Minnewaska Community Health Services
Inspection Findings
F-Tag F0880
F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
reviewed Resident R5's electronic medical records and verified Resident R5's orders and care plan both identified Resident R5 was on EBP. RN-A indicated he was unaware Resident R5 was on EBP, and stated EBP was important to prevent spread of infections. RN-A indicated usual facility process was to be notified of residents on EBP through report and their care plan. RN-A stated he should have checked Resident R5's care plan prior to wound care. RN-A also indicated the usual facility practice was to put EBP signage up with instructions when residents were on EBP, and was not aware why Resident R5 did not have signage for EBP posted. RN-A also verified he had not completed hand hygiene after removing gloves and prior to applying new gloves during wound care. RN-A indicated he should have sanitized hands between glove use, but there was no hand sanitizer in Resident R5's room.
During observation on 11/10/25 at 12:45 p.m., director of nursing (DON) walked in hallway near dining room and was heard telling a nursing assistant to remember purple stars means gowns. Then at 1:02 p.m.
DON applied a purple star to Resident R5's nameplate near Resident R5's door, then moved the dresser with PPE from the end of the hall and placed it next to Resident R5's door. During interview on 11/10/25 at 1:12 p.m., DON verified Resident R5 had wounds and was on EBP. DON stated her expectation was gowns and gloves be worn during personal cares and wound cares for Resident R5. DON indicated the facility used purple stars to notify staff residents were on EBP. DON confirmed Resident R5 did not have a purple star up until she applied one that afternoon, and she had put purple stars up and PPE outside other residents' rooms that day who were also on EBP. DON further stated her expectation was that staff complete hand hygiene after remove gloves, prior to applying new gloves to prevent spread of infection. The facility policy titled Enhanced Barrier Precautions, undated, identified EBP was for the prevention of transmission of multidrug resistant organisms. The facility would have the discretion on how to communicate to staff which residents required the use of EBP, as long as staff were aware of which residents required the use of EBP prior to providing high-contact care activities. Gowns and gloves would be available immediately near or outside a resident's room and to ensure alcohol-based hand rub was in every resident room, ideally both inside and outside of the room. Position a trash can inside resident's room and near the exit for discarding PPE after removal. The facility policy titled Hand Hygiene Policy, undated, identified all staff would perform proper hand hygiene to prevent spread of infection to other personnel, residents, and visitors. The policy identified if task required gloves, to perform hand hygiene prior to donning gloves, and immediately after removing gloves. The facility policy titled Clean Dressing Change, undated, identified facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination. Instructions included to wash hands and put on gloves. After removing the soiled dressing, remove gloves, wash hands and put on clean gloves. Clean wound, measure wound, remove gloves, then wash hands and put on new gloves. Apply ointments or creams, and secure dressing, mark and initial, then dispose of gloves, and wash hands.
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If continuation sheet
Minnewaska Community Health Services in STARBUCK, MN inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in STARBUCK, MN, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Minnewaska Community Health Services or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.