Citations in Minnesota
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Minnesota.
Statistics for Minnesota (Last 12 Months)
Financial Impact (Last 12 Months)
Some of the Latest Corrective Actions taken by Facilities in Minnesota
- Provided comprehensive nurse education on medication administration and transcription, the five rights, label–order matching, and protocols for pharmacy/physician clarification (J - F0760 - MN)
- Delivered training on medication types, high-risk drugs, error prevention, and national safety standards (J - F0760 - MN)
- Initiated ongoing compliance audits of medication practices (J - F0760 - MN)
Failure to Follow Five Rights of Medication Administration Leads to Significant Methadone Overdose
Penalty
Summary
Facility staff failed to follow the five rights of medication administration for a resident with multiple complex medical conditions, including Multiple Sclerosis, paraplegia, and chronic pain. The staff did not compare the written order on the Medication Administration Record (MAR) with the prescription label on the Methadone bottle before administration. As a result, the resident received five times the prescribed dose of Methadone over the course of three days, totaling nine incorrect administrations. The error occurred because staff administered Methadone based on outdated or incorrect information, specifically using the concentration and dosing instructions from a discontinued medication bottle rather than the current prescription. Multiple nurses, including agency staff, RNs, and LPNs, administered the incorrect dose, each failing to verify the medication concentration and dosage as indicated on the new prescription bottle. The MAR and narcotic record contained conflicting information, and staff relied on these records without cross-checking the actual medication label, leading to repeated overdoses. The resident experienced a significant decline following the medication errors, including impaired speech, inability to verbalize needs, decreased oral intake, lethargy, and increased weakness. Observations and interviews with staff and the resident's significant other confirmed these changes, noting that the resident was previously able to speak and eat but became largely nonverbal and unable to tolerate food or oral medications after the errors. The medication error was discovered during a medication count, and subsequent interviews revealed that staff had not recognized the change in medication concentration or the impact of the error until the resident's condition had significantly deteriorated.
Removal Plan
- Provide education to nurses on medication administration and transcription, the five rights of medication administration, ensuring medication labels match physician orders, and contacting pharmacy or physician for clarification.
- Educate all nurses on medication types, prevention of errors, high risk medications, and compliance with national safety standards.
- Review pain medication management for accuracy and ensure the label on the bottle matches the physician order in the medical record.
- Review orders and liquid medication labels for all like residents to ensure labels on bottles match the orders in the medical record.
- Initiate compliance audits.
Latest Citations in Minnesota
Surveyors found that kitchen staff failed to properly clean a commercial can opener and did not sanitize a food thermometer between checking different food items, using a dirty washcloth instead of alcohol wipes or sanitizing solution. The culinary director and DON confirmed these were infection control issues and not in line with facility policy.
Staff did not consistently remove PPE or perform hand hygiene before exiting rooms for residents on enhanced barrier precautions, and housekeeping staff failed to change gloves and sanitize hands between cleaning different rooms. During meal assistance, nursing assistants did not perform hand hygiene between helping multiple residents, and in one case, used bare hands to assist with eating. These actions were not in line with facility policies or infection prevention expectations.
A resident with dysphagia, cognitive impairment, and a history of choking incidents did not have speech therapy recommendations or physician orders for safe swallowing—such as upright positioning, crushing medications, and specific eating techniques—incorporated into their care plan. Despite staff and family being aware of the swallowing difficulties and receiving education, the care plan was not updated to reflect these critical interventions.
A resident with multiple medical conditions and total assistance needs for transfers experienced delays in receiving incontinence care after requesting help, resulting in discomfort and distress. Staff did not promptly respond to the resident's request, and there was a lack of awareness and implementation of the resident's care plan and toileting preferences. The incident demonstrated a failure to provide care in a respectful and dignified manner as required by facility policy.
The facility did not follow physician orders for daily monitoring of heart failure symptoms for a resident, omitting required assessments and documentation of lung sounds, edema, and oxygen saturations. Additionally, another resident with multiple comorbidities developed a wound on the right great toe that was not comprehensively assessed or documented, with missing wound descriptions and measurements, and the wound was not entered into the wound management system as required by facility policy.
A resident with chronic respiratory failure and hypoxia was not provided continuous oxygen therapy as ordered, resulting in a significant drop in oxygen saturation and observable respiratory distress. Staff confirmed the oxygen was not turned on, and there was no documentation of the incident or the resident's low oxygen levels in the medical record, despite facility policy and physician orders.
A resident with chronic pain and multiple diagnoses did not receive consistent pain assessment and monitoring, as pain ratings and locations were often missing from documentation when PRN pain medications were given. The resident reported ongoing severe pain and lack of follow-up after medication administration, and staff interviews confirmed gaps in pain assessment and documentation, resulting in a deficiency related to pain management.
A resident with a missing front tooth and oral health issues did not receive follow-up for a dental referral or recommended use of an over-the-counter fluoride rinse, despite documented recommendations and facility policy. Staff interviews revealed a lack of awareness and action regarding these dental care needs.
A resident with Parkinson's disease and moderate cognitive impairment, who required assistance for transfers, was left unattended during a transfer by a nursing assistant. The resident attempted to turn near a nightstand, became entangled, and fell, resulting in a femur fracture. The care plan did not clearly specify the required level of assistance prior to the incident, and staff did not follow the established plan of care.
Multiple residents with significant care needs experienced prolonged call light response times, sometimes waiting over an hour or more for assistance with toileting, hygiene, and mobility. These delays, caused by insufficient staffing and staff being pulled to other duties, led to actual harm for a resident with multiple sclerosis and anxiety, who waited nearly three hours for incontinence care and experienced increased distress and feelings of helplessness. Other residents also reported emotional distress and incontinence episodes due to delayed responses.
Failure to Maintain Sanitary Food Preparation Practices and Equipment
Penalty
Summary
The facility failed to maintain proper sanitation and infection control practices in the main production kitchen, as evidenced by observations of a commercial can opener and food thermometer. The can opener blade was found with dark tan, black, and red debris caked along its surface during two separate observations, and the culinary director confirmed the buildup, stating the can opener was only washed three to four times a week and was unsure of the last cleaning. The director acknowledged that a dirty blade posed a risk for cross-contamination and that it should be cleaned daily. Additionally, a cook was observed using a moist, stained washcloth to wipe a food thermometer between checking different food items, rather than using alcohol wipes or a sanitizing solution as required by facility policy. The cook admitted to never using alcohol wipes and instead would use a clean washcloth to prevent cross-contamination. The culinary director confirmed this was not the facility's procedure and that proper sanitization was necessary. The director of nursing also identified these practices as infection control issues. Facility policies required all food contact surfaces and utensils to be properly washed and sanitized, and specifically stated that thermometers should be sanitized between each food item.
Infection Control Deficiencies in PPE Use, Housekeeping, and Dining Assistance
Penalty
Summary
Staff failed to consistently follow infection prevention and control protocols in several areas of care. For residents on enhanced barrier precautions (EBP), staff did not remove personal protective equipment (PPE) or perform hand hygiene before exiting resident rooms. In one instance, a nursing assistant exited a resident's room wearing a gown and gloves, cleaned a mechanical lift in the hallway, and only then removed PPE and performed hand hygiene. Another nursing assistant removed gloves but not the gown before leaving a resident's room, carrying the gown down the hallway before being corrected by a nurse. Interviews with staff and the infection preventionist confirmed that PPE should be removed and hand hygiene performed before leaving rooms under EBP, but the facility's policy did not clearly specify this requirement for EBP, only for contact precautions. Housekeeping staff also failed to change gloves and perform hand hygiene between cleaning different resident rooms. One housekeeping aide was observed wearing the same gloves while cleaning two separate rooms, handling cleaning equipment, and touching environmental surfaces without changing gloves or sanitizing hands. The director of environmental services and the infection preventionist both stated that gloves should be changed and hand hygiene performed between rooms to prevent cross-contamination, in accordance with facility policy. During meal assistance, nursing assistants did not perform hand hygiene between assisting multiple residents. Staff were observed using the same hand to feed and wipe the mouths of two different residents without sanitizing hands in between, and in one case, a staff member used their bare hands to assist a resident with eating. Staff interviews confirmed awareness of the need for hand hygiene before and after meal assistance, but there was confusion about procedures when assisting more than one resident at a time. The facility's feeding policy required hand hygiene before and after assisting with eating but did not address hand hygiene between residents when assisting multiple individuals.
Failure to Update Care Plan with Swallowing Safety Interventions
Penalty
Summary
The facility failed to update and implement a comprehensive care plan to address a resident's swallowing difficulties and risk of choking, despite multiple documented incidents and professional recommendations. The resident had a history of unspecified tremor, partial digestive tract removal, oropharyngeal dysphagia, and cognitive impairment, and required set-up assistance with meals. Although the resident was observed to have difficulty swallowing medications, resulting in coughing and choking episodes, the care plan only included a general intervention for eating set-up and did not reflect the specific risks or interventions needed for safe swallowing. Speech therapy evaluated the resident and provided detailed recommendations, including crushing medications, upright positioning during and after meals, slow eating, small bites and sips, thorough chewing, and specific swallowing techniques. These recommendations, as well as the physician's order to crush medications, were not incorporated into the resident's care plan or the nursing assistant care guide. Interviews with staff and family confirmed awareness of the resident's swallowing issues and the education provided, but the care plan remained incomplete, lacking the necessary interventions to address the identified risks.
Failure to Provide Dignified and Timely Incontinence Care
Penalty
Summary
A deficiency occurred when staff failed to address a resident's need for incontinence assistance in a respectful and dignified manner. The resident, who had intact cognition and multiple diagnoses including cancer, anemia, hypertension, diabetes, psychotic disorder, and COPD, was always incontinent of bowel and bladder and required extensive assistance for toileting and total assistance for transfers using a full body mechanical lift. The resident's care plan directed staff to check and change her and/or offer a bed pan at specific times and as needed, but documentation showed the bowel toileting program was inconsistently followed, with the program only implemented one day during a reference week. On the day of the observed incident, the resident requested assistance after an incontinence episode following breakfast. Multiple staff entered and exited the room, assisting the roommate and performing other tasks, but did not promptly address the resident's request for incontinence care. The resident waited for an extended period, expressing discomfort and distress about her situation. Staff interviews confirmed that the resident required assistance of two for transfers and that she did not like using the bed pan due to discomfort. Although the use of a commode had been discussed, it had not been trialed, and staff were not fully aware of the resident's preferences or continence needs. Interviews with nursing staff and administration revealed a lack of awareness regarding the resident's toileting preferences and the implementation of her care plan. Staff responses indicated that assistance was provided after other tasks were completed, and there was no clear communication or prioritization to meet the resident's needs in a timely manner. The facility's policy required residents to be treated with respect and dignity, but the observed delay and lack of individualized care did not align with these expectations.
Failure to Monitor Heart Failure and Document Skin Wound Assessment
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and resident needs for two residents. For one resident with a known history of heart failure and peripheral vascular disease, the discharging hospital physician had directed staff to monitor for signs of heart failure daily, including assessments of lung sounds, peripheral edema, and oxygen saturations at rest and with activity. However, the resident’s electronic medical record lacked any documentation or orders for these assessments, and there was no evidence that staff routinely monitored or documented lung sounds or edema. Oxygen saturations were checked daily, but it was not specified whether these were measured at rest or with activity. Interviews with nursing staff and the assistant director of nursing confirmed that the required monitoring and documentation were not in place, despite the hospital’s explicit instructions. For another resident with multiple comorbidities including heart failure, liver cirrhosis, and polyneuropathy, the facility failed to comprehensively assess and document a non-pressure skin condition on the right great toe. Although the care plan and skin risk assessments required regular skin checks and documentation of any new wounds, the records did not include a description or measurements of the wound when it was first identified. Progress notes referenced a sore and dressing changes, but lacked detailed physical descriptions or measurements. The wound was not entered into the facility’s wound management system as required by policy, and there was no consistent tracking or documentation of the wound’s status over time. Interviews with nursing staff, the assistant director of nursing, and the nurse practitioner revealed that the wound was not properly documented or tracked according to facility policy. The facility’s skin integrity policy required that new wounds be documented in the wound management area with specific details, but this was not done. As a result, the wound’s progression could not be adequately monitored, and there was insufficient information to ensure timely and appropriate interventions.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
A deficiency occurred when a resident with chronic respiratory failure, hypoxia, and other significant health conditions was not provided oxygen therapy as ordered by the physician. The resident had orders for continuous oxygen via nasal cannula at 2 to 4 liters per minute to maintain oxygen saturation above 90%. Multiple observations revealed that the resident's oxygen tank was not turned on while the nasal cannula was in place, and the resident was found with rapid, labored breathing and an oxygen saturation as low as 69%. Staff confirmed the oxygen was not on and that the resident required continuous oxygen. The oxygen was subsequently turned on and the flow rate increased, resulting in improved oxygen saturation. The resident's electronic medical record did not contain documentation of the incident or the drop in oxygen saturation below 90%. Additionally, a safety event was recorded as a medication incident, but lacked vital signs and progress notes. Interviews with staff indicated that nursing assistants were responsible for switching oxygen tanks, while nurses were responsible for monitoring oxygen saturation and flow rates. The nurse manager and DON confirmed that there was no documentation of the incident in the medical record, despite facility policy requiring oxygen to be administered per order.
Failure to Appropriately Monitor and Assess Pain Complaints
Penalty
Summary
The facility failed to appropriately monitor and comprehensively assess pain complaints for a resident with a complex pain history. The resident had diagnoses including fibromyalgia, chronic pain, diabetes, neuropathy, restless leg syndrome, depression, and psychotic disorder, and was prescribed both scheduled and PRN pain medications, as well as non-pharmacological interventions. The resident's care plans and assessments indicated frequent pain that affected sleep and daily activities, and the resident was able to verbalize pain and pain relief. Despite these interventions, documentation and monitoring of pain were inconsistent. Review of the resident's medication administration records and progress notes revealed that pain ratings and pain locations were often missing when PRN pain medications were administered. Specifically, several instances were noted where pain ratings or locations were not documented, and there was a lack of follow-up after pain medication administration. Additionally, the resident reported ongoing severe pain, rating it as eight or nine out of ten, and stated that pain medications were not effective and that nurses did not return to reassess pain after administration. Staff interviews confirmed that pain assessments were not always completed or documented as required, and follow-up on resident complaints was lacking. The facility's pain management policy required ongoing pain assessment, documentation of pain characteristics, and monitoring the effectiveness of interventions. However, the records showed that pain assessments were not consistently performed or documented, and there was insufficient evidence of comprehensive pain monitoring. This failure to follow policy and ensure thorough pain assessment and documentation led to the deficiency identified during the survey.
Failure to Follow Up on Dental Referral and Oral Care Recommendations
Penalty
Summary
The facility failed to ensure that a routine dental referral and recommended oral care interventions were followed for a resident who was cognitively intact and required supervision with oral hygiene. The resident had a history of broken natural teeth, inflamed and bleeding gums, and was self-conscious about a missing front tooth. A dental assessment recommended direct staff supervision for oral care, use of an over-the-counter fluoride rinse twice daily, and a dental referral to repair or replace the missing tooth. However, the resident's care plan did not include interventions for the fluoride rinse, and there were no active orders or documentation indicating the resident was using the rinse or that the dental referral was followed up on. Interviews with facility staff revealed a lack of awareness and follow-through regarding the dental recommendations. The social services designee was unaware if the resident had been scheduled for a follow-up dental appointment, and the Health Information Director (HID) confirmed that the referral for dental repair was not acted upon. The HID also stated that he was responsible for reviewing dental forms and following up on recommendations but had not done so in this case. The registered nurse was similarly unaware of the recommendations for the fluoride rinse and dental follow-up. Facility policy required assistance in obtaining routine dental care, but this was not provided as required for the resident.
Failure to Provide Adequate Supervision and Assistance During Resident Transfer Resulting in Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with Parkinson's disease, depression, and anxiety, who was at risk for falls, did not receive adequate supervision and assistance during a transfer. The resident's physical therapy evaluation indicated a need for contact guard assistance for transfers, and the admission Minimum Data Set (MDS) documented a requirement for supervision or touching assistance. However, the resident's care plan did not specify the required level of transfer assistance, and the nursing assistant care sheet indicated assist of one with a gait belt and walker. On the day of the incident, the resident was being assisted in her room by a nursing assistant who placed a gait belt on her and allowed her to stand near the nightstand to brush her hair. The nursing assistant then left the resident unattended to retrieve her walker. During this time, the resident attempted to turn, became entangled with the nightstand, lost her balance, and fell, resulting in a right femur fracture. The staff member was not within close reach to prevent the fall. Interviews with staff confirmed that the resident was supposed to be assisted by one staff member with a gait belt and walker for transfers and ambulation, but the care plan had not been updated to reflect this until after the fall. The facility's fall management policy required interventions to be implemented through a resident-centered plan of care, but the lack of clear documentation and failure to follow the established plan of care contributed to the incident.
Failure to Provide Sufficient Staffing Results in Prolonged Call Light Response Times and Resident Harm
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in prolonged call light response times for multiple residents. Several residents, including those with significant physical and psychosocial needs, experienced extended waits for assistance, sometimes exceeding one to three hours. These delays were documented through call light logs and corroborated by resident interviews, which described repeated instances of unmet needs for toileting, hygiene, and mobility assistance. Staff interviews confirmed that inadequate staffing levels, particularly when only two nursing assistants were present instead of the expected three, contributed to the inability to respond to call lights in a timely manner. One resident with multiple sclerosis, anxiety, depression, and a history of trauma was left waiting for nearly three hours for incontinence care, leading to increased anxiety, distress, and feelings of helplessness. This resident was dependent on staff for transfers and personal care, and her care plans emphasized the importance of timely assistance to prevent urinary tract infections and support her psychosocial well-being. Despite these documented needs, call light logs showed frequent delays, and the resident reported feeling unsafe and emotionally affected by the lack of prompt care. Other residents with conditions such as Parkinson's disease, functional quadriplegia, and pressure ulcers also experienced similar delays, sometimes resulting in incontinence episodes and emotional distress. Staff interviews revealed that the shortage of nursing assistants made it difficult to answer call lights promptly, especially during times when staff were pulled to cover other duties or when scheduled staff left due to illness. Residents and their representatives described feelings of helplessness, frustration, and loss of dignity due to the prolonged waits. The facility's own grievance logs and staff acknowledged the negative impact of these delays on residents' psychosocial well-being, including increased anxiety and diminished trust in staff. The documented call light response times and resident accounts demonstrate a pattern of insufficient staffing leading to unmet resident needs.
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