Andrew Residence
Inspection history, citations, penalties and survey trends for this long-term care facility in Minneapolis, Minnesota.
- Location
- 1215 South 9th Street, Minneapolis, Minnesota 55404
- CMS Provider Number
- 24E116
- Inspections on file
- 22
- Latest survey
- November 25, 2025
- Citations (last 12 mo.)
- 15 (1 serious)
Citation history
Health deficiencies cited at Andrew Residence during CMS and state inspections, most recent first.
The facility's system for reconciling non-narcotic, controlled medications relied on three-ring binders with loose paper, making it difficult for staff to detect if medication sheets or cards were removed. Staff and the DON confirmed that this method did not allow for timely identification of missing or diverted medications, as there was no secure or reliable way to track changes, and staff often depended on memory to notice discrepancies.
Two residents reported that a washing machine on the 5th floor was intermittently broken for months, with the most recent outage lasting over two weeks. Staff interviews confirmed ongoing issues, communication breakdowns, and incomplete repair documentation. Observations showed the machine contained standing dirty water and debris, and at times lacked an 'OUT OF ORDER' sign, resulting in an unsanitary environment.
Two residents had inaccurate MDS assessments, including one who was incorrectly documented as receiving insulin injections when only non-insulin diabetes medications were administered, and another who was coded with a dementia diagnosis not supported by the medical record. Nursing staff and the DON confirmed these errors after review.
A resident with COPD received oxygen therapy without documented baseline SpO2 or clear parameters for when to initiate or discontinue supplemental oxygen. The care plan and physician orders lacked specific guidance, and staff confirmed these omissions during interviews. Facility policy did not address the need for baseline SpO2 or individualized parameters.
A resident with schizoaffective disorder and a history of unsafe smoking behaviors sustained burns after using a cigarette to remove arm hair. Although staff implemented one-to-one supervision and escort for cigarette smoking, this intervention was not documented in the care plan, despite being communicated verbally and in progress notes. The care plan did not reflect the resident's current safety needs or the interventions being provided.
Two residents with wounds requiring bacitracin ointment did not have proper transcription or documentation of the medication in the MAR or EHR, despite its administration being recorded in progress notes. Facility staff confirmed that the standing order for bacitracin was not individually transcribed or documented with all required elements, leading to incomplete records and failure to follow professional standards for medication documentation.
A resident with an indwelling suprapubic catheter did not have Enhanced Barrier Precautions (EBPs) identified in the care plan, and staff failed to use required PPE, including gowns and gloves, during high-contact care activities such as shaving. A nursing assistant entered the room without hand hygiene or a gown, only donning gloves after entry, and completed shaving without following full EBP protocols. The DON confirmed that both gown and glove use were required for such care but were not implemented.
A resident with severe cognitive impairment was found with a broken bed rail due to the facility's failure to conduct regular inspections of hospital beds. Despite daily staff rounds, the broken condition was not reported. Interviews revealed no scheduled maintenance checks or logs, and the maintenance engineer was unaware of proper installation procedures.
The facility failed to ensure that the call light system was accessible from the floor in a multi-resident bathroom for three residents identified as fall risks. Observations showed that call lights were positioned too high for residents to reach if they fell. Interviews confirmed the residents' inability to access the call lights from the floor, despite their care plans emphasizing the need for immediate assistance. The DON acknowledged the issue but was uncertain about the necessity of floor-level access.
Inadequate Medication Reconciliation System for Non-Narcotic Controlled Medications
Penalty
Summary
The facility failed to ensure an adequate system for medication reconciliation to timely identify loss or diversion of non-narcotic, controlled medications across all medication carts reviewed. Observations and interviews revealed that non-narcotic, controlled medications were stored in permanently affixed lock boxes within locked medication carts, and staff reconciled these medications every shift using a three-ring binder with loose, three-hole punched paper. Staff members confirmed that the reconciliation process involved comparing the count of medications in the locked box to the corresponding sheet in the binder, and referencing the medication administration record if discrepancies were noted. However, staff also acknowledged that the use of loose paper in a three-ring binder made it difficult to detect if a medication sheet and the corresponding medication card were removed, as there was no way to tell when a sheet was missing until the next administration of the medication. The director of nursing (DON) and multiple staff members confirmed that the current practice did not provide a reliable method for timely identification of missing or diverted non-narcotic, controlled medications. The facility's policy required shift change counts and documentation on a controlled drug record and a C-drug Count Acknowledgement Form, but did not specify the use of a bound book or other secure method for recordkeeping. Staff expressed uncertainty about how they would notice if documentation or medication was removed, relying instead on memory or familiarity with the medications. This system limitation was observed on all floors reviewed, and the DON acknowledged the inadequacy of the current practice for tracking and reconciling non-narcotic, controlled medications.
Failure to Maintain Functional and Sanitary Laundry Equipment
Penalty
Summary
The facility failed to ensure that equipment was in proper working order and to maintain a sanitary environment in the 5th floor laundry room. Two residents, both cognitively intact and independent with activities of daily living, reported that one of the two washing machines had been intermittently broken for several months, with the most recent outage lasting over two weeks. Multiple staff interviews confirmed ongoing issues with the washing machine, including repeated breakdowns, delays in repairs, and a lack of awareness about the presence of standing water inside the machine. Staff described a process for reporting repairs through TELS tickets, but there was evidence of communication breakdowns between residents, staff, and maintenance, as well as incomplete documentation of repair requests. Observations over several days revealed that the broken washing machine contained dark grey standing water with floating debris and a film layer, and at times lacked an "OUT OF ORDER" sign. Housekeeping and maintenance staff confirmed the unsanitary condition and the extended period the machine had been out of service. Maintenance staff were at times unaware of the duration of the breakdown or the presence of standing water. Record review showed only one documented TELS report for the issue, despite staff claims of multiple reports, and a complete TELS report was not provided upon request.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate completion of Minimum Data Set (MDS) assessments for two residents. For one resident, the quarterly MDS indicated the resident was cognitively intact, had a diagnosis of diabetes, and received seven days of insulin injections. However, review of the medication administration record (MAR) did not show any insulin injections administered during the observation period. Further investigation revealed that the resident was prescribed Metformin, an oral diabetes medication, and Victoza, a non-insulin injectable medication. Both the registered nurse and the Director of Nursing confirmed that Victoza is not an insulin and should not have been recorded as such on the MDS. For another resident, the quarterly MDS documented an active diagnosis of non-Alzheimer's dementia. Upon review of the resident's medical record, there was no documentation to support a diagnosis of non-Alzheimer's dementia. The Director of Nursing confirmed that this was an error in the MDS coding, as the diagnosis was not present in the medical record. These inaccuracies in the MDS assessments were identified through interviews and record reviews.
Failure to Establish Baseline SpO2 and Oxygen Therapy Parameters for Resident with COPD
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident with chronic obstructive pulmonary disease (COPD) by not identifying a baseline SpO2 (blood oxygen level) and not establishing clear parameters for the use or discontinuation of supplemental oxygen therapy. The resident's care plan and physician orders included the use of an oxygen concentrator at 4 liters per minute via nasal cannula as needed, but did not specify when to initiate or discontinue oxygen, nor did they document the resident's baseline SpO2. The Treatment Administration Record showed SpO2 levels ranging from 91% to 99%, but did not indicate whether supplemental oxygen was in use at the time of these readings. Interviews with nursing staff and the director of nursing confirmed the absence of parameters and baseline SpO2 in the resident's orders and care plan. The director of nursing acknowledged that such information is expected, especially for residents with COPD, due to the risks associated with over-oxygenation. The facility's existing oxygen concentrator policy did not address the identification of baseline SpO2 or provide guidance on parameters for use based on resident-specific risk factors.
Failure to Update Care Plan with Smoking-Related Safety Intervention
Penalty
Summary
The facility failed to revise the care plan for a resident with schizoaffective disorder and a history of unsafe smoking behaviors, specifically not including a smoking-related safety intervention after the resident sustained burns from using a lit cigarette to remove arm hair. The resident was known to have cognitive impairments affecting judgment and had a documented history of self-inflicted burns related to smoking, with previous assessments identifying him as vulnerable and requiring specific interventions, such as the use of flameless lighters and staff assistance with hair removal. Despite these known risks and a recent incident where the resident burned himself with a cigarette, the care plan was not updated to reflect the newly implemented intervention of one-to-one staff escort and supervision when the resident smoked cigarettes. Multiple staff interviews confirmed that the resident required one-to-one supervision when smoking cigarettes, a measure that was verbally communicated and documented in progress notes and incident reports, but not formally included in the resident's care plan. Staff relied on verbal communication, staff logs, and program sheets to know about the intervention, but the care plan, which is the primary document for guiding resident care, did not reflect this critical safety measure. The omission was acknowledged by several staff members, including the program director, director of nursing, and director of clinical services, who all stated that the intervention should have been included in the care plan for consistency and continuity of care. Facility policies required that residents assessed as vulnerable for unsafe smoking behaviors have a vulnerability care plan with outlined interventions, and that care plans be reviewed and revised as needed. However, the implemented intervention of one-to-one staff escort for cigarette smoking was not documented in the care plan, despite being in practice. This failure to update the care plan meant that the formal documentation did not accurately reflect the resident's current needs and the interventions being provided to ensure his safety.
Failure to Properly Document and Transcribe Standing Order Medication Administration
Penalty
Summary
The facility failed to ensure that professional standards of practice for documentation were followed during the transcription and administration of a standing order medication, specifically bacitracin ointment, for two residents with wounds. The standing order for bacitracin required that it be transcribed into the resident's medication administration record (MAR) with all necessary details, including the prescribing practitioner's name, medication name, dosage, route, frequency, duration, and indication for use. However, for both residents, the administration of bacitracin was documented in progress notes but not properly transcribed or documented in the MAR or electronic health record (EHR) as required by facility policy and professional standards. For the first resident, who had a history of schizoaffective disorder and sustained multiple self-inflicted burns and other minor wounds, bacitracin was applied on several occasions as documented in progress notes. Despite this, there was no corresponding order or documentation in the MAR or EHR specifying the use of bacitracin, nor were the required elements of a complete medication order present. Nursing staff confirmed that the standing order for bacitracin should have been transcribed into the MAR and EHR, but this was not done. The facility's process relied on a general standing order in the physician orders, without individual transcription upon use, which led to incomplete documentation and lack of clarity regarding the administration of the medication. For the second resident, who sustained a burn to the finger, bacitracin was also applied and documented in progress notes prior to the transcription of a wound care order into the MAR. The MAR did not include all required elements of the bacitracin order, and the wound care order did not specify the seven-day limit as required by the standing order. Interviews with nursing staff and the DON revealed that the facility practice was not to transcribe individual standing orders into the MAR or EHR unless specifically utilized, and that documentation of administration was often limited to progress notes rather than the MAR. This practice resulted in incomplete and inconsistent documentation of medication administration, failing to meet professional standards and facility policy.
Failure to Use Required PPE During High-Contact Care for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to implement appropriate infection prevention and control measures by not ensuring staff used required personal protective equipment (PPE) during high-contact care for a resident with an indwelling suprapubic catheter. The resident had multiple urinary diagnoses, including bladder disorder, urethral stricture, benign prostatic hyperplasia, bladder neck obstruction, and overactive bladder, and required regular shaving of the head and body as part of activities of daily living. The care plan for the resident did not identify the need for Enhanced Barrier Precautions (EBPs) despite the presence of an indwelling catheter, and signage on the resident's door indicated the need for PPE during high-contact care activities. During observation, a nursing assistant entered the resident's room without performing hand hygiene or donning a gown, and only put on gloves after entering the room. The assistant proceeded to shave the resident's inner thigh, pubic area, buttocks, and arms, then exited the room carrying soiled supplies in gloved hands without performing hand hygiene. The assistant stated she had not been instructed to use a gown for this care activity and only used gloves. The director of nursing confirmed that EBPs, including gown and glove use, were required for residents with indwelling devices during high-contact care, and that these precautions should have been included in the care plan.
Failure to Conduct Regular Bed Inspections
Penalty
Summary
The facility failed to conduct regular inspections of hospital bed frames, mattresses, and bed rails, leading to a deficiency involving a resident with a broken bed rail. The resident, who had severe cognitive impairment and was independent in activities of daily living, was observed with a broken pivoting assist device (PAD) on their bed. The right PAD was not aligned with the bed frame and was touching the floor, indicating it was broken. Despite daily staff rounds, the broken condition of the PAD was not reported or addressed until it was observed by surveyors. Interviews with facility staff revealed a lack of scheduled maintenance checks for the resident's bed, and no maintenance logs were kept. The maintenance engineer admitted to not reviewing the manual for proper installation and was unaware of the correct procedures. The facility's Director of Nursing confirmed that the bed had been in use since the care plan intervention date, but no maintenance policy or inspection logs were provided. The owner's manual for the bed recommended periodic inspections, which were not conducted, leading to the deficiency.
Inaccessible Call Light System in Multi-Resident Bathroom
Penalty
Summary
The facility failed to ensure that the resident call light system was accessible from the bathroom floor in a multi-resident bathroom for three residents. Observations revealed that the call lights were positioned on the walls with cords that were not reachable from the floor, being approximately two to three feet above it. Interviews with the residents confirmed that they were unable to reach the call lights if they fell while using the toilet or shower, despite having a history of falls and being identified as fall risks. The care plans for these residents emphasized the importance of using the emergency call-light system for immediate assistance, yet the physical setup did not support this need. The Director of Nursing acknowledged that the call lights might not be within reach if the residents were on the floor, but expressed uncertainty about the necessity of floor-level access due to the residents' ambulatory status. The facility's policy on the emergency monitoring system indicated that pull station transmitters should be located in resident rooms, bathrooms, and other common areas, with all activations requiring a timely response from staff. However, the current setup in the multi-resident bathroom did not align with this policy, as it did not allow residents to access the call system from the floor, potentially delaying urgent assistance.
Latest citations in Minnesota
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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