St Marks Living
Inspection history, citations, penalties and survey trends for this long-term care facility in Austin, Minnesota.
- Location
- 400 15th Avenue Southwest, Austin, Minnesota 55912
- CMS Provider Number
- 245369
- Inspections on file
- 26
- Latest survey
- March 2, 2026
- Citations (last 12 mo.)
- 6 (1 serious)
Citation history
Health deficiencies cited at St Marks Living during CMS and state inspections, most recent first.
The facility failed to ensure safe mechanical lift transfers and comprehensive fall analysis for multiple residents. A resident with multiple comorbidities and a high fall risk, who required 2-person assist and a large harness with a sit-to-stand lift, previously fell from the lift when a NA transferred the resident alone; the incident was not fully assessed for sling size or used to revise the care plan for the resident’s tendency to fall asleep in the lift. Later, two NAs attempted to transfer this resident using an XL harness instead of the ordered large size and initially did not cinch the torso strap until prompted by a surveyor, despite staff acknowledging that failure to cinch could allow a resident to fall. Another resident assessed as needing a large sling for a total lift was found sitting on an XL sling, with the care plan and Kardex conflicting with the sizing assessment, and staff relying on outdated paper guides. A third resident with brain cancer and prior falls had multiple falls where root cause analysis forms were incomplete or not linked to specific, timely interventions, and care plan changes (such as toileting programs and equipment changes) were delayed or not clearly tied to identified causes.
The facility failed to provide ongoing comprehensive RN assessment and individualized pressure-relief interventions for three residents at risk for or with pressure ulcers. One resident with MS and multiple comorbidities developed a facility-acquired stage 2 sacral ulcer that progressed to stage 3 while weekly skin assessments lacked detailed wound characteristics, repositioning orders were not reassessed, staff relied on the resident to self-reposition in a wheelchair, and a prescribed foam dressing was omitted from transcribed orders. A second resident with multiple serious diagnoses and buttock scarring had incomplete wound documentation, was found on a deflated air mattress with an improperly placed foam dressing, and developed a new open right-buttock wound. A third resident with a stage 2 buttock ulcer had orders for frequent offloading, but there was no documented reassessment of repositioning frequency, and wound assessments were minimal and inconsistent. Staff interviews and facility policy review showed that required weekly comprehensive RN wound assessments, including accurate staging, measurements, and evaluation of pressure-relief measures, were not being completed for residents with pressure ulcers.
A resident with complex cardiac and renal conditions was given another resident’s full set of morning medications when an agency TMA entered the wrong room and failed to verify identity or follow the rights of medication administration, leading to unresponsiveness, hypotension, and acute kidney injury requiring hospitalization. During observation of other medication passes, an RN misread an order for an oral antifungal as “swish and spit” instead of the ordered “swish and swallow,” and another resident with heart failure, Parkinson’s disease, dementia, and hospice services received an extra scheduled dose of lorazepam when a TMA assumed there was a PRN order and did not verify the MAR. Multiple TMAs and an RN demonstrated incomplete understanding of the rights of medication administration, and medication pass audits and competencies had been performed by an unlicensed administrator without formal medication training and by LPNs, despite facility policy requiring verification of resident identity and triple-checking the right resident, medication, dose, time, and route.
The facility’s QAPI committee consistently collected monthly data on falls, pressure ulcers, and medication errors but did not perform root cause analyses, prioritize high-risk or recurring issues, develop PIPs, or document action plans or follow-up. During this period, multiple falls occurred, including one involving improper use of a sit-to-stand lift harness after a prior lift-related fall, and another resident’s falls were not comprehensively investigated or addressed with targeted interventions. A resident sustained actual harm when given another resident’s medication, leading to unresponsiveness, hypotension, hospitalization, and acute kidney injury. Three residents with pressure ulcers were not adequately monitored or assessed, and one developed a sacral Stage 2 ulcer that progressed to Stage 3. The medical director and administrator acknowledged that QAPI meetings focused on data review without documented discussion, analysis, or implementation of action plans, despite the facility’s written QAPI plan requiring such activities.
A resident with multiple serious diagnoses, including CHF, CKD, Afib, and a history of syncope, experienced a brief syncopal episode during a transfer when a TMA assisted the resident to stand with a gait belt. The resident went limp, was lowered back into a recliner, then became alert and responsive, and nursing staff, including two LPNs and an RN manager, responded. Although staff acknowledged this was a change in condition that required documentation and provider notification, one LPN did not obtain vital signs, did not notify the provider, and did not write a nursing note, and there was no documentation that the physician was notified at the time of the event. The DON and the MD both later stated the provider should have been notified immediately, and the facility’s change of condition policy required physician notification for status changes.
A resident with heart failure, prior mini-strokes, and on anticoagulant therapy was mistakenly given another resident’s medications by a TMA, after which the resident became unresponsive and was sent to the ED. Although an incident report and a brief progress note were completed, the LPN who repeatedly assessed the resident and obtained multiple sets of vital signs after the error did not document these assessments or vital signs in the EHR. This lack of documentation conflicted with facility policy requiring complete, accurate, and objective charting of services provided, changes in condition, and events or incidents involving the resident.
The facility did not comprehensively assess or monitor non-pressure related skin injuries for three residents, including a resident on anticoagulant therapy who developed significant bruising after hitting bed rails, and two residents who sustained bruises and hematomas after falls. Care plans were not updated to reflect new injuries, protective interventions were not implemented or documented, and ongoing monitoring and physician notifications were lacking, contrary to facility policy and professional standards.
The facility failed to properly assess and address fall risks for three residents, including not updating care plans, not completing root cause analyses, and not ensuring interventions such as call light accessibility and staff assistance were implemented. In one case, a resident with dementia and a history of falls continued to self-transfer without staff intervention, while another resident's call light was left out of reach, preventing them from requesting help. Documentation and monitoring of interventions were incomplete or inaccurate, resulting in repeated deficiencies in fall prevention.
A resident with urinary retention and other comorbidities suffered harm after an LPN inserted a larger indwelling catheter without confirming urine return, inflated the balloon in the urethra, and failed to monitor for complications. The resident experienced pain, hematuria, and a urinary tract infection, requiring hospitalization. Staff did not follow proper catheter protocols, failed to document physician orders, and did not assess or monitor the resident after the procedure.
Staff did not consistently use gowns and gloves for high-contact care activities or perform proper hand hygiene for several residents with wounds, catheters, or other conditions requiring enhanced barrier precautions. Despite posted signage and facility policy, staff were observed providing care and moving between residents without following required infection prevention protocols.
A resident with advanced dementia and malnutrition, dependent on staff for eating, was left sitting unattended with her meal for an extended period while staff intermittently assisted her and prioritized other tasks. Staff and facility leadership acknowledged that best practice is to sit and engage with residents needing assistance during meals to ensure dignity and respect.
A resident with multiple chronic conditions had significant gaps in their medical record, including missing physician orders, hospital discharge summaries, and outpatient provider notes. Staff interviews revealed inconsistent processes for obtaining and uploading external medical records, with some nurses lacking access and the HUC depending on nursing staff to provide documents. The facility's EHR policy did not outline procedures to ensure records were complete and accurate, resulting in incomplete documentation.
Improper Mechanical Lift Use and Inadequate Fall Root Cause Analysis
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe use of sit-to-stand and total body mechanical lifts, including correct sling/harness sizing, proper strap application, and adherence to care plans and manufacturer instructions. One resident (R4), with diagnoses including heart failure, chronic kidney disease, pancreatic cancer, diabetes, osteoarthritis, and a history of falls, was assessed as high fall risk and required assistance of two staff with a sit-to-stand lift using a large harness for all transfers. Despite this, on a prior date R4 experienced a witnessed fall from a sit-to-stand lift when a nursing assistant transferred the resident alone, contrary to the care plan, and the resident slipped out of the harness and fell to the floor, later reporting left shoulder pain. The facility’s documentation of that incident did not identify the sling size used, did not show a comprehensive assessment to determine the correct sling size for subsequent transfers, and the care plan was not revised to address the resident’s tendency to fall asleep in the lift. On a later observation, two nursing assistants (NA-C and NA-D) prepared to transfer R4 from bed to shower chair using a sit-to-stand lift with an extra-large (XL) harness draped over the lift, which they both believed was the correct size. Neither had a resident care guide in the room identifying the correct harness size. After the surveyor intervened and prompted verification, NA-D checked the resident care guide and discovered R4 was supposed to use a large harness, not an XL, and had to obtain the correct size from another unit because it was not available on R4’s wing. During the same transfer, after the large harness was applied and R4 was raised to standing, the torso strap was not cinched until the surveyor intervened and instructed the staff to tighten it. NA-C acknowledged she knew the torso strap needed to be cinched as the resident stood and that failure to do so could allow a resident to fall out of the lift, but stated she had overlooked this step. Staff also reported they had not received any re-education on proper mechanical lift use or following care plans since initial orientation. A second resident (R9), with diagnoses including heart failure, chronic respiratory failure, and chronic kidney disease, required total mechanical lift transfers and had been assessed via a sling/harness sizing assessment as needing a large sling. However, the resident’s care plan and Kardex directed staff to use an XL sling, conflicting with the sizing assessment. During observation, R9 was seated in a wheelchair on top of a sling whose size markings were washed off; a trained medication aide identified the sling as XL based on its color coding and confirmed via the Kardex that the resident was supposed to be in a large sling. The aide stated the resident could have fallen out of the oversized sling. The DON later confirmed that staff had been using the paper nurse aide care guide to verify sling size and that R9 had not been transferred with the correct sling size. The facility also failed to comprehensively investigate and analyze falls for root cause and to implement appropriate, person-centered interventions for another resident (R3) with malignant brain neoplasm, heart failure, osteoporosis, moderate cognitive impairment, and a history of falls. R3’s fall care plan included general interventions such as following the fall protocol, routine safety checks, anticipating needs, and reviewing past falls to determine causes, but subsequent fall incident documentation and root cause analysis worksheets were incomplete or lacked clear causal analysis and corresponding interventions. After an unwitnessed bathroom fall assisted by a family member, the root cause section was left blank, and the only care plan revision was to encourage family not to transfer the resident and to ask staff for assistance. Later falls, including one where the resident was found on the bathroom floor without a walker and another where the resident independently walked to the bathroom and lost balance, identified factors such as brain cancer, weakness, and self-transfers, but did not show comprehensive analysis or immediate interventions to mitigate further falls. One intervention, placing a dycem mat in the wheelchair seat, lacked a documented rationale linked to the identified causal factors. The DON acknowledged that comprehensive causal analyses had not been completed for each of R3’s falls and that toileting, identified as a root cause, was not addressed in the care plan until several days after repeated falls. The immediate jeopardy began when NA-C and NA-D had to be stopped from using the wrong harness size for R4 and failed to cinch the torso strap during a sit-to-stand transfer, despite R4’s prior fall from a sit-to-stand lift and existing care plan requirements. The medical director stated that any resident being transferred using a mechanical lift without the care plan and/or policy being followed had the likelihood to cause serious harm, serious injury, or death in the event of a fall from the lift.
Removal Plan
- The facility identified all residents who use a sit-to-stand lift, assessed each resident for the correct harness size needed, and educated each member of the nursing staff who will or may use the sit-to-stand lift.
- The facility assessed R4 and all residents using mechanical lifts for proper transfer method, correct sling/harness size, and care plan accuracy.
- The facility verified sling/harness size for each resident through therapy documentation, direct measurement, manufacturer guidelines, and care plan accuracy.
- The facility reviewed and updated the mechanical lift transfer policy to require sling/harness size documented in the care plan and Kardex, require 2-assist transfers when indicated, require staff verification of sling size prior to transfer, and require cinching of waist/middle straps before elevation.
- The facility updated care plans to specifically identify type of lift, assist level, and sling/harness size.
- The facility updated the Kardex to match the care plan.
- The facility updated care sheets to match the care plan.
- The facility provided education to all licensed nurses and other certified individuals on manufacturer recommendations, proper sling application, proper strap placement and cinching, when sit-to-stand lifts are contraindicated, and always following the care plan.
Failure to Provide Comprehensive Pressure Ulcer Assessment and Pressure-Relief Interventions
Penalty
Summary
The deficiency involves the facility’s failure to provide comprehensive, ongoing assessment and individualized pressure-relief interventions for residents at risk for or with pressure ulcers, resulting in actual harm to one resident whose facility-acquired stage 2 pressure ulcer deteriorated to stage 3. For one resident with multiple sclerosis, diabetes, heart failure, neurogenic bladder and bowel, and chronic kidney disease, the Braden assessments identified moderate risk and the care plan called for heel elevation, pressure-reducing surfaces, and turning/repositioning in bed and chair. Despite repeated weekly skin assessments documenting “redness to bottom/skin breakdown” over several weeks, these assessments lacked wound location, measurements, type, or other characteristics. When a stage 2 pressure ulcer on the left buttock was first documented, there was a delay in obtaining a specific wound treatment order, and once ordered, subsequent skin assessments continued to list the wound as a stage 2 ulcer with unchanged measurements and minimal description, even after a nurse practitioner later documented that the ulcer had progressed to stage 3 with detailed measurements and wound characteristics. From the time the stage 2 ulcer was identified until the nurse practitioner documented stage 3 status, the record did not show that existing pressure-relief interventions were evaluated for effectiveness or that new interventions were added. The resident’s repositioning schedule in bed and chair was not reassessed for appropriateness, and there was no comprehensive assessment of skin tolerance to pressure over time. Staff interviews revealed that direct care staff were unaware of the ordered frequency for repositioning in the wheelchair and relied on the resident to self-reposition, even though the resident reported sometimes being unable to feel when her buttocks were getting sore due to MS and sometimes forgetting to reposition. The resident’s ROHO cushion had been placed backwards on multiple occasions, and the resident stated that this worsened her bottom when not placed correctly. Documentation also showed that a foam dressing ordered by the nurse practitioner was omitted from the transcribed treatment orders, and treatments were carried out without the foam dressing, while weekly skin assessments continued to record the wound as a healing stage 2 ulcer with the same measurements and no detailed characteristics. Two additional residents with buttock wounds and pressure injury risk also did not receive weekly comprehensive RN wound assessments as required by facility policy. One resident with heart failure, chronic kidney disease, pancreatic cancer, diabetes, and a history of falls had old scarring on the buttocks and was admitted with a buttock wound. Orders were in place for foam dressings and daily assessment, and a nurse practitioner later identified a stage 2 pressure injury to the left medial buttock and incontinence-associated dermatitis with multiple small open wounds. However, subsequent skin assessments lacked full wound descriptions, did not address all wounds identified by the nurse practitioner, and there was a period where no comprehensive wound assessment was documented. During observation, this resident was found lying on a completely deflated, unplugged air mattress with no other barrier between the bedframe and mattress, and staff were unsure how long the mattress had been deflated or when the resident was last repositioned. A new open wound was observed on the right buttock with macerated edges and a foam dressing stuck to the brief instead of the wound. Another resident with heart failure, chronic respiratory failure, and chronic kidney disease had a documented stage 2 pressure ulcer on the left buttock and was assessed as moderate risk on the Braden Scale. The care plan called for turning and repositioning every two hours in bed and chair, pressure-relieving surfaces, and laying the resident down between meals to offload the buttocks. A nurse practitioner ordered a silicone bordered foam dressing and frequent repositioning/offloading, but there was no documentation of a comprehensive assessment to determine the appropriate repositioning frequency or any revision of the existing every-two-hour schedule. Serial skin assessments showed the wound measurements remaining the same for several weeks with minimal description, and when the wound later deteriorated with increased size, the assessment still lacked detailed wound characteristics. A separate weekly wound observation tool documented a stage 2 pressure ulcer with different measurements, indicating inconsistent documentation. Interviews with nursing staff and management confirmed that weekly comprehensive RN wound assessments were not being performed for residents with pressure ulcers, that staff were unclear about who was responsible for staging and comprehensive assessment, and that the DON later recognized that required RN comprehensive assessments, including full wound descriptions and evaluation of pressure-relief measures, had not been completed for these residents. Overall, the deficiency centers on the facility’s failure to ensure that residents with or at risk for pressure ulcers received consistent, comprehensive RN wound assessments, accurate staging and measurement, timely and correctly transcribed treatment orders, and individualized reassessment of pressure-relief interventions. This failure was evidenced by incomplete and inaccurate skin assessments, lack of documented evaluation of repositioning schedules and pressure-relief devices, staff unawareness of ordered repositioning frequencies, improper use of pressure-relieving equipment such as ROHO cushions and air mattresses, and the absence of weekly comprehensive RN wound assessments despite facility policy requiring them.
Significant Medication Error and Multiple Medication-Pass Failures
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors by not adhering to the rights of medication administration. One resident with diagnoses including heart failure, transient cerebral ischemic attacks, renal insufficiency/failure, and use of anticoagulants was inadvertently given another resident’s full set of morning medications by a trained medication aide (TMA) who was agency staff and unfamiliar with the resident. The TMA prepared medications for the intended resident, verified that resident’s picture and room number in the EHR, but then entered the wrong room and did not verify the room number or the resident’s identity before administering the medications. The TMA administered multiple medications not prescribed to this resident, including antihypertensives, diuretics, antiplatelet, antidepressant, anticonvulsant/mood stabilizer, diabetic medication, and others, and only realized the error when attempting to give an inhaler that the resident stated she did not take. Following administration of the wrong medications, the resident initially had stable vital signs but later became unresponsive, with no response to verbal commands and only a grimace to sternal rub, prompting transfer to the emergency department. Hospital documentation identified accidental drug ingestion, hypotension secondary to accidental drug ingestion, blurry vision, orthostatic hypotension, and an acute kidney injury with elevated creatinine. The resident experienced symptomatic orthostatic hypotension with dizziness and blurry vision on standing and required interventions such as compression wraps, abdominal binder, hydration, and titration of midodrine. The medical director considered this a significant medication error and stated that the resident’s hypotension and acute kidney injury were likely caused by receiving medications not prescribed to her. Additional deficiencies were identified in the facility’s medication administration practices for other residents. One resident with heart failure and GERD was observed during a medication pass when an RN misread an order for an oral antifungal as “swish and spit” instead of the ordered “swish and swallow,” and the RN acknowledged this as a medication error. Another resident with heart failure, Parkinson’s disease, dementia, and hospice services had an order for scheduled lorazepam 1 mg three times daily; this resident received an extra dose of lorazepam when a TMA assumed there was an as-needed order and did not verify the physician’s orders before administering the additional dose. Multiple staff interviews revealed that TMAs and an RN had incomplete or unclear understanding of the rights of medication administration, and that medication pass audits and competencies had been conducted by an administrator who was not a licensed nurse and had no formal training in medication administration, as well as by LPNs, contrary to the DON’s statement that such competencies should have been done by an RN. The facility’s own policy required verification of resident identity and triple-checking the label for right resident, medication, dosage, time, and route, which was not followed in these instances. The facility’s failure to ensure that staff consistently followed the rights of medication administration, verified resident identity, and accurately read and followed physician orders led to a significant medication error causing actual harm to one resident and additional medication errors for two other residents. Staff interviews confirmed lapses in performing the required checks and in understanding all components of the rights of medication administration, despite recent audits and competencies. The documented events show that the facility did not effectively implement its own medication administration policy, resulting in residents receiving medications that were incorrect in recipient, route, or dose.
Failure of QAPI Process to Address Falls, Med Errors, and Pressure Ulcers
Penalty
Summary
The facility failed to ensure its QAPI committee identified, investigated, analyzed, and responded to high-risk issues related to falls, medication errors, and pressure ulcers, despite consistently collecting data on these events. From May 2025 through January 2026, the facility tracked numbers of falls, pressure ulcers, and medication errors each month, but the documentation did not include root cause analyses, prioritization of high-risk or recurring issues, development of performance improvement projects, implementation of corrective actions, or monitoring of interventions for effectiveness. QAPI records for these months showed counts of falls, pressure ulcers of various stages, and medication errors, but repeatedly noted no documented discussion or action plans, and often lacked information on whether pressure ulcers were facility-acquired or present on admission. The deficiency was further evidenced by specific care failures cited under related tags. For falls and safety, staff used the wrong size harness for a sit-to-stand mechanical lift transfer for one resident after that resident had previously fallen from a sit-to-stand lift and sustained minor injuries. The facility also failed to comprehensively investigate and analyze falls for root cause and to implement appropriate interventions to prevent or reduce the risk of future falls for another resident. For medication administration, one resident experienced a significant medication error when staff did not observe the rights of medication administration and gave the resident another resident’s medication, resulting in the resident becoming unresponsive, requiring hospitalization for hypotension, and developing an acute kidney injury. For pressure ulcer care, the facility failed to monitor, comprehensively assess, and develop and implement individualized interventions to prevent or mitigate the risk of pressure ulcers and prevent deterioration for three residents reviewed for pressure ulcers. One of these residents developed a Stage 2 sacral pressure ulcer that deteriorated to a Stage 3 ulcer. Interviews with the medical director and the administrator confirmed that, although the QAPI committee met monthly and reviewed data on wounds, falls, and medication errors, there were no current action plans addressing these issues, no minutes documenting discussions over the last four quarters, and no evidence that adverse outcomes were being analyzed and acted upon as outlined in the facility’s own written QAA/QAPI plan.
Failure to Notify Physician After Resident Syncopal Episode
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of a resident’s change in condition following a syncopal episode. The resident had multiple significant diagnoses, including pneumonia, acute respiratory failure, chronic heart failure, chronic kidney disease, atrial fibrillation, and syncope, and the admission MDS indicated no cognitive deficits. On 4/3/26, a trained medication assistant (TMA-A) assisted the resident to stand with a gait belt; upon rising, the resident leaned forward, went limp, and was lowered back into a recliner. The resident then opened his eyes and spoke. TMA-A immediately called for assistance via walkie talkie, and LPN-A, LPN-B, and the RN nurse manager (RN-NM) responded. A health status note later documented that the resident had passed out for a few seconds during the transfer and that a nurse was notified and evaluated the resident. Despite this documented change in condition, there was no indication in the resident’s record that the physician was notified on the day of the event. LPN-A reported that when she entered the room the resident was alert, and she left because it was the end of her shift, stating that a provider should be updated any time a resident has a change in condition. LPN-B stated she responded to the call, found the resident alert and following commands, but did not check vital signs, did not notify the provider, and did not complete a nursing note, explaining there was a lot going on that shift; she also acknowledged that a note and provider notification should occur with a change in condition. RN-NM stated that when she entered, the resident was alert and LPN-B was obtaining vital signs, and confirmed there was no nurse’s note or provider notification documented, despite the resident not having had such an episode previously at the facility. The DON stated the provider should have been notified the day of the event because it was a significant change from baseline, and the physician later reported learning of the dizziness episode days afterward during routine rounds, stating she would have wanted immediate notification. The facility’s Change of Condition policy instructed staff to notify the physician in the event of a status change.
Failure to Document Assessments After Significant Medication Error
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete, accurate, and readily accessible medical record for a resident who experienced a significant medication error. The resident had diagnoses including heart failure, transient cerebral ischemic attacks, and use of anticoagulants, and was documented on the admission MDS as having moderate cognitive impairment and taking an anticoagulant. On the date of the incident, a progress note recorded that a trained medication aide notified the nurse that the resident had been given another resident’s medications by mistake. A medication error incident report documented that the resident had inadvertently received another resident’s medications and subsequently became unresponsive, requiring transfer to the emergency department. A later progress note described the resident as unresponsive, with eyes closed and not responding to verbal commands, and only a facial grimace in response to a sternal rub, along with recorded vital signs and the decision to call an ambulance. During interview, the LPN on duty stated that she had taken the resident’s vital signs multiple times and performed assessments after the medication error but did not enter any of these vital signs or assessments into the electronic health record. The DON confirmed that these vital signs and assessments should have been documented in the resident’s record to ensure it was complete and accurate, consistent with the facility’s Charting and Documentation Policy, which requires documentation of services provided, changes in condition, and events or incidents involving the resident, and specifies that documentation must be objective, complete, and accurate.
Failure to Assess and Monitor Non-Pressure Skin Injuries and Implement Interventions
Penalty
Summary
The facility failed to comprehensively assess and monitor non-pressure related skin impairments for three residents reviewed for injuries, and did not ensure appropriate interventions were in place to reduce bruising for a resident at risk due to anticoagulant therapy. One resident with diagnoses including heart failure, diabetes, and atrial fibrillation was on anticoagulant medication and had a care plan identifying risk for bruising. Despite documentation of a large bruise on the right upper arm after hitting bed rails, there was no evidence of ongoing monitoring or assessment of the bruise, nor were protective pads placed on the bed rails as recommended. Additionally, new bruising observed on the left forearm was not communicated to the physician, and protective sleeves were not included in the care plan or consistently used. Another resident with chronic kidney disease experienced an unwitnessed fall resulting in multiple bruises on the lower back. The initial assessment documented the presence and size of the bruises but lacked comprehensive details such as units of measurement, specific locations, and characteristics. The care plan was not updated to reflect the injuries, and there was no evidence of ongoing monitoring or documentation of the bruises' progression. Nursing staff interviews confirmed a lack of clear protocol for monitoring bruises, and the DON acknowledged that comprehensive assessments and care plan updates were not completed as expected. A third resident with a history of falls and other chronic conditions sustained a hematoma on the forehead and a skin tear after a fall. The records did not show a comprehensive assessment or ongoing monitoring of the hematoma or bruise. Observations confirmed the presence of a healing bruise, but documentation was incomplete regarding color, pain, and progression. The DON confirmed that physician notification and monitoring orders were not present in the records, and the facility's own policy requiring comprehensive skin assessments and documentation was not followed.
Failure to Assess, Implement, and Monitor Fall Prevention Interventions
Penalty
Summary
The facility failed to comprehensively assess and evaluate the causal factors for falls and did not develop or monitor the effectiveness of appropriate interventions to reduce the risk of falls for three residents. For one resident with dementia, muscle weakness, and a history of falls, the care plan required staff assistance for transfers and toileting, but the resident frequently self-transferred and toileted independently. Staff interviews revealed that the resident rarely used the call light for assistance, and staff were aware of her self-transferring but did not address it or reassess her needs. The fall investigation documentation was incomplete, with missing root cause analysis and lack of follow-up on intervention effectiveness. The care plan and fall risk assessments were not updated to reflect the resident's actual behaviors and risks, and interventions such as 'call, don't fall' signage were not appropriate for her cognitive status. Another resident with heart failure, diabetes, and atrial fibrillation, who required maximum assistance for transfers and was on anticoagulant therapy, experienced a fall resulting in minor injuries. The fall record and care plan did not include a comprehensive analysis or root cause of the fall, and the intervention implemented was limited to signage. During observation, the resident's call light was found out of reach, and the resident was unable to request assistance when needed, directly contradicting the care plan intervention to keep the call light within reach. A third resident with a history of falls and severe cognitive impairment also experienced deficiencies in the implementation of fall prevention interventions. The facility failed to ensure that identified interventions were consistently implemented and did not reassess or monitor the effectiveness of interventions after falls occurred. Across all cases, documentation was incomplete, care plans were not updated to reflect current risks and needs, and staff did not consistently follow or reassess interventions, leading to repeated deficiencies in fall prevention and supervision.
Improper Catheter Insertion and Monitoring Leads to Resident Harm
Penalty
Summary
A deficiency occurred when a resident with a history of urinary retention, diabetes mellitus, and chronic kidney disease experienced improper insertion of an indwelling urinary catheter. The resident had a care plan in place to prevent catheter-related trauma, with interventions including care per orders, proper positioning of catheter and tubing, and monitoring for signs of urinary tract infection. Despite these interventions, the resident's catheter was changed to a larger size following complaints of leakage, but the process was not properly documented or assessed. There was no physician order documented for the catheter flush or the size change, and the assessment of catheter placement and the resident's tolerance to the procedure was not completed. The nurse who inserted the new catheter did not confirm urine return before inflating the balloon, which is a critical step to ensure proper placement in the bladder. The nurse also lacked competency training for catheter insertion and was unaware of the correct procedure. After the catheter was inserted, the resident experienced significant pain, hematuria, and eventually developed a urinary tract infection. Staff failed to monitor the resident's urinary output, pain, and catheter patency following the procedure, and there was a lack of communication among staff regarding the resident's condition and the absence of urine return after catheter insertion. Subsequent medical evaluation revealed that the catheter balloon had been inflated within the urethra, causing urethral perforation, hematuria, and infection. The resident required hospitalization, intravenous antibiotics, and urology consultation. Documentation and interviews confirmed that staff did not follow proper catheter insertion protocols, did not obtain necessary physician orders, and did not perform or document ongoing assessments or monitoring after the procedure, all of which contributed to the resident's harm.
Failure to Implement Enhanced Barrier Precautions and Hand Hygiene
Penalty
Summary
The facility failed to ensure that enhanced barrier precautions (EBP), specifically the use of gown and gloves during high-contact resident care activities, were consistently implemented for residents requiring these precautions. Observations revealed that staff did not use gowns or gloves when providing care to residents with wounds, foley catheters, or other conditions necessitating EBP, despite signage indicating the need for such precautions. For example, a nursing assistant provided feeding assistance and removed clothing protectors for residents with wounds and catheters without donning the required protective equipment or performing hand hygiene before or after care. In another instance, a licensed practical nurse repositioned a foley catheter bag and applied lotion to a resident's feet, initially using only gloves and not a gown, before later donning both for a transfer. Additionally, the facility did not ensure proper hand hygiene practices were followed. Staff were observed failing to perform hand hygiene before and after direct resident contact, after removing gloves, and when moving between residents or care activities. These lapses occurred even though the facility's policies and posted signage required such practices, and both the infection preventionist and director of nursing confirmed that their expectations were for staff to adhere to EBP and hand hygiene protocols. The facility was unable to provide a copy of its Enhanced Barrier Precaution Policy when requested.
Failure to Provide Dignified Dining Experience for Non-Communicative Resident
Penalty
Summary
A resident with Alzheimer's disease and malnutrition, who was unable to communicate needs due to advanced dementia and required extensive assistance with eating, was observed during breakfast sitting at a table with other residents. The resident was not feeding herself and was intermittently assisted by a nursing assistant who stood while feeding her a spoonful of oatmeal before leaving to assist other residents. The nursing assistant returned only briefly to provide another bite before leaving again, resulting in the resident sitting unattended for an extended period with her meal in front of her. Interviews with staff confirmed that the usual practice was to sit with the resident and provide attentive, uninterrupted assistance during meals, but on this occasion, staff were passing trays and only provided sporadic help. The facility's social services director and administrator both stated that staff should sit with residents needing assistance and engage with them to ensure a dignified and respectful dining experience. The facility's policy also states that residents have the right to be treated with respect, kindness, and dignity.
Incomplete and Inaccurate Medical Records Due to Gaps in EHR Integration
Penalty
Summary
The facility failed to maintain a complete, accurate, and readily accessible medical record for a resident with a history of urinary retention, diabetes mellitus, and chronic kidney disease. Multiple gaps were identified in the resident's electronic health record (EHR), including missing physician orders for an indwelling urinary catheter, absent hospital history and physical or discharge summaries following hospitalizations, and lack of documentation from an outpatient urology visit. Staff interviews revealed uncertainty and inconsistency in the process for obtaining, reviewing, and uploading external medical records into the facility's EHR. Some nurses did not have access to outside medical records, and the health unit coordinator (HUC) relied on nursing staff to provide documents for scanning, which did not always occur. The facility's policy on electronic health records did not specify procedures for ensuring the completeness and accuracy of resident records. The director of nursing (DON) confirmed that only a portion of nurses could access external EHRs and that there was no established policy or procedure for integrating this information into the facility's records. As a result, important medical information, such as orders and provider notes, was not consistently included in the resident's chart, leading to incomplete and inaccurate documentation.
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A resident with intact cognition and multiple diagnoses, including AFib, HF, stroke, anxiety, and depression, was permitted to self-administer nebulizer treatments after staff setup without an IDT self-administration assessment. The EMR lacked documentation of the resident’s competency and safety to manage the nebulizer, including understanding the medication, following directions, operating the equipment, recognizing side effects, and storing the medication and equipment. Staff and the DON confirmed the assessment had not been completed before the self-administration order was implemented.
Failure to Assess and Monitor Antipsychotic Use: A resident with severe cognitive impairment, dementia, anxiety, and mood disorder received Risperidone for agitation and paranoia, but the EMR did not show an AIMS assessment on admission or timely target behavior monitoring. The RN case manager and DON confirmed that baseline AIMS and ongoing behavior monitoring should have been in place when the antipsychotic was started, but the resident’s record lacked measurable target behaviors and documentation of medication effectiveness.
Incomplete Care Plans for Anticoagulant Therapy and Cardiac-Related Needs: The facility failed to include key diagnoses, devices, and medication-related risks in care plans for two residents. One resident’s plan did not address Eliquis use, cardiac conditions, pacemaker presence, or condom catheter care, and another resident’s plan did not address Eliquis therapy or related bleeding-risk monitoring. The DON and RN case manager confirmed these items should have been care planned.
Failure to provide scheduled bathing and grooming assistance: Two residents with intact cognition and ADL dependence did not receive bathing as documented on a weekly schedule, and one resident also had unaddressed facial hair and greasy, unkempt hair. Records did not show consistent weekly baths, additional refusals, or reasons for missed care, and staff interviews confirmed residents were expected to receive at least weekly bathing unless they refused and that facial hair should be shaved when noticed.
A resident with intact cognition and multiple diagnoses, including BPH and stroke, had a physician order for a condom catheter at bedtime, but the EMR lacked orders or instructions for cleaning, disinfecting, monitoring, or changing the drainage bag. During observation, the bag was seen hanging in the bathroom, and an LPN, RN case manager, and DON all confirmed the absence of documented guidance for the catheter drainage bag care.
Failure to preserve dignity occurred when staff placed a brief on a cognitively intact resident who was continent of bowel and bladder. The resident stated the brief made him feel like a baby, and a NA confirmed she applied it even though he was not incontinent; RN and DON both verified the resident was continent and that briefs should not be placed on continent residents.
Failure to provide restorative ambulation and respond to a decline in mobility: A resident with dementia, weakness, chronic pain, and limited physical mobility was care planned for daily ambulation with a FWW and staff assist of 1, but the rehab record repeatedly showed ambulation as not applicable and staff interviews confirmed the task was often not done. The resident stated she could no longer walk, staff reported she had not walked for weeks and now required a sit-to-stand lift with assist of 2 for transfers, and the chart lacked an ADL decline assessment or revision of the ambulation care plan.
A resident with mild cognitive impairment, hemiplegia, hemiparesis, and limited ROM had restorative orders for PROM, stretching, and hand splints, but staff did not consistently offer or complete the interventions. Documentation showed the splints were sometimes marked not applicable instead of refused, and leg stretches were completed only a few times with no explanation for missed care. Staff interviews confirmed the restorative tasks often were not done, and the DON stated the resident’s restorative program needed to be updated.
Dirty can opener and contaminated dry storage bins: The DCS observed four labeled dry-goods bins with dirty rims, dry matter on the bin walls, and a scoop left inside a flour bin with flour on it. The attached can opener also had dry red matter on the blade, and the cook said it had been used that morning to open cream of corn for lunch. The DCS verified the findings and stated the can opener should be washed after each use and the dry bins and scoops should be kept clean.
Dignified Medication Administration Not Maintained: A resident with severe dementia, hallucinations, anxiety, PTSD, and delusional disorder was observed during med pass in the dining room. An RN attempted to administer meds by pouring them from a plastic cup into the resident’s mouth, continued despite the resident pulling away and moving her head, and then raised her voice and questioned why the resident would not take the meds after one pill was spit out and thrown on the floor. The resident stated the nurse was not being nice, and the RN left with the refused meds.
Missing Self-Administration Assessment for Nebulizer Use
Penalty
Summary
The facility failed to ensure an interdisciplinary team (IDT) assessment was completed before allowing a resident to self-administer nebulizer treatments. The resident had intact cognition and required assistance with ADLs, and diagnoses included atrial fibrillation, heart failure, BPH, stroke, malnutrition, anxiety disorder, and depression. Physician orders showed Ipratropium-Albuterol nebulizer treatments three times daily, and the EMR later included an order permitting the resident to self-administer nebulizer treatments after staff setup, but there was no evidence that an IDT self-administration assessment had been completed first. The record also lacked documentation showing the resident’s competency and safety to self-administer the nebulizer medication and treatment, including the ability to understand the medication purpose, follow directions, safely operate the equipment, recognize side effects or adverse reactions, and ensure safe administration and storage. During observation, the resident had nebulizer equipment and medication available in the room. The resident stated staff set up the medication cup and left while the treatment ran, then returned to ensure the machine was turned off; staff cleaned the nebulizer mask afterward. An LPN and RN confirmed the treatment was set up by staff, and the RN and DON stated a self-administration assessment should have been completed before the resident was permitted to self-administer medications.
Failure to Assess and Monitor Antipsychotic Use
Penalty
Summary
The facility failed to ensure that a resident receiving psychotropic medications was adequately assessed and monitored. R3’s admission MDS identified severe cognitive impairment and the need for assistance with ADLs, with diagnoses including non-traumatic brain dysfunction, unspecified dementia without behavioral, psychological, mood, or anxiety disturbances, non-Alzheimer’s dementia, anxiety disorder, and mood affective disorder. The resident’s physician orders included Risperidone 0.25 mg, two tablets by mouth every four hours PRN for agitation and paranoia, with a maximum of three PRN doses in 24 hours, and Risperidone 0.5 mg, one tablet by mouth three times daily for paranoia/agitation. R3’s EMR did not show that an AIMS assessment was completed upon admission despite the resident receiving antipsychotic medication, and the assessment was only completed after surveyor request. The record also lacked evidence that target behavior monitoring had been initiated for the antipsychotic use, with no measurable target behaviors documented, including frequency, duration, severity, precipitating factors, or response to interventions for agitation and paranoia. Interviews with the RN case manager and DON confirmed that AIMS assessment and behavior monitoring should have been completed upon admission or initiation of antipsychotic medications, and both acknowledged that target behavior monitoring had not been initiated.
Incomplete Care Plans for Anticoagulant Therapy and Cardiac-Related Needs
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents with significant medical conditions and medication-related needs. One resident had intact cognition and diagnoses including atrial fibrillation, heart failure, BPH, stroke, malnutrition, anxiety disorder, depression, and a cardiac pacemaker, and was receiving Eliquis. The resident also had a physician order for a condom catheter at bedtime and removal when getting up for the day. The comprehensive care plan printed 5/20/26 did not identify interventions or monitoring related to anticoagulant use, including bleeding risk, adverse effect monitoring, or staff awareness of anticoagulant precautions, and it also lacked interventions related to the resident’s cardiac conditions, pacemaker, and condom catheter use, including skin integrity monitoring and resident-specific catheter care preferences. A second resident with severe cognitive impairment and diagnoses including non-traumatic brain dysfunction, unspecified dementia, non-Alzheimer’s dementia, anxiety disorder, and mood affective disorder was also receiving Eliquis. The resident’s comprehensive care plan printed 5/19/26 did not include anticoagulant therapy, bleeding risk precautions, monitoring for adverse effects, or other interventions related to anticoagulant medication use. During interviews, the RN case manager and DON confirmed that anticoagulant therapy, the condom catheter, cardiac conditions, and pacemaker presence should have been addressed on the care plans and acknowledged that these items were not included.
Failure to Provide Scheduled Bathing and Grooming Assistance
Penalty
Summary
The facility failed to ensure that two residents who required assistance with activities of daily living received routine bathing and grooming services needed to maintain personal hygiene and dignity. R2’s MDS identified intact cognition and a need for ADL assistance, and the care plan directed staff to assist with dressing, grooming, bathing, and oral care while honoring personal hygiene preferences. R21’s MDS also identified intact cognition and a need for ADL assistance, and the care plan directed staff to assist with dressing, grooming, bathing, and oral care. R2’s bathing record showed a weekly bathing schedule, but the documentation did not show bathing was completed every week as scheduled. Baths were documented on several dates, but the time between some baths exceeded one week, and the record did not show additional refusals or reasons why scheduled baths were missed. During observation, R2’s hair was messy and greasy, and long white chin hairs were present. R2 stated she did not get baths very often because the facility was short staffed and said she did not have access to tweezers, a shaver, or a mirror. The EMR did not document that grooming assistance had been offered or provided for facial hair care. R21’s bathing record also showed a weekly bathing schedule, but the documentation did not show bathing was completed every week as scheduled. The record showed one refusal and several baths, but some intervals between baths exceeded one week, and there was no documentation of additional refusals or reasons for missed baths. R21 stated she had been in the facility since mid-April and had yet to have a bath or shower, and said staff were waiting for physician approval because of wounds, though that had been a while. R21 also stated she had only had her hair washed once with a shampoo shower cap while in bed. Staff interviews confirmed residents were expected to receive at least one bath weekly unless they refused, refusals should be documented, and facial hair should be addressed when noticed.
Missing Orders and Documentation for Condom Catheter Drainage Bag Care
Penalty
Summary
The facility failed to ensure appropriate care and services were provided for management of a resident’s external urinary catheter system. The resident had intact cognition and required assistance with ADLs, and diagnoses included atrial fibrillation, heart failure, BPH, stroke, malnutrition, anxiety disorder, and depression. Physician orders dated 4/29/26 indicated use of a condom catheter at bedtime, but the electronic medical record did not contain physician orders or documented instructions for cleaning, disinfecting, monitoring, or routinely changing the associated catheter drainage bag. During observation on 5/19/26 at 11:57 a.m., the resident’s catheter drainage bag was seen hanging on the side rail in the bathroom. Record review and observation did not identify documentation that the drainage bag was routinely cleaned, disinfected, monitored, or replaced according to accepted standards of practice. An LPN confirmed there were no physician orders addressing when the drainage bag should be changed or instructions for cleaning or disinfecting it. An RN case manager stated the drainage bag should have been changed weekly, but no orders related to changing, cleaning, or disinfecting were present. The DON stated the facility expected clear physician orders and nursing instructions for catheter care, cleaning, monitoring, and replacement schedules, and confirmed the facility could not provide evidence that such orders or guidance were in place for the resident’s condom catheter drainage bag care.
Failure to Preserve Dignity by Placing a Brief on a Continent Resident
Penalty
Summary
The facility failed to provide services in a dignified manner for 1 resident who was cognitively intact and had diagnoses including renal insufficiency, DM, and hypertension. The resident’s MDS identified him as continent of bowel and bladder and needing staff assistance with ADLs including bed mobility, transfers, and toileting. A bowel and bladder assessment also identified the resident as continent, and the care plan stated he was aware of the need to void or defecate and would request to use the toilet as needed. During interview, the resident stated staff put diapers on him even though he was not incontinent and said it made him feel like a baby. During observation, a NA placed a brief on the resident, and the resident showed the surveyor the brief and stated it had just been put on him a few minutes earlier. The NA verified she placed a brief on the resident that morning even though he was not incontinent and said she was unsure why she did so. RN-A confirmed the resident was continent and stated staff put a brief on him out of habit. The DON stated staff should not place a brief on residents who are continent and that it was important to maintain the resident’s dignity.
Failure to Provide Restorative Ambulation and Address Decline in Mobility
Penalty
Summary
The facility failed to provide restorative ambulation services and failed to respond to a decline in ambulation status for one resident who had mild cognitive impairment, dementia, hypertension, diabetes, weakness, and chronic pain. The resident’s care plan and restorative documentation directed daily ambulation with a front wheeled walker and staff assistance of one, and the resident was also identified as having limited physical mobility and being at risk for falls due to weakness, chronic pain, and an unsteadied gait and balance. However, the nursing rehab point-of-care record repeatedly documented ambulation as “not applicable,” with only one entry showing the resident ambulated for 15 minutes and one entry showing refusal. The resident stated she could no longer walk and that staff needed to help her get into bed and her wheelchair. Staff interviews confirmed the ambulation task was not being completed. A nursing assistant stated aides were responsible for ambulation but were not completing it, and another nursing assistant stated ambulation was supposed to be done but was not done very often; that staff documented it as not applicable when it did not get done; and that the resident had not walked at all for several weeks and was using a sit-to-stand lift with assist of two for all transfers. An RN stated the task just did not get done and that no plan had been created to fix it. The DON stated the resident’s condition had changed and a therapy evaluation should have been requested, and also stated the care plan needed revision because the resident would not be transferred with an assist of one. The resident’s medical record lacked an assessment for ADL decline, including any revision to the ambulation care plan.
Failure to Complete and Document Restorative ROM and Splinting
Penalty
Summary
The facility failed to ensure range of motion (ROM) was completed in accordance with therapy recommendations to maintain mobility for one resident with mild cognitive impairment who was dependent on staff for all care areas and had diagnoses including diabetes, hemiplegia, and hemiparesis. The resident’s care plan identified limited physical mobility, fall risk, weakness, contractures, and limited ROM, and included restorative nursing interventions for bilateral lower extremity passive ROM to active ROM, passive hamstring and heel cord stretches, PROM to both hands, and splint use for the hands. The resident’s restorative documentation from 4/20/26 through 5/19/26 showed the hand splints were worn 41 times and marked not applicable 20 times out of 90 opportunities, but the documentation did not identify refusals to wear the splints. The leg stretches were completed 3 times out of 30 opportunities, and the documentation did not identify why the stretches were not performed or whether they were refused. The resident’s untitled nurse aide care sheet also identified a restorative program and encouragement to participate in the Well Fit program. During interviews, a nursing assistant stated staff were supposed to encourage participation in the Well Fit program and complete PROM and AROM, but it did not get done very often and was often documented as not applicable because it was not offered. An RN stated nursing assistants were responsible for restorative programs but they did not get done, and no plan had been created to fix the issue. The DON stated staff should have offered the tasks and documented refusals, but believed staff may have stopped offering after repeated refusals; the DON also stated the restorative program needed to be updated and that staff were documenting tasks as not applicable, which she was unaware of.
Dirty can opener and contaminated dry storage bins
Penalty
Summary
The facility failed to keep 1 of 1 commercial can opener clean and sanitary and failed to store dry goods removed from original packaging in a manner that reduced the risk of cross-contamination. During an initial tour with the Director of Culinary Services (DCS), four white plastic bins in the food preparation area were observed on the floor and labeled for flour, white sugar, rice, and powdered sugar. The flour bin was about one-third full and had a black scoop partially covered with flour, including the handle. The bin labeled white sugar had yellowish-tan dry matter on the right lateral wall, and the front wall had red dry matter measuring 6-7 cm in diameter. The rims around the lids of all four bins were dirty with dark dust-like particles, and the DCS verified these findings and stated the scoop should not be left inside the bins and needed to be clean inside and out. The attached [NAME] brand can opener was also observed with its blade halfway covered with dry, red-colored matter. On a later kitchen tour, the can opener blade still had dry red matter, which had been pushed upward by 0.2 cm, and a small light amber particle was noted below it. The cook stated he had used the can opener that morning to open a can of cream of corn used for lunch. The DCS verified the dry matter on the can opener and stated it should be washed every time it was used to prevent cross contamination. Facility policy stated dry storage areas would be maintained to keep food safe and free of infestation or contamination, and the sample cleaning schedule stated can openers should be clean after each use.
Dignified Medication Administration Not Maintained
Penalty
Summary
The facility failed to provide a dignified experience for 1 of 2 residents, R20, during medication administration. R20’s records showed severely impaired cognition, inattention, disorganized thinking, verbal behaviors toward others, and diagnoses including severe dementia with psychotic disturbance, visual hallucinations, generalized anxiety disorder, PTSD, and delusional disorder. Her care plan identified mood, behavior, and sleep alterations related to Alzheimer’s disease, dementia, generalized anxiety disorder, paranoia, public outbursts, and accusations that people were throwing medications down her throat, and it directed staff to redirect and reapproach when she was resistive or combative, use a calm approach, provide reassurance, and offer comfort items. During observation, RN-A brought medications to R20 in the dining room and attempted to pour them from a small plastic cup into her mouth. When R20 removed one medication, Divalproex, and threw it on the floor, RN-A attempted again to pour the remaining medications into her mouth while R20 moved her head back and forth and tried to pull away. RN-A then raised her voice, stated the resident’s name, told her she needed to take her medications, pulled her chair back from the table, picked up the Divalproex from the floor, placed it in a separate cup, and asked why she would not take her medications. R20 responded that it was because the nurse was not being nice. RN-A then left with the remaining refused medications and stated R20 would take them later and that she always had a behavior when taking her morning medications.
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