Citations in Minnesota W

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to comprehensively assess pain and to offer or attempt non-pharmacological pain interventions prior to administering PRN pain medications for two residents. One resident had severely impaired cognition, cellulitis of the right leg, type 2 diabetes, and chronic pain syndrome, with an admission MDS indicating frequent pain that interfered with day-to-day activities and use of both scheduled and PRN pain medications. This resident’s care plan included multiple non-pharmacological pain interventions such as ice, heated blankets, massage, repositioning, music, essential oils, food/drink, and relaxation breathing. Despite this, the MAR and corresponding progress notes for multiple PRN administrations of acetaminophen and oxycodone in January did not document any non-pharmacological interventions being attempted or offered prior to medication administration. The second resident had intact cognition, a stage 3 pressure ulcer, COPD, and chronic pain, with a quarterly MDS indicating almost constant pain and use of scheduled and PRN pain medications. This resident’s care plan identified a focus on pain risk related to generalized chronic pain and lower back pain, with interventions that included offering non-pharmacological pain relief prior to pain medication administration, listing the same types of non-pharmacological options as for the first resident. However, the MAR for January showed several PRN oxycodone administrations, and the associated progress notes documented that the medication was given and effective but did not include any record of non-pharmacological interventions being offered or attempted beforehand. Interviews with both residents confirmed that they experienced ongoing pain and used PRN pain medications, and each reported that repositioning sometimes helped relieve their pain. Interviews with LPN staff, the NP, and the DON established that facility practice and expectations were that non-pharmacological interventions should be offered prior to PRN pain medication administration and that such offers and any refusals should be documented in the PRN medication administration note or progress note. The DON confirmed that the medical records for the two residents did not contain documentation of non-pharmacological interventions being offered or refused prior to every PRN pain medication administration. The facility’s Pain Assessment and Management policy stated that pain management is based on appropriate assessment and treatment, including the use of non-pharmacological interventions alone or with medications, and provided examples of environmental, physical, exercise, and cognitive/behavioral interventions, which were not consistently reflected in the documentation for these residents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Failure to implement effective and timely pest control measures resulted in an ongoing mouse infestation affecting resident rooms and common areas. Multiple residents reported frequently seeing mice in their rooms, including one resident who stated she sees mice "all of the time" and recently observed a mouse running from her room into the hallway. Another resident reported seeing mice in her room on approximately ten different occasions and overheard a nurse say a mouse was seen coming out of a power outlet. This resident also had pressure ulcers on her coccyx and expressed concern about the mouse infestation. Observations showed food stored in resident rooms, including food in containers and bags on a nightstand, and clutter such as stacked plastic totes, bags of clothing, and miscellaneous items on beds and in rooms. Residents described taking their own measures to address the mice, including one resident who kept Rat/Mice X products in his walker seat and placed them in the corners of his room, and another who found a dead mouse between stacked plastic totes and removed it herself. That same resident reported a mouse caught in a sticky trap that she moved to a hallway garbage can, and described watching two baby mice playing on her floor by her bed and hearing mice in the walls at night. Staff interviews corroborated the infestation, with an RN reporting seeing mice in the breakroom and hearing resident complaints of mice in rooms. A physical therapy assistant reported a broken bed in a back hallway piled with old wheelchair parts and bags of unknown items, and stated she had observed a resident who liked to store food in that bed and had seen mouse droppings there. The maintenance director acknowledged awareness of a mouse problem in the building for almost a year and stated it worsened during cold weather. He reported that an outside pest control company visits monthly and as needed, and that nurses are instructed to document mouse sightings in a book for targeted treatment. However, he and the administrator both stated that a recent pest control visit did not occur as planned because the company reported being out of bait and products. The dietary manager confirmed there was a mouse problem and stated more proactive treatment was needed, noting that mice had been trapped in a live trap under the three-compartment sink in the kitchen, although she had not personally seen mice or droppings in the kitchen and food there was contained. The facility’s pest control policy required an ongoing program to keep the building free of insects and rodents and prohibited accumulation of garbage and trash, but the observed mouse activity, resident reports, cluttered rooms and storage areas, and reliance on residents’ own pest control efforts demonstrated that effective pest control measures were not implemented.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to timely report an allegation of sexual assault to the State Agency within the required 2-hour timeframe after an incident in which one resident groped another resident’s breasts without consent in the dining room. On the morning of 1/20/26 at approximately 9:15 a.m., a registered nurse (RN-A) observed that a male resident (R1) approached the dining room to greet his wife (R3), moved around a table when asked by an aide, and then came behind another resident (R2) and groped her breasts without her consent. R1 was redirected to his room and educated, and he demonstrated little to no remorse for his actions. RN-A reported that R2 was aware the incident occurred but soon closed her eyes and showed no visible negative reaction or distress, and later staff interviews found R2 had slight to no recall of the incident. Police and the responsible parties for R1 and R2 were notified, and RN-A, who had not worked at the facility for long and was unfamiliar with the residents’ plans of care, stated that the plan of care was nonetheless followed. The facility’s incident report shows that the allegation was reported to the State Agency at 4:25 p.m. on 1/20/26, more than 2 hours after the incident. During an interview on 1/29/26, the social worker stated that the decision was made to report to the State Agency after most of the investigation had been completed and acknowledged she was not aware that the report should have been made first. She agreed that the incident was reported late and not within the 2-hour requirement set by regulations and the facility’s “Maltreatment Reporting Guidelines” policy, which requires immediate reporting, but no later than 2 hours after an allegation of abuse, neglect, financial exploitation, injuries of unknown source, or misappropriation of property.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure that therapeutic and modified diets were implemented and served in accordance with physician orders for three residents with dysphagia and high aspiration risk. One resident with dementia, dysphagia, aphasia, and a strict NPO order following a stroke was brought to the dining room after a therapy session, even though she did not normally dine there. The dining assistant, who had not used the available tablet to verify diet orders and believed the resident was someone else, served her a regular textured meal consisting of a ham or turkey sandwich with cheese and juice. The resident’s significant other observed her eating a sandwich and salad, and a staff member then stated she was not supposed to have food. The RN assessed the resident, found her SpO2 at 71%, and she was sent to the ED, where documentation indicated a transient hypoxic episode after being given lunch despite strict NPO status, with concern for an aspiration event. Another resident with multiple sclerosis, mild cognitive impairment, and dysphagia had a physician order for a Level 4 pureed texture diet with thin liquids. Her care plan identified a regular diet with pureed meats and directed staff to serve the diet as ordered. She had a recent history of choking and regurgitation episodes, including an event where she was spitting up food, had wheezing in the lower lung lobes, and required an ED visit with EGD and extraction of a food bolus. Despite this history and the ordered pureed diet, surveyors observed her in the dining room eating a hotdish made from stuffing with chunks of turkey, which dining staff identified as appropriate for a regular or minced and moist diet, not a pureed diet. At the time of observation, dining assistants acknowledged that diet information was available on iPads and diet slips but admitted they sometimes did not use them, and no such tools were in use until prompted by the surveyor. A third resident with dementia, expressive aphasia, and dysphagia had physician orders and a care plan for a Level 4 pureed texture diet with Level 2 mildly thick liquids. The care plan also documented that his family member could provide thin liquids and different textures only when present and that snacks left by the family for use in the resident’s absence were to be compatible with his modified diet. Progress notes documented prior concerns about pocketing food, a choking episode in the dining room where he was not breathing and had turned purple, and subsequent changes to a pureed diet and restrictions on snacks in his room. Despite these orders and documented risks, surveyors observed him independently propelling himself in his wheelchair near the dining room while eating Oreo cookies without staff supervision. The DON later confirmed there was no signed consent for a liberalized diet and that the family member did not want him to have Oreo cookies, and the facility’s own therapeutic diet policy required that snacks be compatible with the therapeutic diet.

Removal Plan

• Review the facility process for ensuring the correct resident receives the correct diet as prescribed by the provider.
• Review and revise care plans for accuracy.
• Educate all staff with competency on resident care plan revisions, the facility procedure for implementing physician-ordered diets, diet textures, and protections from negative outcomes.
• Implement meal tray audits.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to identify, comprehensively assess, monitor, and implement effective interventions to prevent and manage pressure ulcers for multiple residents, with Immediate Jeopardy for one resident. One resident with paraplegia, diabetes, obesity, an indwelling catheter, and an ostomy was dependent for lower body care and transfers and was identified as at risk for pressure ulcers. On admission, the resident’s right heel wound was noted but not staged or fully described despite form instructions to document blanchability, size, color, odor, and discharge. The initial care plan did not include a skin integrity problem or the right heel wound, and subsequent skin checks failed to mention the heel wound. For an extended period after admission and readmission, the care plan was not revised to reflect existing and newly identified skin issues, including sacral redness, and pressure-relieving interventions were delayed or incompletely incorporated into the care plan. As time progressed, the resident developed multiple additional areas of impaired skin integrity, including buttocks, coccyx/sacrum, urinary meatus, and foot wounds. Wound clinic records showed comprehensive staging and measurements of the right heel and urinary meatus pressure ulcers and later buttock shearing injuries, while facility documentation (RN wound assessments, skin observations, and progress notes) was inconsistent and often lacked measurements, staging, wound type, and detailed descriptions. New wounds and changes in condition, such as buttock shearing and coccyx pressure areas, were not consistently or comprehensively assessed, and physician notification for new or worsening wounds was not evident for several documented changes. The care plan was not timely updated to include wound clinic recommendations, such as catheter and brief management for the urinary meatus ulcer and interventions to prevent recurrent shearing injuries to the buttocks. In the weeks leading up to the Immediate Jeopardy period, documentation of the resident’s buttock and coccyx wounds remained inconsistent, with alternating descriptions of coccyx versus buttock involvement and characterizations as shearing or pressure sores, without comprehensive wound assessments or clear identification of wound type. Skin observations and wound data collections around the end of the year showed black and blue tissue on the buttocks and new left lateral foot involvement, yet there was no documented physician notification or change in treatment orders for these developments. Wounds were not measured until early January, at which time large buttock wounds with significant eschar and slough, macerated and erythematous margins, and drainage were finally documented. Interviews with nursing staff revealed reliance on a clinical care lead RN to measure wounds and obtain orders, acknowledgment that wounds had not been measured for weeks, and use of treatments such as hydrofera blue and cleansing with soap and water or wet wipes without clear physician authorization or articulated evidence-based rationale. Throughout this period, the resident was not placed on a formal turning and repositioning schedule despite being at risk for pressure ulcers and dependent for repositioning. Staff and interdisciplinary team notes repeatedly referenced the resident’s refusals to get out of bed or reposition, but these notes were often verbatim over multiple entries and did not reflect new assessments or individualized interventions to address refusals. Nursing assistants reported that the resident rarely refused care and would usually accept care when re-approached, while a nurse later stated the resident had not received education on the risks of not repositioning prior to hospitalization. The clinical care lead RN stated that shearing was not a form of pressure, that the resident’s discolored buttocks were “always” monitored, and that larger protective dressings such as Mepilex were sometimes not used due to size or payor concerns, leading to use of ABD pads instead. By the time the resident was evaluated at the wound clinic in January, the buttock and foot wounds were classified as unstageable and stage 3 pressure ulcers, with the gluteal wound described as very advanced and infected, and subsequent hospital records documented sacral decubitus ulcer with osteomyelitis and cellulitis. Additional observations after the resident’s return from the hospital showed ongoing gaps in wound management and monitoring. Nursing staff could not initially locate dressing change orders, and the resident reported that no care had been provided to his heels over the weekend and that wedges for repositioning were only used if he requested them. On examination, facility leadership identified a dark, non-blanching area on the right lateral foot that was questioned as an unstageable pressure ulcer or suspected deep tissue injury, while the clinical care lead RN initially characterized it as a blister and a diabetic wound. Toenails pressing into adjacent toes and causing skin indentations were discovered only during surveyor observation, and improvised measures such as placing gauze between toes were initiated at that time. These documented inactions and inconsistent assessments, monitoring, and interventions for existing and developing wounds contributed to the progression of the resident’s buttock wound to a severe, infected pressure injury requiring hospitalization for osteomyelitis, cellulitis, and soft tissue infection.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure that a resident with a seizure disorder consistently received a prescribed anti-seizure medication, Lacosamide 200 mg twice daily, resulting in multiple missed doses over several days. The resident had diagnoses including encephalopathy, seizure disorder, generalized weakness, alcoholic dementia, and metabolic encephalopathy, and the care plan required administration of anti-seizure medication as ordered, positioning to prevent injury during seizure activity, airway management, documentation of seizure characteristics, and monitoring of neurological status after any seizure activity. Physician orders also directed staff to monitor for seizure activity every shift. The January Medication Administration Record showed that the resident did not receive either scheduled dose of Lacosamide on three consecutive days, with six missed doses documented as “medication not available,” and an additional morning dose was not administered on a subsequent day. Three different nurses failed to administer these doses. During this period, there was no documentation that the physician or pharmacy had been notified that the medication was unavailable or that doses were missed, despite the standing order and facility policy requiring medication ordering and reordering when supplies were low. The Treatment Administration Record showed that seizure monitoring tasks were checked off as completed, but the resident’s record and progress notes did not contain documentation of the results of this monitoring or any evidence of increased monitoring after the missed doses. Nursing staff interviews revealed multiple failures in communication and follow-through. One LPN reported caring for the resident on two evenings, finding the medication absent from the cart, and not administering the doses; he did not notify the pharmacy, provider, or nurse manager and did not report the issue to the night nurse. Another LPN stated she received report that the anti-seizure medication was not available, called the pharmacy to reorder it, and was told it would be delivered; she observed that the medication arrived as she was leaving but did not notify the provider or give report to the night nurse, and the dose was not given. A unit manager RN later found 10 tablets of Lacosamide in the medication cart after the resident had been sent to the hospital. A pharmacist confirmed there were no electronic requests for the medication on two of the days in question and that a prescription was already on file to supply the facility upon request. A nurse practitioner reported having no record of any notification from the facility about the medication being unavailable or any refill request, and described being called only when the resident had a change in condition and was found actively seizing, with three seizures observed within seven minutes before EMS transport to the hospital ICU. On the morning the resident was transferred to the hospital, an RN caring for the resident found the resident very sleepy and difficult to arouse and determined it was not safe to administer medications, including the anti-seizure medication, and notified the onsite provider of the change in condition. A progress note documented that the resident was non-responsive and tremoring, and the provider ordered transfer to the hospital. Hospital admission notes indicated the resident was admitted to the ICU with seizure activity and concern for status epilepticus, requiring intubation and ventilator support, and that the resident had been out of Lacosamide for the past three days because it had not been available. A head CT scan identified a thin subdural hemorrhage versus dural thickening along the left cerebral convexity. The DON stated that staff failed to obtain the medication from the pharmacy, resulting in missed doses, did not update the provider when doses were missed, and did not follow medication re-order procedures or complete follow-up to ensure timely delivery of the medication.

Removal Plan

• Suspended LPN-A, LPN-B and LPN-C pending investigation and provided re-education.
• Reviewed the policy and procedure for safe medication and developed a plan to ensure a sufficient supply of medications for residents for timely administration.
• Reassessed all residents with seizure medications to ensure their safety.
• Began re-education and competency testing for nursing staff to ensure compliance with medication administration.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to timely and comprehensively update a resident’s care plan to reflect existing and newly developed pressure ulcers and related interventions. The resident was admitted with paraplegia, type 2 diabetes, obesity, and a documented right heel wound on the Nursing Admit/Re-admit Data Collection, but that form lacked required descriptive details such as staging, blanchability, size, color, odor, or discharge. The admission MDS identified the resident as at risk for pressure ulcers, with significant lower extremity impairment, dependence for lower body care and transfers, and use of pressure-reducing devices, but no pressure ulcers were documented at that time. The initial care plan dated the day after admission did not include a skin integrity focus or identify the right heel wound, although it did address assistance needs for turning and transfers. A subsequent care plan identified only potential for pressure ulcer development and general preventive interventions, without specifically addressing the existing right heel wound. As the resident’s condition evolved, the facility did not revise the care plan to reflect new pressure ulcers and specific wound-related interventions in a timely manner. An RN wound assessment later identified an unstageable right heel pressure ulcer, but the assessment did not address a red sacrum noted on the same date, and the care plan was not updated at that time to include off-loading boots, which were only added months later. A progress note documented a new pressure sore on the right buttock and the resident’s refusal to get up in a chair at mealtimes despite education on repositioning, yet there was no indication the care plan was revised to address this new wound. A wound clinic report then identified a stage 3 right heel ulcer and a stage 3 ulcer at the urinary meatus related to catheter tension and incontinent brief use, with specific directions regarding catheter device positioning, removal of the brief, and use of barrier cream. The record showed no corresponding care plan revisions to include the new urinary meatus ulcer or the clinic’s catheter and incontinent garment interventions until a later date, and interventions for prevention/minimization of recurrent buttock shearing injuries were also delayed, contrary to the DON’s stated expectation that RN nurse leaders update care plans with changes.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to assist a resident in obtaining requested dental services, as required by facility policy. The resident, who had paraplegia and type 2 diabetes, was cognitively intact and had no documented dental issues such as cavities, broken teeth, dentures, or bridges on the admission MDS and Nursing Admit/Re-admit Data collection. However, the Nursing Admit/Re-admit Data form included a comment that the resident would like to pursue dental care. Despite this documented request, there was no evidence in the medical record of any attempts to arrange a dental appointment. During interviews, the resident reported that no one at the facility had worked with him to make a dental appointment, although he stated he had informed the clinical care leader RN. The clinical care leader RN confirmed she completed the Nursing Admit/Re-admit Data and acknowledged that county case workers managed the resident and that either they or the DON would have to approve a dental appointment, describing it as a process. She was unable to articulate the process for obtaining a dental appointment when requested by a resident and was unsure who was responsible for initiating it. Review of the resident’s record by the clinical care leader RN did not reveal any documentation of efforts to set up a dental visit, despite the facility’s policy stating that the location provides or obtains routine and 24-hour emergency dental services and assists residents, when necessary, in making appointments and arranging transportation and referrals.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to follow infection prevention and control practices during wound care and other direct care for two residents. For one resident with paraplegia, multiple pressure ulcers, an indwelling catheter, and an ostomy, staff performed extensive wound and wound vac care without consistently sanitizing hands between glove changes, moved and placed wound supplies on undisinfected surfaces, and handled clean and dirty items interchangeably. During the wound care, staff removed and applied dressings to multiple wounds, manipulated the wound vac, and cleaned blood using gauze taken repeatedly from the same package, sometimes after touching contaminated items, and without always performing hand hygiene between glove changes. The suction tubing from the wound vac fell to the floor and leaked secretions, and the canister was discarded, while staff continued to work in the area. After this care, another nurse entered the room wearing gloves but no gown, removed IV medication, flushed the IV, and left the room without performing hand hygiene. For a second resident with Alzheimer’s, dementia, edema, and a history of pressure ulcers, staff also failed to adhere to infection control practices during toileting, catheter care, and wound care. A nursing assistant performed perineal care, manipulated the mechanical lift, wheelchair, catheter bag and tubing, moved equipment in and out of the room, handled a blanket and pillow, and went into the bathroom and hallway, all while wearing the same pair of gloves and without changing them until the end of the sequence. During wound care to the resident’s legs, a nurse removed heel protectors soaked in bodily fluids, dropped gauze on the floor and picked it up, and placed dressings on a chair that had not been disinfected, while intermittently changing gloves and sometimes sanitizing hands, but not consistently between all clean and dirty contacts. In a subsequent wound assessment of the second resident’s buttocks, a hospice nurse and an LPN initially provided care such as obtaining vital signs and administering medications without gowns or gloves, then donned gowns and gloves to perform wound care and catheter care. During this care, they removed dressings, washed the buttocks with wet wipes obtained from the bathroom sink, applied cream, and handled wound care supplies and the catheter cover without removing gloves or sanitizing hands between touching the resident’s buttocks and clean surfaces. Staff interviews confirmed awareness that gloves should be changed when soiled, between different tasks, and that wearing dirty gloves was an infection control issue. The DON stated that following enhanced barrier precautions and infection control was confusing.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to develop and implement comprehensive care plans addressing the use of blood‑thinning medications for three residents receiving antiplatelet or anticoagulant therapy. For one resident with a history of stroke and dysphagia who received clopidogrel via G‑tube and aspirin via J‑tube, the admission MDS documented antiplatelet use and the Treatment Administration Record (TAR) contained physician‑ordered monitoring related to blood‑thinning medications. However, the comprehensive care plan in effect at the time of survey did not identify any problem, goal, or interventions related to blood‑thinner use, did not identify the resident as being at risk for bleeding, and did not include interventions to manage or mitigate bleeding risk. The Kardex and requested care guide also did not identify the resident’s use of blood‑thinning medications. A second resident with atrial fibrillation had an admission MDS documenting anticoagulant use and a physician’s order for apixaban twice daily. The FDA‑approved labeling for apixaban notes increased risk of serious, potentially fatal bleeding and lists signs and symptoms of blood loss. The January TAR showed physician‑ordered monitoring interventions associated with blood‑thinning medications, but the comprehensive care plan did not include any problem, goal, or interventions related to anticoagulant therapy. This resident was not identified in the care plan as being at risk for bleeding, and there were no individualized interventions addressing management or mitigation of bleeding risk. The Kardex did not identify the resident’s use of blood‑thinning medications, and the requested care guide was not provided. A third resident with an infection and inflammatory reaction due to an internal joint prosthesis of the left knee had an admission MDS documenting anticoagulant use and a physician’s order for daily enoxaparin injections. The FDA‑approved labeling for enoxaparin states it should be used with extreme caution in conditions with increased risk of hemorrhage. The January TAR again showed physician‑ordered monitoring interventions related to blood‑thinning medications, but the comprehensive care plan did not identify any problem, goal, or interventions related to anticoagulant therapy or bleeding risk. The Kardex and an undated care guide did not identify the resident’s use of blood‑thinning medications. During interview, this resident reported receiving a daily blood‑thinner injection in the abdomen and experiencing bruising at the injection site. Staff interviews revealed that NAs rely on care guides and Kardexes, which did not list blood‑thinner use, and that the nurse manager and DON were unaware or unable to explain the need to address blood‑thinning medications and associated bleeding risk in the care plans. The facility’s care planning policy lacked specific guidance requiring identification and care planning of high‑risk medications and routes, and therefore did not ensure foreseeable risks such as bleeding from blood‑thinning medications were addressed through individualized care plan interventions.