Barnes-Kasson County Hospital

In the surveyor’s words

From the most serious findings on record at Barnes-Kasson County Hospital, in the surveyor’s own words.

• Actual harm, isolatedF686Aug 6, 2026

  Based on clinical record review, facility policy review, observation, and staff interviews, it was determined that the facility failed to consistently implement interventions to prevent the development and worsening of pressure injuries for one of 12 residents reviewed (Resident 2). This failure resulted in actual harm when Resident 2 developed a Stage 2 pressure injury that subsequently deteriorated and was identified as an unstageable pressure injury.Findings include: According to the National Pressure Injury Advisory Panel (NPUAP) September 2025 a pressure injury is localized damage to the skin and underlying soft tissue. The skin injury occurs due to intense and/ or prolonged pressure or pressure in combination with shear. […]

• Actual harm, isolatedF689Apr 13, 2023

  Based on a review of clinical records and select incident reports, and staff interviews it was determined that the facility failed to consistently provide individualized fall prevention interventions planned to meet resident's safety and supervision needs based on known risk factors, history of falls and displays of unsafe behaviors to prevent falls for two residents (Resident 10 and 33) resulting in a serious injury, a fractured hip, to one resident (Resident 10) and failed to maintain an environment free of potential accident hazards in one resident's room (Resident 26) out of 13 sampled residents. […]

• Actual harm, isolatedF600Sep 10, 2021

  Based on a review of clinical records, select incident reports and select facility investigative reports and staff and resident interview it was revealed that the facility neglected to provide the care necessary to prevent physical harm, a serious injury, a fractured femur, sustained during an avoidable fall, by one of 13 residents reviewed (Resident 7). Findings include: A review of the clinical record review revealed that Resident 7 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident 7's quarterly (MDS) Minimum Data Set Assessment (a federally mandated standardized assessment tool completed at various intervals to plan resident care) dated May 17, 2021, revealed that the resident was cognitively intact and required extensive… […]

• Actual harm, isolatedF684Sep 10, 2021

  Based on a review of clinical records, incident investigations and select facility policy and staff interviews it was revealed that the facility failed to timely identify and act upon a change in resident condition, to assure the resident received timely and necessary treatment and prompt medical intervention at level required, which compromised the condition and caused ongoing pain for one resident out of 12 sampled (Resident 20). Findings include: A review of clinical records revealed Resident 20 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF881Mar 7, 2024

  Based on a review of clinical records and select facility policy and staff interview it was determined that the facility failed to maintain an antibiotic stewardship program that includes a system to effectively monitor antibiotic usage as evidenced by five of 13 sampled residents (Resident CR1, 9, 3, 10 and 20). Findings include: A review of the facility policy for Antibiotic Stewardship, dated as reviewed February 2023, revealed that antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. The purpose of the antibiotic steward ship program is to monitor the use of antibiotics in our residents. […]