Benedictine Care Community
Inspection history, citations, penalties and survey trends for this long-term care facility in Ada, Minnesota.
- Location
- 201 9th Street West, Ada, Minnesota 56510
- CMS Provider Number
- 245502
- Inspections on file
- 19
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 10 (1 serious)
Citation history
Health deficiencies cited at Benedictine Care Community during CMS and state inspections, most recent first.
A resident with intact cognition and no baseline hallucinations developed new hallucinations, emotional distress, vomiting, shaking, diarrhea, generalized pain, fatigue, and persistent fevers with tachycardia over several days. Despite documented vital sign abnormalities and atypical behaviors, nursing staff relied on scheduled acetaminophen, did not complete a thorough assessment, and did not notify the provider as required by facility policy. IDT discussions occurred but did not include review of progress notes or vital signs, and some staff attributed symptoms to influenza or the resident’s psychiatric history, delaying escalation. The resident was only sent to the ED after appearing pale and toxic with ongoing pain and shivering, where she was diagnosed with UTI, obstructing ureteral stone, sepsis with acute renal failure, and septic shock, confirming a failure to timely recognize and act on a significant change in condition.
Surveyors found that the RN designated as the infection preventionist had not completed the required specialized infection prevention and control training. Review of the RN’s training records showed no evidence of IP-specific education, and during interview the RN confirmed she had begun but not finished the required coursework. This was not consistent with the facility’s policy, which requires the IP to be qualified by education, training, certification, or experience and to have completed specialized infection prevention and control training.
A resident with intact cognition and a care plan noting risk for infection due to urinary incontinence developed new hallucinations, severe pain, vomiting, diarrhea, fatigue, refusal of medications, poor intake, and repeated fevers with tachycardia over several days. Despite abnormal vital signs and documented behavioral and neurological changes, staff did not notify the attending MD as required by facility policy and the care plan directive to update the provider as needed. The resident’s condition worsened until she appeared ill, shivering, pale with a grey hue, and reporting pain all over, prompting transfer by ambulance to the ED, where she was diagnosed with sepsis due to E. coli, UTI from an obstructing ureteral stone, acute kidney injury, and septic shock. The attending MD later confirmed she had not been informed of the change in condition and stated she should have been contacted when the resident developed a fever.
The facility did not ensure that all staff completed required annual abuse training and did not effectively track compliance with these requirements. A nursing assistant hired more than a year prior had no documented annual abuse training, and an RN had not completed abuse training since hire, as shown in their training records. The HR manager reported that unit managers were responsible for staff training completion, that corporate sent quarterly notices about required trainings, and that she provided reminders, but she did not monitor which staff had outstanding training. Facility policy required a designated super registrar to manage training tracking, completion of hire courses before independent work on the floor, and quarterly assignment of annual training requirements.
Two residents admitted with indwelling catheters did not receive care in accordance with physician orders when the facility lacked the ordered catheter sizes and appropriate supplies. For one resident with spinal cord injury and bladder dysfunction, staff used tape instead of a Foley clamp during a bath and later replaced a 20 Fr catheter with an 18 Fr catheter because the correct size was not in stock. For another resident with UTI, urinary retention, and chronic kidney disease, staff informed the family that a 14 Fr catheter with a 5 cc balloon was unavailable and inserted a 16 Fr catheter with a 10 cc balloon instead. An RN and the DON reported that admission staff should verify supply availability and that the DON was responsible for ordering supplies; the DON acknowledged that alternate catheter sizes were used without obtaining new physician orders, despite facility policy requiring physician orders to be followed as prescribed.
A resident who had recently undergone hip surgery did not receive timely assessment, monitoring, or documentation of changes in her surgical incision. When signs of infection such as redness, drainage, and pain developed, nursing staff failed to promptly notify the provider or document these changes, despite daily dressing orders. This led to the resident developing a severe infection and sepsis, requiring hospitalization, surgery, and IV antibiotics.
A resident with a recent hip surgery developed signs of infection at the surgical site, including purulent drainage, redness, swelling, and pain. Despite these changes, staff did not consistently document wound assessments or promptly notify the provider, resulting in a delay in medical intervention. The resident was later hospitalized with sepsis and required IV antibiotics and surgical intervention.
Residents lost the ability to perform ADLs without a documented medical reason, as the facility did not ensure that declines in ADL performance were clinically unavoidable or supported by medical documentation.
A resident did not receive appropriate care to maintain or improve ROM and mobility, resulting in a decline that was not attributed to a medical reason.
Grievance forms and procedures were not posted in prominent locations, and residents were unaware of how to file grievances. Staff interviews confirmed that forms were kept behind the nurses' station, requiring residents to ask staff for access, contrary to facility policy stating forms should be readily available.
The facility did not include agency staff hours in its PBJ submissions to CMS because agency staff were not punching in for their shifts, resulting in incomplete and inaccurate direct care staffing data for all residents. This was confirmed by review of timecards and PBJ reports showing low weekend staffing, and acknowledged by both the corporate submitter and administrator.
A resident with severe cognitive impairment and multiple chronic conditions was allowed to self-administer a nebulizer treatment without a completed SAM assessment or physician order. An LPN left the resident unattended during the treatment, contrary to facility policy and care plan directives, and the resident removed the mask and left the room while medication was still being dispensed. Staff interviews confirmed the lack of required assessment and supervision.
A resident with severe cognitive impairment and multiple diagnoses was not assisted with shaving despite visible facial hair and a documented need for staff support with personal hygiene. Observations and staff interviews confirmed the lack of recent assistance, contrary to the resident's care plan and facility policy.
Failure to Recognize and Respond to Resident’s Change in Condition Leading to Sepsis and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to identify and act on a resident’s change in condition despite clear signs of acute illness and a care plan for potential infection. The resident had intact cognition per the annual MDS and no baseline hallucinations, delusions, or behaviors. Her care plan identified a self-care deficit and potential for infection related to urinary incontinence, with directions to update the provider as needed. Beginning several days before hospitalization, progress notes documented new hallucinations and emotional distress, including the resident yelling and crying about her babies being murdered and being taken from her, and an IDT discussion noting hallucinations and behavioral changes. These symptoms were atypical for this resident and represented a change from her baseline. Over the following days, the resident developed and sustained fevers and other signs of systemic illness. Vital signs showed temperatures of 101.7°F with a pulse of 140 bpm, later rising to 103.2°F and remaining elevated around 101–100°F over multiple readings, along with low-grade fevers on subsequent days. Progress notes documented vomiting, visible shaking, feeling cold, episodes of incontinent diarrhea, reports of pain “everywhere,” crying, tearfulness, fatigue, and refusal of medications and meals. Despite these findings, nursing staff treated the resident only with scheduled acetaminophen and did not conduct a documented comprehensive nursing assessment or notify the provider when the fevers and other symptoms emerged and persisted. The IDT discussed the resident’s fevers, fatigue, medication refusals, and verbal behaviors but did not review the progress notes or vital signs in detail, and no provider notification occurred at that time. Staff interviews further confirmed that the change in condition was not appropriately recognized or escalated. One RN stated she had not identified anything out of the ordinary beyond weakness and a presumed low-grade influenza, and that staff believed the resident might be recovering when a single temperature reading was normal. Another RN acknowledged that the resident’s change in condition occurred over a weekend when the IDT was not present and that the team did not review the progress notes or vital signs during the subsequent IDT meeting. A different RN reported that she did not assess the resident after the IDT discussion because the resident was asleep and her temperature had decreased slightly, and she felt that the resident’s bipolar diagnosis and prior behaviors had masked the change and interfered with judgment. The facility’s own policy required licensed nurses to evaluate significant changes in condition, obtain vital signs, and notify the provider of abnormal vital signs, behavioral or neurological changes, and worsening pain, but this process was not followed for this resident, resulting in delayed recognition and treatment of sepsis and subsequent hospitalization. Ultimately, the resident was sent to the ED only after she appeared pale with a grey hue, had dark circles under her eyes, was shivering, reported generalized pain, and continued to feel unwell. In the ED, she was found to be ill-appearing and toxic-appearing, with a high fever, tachycardia, hypotension, low GFR, and a diagnosis of sepsis with acute renal failure, septic shock, acute kidney injury, ureteral obstruction, and UTI. The attending MD later stated that the facility had not contacted her when the resident developed a fever and that earlier evaluation could have avoided the septic shock. The NP who saw the resident in the ED described her as barely responsive, with low blood pressure requiring IV fluids and vasopressors, and indicated that while the ureteral stone itself was not avoidable, the sepsis and unnecessary pain could have been prevented if the resident had been sent to the ED sooner. These facts support the finding that the facility failed to provide appropriate treatment and care according to orders, the resident’s preferences and goals, and its own change-in-condition policy.
Removal Plan
- Review policies and procedures related to change in condition and physician notification.
- Review all residents for a potential change in condition.
- Educate nursing staff on policies and procedures related to change of condition and resident monitoring, qualifying factors for a change of condition, assessment of resident symptoms without bias, and timely physician notification and treatment of resident symptoms.
Designated Infection Preventionist Lacked Required Specialized Training
Penalty
Summary
The facility failed to ensure that the designated infection preventionist (IP) completed the required specialized training for directing the infection prevention and control program. Surveyors’ review of the personnel training record for a registered nurse identified as the facility’s IP showed no evidence of training related to the IP role. In an interview, the RN confirmed she was the designated IP, stated she had started the required training, but acknowledged she had not had time to finish it. The facility’s policy titled “Infection Preventionist Role,” dated 8/2023, specified that the IP or designee is responsible for directing the infection prevention and control program and should have appropriate background and training, be qualified by education, training, certification or experience, and have completed specialized training in infection prevention and control. This lack of completed specialized IP training for the designated RN, as documented in records and confirmed in interview, was inconsistent with the facility’s own policy requirements for the infection preventionist role.
Failure to Notify Physician of Resident’s Significant Change in Condition Leading to Hospitalization for Sepsis
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician of a resident’s significant change in condition despite multiple abnormal findings and behavioral changes. The resident had intact cognition, was care planned for potential infection related to urinary incontinence, and was described as alert, oriented, and independent in decision-making. Over several days, progress notes documented new hallucinations, delusions, crying, and verbal outbursts, including statements about murdering her babies and fears about her babies being taken away. The IDT discussed these behaviors and noted hallucinations. Concurrently, the resident reported vomiting all night, severe pain, and feeling unable to move. Vital signs showed repeated fevers, including temperatures over 101°F and up to 103.2°F, along with tachycardia over 100 bpm. The resident also experienced incontinent diarrhea, generalized pain, fatigue, refusal of medications, and poor oral intake. Despite these documented changes—abnormal vital signs, new behavioral and neurological symptoms, worsening pain, and functional decline—there was no evidence that staff notified the attending physician of the change in condition, even though the care plan directed staff to update the provider as needed and facility policy required provider notification for significant changes and abnormal findings. The IDT noted the resident’s fevers and behaviors and planned to assess and contact the provider “if necessary,” but the physician later confirmed that staff had not contacted her when the resident developed a fever and other symptoms. The resident was eventually noted to be shivering, pale with a grey hue, with dark circles under her eyes, reporting pain all over and not feeling well, at which point an ambulance was called and she was sent to the ED, where she was diagnosed with sepsis due to E. coli with acute organ dysfunction, septic shock, UTI secondary to an obstructing ureteral stone, and acute kidney injury. The physician and another MD interviewed both stated that they had not been notified of the change in condition and that they should have been contacted when the resident developed a fever.
Failure to Ensure and Track Completion of Annual Abuse Training for Staff
Penalty
Summary
The facility failed to ensure completion and tracking of required annual abuse training for staff, resulting in two of ten staff reviewed not having current abuse education. A nursing assistant hired on 11/7/25 had no record of completed annual abuse training as of a training record printed on 3/5/26. A registered nurse hired on 8/28/24 had not completed annual abuse training since the date of hire, according to a training record printed on 3/5/26. During an interview, the human resources manager stated that managers were responsible for ensuring their staff completed training, that the corporate office sent quarterly messages regarding required trainings, and that she reminded managers, but she did not track which staff had or had not completed required training. The facility’s Regulatory and Compliance Education policy dated 5/1/24 stated that each community should assign an associate to the super registrar role to manage tracking of the training system, that assigned hire courses should be completed before an associate works independently on the floor, and that annual requirements are established and assigned quarterly.
Failure to Follow Physician Orders for Catheter Supplies and Sizes
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders by not having the correct catheter supplies available upon admission and by using alternate catheter sizes without physician orders for two residents with indwelling catheters. One resident with a spinal cord injury, neuromuscular bladder dysfunction, and depression was admitted with an order for catheter changes every four weeks and as needed, and a care plan identifying a urinary catheter for obstructive uropathy. Progress notes documented that staff did not have a Foley catheter clamp available when the resident requested a tub bath, so they used tape to kink and clamp the catheter. Later, when attempting to flush the catheter, staff found it plugged and discovered the correct catheter size was not in stock. The resident had a 20 French catheter with a 10 cc balloon in place, but staff replaced it with an 18 French catheter with a 10 cc balloon instead of the ordered size. A second resident admitted with diagnoses including UTI, urinary retention, and chronic kidney disease had a physician order for a one-time insertion of a 14 French catheter with a 5 cc balloon. Progress notes indicated that staff informed the family they did not have a 14 French catheter available and therefore replaced it with a 16 French catheter with a 10 cc balloon. Interviews with an RN and the DON revealed that the person entering admission orders was expected to check supply availability and that the DON was responsible for ensuring the correct catheter sizes were in stock. The DON acknowledged that the correct catheter size was not available for the first resident at admission, that a different size was used without obtaining a physician order, and that she was not aware the correct size was also unavailable for the second resident. Facility policy stated that all physician orders were to be followed as prescribed and that any orders not followed should be documented in the medical record during that shift; the facility’s policy on physician notification of changes in orders was requested but not provided.
Failure to Assess, Monitor, and Report Surgical Site Infection
Penalty
Summary
The facility failed to ensure that a resident received necessary medical attention and comprehensive assessment following a change in her left hip surgical incision. After undergoing surgery for a left subtrochanteric femur fracture, the resident's incision was initially documented as healing well, with no drainage or pain. However, after staple removal, there were periods where no documentation was made regarding the incision, and when changes such as redness, purulent drainage, and tenderness were observed, these were not promptly reported to the provider. Nursing staff did not consistently assess, monitor, or document the condition of the surgical site, despite orders for daily dressing changes and assessments. When signs of infection, including purulent drainage, erythema, and pain, were noted, there was a lack of timely communication with the provider. Nursing assistants reported changes to the nursing staff, but these concerns were not documented or escalated as required. The provider was not notified immediately when infection indicators appeared, and documentation of assessments and interventions was inconsistent. Interviews with staff confirmed that the expected protocol was not followed, and that the provider should have been contacted as soon as infection was suspected. As a result of these failures, the resident developed a post-surgical abscess and sepsis, requiring hospitalization, surgery, and the insertion of a PICC line for IV antibiotics. The hospital records indicated that the infection had progressed significantly by the time of transfer, and staff interviews acknowledged that earlier recognition and intervention could have prevented the escalation. Facility policies required daily assessment and documentation of wounds, as well as prompt provider notification for signs of infection, but these were not adhered to in this case.
Failure to Promptly Notify Provider of Post-Surgical Infection
Penalty
Summary
A deficiency occurred when facility staff failed to promptly notify a physician of a significant change in a resident's condition following hip surgery. The resident, who had a history of a left subtrochanteric femur fracture treated with open reduction and internal fixation, developed signs of infection at the surgical site, including purulent drainage, erythema, swelling, and pain. Documentation shows that from 8/27 through 8/31, there was no recorded assessment of the surgical incision, despite daily dressing changes being required. On 9/1, the resident exhibited clear signs of infection, such as purulent drainage and tenderness, but there was no evidence that a provider was notified at that time, nor was this action documented. Nursing staff and nursing assistants observed and reported changes in the resident's incision, including increased redness, drainage, and pain, to the nurse on multiple occasions. However, these observations were not consistently documented, and the provider was not contacted promptly. Interviews with staff confirmed that the expected protocol was to notify a provider immediately when signs of infection were present, such as purulent drainage, redness, and pain. The provider was not contacted until several days after the initial signs of infection appeared, and only after the resident's condition had further declined, resulting in the need for hospital transfer. The resident was ultimately hospitalized with a diagnosis of sepsis due to a post-surgical abscess, requiring intravenous antibiotics and surgical intervention. Facility policy required daily assessment and documentation of wounds, as well as immediate provider notification upon identification of infection signs. The failure to assess and document the surgical site daily, combined with the delay in notifying the provider of significant changes, directly contributed to the deficiency identified in the report.
Failure to Prevent Unjustified Decline in ADL Abilities
Penalty
Summary
Residents experienced a loss in their ability to perform activities of daily living (ADLs) without a documented medical reason. The facility failed to ensure that residents maintained their highest practicable level of functioning in ADLs, as required, unless a decline was clinically unavoidable due to a medical condition. This deficiency was identified through surveyor observation and review of resident records, which did not provide evidence of a medical justification for the decline in ADL performance.
Failure to Maintain or Improve Resident Range of Motion
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide appropriate care to maintain and/or improve a resident's range of motion (ROM), limited ROM, and/or mobility. The facility did not ensure that care and services were provided to prevent a decline in the resident's physical abilities, except in cases where such decline was due to a documented medical reason. This resulted in the resident experiencing a decline in ROM or mobility that was not medically justified.
Grievance Forms Not Accessible to Residents
Penalty
Summary
The facility failed to ensure that grievance forms and procedures were posted in prominent locations throughout the building, making it difficult for residents and their representatives to file grievances, including anonymously. During a resident council meeting, five residents reported being unaware of how to file a grievance form. Subsequent observation by the surveyor confirmed that grievance forms were not visible or accessible in common areas of the facility. Interviews with facility staff, including the social worker and administrator, revealed that grievance forms were kept behind the nurses' station, requiring residents to request them from staff rather than accessing them independently. The facility's posted grievance procedure encouraged residents to notify the nurse in charge or contact specific facility leaders if concerns could not be resolved, and the policy stated that concern forms should be readily available. However, these forms were not accessible as described, and residents were not informed of their location or how to use them.
Failure to Accurately Report Agency Staffing Data in PBJ Submissions
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to CMS for the first quarter reviewed. Specifically, agency staff were not punching in for their shifts, resulting in their hours not being included in the Payroll Based Journal (PBJ) submissions. This omission was confirmed through a review of agency staff timecards and the PBJ report, which identified excessively low weekend staffing. The corporate submitter responsible for PBJ submissions acknowledged that she was unaware of the low weekend staffing trigger and confirmed that agency staff who did not punch in were excluded from the PBJ data sent to CMS. The administrator also verified that agency staff had not been punching in during the first quarter, which led to incomplete staffing data being reported. The facility's policy required that all direct care staffing information, including agency and contracted staff, be submitted to CMS according to the specified schedule. The failure to ensure agency staff were properly recorded resulted in inaccurate staffing information being reported for all 39 residents in the facility.
Failure to Assess and Supervise Self-Administration of Nebulizer Medication
Penalty
Summary
A resident with severe cognitive impairment and diagnoses including Alzheimer's disease, diabetes mellitus, and hypertension was observed self-administering a nebulizer treatment without having been assessed for the ability to safely self-administer medications. The resident required extensive assistance with bed mobility, transfers, toileting, and personal hygiene, and there was no completed self-administration of medications (SAM) assessment or physician order permitting self-administration in the resident's electronic health record. The care plan directed staff to administer all medications as ordered by the physician. During observation, an LPN prepared and placed the nebulizer mask on the resident and then left the room, leaving the resident unattended. The resident subsequently removed the mask with medication still being dispensed and left the room, leaving the nebulizer mask on the bed. Interviews with the LPN, RN, and DON confirmed that no SAM assessment had been completed and that staff were expected to remain with the resident during nebulizer administration in the absence of such an assessment or physician order. Facility policy required nurses to assess each resident's mental and physical abilities before permitting self-administration of medications.
Failure to Provide Assistance with Personal Hygiene for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and diagnoses including dementia, diabetes mellitus, and hypertension was not provided with necessary assistance for personal hygiene, specifically shaving facial hair. The resident's care plan and assessments indicated a need for staff assistance with grooming and personal hygiene due to deficits related to dementia and physical limitations. Observations on two consecutive days revealed the resident had several half-inch long gray facial hairs on her chin, upper lip, and around her mouth. Interviews with a family member confirmed the resident's preference to be shaved when facial hair was visible. Further interviews with facility staff, including a nursing assistant and a registered nurse, confirmed that the resident required staff assistance for shaving and had not been recently assisted. The nursing assistant was unsure of the last time the resident had been shaved, and both the registered nurse and the director of nursing stated their expectation that the resident should have been shaved as soon as facial hair was present. Facility policy required that residents unable to perform activities of daily living independently receive necessary services to maintain good personal hygiene, in accordance with their care plans.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
