Auburn Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Chaska, Minnesota.
- Location
- 501 Oak Street, Chaska, Minnesota 55318
- CMS Provider Number
- 245604
- Inspections on file
- 23
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Auburn Manor during CMS and state inspections, most recent first.
Resident mail was not delivered on Saturdays for four residents who raised the issue during Resident Council. Residents reported that Saturday mail was left at the front desk and not sorted and delivered until Monday, while the secretary said she handled mail Monday through Friday and the weekend nursing supervisor was responsible. An RN said she was unaware weekend mail delivery was part of her duties and did not have time to do it when she was the only nurse in the building. The Administrator stated weekend mail was typically delivered Monday, despite the facility policy requiring mail delivery six days a week.
Improper Food Storage and Labeling: Surveyors observed undated and improperly labeled food items in the walk-in cooler and a kitchenette freezer, including stock, carrots, pizza sauce, bread, and partially used ice cream containers covered in frost. The DD was unsure of the food storage policy, and the DON confirmed the items lacked proper labeling and should have been discarded. The facility's policy stated no leftover food could be saved, stored, cooked, or reused, and any food remaining after service had to be discarded immediately.
Failure to Review Resident Rights in Council Meetings: Four cognitively intact residents who regularly attended resident council meetings did not recall resident rights ever being discussed, and meeting minutes did not document any review of rights. A resident rights poster was posted in a hallway, but the residents said they did not know where it was located. The LED could not find documentation that rights were reviewed, and the Admin said the process was not yet standardized.
Two cognitively intact residents were not provided dignified care when staff failed to answer call lights promptly and delayed toileting assistance, resulting in episodes of incontinence. One resident reported waiting over an hour for bathroom help and feeling degraded, while another resident who needed a mechanical lift and two staff said she was embarrassed after becoming incontinent while waiting for assistance. Call light logs showed repeated waits over 30 minutes, and the DON confirmed delays beyond 30, 45, and 60 minutes.
Failure to inform residents how to file anonymous grievances and maintain required grievance records. Four residents stated they were unclear how to file an official grievance or where to find a grievance form to assure anonymity, and all said they could only talk to the DON, who told them concerns were handled internally. The DON stated grievances could be brought to her, the SW, or any staff member, but she had no copies of grievances, investigations/resolutions, or a grievance log, despite the facility policy requiring records to be kept for at least 3 years.
A resident with MS, HTN, neurogenic bladder, COPD, and hyperlipidemia did not receive scheduled 7:00 a.m. medications, and the MAR showed blank boxes for multiple ordered meds including lisinopril, omeprazole, trimethoprim, oxybutynin, baclofen, and gabapentin. The DON confirmed the meds were not administered within the allowable time window and stated medications are expected to be given as ordered.
Failure to Offer COVID-19 Vaccination: A resident with HTN, HLD, and malnutrition was documented as overdue for a COVID-19 vaccine, but the medical record had no evidence the vaccine was offered or given. The IP and DON both confirmed the resident had not been offered or received the vaccine, despite expectations that it would have been completed shortly after admission.
A resident with diabetes and cognitive impairment received insulin despite physician orders to hold the medication for blood sugar levels below 150 mg/dl. Multiple nurses administered insulin when the resident's blood sugar was below this threshold, due in part to incomplete review of electronic medical records. This resulted in severe hypoglycemia, requiring emergency intervention and hospitalization.
The facility failed to provide sufficient nursing staff, resulting in deficiencies such as inadequate pressure ulcer prevention, insufficient assistance with activities of daily living, and dignity concerns. Residents and family members reported long wait times for care, and staff confirmed that staffing levels were insufficient to meet resident needs. Observations showed call lights often went unanswered, highlighting the facility's inability to provide timely care.
The facility failed to secure medication carts, leaving them unlocked and unattended in hallways across multiple units. Staff admitted to neglecting to lock the carts, which contained potentially dangerous medications, despite the facility's policy requiring secure storage.
A resident was left exposed and nude on the toilet facing a courtyard window, compromising their dignity. The nursing assistant left the room without closing the blinds, leaving the resident feeling exposed. Another resident with an indwelling catheter was transported with an uncovered urine drainage bag, violating privacy standards. The facility's policy emphasizes maintaining resident privacy and dignity.
The facility failed to provide a SNFABN to a resident whose Medicare Part A coverage ended while they remained in the facility. Despite notices indicating the last covered day, the resident's medical record did not show that a SNFABN was given. A licensed social worker confirmed the oversight, acknowledging that the SNFABN had been missed. Additionally, a policy regarding SNFABNs was not received during the review.
A privacy breach occurred when an unattended laptop displaying sensitive information about three residents was left open in a facility. Staff members acknowledged the breach, noting that the information should not have been visible. The DON confirmed this was a HIPAA violation, as it exposed private resident information to unauthorized individuals.
A facility failed to maintain a comprehensive care plan for a resident at risk of pressure ulcers. The resident required assistance with ADLs and had a deep tissue injury upon admission. The care plan lacked specific interventions for pressure ulcer prevention and did not document ongoing assessments. Nursing staff interviews revealed a lack of communication and documentation regarding the resident's wound care needs.
A resident with severe cognitive impairment and dependent on staff for personal hygiene care did not receive routine bathing as scheduled. The care plan lacked specific bathing frequency, and staffing challenges led to inconsistencies in providing showers. Documentation was insufficient, with missing records of completed showers, contributing to the deficiency.
A facility failed to assess and address constipation concerns for a resident who reported feeling constipated. Despite the resident's request for proactive interventions, staff only provided medication upon request without discussing other options like prune juice or fiber supplements. The resident's care plan lacked ongoing medications for regular bowel movements, and the facility's bowel management protocol did not provide guidance on comprehensive assessment or documentation.
The facility failed to prevent pressure ulcers in two high-risk residents. One resident was left lying on her back for extended periods without repositioning, contrary to care instructions. Another resident was observed sitting in a recliner for hours without repositioning. Staff were unaware of the last repositioning times, and there was no documentation in the EMR. The DON acknowledged the lack of a system to ensure regular repositioning and missing documentation for refusals.
Two residents with severe cognitive impairments experienced multiple falls without appropriate updates to their care plans or implementation of new interventions. Despite the facility's policy requiring IDT review and intervention updates, these were not consistently completed, leading to a deficiency in fall management.
A facility failed to assess a resident for entrapment risk and did not attempt alternatives before installing grab bars on their bed. The resident, with moderately impaired cognition and requiring substantial assistance, had grab bars affixed without documented attempts of alternative methods. Staff interviews revealed that grab bars were applied on admission without assessing individualized entrapment risks, contrary to facility policy.
A facility failed to limit and re-evaluate the use of PRN Ativan for a resident with severe cognitive impairment and anxiety. The medication was administered without a stop date or timely re-evaluation, and non-pharmacological interventions were not documented. Staff interviews revealed lapses in communication and review processes, leading to the deficiency.
A facility failed to offer a recommended pneumococcal vaccination to a resident with dementia and high blood pressure, as per CDC guidelines. The resident's medical record showed previous vaccinations but lacked evidence of the PCV20 vaccine being offered or administered. An LPN, serving as the infection preventionist, confirmed the oversight, citing a lack of documentation and frequent work demands as reasons for the delay. The facility's policy required offering and documenting immunizations, which was not followed in this instance.
The facility inaccurately coded the MDS for four residents regarding restraint use, as grab bars were incorrectly marked as restraints despite not restricting movement. Additionally, a BIMS assessment was improperly completed for a resident, resulting in an incorrect summary score. The offsite MDS coordinator's reliance on incomplete records and lack of communication with onsite staff contributed to these errors.
A long-term care facility failed to implement a system to monitor antibiotic use, leading to inappropriate administration of antibiotics to a resident with multiple diagnoses, including pressure ulcers and diarrhea. The facility lacked comprehensive documentation and monitoring, as antibiotic stewardship logs were incomplete, and 72-hour antibiotic time outs were often not conducted. Interviews with staff revealed inconsistencies in following the facility's policies on antibiotic use and infection control.
The facility failed to implement a QAPI plan and address repeated quality deficiencies, potentially affecting all 50 residents. Despite holding quarterly QAPI meetings, the facility did not develop performance improvement projects or document corrections for identified issues. The DON stated that QAPI activities were on hold due to new management awaiting further instructions.
The facility failed to adhere to infection control practices, including proper management of catheter bags and ports, and the use of PPE and hand hygiene for residents on enhanced barrier precautions. Observations revealed a lack of signage and inconsistent use of PPE, with staff not following protocols for high-contact care activities, leading to potential risks of spreading multi-drug resistant organisms.
A resident with a history of falls and incontinence was left exposed in their room with the door open, visible from the hallway, when a nursing assistant left to put on PPE. The facility's policy required staff to ensure privacy by closing doors and keeping residents covered, which was not followed in this instance.
A facility failed to prevent accident hazards and assess fall risks for two residents. One resident, with cognitive impairment and hemiplegia, fell from a remote-controlled recliner without a safety assessment. Another resident, post-stroke and on fall precautions, fell while self-transferring, lacking documented interventions. Staff interviews revealed gaps in awareness and documentation of fall interventions, contrary to facility policy.
Two residents had grab bars installed on their beds without comprehensive assessments, discussions of risks and benefits, or informed consent. The facility relied on therapy recommendations and often completed necessary documentation after installation, contrary to policy requirements.
The facility failed to ensure dishware was safe and sanitary, as chipped and cracked dishes were observed in use. A resident reported the issue, and dietary staff had inconsistent practices regarding the disposal of damaged dishware. The facility's policy required immediate discarding of such dishware to prevent cuts and ensure sanitation.
Resident mail not delivered on Saturdays
Penalty
Summary
The facility failed to ensure resident mail was delivered to residents on Saturdays for four residents who raised the concern during Resident Council. During the 4/30/26 Resident Council meeting, R24 stated that mail delivered by the post office on Saturdays was left on the receptionist's desk near the front entrance and then sorted and delivered by the receptionist on Monday morning. R33, R34, and R14 confirmed that Saturday mail was not delivered to residents. During interviews, the secretary stated that she sorted and delivered mail Monday through Friday, and that weekend mail delivery was the responsibility of the nursing supervisor. An RN stated she was unaware that collecting and passing mail was part of her weekend responsibilities and said she did not have time to deliver mail when she was the only nurse in the building overseeing all staff and residents. The Administrator stated it was the responsibility of the secretary at the front desk to deliver mail and acknowledged that mail delivered over the weekend was typically delivered Monday after front desk staff arrived, although her expectation was that mail would be delivered the same day it was delivered to the facility. The facility policy stated resident mail was to be delivered six days a week, Monday through Saturday, in a timely fashion.
Improper Food Storage and Labeling
Penalty
Summary
Food was not stored and labeled properly in the kitchen and in a kitchenette refrigerator/freezer area. During an initial tour and interview with the Dietary Director, surveyors observed an opened box of undated chicken stock, an opened box of undated turkey stock, a metal dish containing sliced carrots without an open or use-by date, and a metal dish containing pizza sauce without an open or use-by date in the walk-in cooler. The Dietary Director stated he was unsure of the food storage policy for leftover food, but believed all food should be dated with both an opened-on and use-by date. In the kitchenette by the north nursing station, surveyors observed a loaf of multigrain bread that was not sealed, not dated, and covered in thick white frost, a partially used gallon bucket of vanilla ice cream with a jack-o-lantern pattern that was covered with thick white frost on the inside and outside, and another partially used gallon bucket of vanilla ice cream that had thick white frost and lacked an open date or use-by date. The DON confirmed the items lacked proper labeling and should have been discarded. The Administrator stated the facility's leftover food policy should be followed by all dietary staff and said she was unaware of leftovers stored in the kitchen or elsewhere in the facility. A policy titled Food-No Leftover Food Retention Policy stated no leftover food was permitted to be saved, stored, cooked, or reused, and any food remaining after service must be discarded immediately.
Failure to Review Resident Rights in Council Meetings
Penalty
Summary
The facility failed to provide ongoing communication to residents about their rights through resident council meetings for 4 of 4 cognitively intact residents who attended those meetings. Quarterly MDS assessments for R33, R34, R14, and R24 indicated each resident was cognitively intact. However, resident council meeting minutes from November 2025 through April 2026 did not show that resident rights were reviewed or discussed during the meetings. During a resident council meeting on 4/30/26, R33, R34, R14, and R24 stated they regularly attended the meetings and did not recall any time when resident rights had been discussed. All four residents stated they did not know where resident rights were posted in the facility, although a resident rights poster was hung in a hallway across from the beauty salon. The life enrichment director stated she took minutes for resident council meetings and described the usual meeting format, but she could not find documentation showing resident rights were discussed. The administrator stated resident rights were reviewed upon admission and said that if social workers attended resident council, they would be responsible for reviewing resident rights, adding that the facility was working on standardizing this process.
Delayed Call Light Response and Toileting Assistance
Penalty
Summary
The facility failed to ensure two cognitively intact residents received services in a dignified manner when staff did not respond to call lights in a timely way and did not provide toileting assistance before the residents became incontinent. One resident had diagnoses including a history of UTI, depression, generalized weakness, and lymphedema. During interview, the resident stated she frequently waited more than an hour for help to use the bathroom and said this caused episodes of bowel and bladder incontinence, which she described as degrading. The second resident had diagnoses including non-traumatic spinal cord dysfunction, peripheral vascular disease, and a personal history of UTI. During interview, the resident stated she required a mechanical lift and two staff members for transfers, and staff frequently had to wait for additional help, during which time she became incontinent on more than one occasion. Call light logs showed multiple call lights lasting more than 30 minutes for both residents, including 26 occasions for one resident and 14 occasions for the other. The DON stated call lights should ideally be answered within 15 minutes, confirmed the logs showed waits beyond 30, 45, and 60 minutes, and could not explain why they were not answered faster.
Failure to Inform Residents of Anonymous Grievance Process and Maintain Grievance Records
Penalty
Summary
The facility failed to ensure residents were aware of how to file grievances anonymously for 4 of 4 residents reviewed for grievances, including R33, R34, R24, and R14. During interviews on 4/30/26, all four residents stated they were unclear how to file an official grievance or where to find a grievance form to assure anonymity. They also stated they could talk to the DON, and the DON had instructed residents that all grievances or concerns were to be handled internally. During interview on 04/30/2026, the DON stated a grievance was any report of a concern a resident felt necessary to discuss about care or the facility, and that residents could bring concerns to her, the SW, or any staff member. She stated residents could fill out the form or staff could assist them if a resident brought forward a verbal grievance, and that she verbally followed up with a one-to-one meeting in the resident's room. However, she also stated she did not have copies of grievances, grievance investigations/resolutions, or a grievance log tracking resident grievances, despite the facility policy requiring a grievance log and records to be kept for at least 3 years. The policy also stated residents may file a grievance orally to an employee, the employee is to complete the grievance report form, and the grievance official will maintain a record of formal complaints.
Missed Scheduled Medication Administration
Penalty
Summary
The facility failed to ensure medications were administered in accordance with physician orders for 1 of 1 residents reviewed for medication administration. The resident’s quarterly MDS indicated the resident was cognitively intact and had diagnoses including Multiple Sclerosis, Hypertension, Neurogenic bladder, Chronic Obstructive Pulmonary Disease, and Hyperlipidemia. During interview, the resident stated she had not received her scheduled 7:00 a.m. medications. Review of the MAR showed blank boxes for the resident’s 7:00 a.m. medications, indicating they had not been administered. The resident was scheduled to receive Glucosamine-Chondroitin 500-400 mg, Lisinopril 20 mg, Omeprazole 20 mg, Multivitamin, Trimethoprim 100 mg, Fluticasone-Salmeterol inhalation aerosol 250-50 mcg/act, Nystatin external powder 100000 u/gm, Oxybutynin Chloride 5 mg, Baclofen 10 mg, and Gabapentin 300 mg, but these medications were not given within the allowable time frame. The DON reviewed the MAR and confirmed the medications had not been received within the allowable window and stated medications were expected to be delivered within one hour before or after the scheduled time.
Failure to Offer COVID-19 Vaccination
Penalty
Summary
The facility failed to ensure COVID-19 vaccinations were offered to 1 of 5 residents reviewed for COVID-19 vaccination status. Resident R6’s quarterly MDS showed the resident was admitted to the facility and had diagnoses of high blood pressure, hyperlipidemia, and malnutrition. R6’s undated client information vaccination record indicated the resident was overdue for a COVID-19 vaccination, but the medical record contained no evidence that the vaccine was offered or provided. The Infection Preventionist stated R6 had been on a list from the previous IP to be completed, but no supportive documentation could be found showing the vaccine was ever offered or completed, and stated it should have been completed within a few days of admission. The DON also confirmed R6 had not been offered or received the COVID-19 vaccination and stated the expectation was that it would have been completed within a week of admission.
Failure to Follow Insulin Administration Parameters Leads to Significant Medication Error
Penalty
Summary
A deficiency occurred when nursing staff failed to follow physician orders regarding insulin administration parameters for a resident with diabetes, dementia, and mild cognitive impairment. The resident had specific orders to hold insulin aspart if blood sugar (BS) was less than 150 mg/dl. Despite this, insulin was administered multiple times when the resident's BS was below the ordered threshold, including readings of 137, 97, 144, and 82 mg/dl. The medication administration record (MAR) reflected these administrations, and interviews with nursing staff revealed a lack of awareness or failure to review the full order details, which were located in a section of the electronic medical record that required additional navigation. The facility had recently implemented a new electronic medical record system, and some staff, including agency nurses, were not fully informed about how to access all relevant order parameters. As a result of these medication errors, the resident experienced severe hypoglycemia, becoming unresponsive with a BS as low as 32 mg/dl. Emergency interventions were required, including administration of glucagon and glucose gel, and the resident was ultimately transported to the hospital for further treatment. The hospital discharge summary confirmed admission for hypoglycemia and related complications. Interviews with facility staff, including the DON and pharmacist, confirmed that the insulin should have been held and that the incident constituted a significant medication error.
Inadequate Staffing Leads to Multiple Deficiencies in Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff and leadership to meet the needs of residents, resulting in several deficiencies. Observations, interviews, and document reviews revealed that the facility did not have enough staff to adequately care for residents, leading to issues such as pressure ulcer prevention failures, inadequate assistance with activities of daily living, and dignity concerns. Specific incidents included a resident being left exposed and nude on the toilet without privacy, and another resident with an indwelling catheter not receiving dignified care. Additionally, the facility did not reassess and implement proactive interventions to reduce the risk of falls for residents who had previously fallen. Residents and family members expressed concerns about the lack of staff and long wait times for care. Interviews with staff members, including a trained medication aide, licensed practical nurses, and a registered nurse, confirmed that staffing levels were insufficient to meet resident needs. Staff reported being unable to complete necessary tasks such as range of motion exercises and personal care due to being pulled to cover other duties. The facility's staffing coordinator and director of nursing acknowledged the staffing challenges, with the director noting that call lights were not being answered promptly, sometimes taking up to an hour. The facility's resident council meeting minutes from several months also highlighted ongoing concerns about inadequate staffing. During interviews, residents described long wait times for assistance, with one resident stating that it could take up to an hour for a call light to be answered. Observations during the survey showed that call lights were often ignored by staff, further indicating the facility's inability to provide timely care. The facility's assessment identified a high percentage of residents requiring total dependence on staff for mobility and other needs, yet the staffing plan did not adequately address these requirements.
Medication Cart Security Lapses
Penalty
Summary
The facility failed to ensure that medications were securely stored, as evidenced by multiple observations of unattended and unlocked medication carts in various units. On Eagle Lane, a medication cart was left unlocked and unattended in the hallway between two resident rooms. A registered nurse (RN-E) admitted to leaving the cart unsecured while attending to a resident who was calling for help. Similarly, on Bluejay Lane, an unlocked and unattended medication cart was observed in the hallway, with numerous residents and family members passing by. A licensed practical nurse (LPN-B) confirmed the cart was unlocked and subsequently secured it, acknowledging the importance of keeping medication carts locked to prevent unauthorized access. On Cardinal Lane, another unattended and unlocked medication cart was observed in the hallway. A registered nurse (RN-C) admitted to forgetting to lock the cart, emphasizing the importance of securing it due to the presence of potentially dangerous medications. The director of nursing (DON) reiterated that all unattended medication carts should be locked to prevent unauthorized access. The facility's policy on the storage of medications and biologicals mandates that all such items be securely stored in locked cabinets or carts, which was not adhered to in these instances.
Failure to Maintain Resident Dignity During Personal Care
Penalty
Summary
The facility failed to provide toileting and personal care in a dignified manner for a resident who was left exposed and nude on the toilet facing a window to the facility courtyard. The resident, who had intact cognition and required assistance with toileting and upper body dressing, was left alone by a nursing assistant who left the room to obtain supplies. The window blinds were not closed, leaving the resident exposed to the courtyard. A trained medication aide later entered the room and closed the blinds, noting the resident's discomfort. The resident expressed feeling exposed and having lost dignity during their stay at the facility. Additionally, the facility did not maintain dignity for a resident with an indwelling catheter. The resident, who had moderate cognitive impairment and was dependent on staff for toileting, was observed being transported in a wheelchair with a visible and uncovered urine drainage bag. The nursing assistant responsible for the transport acknowledged the importance of covering the bag for privacy but was unable to locate a privacy cover in the resident's room. The director of nursing confirmed that urine drainage bags should always be covered, and the facility policy emphasized the importance of maintaining resident privacy and dignity.
Failure to Provide SNFABN to Resident
Penalty
Summary
The facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) to a resident whose Medicare Part A coverage ended while they remained in the facility. The resident's Notice of Medicare Non-Coverage indicated that their last covered day under Medicare A was signed by a family member, but the SNFABN was not provided as the resident won an appeal. Despite a subsequent notice indicating a new last covered day, the resident's medical record did not show that a SNFABN was given before the Medicare Part A coverage ended. A licensed social worker confirmed the oversight, acknowledging that the SNFABN had been missed for the resident. Additionally, a policy regarding SNFABNs was not received during the review.
Resident Privacy Breach Due to Unattended Laptop
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of resident records, as observed during a survey. An unattended laptop was found displaying sensitive information about three residents, including their names, diagnoses, assistance needs, and other personal care details. This laptop was left open and unattended, allowing unauthorized personnel to potentially view the information. Multiple staff members, including nursing assistants and a trained medication aide, acknowledged the breach of privacy, noting that the information should not have been visible. The Director of Nursing confirmed that this incident constituted a violation of HIPAA regulations, as it exposed private resident information to unauthorized individuals. The facility's policy on HIPAA privacy was not adhered to, as staff failed to protect patient information appropriately.
Failure to Maintain Comprehensive Care Plan for Resident at Risk of Pressure Ulcers
Penalty
Summary
The facility failed to develop and maintain an individualized comprehensive care plan for a resident, identified as R42, who required staff assistance with activities of daily living (ADLs) and was at risk for pressure ulcers. The resident's Minimum Data Set (MDS) assessment indicated that R42 had intact cognition and required varying levels of assistance for personal hygiene, dressing, and mobility. Despite these needs, the care plan lacked specific interventions for pressure ulcer prevention and did not reflect the resident's history of pressure injury or the presence of a deep tissue injury upon admission. Observations and interviews revealed that R42 was seated in a wheelchair with a cushion and was aware of a sore on the bottom, which was being treated by staff. However, the care plan did not include necessary interventions such as the use of an air mattress or cushion in the wheelchair to prevent further pressure ulcer development. Additionally, the care plan did not document ongoing assessments or updates regarding the resident's pressure ulcer status, and there was a lack of evidence that the deep tissue injury had healed. Interviews with nursing staff indicated a lack of communication and documentation regarding the resident's wound care needs. Licensed Practical Nurse (LPN)-B, responsible for wound assessments, acknowledged that no further wound assessments had been completed after the initial assessment. The Director of Nursing (DON) confirmed that the care plan did not reflect the resident's care needs, including specific interventions for pressure ulcer prevention. The facility's policy on person-centered care planning required comprehensive care plans to be reviewed and revised as needed, but this was not adhered to in the case of R42.
Failure to Ensure Routine Bathing for Resident
Penalty
Summary
The facility failed to ensure routine bathing was completed in accordance with the identified wishes of a resident who was dependent on staff for bathing care. The resident, who had severe cognitive impairment and was dependent on staff for personal hygiene, reported not receiving her baths every week. Her care plan indicated a need for assistance with activities of daily living due to weakness and other medical conditions, but it lacked specific information on the frequency of bathing. Interviews with a nursing assistant revealed that the resident was scheduled for a twice-weekly shower, but staffing challenges, particularly during the summer months, often resulted in only quick bed baths being provided instead of showers. Documentation in the resident's medical record showed inconsistencies in recording completed showers. The Point of Care Response History for a 14-day period had two entries marked as 'Not applicable,' and progress notes indicated that a shower was not completed on one occasion without any rationale provided. The registered nurse manager confirmed the lack of documentation for the second weekly shower and acknowledged that staff did not consistently report issues with completing showers. The facility's standard ADL protocol did not include information on how completed baths or showers should be recorded or tracked, contributing to the deficiency in ensuring the resident's bathing needs were met.
Failure to Assess and Address Constipation Concerns
Penalty
Summary
The facility failed to adequately assess and address potential signs of constipation for a resident, identified as R41, who reported feeling constipated. Despite R41's admission Minimum Data Set (MDS) indicating no history of constipation, the resident expressed concerns about bowel irregularity and a desire for proactive interventions. The resident reported that staff provided medication upon request but did not discuss other options like prune juice or fiber supplements. The Continence Evaluation for R41 did not indicate any proactive measures for bowel management, and the care plan lacked ongoing medications to promote regular bowel movements. Interviews with staff revealed that R41 had requested a suppository and had experienced periods with multiple days between bowel movements. The Point Of Care (POC) Response History showed irregular bowel patterns, with some days having no recorded movements and others showing loose or formed stools. The Medication Administration Record (MAR) indicated the use of as-needed laxatives, but there was no evidence of a comprehensive reassessment to determine necessary proactive interventions. The registered nurse manager acknowledged the irregular bowel patterns and the use of as-needed laxatives but noted that no concerns had been reported to them. The facility's Protocol For Bowel Management required a bowel movement every 72 hours and stated that the primary physician should be informed if nursing intervention was needed three or more times in a month. However, the policy lacked guidance on assessing or documenting a comprehensive bowel management program, contributing to the deficiency in addressing R41's constipation concerns.
Failure to Prevent Pressure Ulcers in High-Risk Residents
Penalty
Summary
The facility failed to provide adequate care to prevent pressure ulcers for two residents identified as high risk. Resident R5, who was dependent on staff for all activities of daily living, was observed lying on her back for extended periods without being repositioned, despite care instructions requiring repositioning every two hours. Nursing staff, including a nursing assistant and an LPN, were unaware of when R5 was last repositioned, and there was no documentation in the electronic medical record (EMR) to confirm that repositioning had occurred. R5 expressed that she had not been turned since lunchtime, and staff interviews confirmed a lack of adherence to the care plan. Similarly, Resident R37, who had significant cognitive impairment and was also at high risk for pressure ulcers, was observed sitting in a recliner for several hours without repositioning. Nursing staff admitted that R37 was not on a turning and repositioning program, and there was no documentation of repositioning efforts in the EMR. The Director of Nursing acknowledged the absence of a system to ensure regular repositioning and the lack of documentation for refusals. The facility's policy on pressure ulcer prevention was requested but not provided, indicating a potential gap in policy adherence or availability.
Failure to Update Care Plans and Implement Fall Interventions
Penalty
Summary
The facility failed to comprehensively reassess and develop proactive interventions to reduce the risk of further falls and injury for two residents who had sustained falls. Resident R44, with severe cognitive impairment, had a history of falls prior to admission and continued to experience falls after admission. Despite multiple falls, the care plan for R44 was not updated with new interventions, and incident reports lacked documentation of any new strategies to prevent further falls. Interviews with staff revealed that fall reports were not consistently reviewed by the interdisciplinary team (IDT), and new interventions were not documented or implemented. Resident R26, also with severely impaired cognition, experienced an unwitnessed fall from his bed. Although the fall scene investigation form identified potential environmental factors and immediate interventions, the IDT review section was left blank, indicating a lack of follow-up. The care plan for R26 had not been updated with new interventions since a previous fall, and staff interviews confirmed that the expected updates to the care plan and nursing assistant care sheet were not completed. The facility's policy on managing resident falls required evaluation and analysis of fall risks and the implementation of interventions by the IDT. However, the policy was not followed, as evidenced by the lack of IDT review and updates to care plans following falls. Staff interviews highlighted challenges in completing fall reports and implementing new interventions due to staffing issues, which contributed to the deficiency in fall management.
Failure to Assess Entrapment Risk and Alternatives for Grab Bar Use
Penalty
Summary
The facility failed to comprehensively assess a resident, identified as R15, for entrapment risk and did not attempt alternatives before installing grab bars on the resident's bed. R15, who had moderately impaired cognition and required substantial assistance with transferring out of bed, was observed to have grab bars affixed to their bed. The facility's assessment for grab bar use, conducted upon R15's admission, did not document any alternative methods or products attempted prior to the installation of the grab bars. Additionally, the medical record lacked evidence of an assessment for individualized entrapment risk factors, such as R15's medical diagnosis, medications, cognition, or fall risk. Interviews with facility staff revealed that the grab bars were applied on admission without attempting alternatives due to the resident's weight and the need for two staff members to assist with turning in bed. The unit manager acknowledged that while the risks and benefits of grab bar use were reviewed with R15 and consent was obtained, individualized entrapment risk factors were not assessed. The director of nursing confirmed that a nursing assessment should be completed to determine the appropriateness of bedrails, but the facility's policy was not followed in this case, as the necessary assessments and documentation were incomplete.
Failure to Limit and Re-evaluate PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure the use of a PRN psychotropic medication was limited to a 14-day period and re-evaluated by the provider for a resident with severe cognitive impairment and anxiety. The resident, who was on hospice care, had an active order for PRN Ativan without a stop date, which was not reviewed or renewed by the provider within the required timeframe. The resident's Medication Administration Record showed that Ativan was administered twice, with both instances recorded as effective, but the progress notes lacked documentation of non-pharmacological interventions attempted prior to medication administration. Interviews with facility staff revealed that the registered nurse and consulting pharmacist were aware of the missing stop date and the need for re-evaluation, but the oversight occurred due to a lapse in communication and review processes. The consulting pharmacist acknowledged the need for a 14-day re-evaluation and had obtained a six-month extension for the medication. The registered nurse manager noted that the hospice agency should have ensured a stop date was listed, but this was not consistently done, leading to the deficiency.
Failure to Offer Pneumococcal Vaccination
Penalty
Summary
The facility failed to ensure that recommended pneumococcal vaccinations were offered and/or provided in a timely manner to a resident, as outlined by the CDC guidelines. The resident, who was admitted to the care center in August 2024, had a history of dementia and high blood pressure. The resident's electronic medical record indicated that they had received the PCV13 vaccine in December 2017 and the PPSV23 vaccine in March 2019, but there was no evidence that the PCV20 vaccine had been offered or administered, despite CDC recommendations for shared clinical decision-making regarding this vaccine. An interview with the facility's infection preventionist (IP), an LPN, revealed that the resident's family member preferred to sign consent forms for vaccinations, but there was no signed consent or refusal for the PCV20 vaccine in the resident's record. The LPN acknowledged that the PCV20 vaccine had not been offered due to a lack of documentation and stated that they had been unable to follow up with the family member due to being frequently pulled to work on the floor. The facility's pneumococcal immunization policy, last reviewed in April 2024, stated that immunizations would be offered in accordance with professional standards and documented in the resident's medical record, which was not adhered to in this case.
Inaccurate MDS Coding for Restraint Use and BIMS Assessment
Penalty
Summary
The facility failed to ensure the accurate coding of the Minimum Data Set (MDS) regarding restraint use for four residents. The MDS inaccurately indicated that these residents had bed rails used as restraints daily, despite observations and interviews revealing that the grab bars did not restrict the residents' freedom of movement. The nursing assistant and residents themselves confirmed that the grab bars were used for assistance and did not act as restraints. The offsite MDS coordinator admitted to coding the grab bars as restraints due to a lack of assessment documentation and without further clarification from onsite staff. Additionally, the facility did not accurately complete a Brief Interview for Mental Status (BIMS) assessment for one resident. The BIMS assessment was not stopped after nonsensical responses were given, leading to an incorrect summary score and the absence of a required Staff Assessment for Mental Status. The offsite MDS coordinator acknowledged that the staff member conducting the BIMS assessment was unsure of the procedure and did not stop the assessment as required. These deficiencies highlight a lack of proper assessment and documentation practices within the facility, leading to inaccuracies in the MDS coding for both restraint use and cognitive assessments. The offsite MDS coordinator's reliance on incomplete electronic records and lack of communication with onsite staff contributed to these errors.
Failure to Monitor Antibiotic Use in LTC Facility
Penalty
Summary
The facility failed to develop and implement a comprehensive system to monitor antibiotic use, which led to the inappropriate administration of antibiotics to a resident, identified as R198. The resident had multiple diagnoses, including diarrhea and pressure ulcers, and was prescribed antibiotics such as amoxicillin-pot clavulanate and cephalexin. Despite the presence of loose stools and a foul odor from the wounds, there was no documentation of infection symptoms or a clear rationale for the antibiotic use. The facility did not provide the necessary antibiotic stewardship logs for April and May 2024, indicating a lack of systematic tracking and monitoring of antibiotic use. Interviews with facility staff revealed inconsistencies in the monitoring and documentation of antibiotic use. The Infection Prevention Manager (IPPM) admitted that the 72-hour antibiotic time outs were often not completed, and there was no process for daily documentation of antibiotic treatment and resident symptoms. The Director of Nursing (DON) acknowledged the importance of monitoring resident symptoms and temperatures but noted that the facility lacked a structured process for ensuring this was done consistently. The absence of a comprehensive antibiotic stewardship program and the failure to document and monitor antibiotic use contributed to the deficiency. The facility's policies on antibiotic stewardship and infection control were not effectively implemented. The policies required tracking antibiotic use and outcomes, as well as educating staff and residents about appropriate antibiotic use. However, the facility did not adhere to these policies, as evidenced by the incomplete antibiotic stewardship logs and the lack of documentation for antibiotic time outs. The failure to follow these policies and procedures resulted in the inappropriate use of antibiotics, potentially affecting all residents in the facility.
Failure to Implement QAPI Plan and Address Deficiencies
Penalty
Summary
The facility failed to implement a Quality Assurance and Performance Improvement (QAPI) plan to maintain acceptable levels of performance and continual improvement. The facility did not conduct ongoing quality assessment and assurance activities, nor did it develop and implement appropriate plans of action to correct repeated quality deficiencies. These deficiencies were identified during the survey and had the potential to adversely affect all 50 residents residing in the facility. During document review, it was noted that the QAPI quarterly meeting minutes from various dates included a section on survey results and plans of correction, highlighting issues with pharmacy review, vaccinations, and TB testing. However, during an interview, the Director of Nursing (DON) stated that the facility had not developed performance improvement projects and lacked formal documentation for correcting previously identified deficiencies. The DON mentioned that QAPI activities were on hold due to new management awaiting further instructions on processes.
Infection Control Deficiencies in PPE and Catheter Management
Penalty
Summary
The facility failed to adhere to evidence-based practices in infection prevention and control, specifically in the management of catheter bags and ports for two residents, whose catheter bags were observed on the ground. Additionally, the facility did not ensure the proper use of personal protective equipment (PPE) and hand hygiene for two residents on enhanced barrier precautions (EBP) and contact precautions. The facility also failed to identify and track potential infections for a resident reviewed for antibiotic use. One resident, who had impaired cognition and multiple medical conditions including a stage 3 pressure ulcer and an indwelling catheter, was not properly managed under enhanced barrier precautions. Observations revealed a lack of signage indicating the need for EBP, and staff did not consistently use PPE or perform hand hygiene as required. The resident's care plan and orders lacked documentation of EBP or updated transmission-based precautions, and there was no signage or isolation supplies outside the resident's room. Another resident, who had a foley catheter and was on enhanced barrier precautions, was also not managed according to infection control protocols. Staff were observed not wearing gloves during high-contact care activities, and there was a lack of consistent hand hygiene practices. The facility's policies on hand hygiene and EBP were not adequately followed, leading to potential risks of spreading multi-drug resistant organisms (MDROs) among residents.
Failure to Maintain Resident Privacy and Dignity
Penalty
Summary
The facility failed to maintain the privacy and dignity of a resident, identified as R146, during care. R146, who had a history of falls, a nondisplaced intertrochanteric fracture of the right femur, and was incontinent, was observed on a transitional care unit with their room door open and uncovered, visible from the hallway. This occurred when a nursing assistant, NA-B, left the room to put on personal protective equipment, leaving R146 exposed. R146 expressed discomfort with being exposed, stating they felt bare naked. Interviews with staff, including NA-B, NA-G, RN-A, RN-B, and the director of nursing (DON), revealed that the facility's policy was to ensure residents' privacy by closing doors and keeping residents covered during care. NA-B acknowledged the oversight and expressed surprise at not closing the door. The DON confirmed that leaving a resident uncovered with the door open was a dignity issue and did not respect the resident's modesty. The facility's policy on Resident Rights directed staff to protect and promote the rights of each resident.
Failure to Prevent Accident Hazards and Assess Fall Risks
Penalty
Summary
The facility failed to ensure residents were free from accident hazards, specifically for a resident who used a remote-controlled recliner. The resident, who had mild cognitive impairment, hemiplegia, and other health issues, was found on the floor after an unwitnessed fall. The recliner was in a raised position, and it appeared the resident had used the remote to raise it, leading to the fall. The care plan did not document an assessment of the resident's safety with the recliner, nor was there a discussion of the risks and benefits of using such equipment. Another resident, who had a recent stroke and was on fall precautions, experienced an unwitnessed fall with a head strike while attempting to self-transfer. The resident's baseline care plan lacked interventions related to the physical therapy evaluation that determined a fall risk. The facility's documentation did not include a nursing fall risk assessment for this resident, and no immediate interventions were documented following the fall. Interviews with staff revealed a lack of awareness and documentation regarding specific fall interventions for both residents. The facility's policy required evaluation and analysis of fall risks upon admission and as needed, but this was not adequately implemented. The interdisciplinary team was expected to discuss falls and determine interventions, but immediate measures were not consistently applied or documented.
Failure to Assess and Obtain Consent for Grab Bars
Penalty
Summary
The facility failed to comprehensively assess, discuss risks and benefits, obtain informed consent, and attempt alternatives prior to the installation of grab bars for two residents. Resident R96, who was severely cognitively impaired and at risk for falls, had grab bars installed on their bed without a comprehensive nursing assessment or documented discussion of risks, benefits, and alternatives. The resident's medical record lacked evidence of informed consent prior to the installation of the grab bars, and the grab bars were installed before the required assessments were completed. Resident R146, who had a history of falls and was admitted with a nondisplaced intertrochanteric fracture, also had grab bars installed without a comprehensive nursing assessment or documented discussion of risks, benefits, and alternatives. The resident's medical record did not contain evidence of informed consent prior to the installation of the grab bars. The grab bars were noted on the resident's baseline care plan, but the necessary assessments and documentation were completed after the installation. Interviews with facility staff, including nursing assistants, registered nurses, and the director of nursing, revealed that the facility relied on therapy recommendations for the installation of grab bars and often completed the necessary assessments and documentation several days after installation. The facility's policy required that residents be screened for the need for special equipment, including bed rails, and that risks and benefits be reviewed with the resident or representative, informed consent obtained, and a physician order secured prior to installation. However, these steps were not followed for the residents in question, leading to the deficiency.
Failure to Maintain Safe and Sanitary Dishware
Penalty
Summary
The facility failed to maintain dishware in a safe and sanitary manner, as evidenced by the presence of chipped and cracked dishware being used within the facility. An unidentified resident reported that the facility had a lot of chipped ceramic dishware, including bowls and cups, which they had brought to the staff's attention, but the issue had not been corrected. Observations confirmed the presence of chipped bowls in the dining room, with one nursing assistant assisting a resident to eat oatmeal from a chipped bowl, and another chipped bowl was found in the clean pile ready for use. Interviews with dietary staff revealed inconsistencies in the handling of damaged dishware. Dietary aide (DA)-B stated that chipped and cracked dishes were supposed to be discarded, but upon inspection, a resident was found eating from a cracked bowl. DA-A mentioned that they would remove broken dishware but considered dishes with small chips still usable. The dietary manager (DM) confirmed that chipped or cracked dishware should be discarded to prevent cuts and ensure proper sanitation. The facility's administrator expected dishware to be free of chips and cracks to maintain cleanliness and minimize the risk of foodborne illness. The facility's policy indicated that chipped or cracked dishware should be discarded immediately.
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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