Kittson Healthcare

In the surveyor’s words

From the most serious findings on record at Kittson Healthcare, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Apr 20, 2023

  Based on interview and document review, the facility failed to initiate cardio-pulmonary resuscitation (CPR) for 1 of 3 residents (R1) who was found unresponsive, no respirations or heartbeat with a full code status who wished to receive CPR. The IJ began on [DATE], at approximately 2:15 a.m. when R1 had no respirations or pulse, and CPR was not initiated. The IJ was identified on [DATE], and the interim administrator and assistant director of nursing (ADON) were notified of the IJ on [DATE], at 4:30 p.m. The immediate jeopardy was removed on [DATE], and the deficient practice was corrected prior to the start of the survey and was therefore issued at past noncompliance. […]

• Actual harm, isolatedF689Jul 30, 2026

  Based on observation, interview, and document review, the facility failed to maintain a safe environment by ensuring appropriate precautions remained in place while a freshly mopped floor was wet for 1 of 2 residents (R25) reviewed for falls and failed to provide transfer assistance in accordance with the resident's care-planned interventions for 1 of 1 resident (R9) reviewed for transfer assistance. This resulted in actual harm for R25 when she slipped and fell on the freshly mopped, wet floor, struck her head on the concrete floor, and sustained a head laceration that required emergency medical evaluation and staples.Findings include: R25 R25's annual Minimum Data Set (MDS) dated [DATE], identified R25 had intact cognition, was independent with activities of daily living (ADLs),… […]

• Actual harm, isolatedF689Jun 11, 2025

  Based on observation, interview and document review the facility failed to ensure a transfer belt was used during a transfer for 1 of 2 residents (R30) reviewed for falls. This resulted in actual harm to R30 who sustained a left arm fracture. The facility implemented corrective action prior to the survey; therefore, the deficient practice was issued at past non-compliance. Findings include: R30's Fall Risk (Acuity) observation dated 7/16/24, identified R30 was at risk for falls. R30's quarterly Minimum Data Set (MDS) dated [DATE], identified R30 was cognitively aware and had diagnoses that included blindness, type 2 diabetes, and hypertension (high blood pressure). R30 required partial/moderate assistance (helper did less than half the effort. […]

• Actual harm, isolatedF758Sep 29, 2023

  Based on observation, interview, and record review, the facility failed to ensure residents were monitored for target behaviors, monitored for side effects, and educated on the risks/benefits of psychotropic use prior to initiation for 1 of 3 residents (R1) reviewed for unnecessary medications. This deficient practice caused actual harm when R1 experienced a decline in condition following the initiation and continued increase of a psychotropic medication. Findings include: R1's admission Minimum data set (MDS) dated [DATE], identified R1 was admitted on [DATE]. R1 had minimal difficulty in some environments with hearing, clear speech, and impaired vision, could see large print only. R1 sometimes understood others and responded adequately to simple, direct communication. […]

• No harm, potential for more than minimal, widespreadF880Jul 30, 2026

  Based on observation, interview, and document review, the facility failed to implement Enhanced Barrier Precautions (EBP), including the use of gowns and gloves during high-contact resident care activities, f1 of 1 resident (R18) reviewed for catheters and 1 of 1 resident (R29) reviewed who was receiving wound care. In addition, the facility failed to conduct ongoing infection surveillance to identify and track residents with signs and symptoms of potential infection for 1 of 1 resident (R1) reviewed for infection surveillance. Findings include: R18 R18's quarterly Minimum Data Set (MDS) dated [DATE], identified moderate cognitive impairment and was incontinent of bowel and bladder. R18's diagnoses include chronic kidney disease stage 3 and retention of urine-chronic (long term). […]