, loudly ridiculed her as acting like a two-year-old, threatened to hit her back if struck, told her she would be sent to a locked unit, and questioned who would want to care for her when she cried like a baby. Multiple staff witnessed the loud, stern, and intimidating tone and reported it to an LPN, who recognized it as verbal abuse but did not immediately remove the NA from duty or promptly report the allegation per policy, allowing the NA to continue working on the unit. Following this incident, the resident demonstrated increased crying, combativeness, resistance to care, wandering, self-isolation, and refusal of food, fluids, and medications above baseline, with documentation of significant emotional distress and subsequent ED evaluation for aggressive behaviors and poor intake.
A resident with dementia, bilateral above‑knee amputations, vascular disease, and severe protein‑calorie malnutrition developed a wound on an amputation stump that had a dressing dated several days before any documentation or treatment orders appeared in the record. Although bath audits and nursing notes initially reported no skin issues, a later assessment described a full‑thickness stage 4 ulcer/diabetic ulcer on the stump with exposed bone, erythema/edema, slough, and moderate serosanguineous drainage. Nursing staff interviews showed no one could identify who first discovered the wound or applied the initial dressing, and there was no evidence that the wound was assessed, the provider notified, or standing orders implemented when it was first present, despite facility expectations that new wounds be promptly evaluated and reported.
Failure to Follow Professional Standards for Ophthalmic Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice for administering ophthalmic medications to a resident with dry eye syndrome and degenerative eye disease. The resident was cognitively intact, required assistance with ADLs, and had physician orders for cyclosporine ophthalmic emulsion 0.05% one drop in both eyes twice daily and Refresh Tears ophthalmic solution one drop in both eyes four times daily for dry eyes. The administration summary showed that both eye medications were scheduled for the same time and were documented as being given at the same time on multiple dates. During a medication pass observation, a trained medication aide administered the ordered oral medications, then applied gloves and instilled one drop of cyclosporine in each eye, immediately followed by one drop of Refresh Tears in each eye, without any waiting period between the two medications. The surveyors referenced guidance from the American Academy of Allergy, Asthma, and Immunology stating that when more than one eye drop is ordered, three to four minutes should be allowed between drops in the same eye, and five to fifteen minutes should be allowed between different eye medications to prevent dilution. Interviews with the DON, pharmacy consultant, and medical provider confirmed that best practice and the provider’s recommendation were to wait between administration of cyclosporine and Refresh Tears, with the medical provider specifying a fifteen-minute interval. The facility did not provide a policy on ophthalmic medications when requested. The observed practice and documented administration times demonstrated that staff did not follow these professional standards or the medical provider’s recommended interval between the two eye medications.
Failure to Follow Wheelchair Transport Care Plan Leads to Fall With Injuries
Penalty
Summary
The deficiency involves the facility’s failure to implement care-planned fall prevention interventions for a resident at high risk for falls, resulting in a fall with injury. The resident had diagnoses including aphasia, dysphagia, muscle weakness, traumatic brain injury, and impaired mobility, with severe cognitive impairment documented on the MDS and dependence on staff for transfers and wheelchair transport. A care plan addressing wheelchair transport safety and positioning directed staff to ensure the resident was fully positioned and supported in the wheelchair prior to transport, verify footrests were in place prior to transport, and monitor for leaning, sliding, or unsafe positioning. An additional care-planned approach required wheelchair pedals to be on at all times. On the date of the incident, a nursing assistant transported the resident in a manual wheelchair from the shower room to the resident’s room without the foot pedals in place, contrary to the care plan. While being wheeled through the doorway, the wheelchair struck the door frame, causing the chair to stop and the resident, who had begun leaning forward, to fall out of the wheelchair onto the floor. Progress notes and ED documentation identified that the resident sustained a T12 vertebral fracture, a head injury with concussion, an abrasion and contusion to the head, a bruise to the left knee, and multiple lacerations to the right hand requiring sutures. The nursing assistant later acknowledged awareness that the foot pedals should have been on but did not apply them because the transport was only from the shower to the room. The DON confirmed that the resident’s care plan had not been followed when the fall occurred.
Failure to Implement and Update Pressure Ulcer Prevention and Treatment Led to Avoidable Unstageable Coccygeal Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, monitor, and implement individualized pressure ulcer prevention and treatment interventions for multiple high‑risk residents, resulting in an avoidable, unstageable coccygeal pressure ulcer for one resident that required surgical debridement and hospitalization. The resident had primary progressive multiple sclerosis, hereditary spastic paraplegia, obesity, and pre‑existing pressure‑related deep tissue injury to the left heel, and was identified as high risk for pressure ulcers on the Braden Scale due to constant moisture, chairfast status, very limited mobility, inadequate nutrition, and friction/shear risk. Hospital records on readmission documented irritant contact dermatitis of the bilateral gluteal cleft with specific cleansing and barrier cream orders, and facility documentation showed the resident could not reposition in bed or chair and required assist of two and a full‑body mechanical lift for transfers. Despite this, the admission/readmission skin assessment and weekly skin checks lacked measurements and detailed wound characteristics for the heel ulcer and gluteal dermatitis, and the care plan did not include comprehensive, individualized interventions beyond generic repositioning and wound care orders. After a new coccyx pressure ulcer was identified and documented as a stage 2 lesion, the facility failed to promptly and accurately update the care plan and implement recommended pressure‑relieving interventions. The wound nurse practitioner on 3/5 ordered coccyx wound care, an air mattress, pressure offloading, and a dietician consult, but the care plan was not revised and there was no evidence that an air mattress was placed on the bed for nearly two weeks. The environmental services director later confirmed that when the resident was moved to a new room, the gel mattress was not transferred, and the air mattress requested on 3/17 was not actually placed until the following day, despite being marked as completed. During this period, TAR documentation showed gaps in the every‑2‑hour repositioning order, and staff interviews revealed that CNAs were unaware of which residents were on repositioning programs, were not consistently repositioning residents, and had not received recent education on pressure ulcer prevention. The DON and RN case manager acknowledged that the coccyx wound increased in size and changed color between assessments, that the bed lacked the ordered gel mattress, and that the physician was not notified of the wound’s deterioration at that time. The facility also failed to timely modify toileting and incontinence care practices despite knowledge that the resident was being left on a bedpan for extended periods. The DON reported hearing before an IDT meeting that the resident had fallen asleep on a bedpan for an undetermined amount of time, but the care plan was not revised to discontinue bedpan use and implement a bedside commode until after the coccyx wound had significantly worsened. CNAs confirmed that the resident sometimes fell asleep on the bedpan and that they were not informed she should no longer use it until after the sore had worsened. Subsequent wound assessments documented rapid progression of the coccyx wound from a small stage 2 ulcer to a large, malodorous, necrotic wound with eschar, slough, erythema, and purulent drainage, ultimately classified as an unstageable pressure ulcer. The DON, NP, PA, and medical director all indicated that the lack of a pressure‑relieving mattress, failure to adjust pressure‑reducing interventions, and prolonged time on a bedpan likely contributed to the development and deterioration of the resident’s pressure ulcer, which was determined to be avoidable and resulted in hospitalization and surgical debridement. Additional documentation and interviews showed systemic assessment and communication failures related to pressure ulcer management. Weekly skin checks and wound assessments often omitted complete measurements, staging, and wound characteristics, and changes in wound size and appearance were not consistently recognized as deterioration or communicated to providers. The DON acknowledged that a 3/12 assessment showing increased wound size and purple discoloration should have been identified as a deep tissue injury and reported to the physician, but this did not occur. When nursing later documented foul odor, increased pain, and expanding necrotic tissue, telemedicine and PA responses deferred in‑person evaluation and ED transfer despite earlier recommendations that the resident be sent to the ED if an in‑person provider could not assess the wound. The NP ultimately found a large, malodorous, purulent wound with expanding eschar and ordered transfer to the hospital, where imaging and surgical findings confirmed a large necrotic sacral wound requiring extensive debridement. Throughout this sequence, the facility did not consistently follow its own pressure ulcer protocols, did not ensure ordered pressure‑relieving equipment was in place, and did not promptly revise care plans or interventions in response to known risk factors and documented wound changes. The report also notes that other residents reviewed for pressure ulcers were affected by similar failures in monitoring and individualized intervention, though detailed narratives focus primarily on this resident. Staff interviews revealed that CNAs relied on paper care guides that did not clearly identify residents on repositioning programs or at risk for skin breakdown, and that they were unaware of some residents’ special mattress orders or toileting restrictions. The DON and medical director stated that residents at risk for pressure ulcers should have immediate pressure‑relieving interventions and that existing ulcers require ongoing evaluation to prevent deterioration, but the documented practices for this resident did not align with those expectations. These combined actions and inactions—insufficient assessment detail, delayed or missing care plan revisions, failure to implement ordered support surfaces and repositioning, and delayed response to wound deterioration—constituted the deficiency in providing appropriate pressure ulcer care and preventing new ulcers from developing.
Failure to Assess, Care Plan, and Obtain Consent for Bed Grab Bar Use
Penalty
Summary
The deficiency involves the facility’s failure to follow required procedures before installing and using bed grab bars for a resident. The resident had diagnoses including spastic hemiplegia affecting the left side and muscle weakness, and an admission MDS indicating moderate cognitive impairment. During observation, the resident was seen in a power chair with bilateral grab bars on the bed and reported using them to roll in bed and for transfers. The resident’s care plan, dated 1/23/26, documented a need for assistance with bed mobility and independence with transfers but did not mention or address the use of grab bars or side rails. Review of the electronic medical record showed no completed grab bar/side rail or bed mobility device assessment to determine the necessity of the grab bars or whether the resident could safely use them. There was also no evidence that the resident or the resident’s representative had been educated on the risks of having a grab bar on the bed or that informed consent had been obtained. In interviews, an LPN and the ADON both stated that a bed mobility device assessment was required to determine need and safety prior to installing grab bars, and both confirmed that no such assessment was present in the resident’s record.
Failure to Perform Hand Hygiene and Change Gloves During Wound Care
Penalty
Summary
Surveyors observed that a registered nurse (RN) and a nurse practitioner (NP) did not follow the facility’s established infection control practices during wound care for one resident. During a wound treatment, the RN wore gloves while removing the dressing from the resident’s left heel, then removed the dressing from the right heel, sprayed both wounds with wound cleanser, wiped the left heel with gauze, and then used a clean gauze pad to wipe the right heel. The RN did not remove her gloves or perform hand hygiene after disposing of the soiled dressings or between cleaning the left and right heel wounds, contrary to the facility’s written wound care procedure, which requires glove removal and hand hygiene after removing the previous dressing and again after cleaning the wound. The resident’s admission MDS documented diagnoses including multiple rib fractures, heart failure, dementia, anxiety, and the presence of a pressure ulcer, and indicated the resident was cognitively intact and required staff assistance with care and transfers. The resident’s care plan identified pressure ulcers on both heels requiring wound care. In interviews, the RN, NP, and the DON/infection prevention nurse each stated that gloves should be changed when moving from dirty to clean areas and that hand hygiene is expected after glove removal and between wounds to prevent infection, confirming that the observed practice did not align with facility policy or expected infection control standards.
Failure to Timely Revise Care Plan for Toileting and Skin Integrity
Penalty
Summary
The deficiency involves the facility’s failure to timely revise and individualize a resident’s care plan to address toileting and incontinence needs in relation to impaired skin integrity. The resident had diagnoses including primary progressive multiple sclerosis, hereditary spastic paraplegia, obesity, and a pressure-induced deep tissue injury to the left heel. A Significant Change MDS identified the resident as dependent for toileting hygiene, with lower extremity range-of-motion limitations, wheelchair use, dependence for transfers, occasional urinary incontinence, intact cognition, and at risk for pressure ulcers with existing unhealed pressure injuries and MASD. The resident’s skin-focused care plan, revised on various dates, included skin inspections, wound care orders, weekly skin checks, pressure ulcer care to the left heel, nutritional supplements, and a gel mattress, but did not include an individualized toileting or incontinence plan. On a weekly skin check dated 3/3/26, nursing staff identified a new Stage 2 pressure ulcer on the coccyx and contact dermatitis on both gluteal folds. An IDT Final Post Review Follow Up dated 3/10/26 (signed 3/23/26) documented that a new skin issue had occurred and that interventions after the incident included wound care treatment orders, increased repositioning, and increased incontinent care. However, the resident’s care plan from 3/3/26 through 3/16/26 did not show revisions reflecting increased incontinence care or a repositioning schedule, and the care plan was not updated to include these elements until 3/17/26. During this period, the care plan still lacked an individualized toileting plan despite the resident’s identified incontinence and new coccyx pressure ulcer. Progress notes on 3/17/26 documented that the resident’s coccyx wound had declined, with an evaluation describing a deteriorating wound characterized as a Kennedy terminal ulcer/End of Life, staged as a Stage 4 pressure ulcer, in-house acquired, with increased size, exudate, odor, pain, and surrounding erythema. On that same date, the skin focus care plan was revised to include prompt incontinence care and keeping the skin clean and dry, and the elimination focus care plan was revised to address incontinence due to neurogenic bladder with use of a bedside commode offered every 2–3 hours. A nursing assistant reported that when working with the resident, the resident would sometimes fall asleep on the bedpan and forget to ask staff to remove it, and that she was not aware the resident was not supposed to use the bedpan until after the sore had worsened. The DON stated that the resident’s care plan had not been revised earlier to include a turning and repositioning schedule or toileting changes, and that it should have been revised as soon as staff learned the resident was falling asleep on the bedpan, rather than waiting until after the pressure ulcer worsened.
Failure to Assess and Notify Provider for Right Gluteal Wound
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess and appropriately manage a non‑pressure skin issue on a resident’s right gluteal area, and to notify the physician in a timely manner. The resident had diagnoses including diabetes, Crohn’s disease, and a kidney transplant, and the MDS indicated occasional bowel incontinence, no pressure ulcers, and no moisture‑associated skin damage at that time. Earlier documentation identified a resolved MASD to the right gluteus, and a progress note later described a sacral wound with creams applied, noting that sores were still open and painful during application, but without any measurements, wound characteristics, or evidence of physician notification. Subsequent wound assessments documented an open lesion on the right gluteus with specific measurements on multiple dates, but did not identify the wound type or other characteristics, and the record did not show physician notification or treatment orders for the right gluteal lesion. Provider orders in place initially addressed cleansing the buttocks and applying barrier cream, and later included a detailed wound care order for a stage 3 pressure ulcer documented on the left buttocks. However, the resident’s record did not contain a specific treatment order for the right gluteal wound, despite the ongoing documentation of an open lesion in that area. Interviews revealed confusion and inconsistency in wound identification and classification. The DON stated that the right gluteal wound was documented as an open lesion because she did not feel comfortable determining the wound type, and acknowledged that the physician should have been notified when the wound was first identified. The DON was unaware that the NP had documented the wound as being on the left buttocks and as a stage 3 pressure ulcer, while the RN reported that the wound had never been on the left buttocks and that she had been applying the left‑sided wound orders to the right gluteal area because there was no open area on the left. The resident reported a recurring painful area on the right buttocks and chronic stool leakage since prior anal fistula surgery. The facility’s own wound treatment policy required comprehensive assessment of wound etiology and characteristics, consistent measurement and documentation, and provider notification in the absence of treatment orders, which were not followed for this resident’s right gluteal wound. The deficiency centers on the lack of a comprehensive wound assessment for the right gluteal lesion, incomplete documentation of wound characteristics, failure to clearly determine and document the wound etiology, and failure to notify the physician and obtain appropriate treatment orders when the wound was identified and remained open. These actions and inactions resulted in a discrepancy between the documented wound location and type and the actual clinical presentation, as well as a period during which the right gluteal wound had no specific, clearly ordered treatment despite being open and painful.
Failure to Perform Hand Hygiene and Implement Enhanced Barrier Precautions During Wound Care and Transfers
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper hand hygiene during wound care and to consistently implement Enhanced Barrier Precautions (EBP) for a resident requiring such measures. The resident had diagnoses including diabetes, a non-pressure chronic ulcer of the right lower leg, and a kidney transplant, and a wound assessment documented an open lesion on the right gluteal area. The resident’s care plan and a sign posted outside the room specified that EBP, including gown and gloves, were required for high-contact care activities such as dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, catheter care, and wound care. During one observation, the DON performed hand hygiene and donned a gown before entering the resident’s room for a telehealth wound assessment. Inside the room, the DON went into the bathroom, applied gloves without performing hand hygiene, removed the resident’s brief, and removed a foam dressing from the right gluteal area that had stool on one corner. After discarding the soiled dressing, the DON removed gloves and then applied new gloves without performing hand hygiene between glove changes. When questioned, the DON stated that hand hygiene should be done when hands or gloves are visibly soiled and before and after removing or applying gloves, and acknowledged that hand hygiene had not been performed each time gloves were removed and reapplied. In a separate observation, the resident was transferred using a sit-to-stand mechanical lift while EBP requirements were not fully followed. An NA entered the room wearing a gown and gloves with the lift, and the DON applied the lift harness under the resident’s arms and cinched the waist strap, encountering the resident’s clothing, while not wearing gloves. After the transfer to bed, the DON pulled down the resident’s pants and removed the harness while touching the resident’s clothes. Following wound care by a CNP-WOC, the DON again assisted the resident by sitting the resident on the edge of the bed, applying the lift harness, and adjusting the resident’s pants and shirt while wearing a gown but no gloves. The DON stated that EBP was only needed for catheter or wound care and not for transfers, and only upon reading the posted EBP sign acknowledged that EBP was required for all high-contact resident care activities, including transfers.
Failure to Protect Resident From Verbal Abuse and Delay in Removing Alleged Perpetrator
Penalty
Summary
The deficiency involves the facility’s failure to protect a vulnerable resident from mental abuse and to respond appropriately to an allegation of abuse. The resident had severe cognitive impairment, Alzheimer’s disease, dementia, anxiety, depression, psychotic disorder, and significant functional dependence, including frequent incontinence and the need for extensive assistance with ADLs and transfers. Her care plan identified behavioral and mood issues such as wandering, yelling, combative behavior, and calling staff names, with interventions including calm approaches, emotional support, redirection, and monitoring for emotional distress and mood/behavior changes. She was identified as a vulnerable adult, with instructions to monitor for signs of emotional distress and to follow the facility’s abuse reporting policy. On the evening in question, while the resident was crying on the phone with her son and expressing a desire to leave, NA-A and NA-B entered to provide evening care using an EZ stand lift. After the resident ended the phone call, multiple staff reported that NA-A spoke to the resident in a loud, stern, and frustrated tone, telling her to stop crying and that she was acting like a two-year-old. When the resident swatted at NA-A, NA-A stated, “If you hit me, I’m going to hit you back,” and later told the resident she was “in trouble now.” Staff reported that NA-A told the resident she would be sent to a locked unit so she could not get out, and questioned who would want to care for her when she cried like a baby, and that nobody would want to keep working with her. NA-C described NA-A yelling commands such as “HOLD ON!” and “Stop crying! Where would you be if you were not here? Probably lying on the floor,” and felt NA-A was obviously upset and overwhelmed. These statements were made in the presence of the resident while she was already distressed and crying. Following this interaction, the resident exhibited crying, yelling, combativeness, resistance to care, wandering into other residents’ rooms, self-isolation, and refusal of food, fluids, and medications above her prior baseline, as documented in behavior charts, target behavior monitoring, and nursing progress notes. Staff documented that she cried most of the morning, was very restless, difficult to redirect, hit and pinched staff, called staff names, and refused care and meals. She required repeated redirection, 1:1 attention, and non-pharmacological interventions, and was ultimately sent to the ED for evaluation of combativeness and emotional distress, where she was treated for dementia with aggressive behavior and hypoglycemia related to poor intake. The report identifies that the resident’s actual response and the reasonable person concept showed serious psychosocial harm, including increased crying and combative behavior above baseline, fear/anxiety manifested as combativeness, resistance to care and social interaction, and self-isolation. The facility also failed to immediately remove the alleged perpetrator from resident care and to promptly report and investigate the allegation in accordance with its abuse policy. After NA-B and NA-C reported to LPN-A that NA-A had yelled at and threatened the resident, LPN-A acknowledged it as verbal abuse but did not initiate immediate protective measures or timely reporting. LPN-A stated she believed she had 24 hours to report because there was no injury, despite facility policy requiring reporting within two hours. NA-A remained on the unit and continued working until the end of her shift, including after staff had clearly communicated their concerns to LPN-A. TMA and NA staff described uncertainty about their authority to remove NA-A and reliance on the nurse to act, while the DON later informed LPN-A that NA-A should have been removed from the floor to prevent further danger to residents. The Immediate Jeopardy was determined to have begun when NA-A’s derogatory, intimidating, and threatening statements were made and continued while she remained on duty with access to the resident and other vulnerable residents.
Failure to Timely Assess and Treat Newly Discovered Stump Wound
Penalty
Summary
The deficiency involves the facility’s failure to provide timely treatment and care for a newly discovered wound on a resident’s above‑knee amputation stump. The resident was admitted with diagnoses including unspecified dementia with behavioral disturbances, vascular dementia, bilateral above‑knee amputations, vascular disease, reduced mobility, and severe protein‑calorie malnutrition, and had no documented ulcers or skin problems on admission or on the most recent MDS. A weekly bath audit on 3/17/26 documented only non‑tender lymph nodes on the right upper hip and did not identify any open areas. However, when the wound was later assessed, the dressing on the stump was dated 3/16/26, indicating that a wound and dressing existed at that time, even though no corresponding assessment, provider notification, or treatment orders were documented. On 3/23/26, nursing staff documented a new skin issue above the resident’s knee at the amputation site, describing a stage 4 pressure ulcer/injury with full‑thickness skin and tissue loss, exposed bone, erythema/edema, and moderate serosanguineous exudate. The wound measured 1.56 cm by 1.64 cm, with 20–29% granulation tissue and 80% slough. A progress note and skin issues assessment on that date confirmed the wound characteristics and staging, and the NP, after reviewing a picture, determined the wound to be a diabetic ulcer with peripheral vascular disease and severe protein‑calorie malnutrition as contributing factors. On that same date, the NP was notified, antibiotic therapy (doxycycline) was ordered for possible cellulitis, and specific wound care orders were initiated, with documentation on the MAR that these treatments were carried out beginning 3/23/26. Multiple interviews with nursing staff revealed that no one could identify who discovered the wound or who applied the initial dressing dated 3/16/26, and there was no documentation of a wound assessment, provider notification, or interim treatment between 3/16/26 and 3/22/26. Several RNs and LPNs who worked shifts from 3/16/26 through 3/20/26 stated they did not notice a wound on the stump and that, per their usual practice, they would have contacted the provider and initiated treatment if they had found one. One LPN recalled seeing a band‑aid with a date on the stump but could not recall the date, and another LPN stated she did not see the wound because she was not looking for one. The facility’s standing orders required staff to assess all wounds daily, change dressings every three days and as needed, treat with normal saline or non‑cytotoxic cleanser and appropriate dressings, and notify the provider the next business day when a new wound or injury was found. Despite these expectations, the wound identified by the dated dressing on 3/16/26 was not assessed, reported, or treated according to orders and facility policy until 3/23/26.
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