Whitewater Health Services
Inspection history, citations, penalties and survey trends for this long-term care facility in St Charles, Minnesota.
- Location
- 525 Bluff Avenue, St Charles, Minnesota 55972
- CMS Provider Number
- 245270
- Inspections on file
- 26
- Latest survey
- June 16, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Whitewater Health Services during CMS and state inspections, most recent first.
Nursing staff, under the direction of the DON and supervisory RNs, routinely took medications prescribed for one resident and administered them to others when their medication supply was depleted. This practice involved several types of medications and was documented on medication cards, often without proper explanation or consent. Neither residents nor their families were informed or asked for permission, and staff interviews confirmed that this was a common and directed practice, constituting misappropriation of resident property.
The facility did not report incidents of medication misappropriation to the state agency within the required timeframe. Multiple staff, including RNs, LPNs, and DONs, were aware of and directed the practice of borrowing medications from one resident to administer to another, often without proper documentation or resident consent. Despite knowledge of these events, the required reporting was not completed, and residents and families were unaware of the medication transfers.
Staff were routinely directed by supervisory personnel to borrow medications from one resident to administer to another, with medication cards showing undocumented or improperly documented dose removals. Multiple nurses confirmed this practice, and administrative staff failed to conduct a thorough investigation into the misappropriation of medications as required by facility policy.
Nursing staff, under direction from facility leadership, routinely borrowed medications from one resident to administer to another when supplies ran out, despite facility policy prohibiting this practice. Multiple residents with complex medical needs received medications not specifically ordered for them, and staff interviews confirmed this was a long-standing and common practice. Documentation and medication records showed doses were removed from medication cards and given to other residents, with unclear processes for replacement and inconsistent documentation.
A resident who was cognitively intact and had an order for Nystatin powder was observed receiving the medication at bedside to self-administer, but no self-administration of medication (SAM) assessment was completed as required. Nursing staff confirmed that a SAM assessment and provider order are necessary before allowing self-administration, and facility policy mandates this process, but it was not followed in this instance.
A resident with multiple medical conditions, including pressure ulcers and urinary retention requiring a catheter, was admitted without a baseline care plan being completed within 48 hours. The resident experienced ongoing, unmanaged pain and reported that staff had not discussed pain goals. Facility leadership confirmed that a resident-specific pain care plan was not in place, and a care plan policy could not be provided.
A resident with multiple complex medical conditions experienced frequent, severe pain that was not adequately managed due to the facility's failure to assess pain needs upon admission, complete pain assessments for all prescribed medications, and offer or document non-pharmacological pain interventions as required by policy. Staff were aware of the resident's ongoing pain but did not consistently follow expectations for timely and comprehensive pain management.
Staff did not consistently follow infection control protocols, including failing to keep a urinary catheter drainage bag off the floor for a resident with a history of infections, not disinfecting a mechanical transfer lift between uses for different residents, and improper use of PPE by housekeeping staff who wore the same gown while cleaning multiple contact precaution rooms. These actions were contrary to facility policy and staff knowledge, as confirmed by interviews.
The facility did not keep state survey results in a location that was easily accessible to residents and visitors. A resident council president was unaware of the availability of these results, and staff were initially unable to locate the survey binder, which was eventually found out of sight among other binders. No policy regarding the posting of survey results was provided when requested.
A resident with a history of brain hemorrhage became unresponsive, and the facility failed to perform a comprehensive assessment or notify the physician promptly. Despite being unresponsive and having a fever, the resident's condition was not adequately communicated to the physician, leading to a delay in hospitalization. The resident was later diagnosed with a new brain hemorrhage and passed away.
Staff at the facility failed to follow hand hygiene protocols during personal care and meal service for three residents. A resident with moderate cognitive impairment was assisted by two NAs who did not perform hand hygiene after removing gloves. Another resident with severe cognitive impairment was similarly assisted without proper hand hygiene. Additionally, a resident with moderate cognitive impairment was assisted by an NA and RN, who also failed to perform hand hygiene. The facility's hand hygiene policy was not followed, as confirmed by the nursing leadership.
The facility failed to submit accurate staffing data for Quarter 2 of Federal Fiscal Year 2024 to CMS, leading to a report of excessively low weekend staffing. The issue was due to the omission of agency pool staff hours in the reports by past interim administrators.
Misappropriation of Resident Medications by Nursing Staff
Penalty
Summary
Multiple nursing staff at the facility engaged in the practice of taking medications prescribed for one resident and administering them to other residents when their own medication supply ran out. This was observed across several residents, with medication cards showing doses removed and annotated for use by other residents, often without proper documentation or consent. The medications involved included levothyroxine, potassium chloride, glipizide, clozapine, oxycodone, and pregabalin. In several cases, there was no indication or explanation for the removal of doses, and the medication cards were marked with initials or notes referencing other residents. Interviews with nursing staff revealed that this practice was directed by the Director of Nursing (DON) and other supervisory nurses, who instructed staff to borrow medications from one resident to give to another. Staff reported that this was a common occurrence, sometimes happening every other day, and that they had received education from the DON on how to borrow medications, though the date of this education was unclear. Staff described a process of contacting the DON or other RNs for direction when a resident's medication was unavailable, and being told to use another resident's supply. Residents and family members interviewed were not aware that medications had been borrowed from them or their family members, and had not been asked for consent. The facility's policy on abuse, neglect, and exploitation defines misappropriation of resident property as the wrongful use of a resident's belongings without consent. The actions observed and described in interviews constitute misappropriation of property, as medications were taken from residents without their knowledge or permission and used for other residents.
Failure to Timely Report Misappropriation of Resident Medications
Penalty
Summary
The facility failed to ensure that alleged violations involving the misappropriation of resident medications were reported to the state agency within 24 hours of the incidents, as required. The misappropriation involved at least five residents, where medications were removed from one resident's supply and administered to another without proper documentation or consent. Multiple medication cards showed doses removed and given to other residents, with some cards lacking clear documentation of the reason for removal, the date, or the initials of the staff involved. The practice of borrowing medications was confirmed through observation, record review, and staff interviews. Several staff members, including RNs, LPNs, and DONs, acknowledged that the practice of borrowing medications from one resident to give to another was common and often directed by nursing leadership. Staff interviews revealed that this practice occurred frequently, sometimes every other day, and that nurses were instructed to document the removal on the medication card, though this was inconsistently done. Residents and family members interviewed were unaware that medications had been borrowed from or for them, and there was uncertainty about whether any doses had been missed as a result. Despite knowledge of the misappropriation by various staff, including human resources and nursing leadership, the incidents were not reported to the state agency as required by facility policy and federal regulations. Staff cited reasons such as lack of access, uncertainty about reporting procedures, or not being involved in the investigation as reasons for not reporting. The facility's own policy defined misappropriation as the wrongful use of a resident's property without consent and required reporting within 24 hours, but this was not followed in these cases.
Failure to Investigate Misappropriation of Resident Medications
Penalty
Summary
The facility failed to thoroughly investigate allegations of misappropriation of resident medications for five of eight residents. Multiple medication cards showed doses removed without proper documentation or explanation, and in several cases, medications were taken from one resident and given to another without following appropriate procedures. Staff interviews revealed that nurses were routinely directed by the Director of Nursing (DON) and other supervisory staff to borrow medications from one resident to administer to another when medications were unavailable, a practice that was reportedly common and sometimes accompanied by informal documentation on medication cards. Specific examples included medication cards for levothyroxine, potassium chloride, glipizide, clozapine, and oxycodone, where doses were removed and either not documented or documented as being given to other residents. In some cases, the initials on the medication cards could not be identified, and the dates and reasons for removal were unclear. Residents involved had a range of medical conditions, including hemiplegia, hypothyroidism, chronic kidney disease, schizoaffective disorder, and acute pain, and the medications in question were prescribed for these conditions. The practice of borrowing medications was confirmed by several nurses, who stated they received direct instructions from the DON or other supervisory staff to do so. Despite the discovery of these practices, the facility did not conduct a thorough investigation as required by its own policies. Interviews with human resources and administrative staff revealed confusion about who was responsible for the investigation, with some staff unaware of any completed investigation, education, corrective action, or audits. The facility's policy required a thorough investigation of misappropriation allegations, including identifying all involved parties, interviewing witnesses, and documenting findings, but these steps were not completed or documented as having been completed.
Failure to Ensure Proper Pharmaceutical Services and Medication Administration
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure that residents' medications were ordered in advance and administered as prescribed. Multiple instances were observed where residents were given medications that were prescribed for other residents when their own supply ran out. This practice was confirmed through medication card reviews, interviews with nursing staff, and documentation, showing that doses were removed from one resident's medication card and administered to another resident. The facility's own policies explicitly prohibit administering medications supplied for one resident to another, yet this practice was ongoing and had become routine among nursing staff. Several residents were affected by this deficiency, including those with complex medical histories such as hemiplegia, hypothyroidism, diabetes, schizoaffective disorder, chronic kidney disease, and post-surgical aftercare. Medication administration records and pharmacy receipts revealed that medications such as levothyroxine, potassium chloride, glipizide, clozapine, oxycodone, and pregabalin were borrowed from one resident and given to another. In some cases, the medication cards were annotated to indicate which resident received the borrowed dose, but there was often no clear documentation or rationale for the removal of doses, and the process for replacing borrowed medications was unclear to staff. Interviews with nursing staff, including RNs and LPNs, confirmed that they had received direction from nursing leadership, including the DON, to borrow medications from other residents when a medication was not available for the intended resident. This direction was given multiple times and had become a long-standing practice in the facility. Staff reported that they would attempt to reorder medications when supplies were low, but if the medication was not available, they would check the emergency medication kit or call the pharmacy. If the medication was still unavailable, they were instructed to borrow from another resident's supply. This practice was not communicated to residents or their families, and some staff expressed awareness that this was not a proper nursing practice.
Failure to Complete Required Self-Administration Assessment Before Allowing Resident to Self-Administer Medication
Penalty
Summary
A resident who was assessed as cognitively intact had a provider order for Nystatin antifungal powder to be applied to both breasts and groin folds every 12 hours as needed. During observation, an RN dispensed the antifungal powder into a medication cup and handed it to the DON, who then placed the cup on the resident's bedside table and left the room. The DON stated that the resident would apply the powder herself when ready. However, there was no documentation of a self-administration of medication (SAM) assessment for this resident. Interviews with nursing staff confirmed that a SAM assessment is required to determine if a resident is safe to self-administer medications and that a provider order is necessary for medications to be left at the bedside. Both the RN and ADON acknowledged that no current residents had a SAM assessment on file, and that such assessments are reviewed every three months for safety. Facility policy also requires specific authorization and assessment before allowing residents to self-administer medications, but this process was not followed in the case of the resident observed.
Failure to Initiate Baseline Care Plan and Address Pain Management Upon Admission
Penalty
Summary
The facility failed to complete and implement a baseline care plan within 48 hours of admission for a newly admitted resident with multiple complex medical conditions, including heart failure, respiratory disease, several pressure ulcers, spinal and lumbar pain, adult failure to thrive, and urinary retention requiring a catheter. At the time of the survey, the resident's admission Minimum Data Set (MDS) assessment had not been completed, and no baseline care plan had been initiated. The resident reported experiencing significant pain, particularly at the site of the urinary catheter, and stated that the pain management provided was ineffective. She also indicated that staff had not discussed her pain goals with her. Interviews with the ADON and DON confirmed that the resident had been experiencing frequent and high levels of pain since admission, and that a resident-specific care plan addressing pain had not been completed. The facility was unable to provide a care plan policy when requested. These findings demonstrate that the facility did not assess or address the resident's immediate needs, particularly regarding pain management, within the required 48-hour timeframe following admission.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a newly admitted resident with multiple complex medical conditions, including heart failure, respiratory disease, several pressure ulcers, spinal and lumbar pain, adult failure to thrive, and urinary retention requiring a catheter. Upon admission, the resident's baseline care plan was not completed, and pain management needs, treatments, and goals were not assessed. Although the resident had physician orders for scheduled pain medications (Lyrica and acetaminophen), pain assessments were inconsistently completed, and non-pharmacological interventions were not documented or offered as required by facility policy. Throughout the resident's stay, documentation and direct observation revealed frequent and severe pain, with the resident repeatedly calling out and expressing that her pain was not being adequately managed. Staff interviews confirmed that non-pharmacological interventions, such as ice, heat, or distraction, were expected to be offered and documented, but these were not provided or recorded for the resident. The treatment administration record lacked evidence of attempted non-pharmacological pain interventions on multiple days, despite ongoing high pain scores and vocal complaints from the resident. Interviews with nursing staff and the assistant director of nursing indicated an awareness of the resident's persistent pain and the expectation to address pain within 15-20 minutes of notification, using both pharmacological and non-pharmacological methods. However, the resident's record showed that these expectations were not met, as non-pharmacological interventions were neither offered nor documented, and pain assessments were incomplete for one of the prescribed medications. Facility policy required staff to recognize, evaluate, and manage pain, but these steps were not consistently followed for this resident.
Failure to Follow Infection Control Practices for Catheter Care, Equipment Disinfection, and PPE Use
Penalty
Summary
Staff failed to follow proper infection control practices in several instances involving residents with complex medical needs. One resident with a urinary catheter and a history of spina bifida, paraplegia, and recurrent urinary tract infections was observed multiple times with their catheter drainage bag placed directly on the floor without a barrier, contrary to facility policy and staff instructions. The resident expressed a preference for the bag to be as low as possible, sometimes resulting in the bag being placed on the floor. Staff interviews confirmed awareness that placing the catheter bag on the floor was an infection control issue, but the practice continued due to the resident's preferences and concerns about drainage effectiveness. In another instance, staff failed to clean and disinfect a mechanical transfer lift between uses for different residents. Nursing assistants used the same lift for two residents without wiping it down or sanitizing it before or after each use. Staff interviews confirmed knowledge of the requirement to clean equipment between residents to prevent infection transmission, but this protocol was not followed during the observed instances. Additionally, proper use of personal protective equipment (PPE) was not maintained by housekeeping staff when cleaning rooms under contact precautions. A housekeeper was observed wearing the same gown while cleaning multiple rooms, only changing gloves between rooms, despite facility policy and supervisor expectations that both gown and gloves should be changed after each room. Interviews with the housekeeper and supervisors confirmed that the correct procedure was not followed, increasing the risk of cross-contamination between rooms.
Survey Results Not Readily Accessible to Residents and Visitors
Penalty
Summary
The facility failed to ensure that state survey results were kept in a location that was readily accessible to all residents and visitors. During a resident council meeting, the resident council president, who was cognitively intact, stated she was unaware that the state survey results were available for review and expressed interest in seeing them. When interviewed, the social worker was unsure of the survey binder's location and was unable to find it in the main atrium. Later, the assistant director of nursing and a corporate vice president located the survey binder stacked among other facility binders, out of sight and not easily accessible to residents or visitors. Additionally, when requested, the facility did not provide a policy regarding the posting of survey results.
Failure to Respond to Resident's Change in Condition
Penalty
Summary
The facility failed to identify, assess, and respond appropriately to a sudden change in condition for a resident, leading to an immediate jeopardy situation. The resident, who had a history of nontraumatic intracerebral hemorrhage and severe cognitive impairment, became unresponsive and remained so for at least seven hours before being hospitalized. Despite the resident's unresponsiveness and elevated temperature, the facility staff did not perform a comprehensive assessment or notify the physician in a timely manner. The resident's condition was first noted to be abnormal between midnight and 1:30 a.m. when a nursing assistant observed the resident to be lethargic, warm, flushed, and weak. This information was reported to an LPN, who took the resident's vital signs but did not find them concerning and did not perform a neurological assessment. The resident's condition was reported again during the shift change at 6:00 a.m., but no significant action was taken until later in the morning when the resident's temperature was recorded at 101.6°F, and the resident remained unresponsive. Throughout the morning, the resident's condition did not improve, and the staff failed to communicate the severity of the situation to the physician, who was only informed of a fever and sleepiness. It was not until the resident's breathing became irregular and the resident was unresponsive to a sternal rub that an ambulance was called. The resident was later diagnosed with a new large brain hemorrhage and passed away. The facility's policy on change in condition was not followed, leading to a delay in appropriate medical intervention.
Failure to Adhere to Hand Hygiene Protocols
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed by staff during personal care and meal service, as observed in three residents. Resident 1, who had moderate cognitive impairment and was dependent on staff for assistance, was observed being assisted by two nursing assistants (NAs) with incontinent care. The NAs did not perform hand hygiene after removing gloves and before applying a new brief and transferring the resident to a wheelchair. Additionally, one of the NAs continued to handle items and assist other residents without performing hand hygiene. Resident 2, who had severe cognitive impairment and was dependent on staff for all activities of daily living, was assisted by the same NAs from a wheelchair to bed. The NAs did not perform hand hygiene after removing gloves following the removal of soiled briefs and application of barrier cream. This lack of hand hygiene was acknowledged by the NAs during an interview, where they admitted to not following the facility's hand hygiene policy. Resident 4, with moderate cognitive impairment and dependent on staff for dressing and grooming, was assisted by an NA and a registered nurse (RN) in changing an incontinent brief. The NA did not perform hand hygiene after removing soiled gloves and before donning a new pair. The facility's policy on hand hygiene, which requires handwashing or the use of an antiseptic hand rub in various situations, was not adhered to by the staff, as confirmed by the regional nurse consultant, director of nursing, and assistant director of nursing during an interview.
Inaccurate Staffing Data Submission
Penalty
Summary
The facility failed to submit accurate and complete staffing data for Quarter 2 of Federal Fiscal Year 2024 to the Centers for Medicare and Medicaid Services (CMS). The CMS Payroll Based Journal (PBJ) Staffing Report indicated excessively low weekend staffing, which was not consistent with the facility's daily staff postings and staffing schedules. The review showed that the number of staff and total hours worked on weekends were not drastically different from weekdays, and the census did not fluctuate significantly during this period. However, the facility did not include agency pool staff hours in their reports, leading to the appearance of low weekend staffing. During an interview, the Corporate President of Customer Success confirmed that staffing needs were determined based on resident acuity and census, and that the level of staffing on weekends was the same as on weekdays. The issue arose because past interim administrators failed to include agency pool staff hours in the required staffing reports. This omission caused the facility's staffing data to appear inaccurate. A facility policy was requested but was not received.
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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