Red Wing Health Center
At least twice throughout the year, every nursing facility in the United States undergoes routine scheduled surveys and investigations conducted by inspectors for Centers for Medicare and Medicaid Services (CMS) and state nursing home agencies. On average, every nursing facility will have 5 to 7 violations identified by the inspectors that must be corrected nearly immediately to ensure the well-being and safety of the residents. If the violation is serious and causes significant harm, or could cause significant harm, to a resident, visitor or employee, the nursing home might be required to pay a fine to continue operating.
In serious cases where CMS identifies dangerous and hazardous conditions, the federal agency will add the nursing home to a Federal watchlist and designate the place as a Special Focus Facility (SFF). This designation identifies the nursing home as a facility that provides health care services much below the national average at unacceptable levels. The healthcare center is given some time to make major corrections and develop better policies and procedures to ensure these changes are permanent.
Recently, Red Wing Healthcare Community received the Special Focus Facility designation by CMS. They are now required to undergo many more scheduled surveys and unannounced investigations compared to nursing homes in good standing. The facility will have months to make quick changes and numerous years to show how their positive corrections have made a permanent improvement in the quality of care they provide their residents before being removed from the list.Red Wing Healthcare Community (SFF)
This 130-certified bed Medicaid/Medicare-participating nursing facility provides cares and services to residents of Red Wing and Goodhue County Minnesota. The Home is located at:
1412 W. 4th St.
Redwing, MN 55066
The Welcov Healthcare-affiliated home provides skilled nursing care along with:
- Post-hospital care
- Brain Injury services
- Ventilator and respiratory care
- Cardiac care
- Neuropathy care
- Diabetic management
- Dementia care
- Respite care
- Wound services
- Joint and orthopedic care
- Neurological and stroke care
- Sepsis and other infection care
- Hospice care
- Inpatient and outpatient therapies
- Short-term and long-term care
- Assisted living options
If the CMS or state nursing home agencies identify serious violations that caused harm or could cause harm to a resident, the nursing facility may be penalized with an issued fine. Within 2016, Red Wing Healthcare Community received a $2000 fine on March 29, 2016, and a $4622 fine on October 31, 2016.Current Nursing Home Resident Safety Concerns
To help evaluate and compare different nursing homes in the community, the Centers for Medicare and Medicaid Services and the state of Minnesota perform routine surveys and investigations. The results of these inspections are uploaded to the federal Medicare.gov website. Many families use this information before deciding where to place a loved one who requires the best hygiene, medical and assistive care.
Unfortunately, Red Wing Healthcare Community has maintained a one out of five stars ranking overall compared to all other nursing homes, assisted living centers and rehabilitation facilities nationwide. This rating includes one out of five stars for health inspections, two out of five stars for staffing, and one out of five stars for quality measures. Some of the serious concerns involving the facility are listed below.
Failure to Hire Employees with No Legal History of Abusing, Neglecting or Mistreating Residents
In a summary statement of deficiencies dated July 28, 2017, the state investigator noted the facility’s failure “to immediately report an incident of alleged emotional abuse to the State Agency of (Office of Health Facility Complaints).” The findings by the State surveyor include an observation of the resident at 8:10 AM on July 26, 2017 “sitting in the dining room.”
This resident “called the surveyor over and reported that a Licensed Practical Nurse (LPN) “is so rude to me, and I am literally afraid of her, she intimidates, scowls, a lot of tension in the air when she works.” The resident also “indicated this is emotional abuse to her.” According to the resident, “the situation has been reported to the Director of Nursing before.” When the resident was reporting “this allegation of abuse, she was crying.”
Twenty minutes later, the two surveyors who discussed the incident with the resident “reported [the resident’s] allegation of emotional abuse to the Director of Nursing [who] explained to the two surveyors the situation for [the resident] was ongoing between the resident targeting [that LPN].” The Director stated that the incidents are “related to her behavior as [the LPN] is very competent, but not cuddly.”
Approximately thirty-four minutes later, the resident “called the surveyor and asked ‘are you sure nothings going to happen to me?’ The surveyor “reassured the resident that there would not be any retaliation for reporting the allegation of abuse.” In response, the Director stated that “I just want to let you know we take abuse allegations seriously” and continued to explain that the resident “has reported to staffing an allegation of abuse against [the LPN] in the past and the facility educated the nurse.” The Director said the nurse “was educated to give [the resident’s] medication in a public place or have another staff present in the immediate area.”
The following day at 8:44 AM, the surveyor met with the Director of Nursing “and asked follow-up questions about [the resident’s] allegation of emotional abuse.” The Director “was asked if she had reported the allegation of abuse to the designated State Agency.” The Director replied that “she had not reported the allegation of abuse because [the resident] was making a false allegation against [the LPN].”
Later that afternoon, the surveyor interviewed the facility’s SSD (Social Service Director) “in regards to when to report allegations of abuse/neglect.” The Social Service Director replied that “I do not care if the resident has 30 cases of allegations toward [the] staff of abuse, we still have to report, it does not matter, we are not the jury, we are reporters.” The investigator asked the Director if “she was aware of the allegation of abuse reported to the Director of Nursing [the previous day the 8:30 AM regarding the resident’s] reporting abuse from the LPN.” The Social Services Director stated that “she was first made aware of the allegation of abuse from [the resident earlier that morning after the resident] had reported [it the previous day].”
In a separate summary statement of deficiencies dated January 31, 2017, the state investigator noted the facility’s failure “to immediately report an allegation of maltreatment to the Administrator and the appropriate State Agency.” The incident involved a resident “who communicated to staff that someone hurt him and [that] he wanted staff to call the police, but the staff members did not call the Administrator or the police until approximately six hours after the allegation was made.”
An LPN in charge of providing the resident care stated that “she did not report the allegation to the Administrator because she did not think it needed to be reported and she was not the Charge Nurse, and she did not feel it was her responsibility to report it.” During the incident, another “staff member went to his room to check on him and then called the police, the appropriate State Agency, and the Administrator. The police arrived at approximately 6:00 PM, and [the resident] eventually told the responding police officer that he had been sexually assaulted by a male.” The victim resident “was later sent to the hospital for evaluation.”
Failure to Develop, Implement and Enforce Policies and Prevent Mistreatment, Neglect or Abuse of Residents
In a summary statement of deficiencies dated July 28, 2017, the state investigator noted the facility’s failure “to follow their Abuse Prevention Plan regarding the immediate reporting of an incident of alleged emotional abuse to the State Agency.” In part, the policy states that “the State Agency must be notified immediately.”
During an interview that occurred at 9:54 AM on July 20, 2017, the facility’s Administrator “indicated his expectation was to report such abuse allegations immediately to the State Agency. During the interview …the Director of nursing stated [the RN] should have started the abuse investigation and reported it immediately. The incident was noted on July 6, 2017, at 6:18 PM, [and] it was not reported to the Office of Health Facility Complaint, the Director of Nursing or Administrator until the next morning which did not follow our policy.”
Failure to Provide Proper Treatment to Prevent a Resident from Developing a New Bedsore, or Allowing Existing Bedsores to Heal
In a summary statement of deficiencies dated July 28, 2017, state investigator noted the facility’s failure “to implement interventions to promote healing for [two residents] with pressure ulcers.” As a part of the investigation, a resident’s quarterly MDS (Minimum Data Set) dated April 4, 2017, was reviewed.”
The MDS revealed “ that the resident has “short and long-term memory problems, severely impaired decision-making, totally dependent on two staff for activities of daily living which included bed mobility, transfers, dressing, toileting, and hygiene.” The report revealed that the resident is “always incontinent of bowel and bladder, [in] pain, unable to answer, functional limitation in range of motion on both sides, unstageable pressure ulcer due to slough or eschar, pressure ulcer not present on prior assessment, feeding tube, suctioning, oxygen.”
The investigator reviewed the resident’s Tissue Tolerance Assessment that showed beginning on March 20, 2017 (no redness throughout the evaluation, is on a pressure reducing mattress, reposition every 2 to 2.5 hours.” No change was made in the documentation by April 28, 2017, and again on June 2, 2017. However, the June 2, 2017, Comprehensive Evaluation of Skin Inspection and Risk Factors revealed the resident’s “wound had worsened since hospital stay, is larger and deeper, continue to do dressing changes daily, and reposition every 2 to 2.5 hours, up in a wheelchair couple times a day requires to staff assist with turning and repositioning in the wheelchair and with all mobility.”
The resident’s CAA (Care Area Assessment) dated July 3, 2017, revealed an unstageable pressure ulcer, requiring a special mattress and wheelchair cushion. By July 26, 2017, the resident‘s Care Plan states that the unstageable area on the right ischium that had healed on April 7, 2017, has reappeared, and the resident “is at risk for more pressure ulcers.” The document shows that “interventions include: pressure relieving mattress on the bed, treatment is ordered, notify physician/nurse practitioner if wound worsens.…”
By July 17, 2017, the pressure right ischium [which] now measured 5 cm x 3 cm x 1.3 cm deep was considered “unstageable, scant drainage, serosanguineous, no odor, cleanse with wound wash, santyl foam to eschar, covered with a dressing, change daily, progress-declined. By July 24, 2017, the depth of the pressure wound had gone from 1.3 cm deep to 2.0 cm deep.
The State surveyor interviewed the Register Nurse providing the resident care at 8:24 AM on July 27, 2017. The nurse reviewed the resident’s progress “wounds, and he had a new pressure ulcer to its coccyx area that was not present one week ago, and his right heel has an area of scar discoloration, which she will monitor to see if it is a pressure ulcer or an old scar tissue.” The nurse stated later that day that the documentation was missing “multiple checkmarks under [the resident’s] turning and repositioning log between June 27, 2017, July 25, 2017, so it is not known if [the resident] was repositioned are not on those shifts.”
Failure to Develop and Implement a Program That Investigates, Controls and Keeps Infection from Spreading
In a summary statement of deficiencies dated July 20, 2017, the state investigator noted the facility’s failure “to ensure proper hand hygiene procedures were followed by staff for [a resident] observed receiving morning care to prevent the spread of infection.” The state investigator interviewed the nursing staff member providing the resident care when the staff member “returned to the resident’s room, she was asked about handwashing” and verified “she had not washed her hands after removing gloves and doing peri care for [the resident].”
The staff member stated that “I usually go to the nursing desk after cares and wash my hands, but just got nervous today.” The facility was reminded of their October 2014 policy titled Handwashing/Hygiene that states that “employees must wash their hands for at least 20 seconds before and after assisting a resident with personal care and after handling soiled or used linens.”
Failure to Ensure the Environment Remains Safe, Easy to Clean, and Comfortable for Residents
As a part of a routine investigation, the surveyor noted on July 20, 2017, that the facility had failed “to ensure an environment that was clean, sanitary and in good repair for 5 of 89 resident rooms.” Observations were made of resident’s room including one with a “leaking bathroom ceiling and hallways, tub rooms, dining room and family lounge.” This deficiency by the facility’s maintenance department includes “bathroom ceiling tile with large brown stains,” and “TV cable hanging down near the doorway.” Additional problems include an observation of many pests that include dead gnats, live ants, dead green longtail flying bugs called midges on the windowsill and the bedside stand.
If you are residing in a nursing facility or have lived in a nursing home in the past and have been neglected, mistreated, or abused, you are likely entitled to receive financial compensation through a monetary recovery claim. However, these cases are complex and often requires the skills of a personal injury attorney who specializes in nursing home abuse and mistreatment cases.
These claims for compensation are handled through contingency fee arrangements, meaning you are not required to make an upfront payment for immediate legal representation. The law firm will be paid only after it has successfully resolved your case by negotiating an acceptable out of court settlement or winning your case at trial.
Contact our office for a free review of your case and legal options.
For information on laws and regulations related to Minnesota nursing homes look here.
Refer to the links below for information on facilities in specific Minnesota cities as well as attorneys with experience prosecuting these cases.