Courage Kenny Rehabilitation Institutes Trp
Inspection history, citations, penalties and survey trends for this long-term care facility in Golden Valley, Minnesota.
- Location
- 3915 Golden Valley Road, Golden Valley, Minnesota 55422
- CMS Provider Number
- 245519
- Inspections on file
- 19
- Latest survey
- April 13, 2026
- Citations (last 12 mo.)
- 7 (1 serious)
Citation history
Health deficiencies cited at Courage Kenny Rehabilitation Institutes Trp during CMS and state inspections, most recent first.
A cognitively impaired wheelchair user with multiple neurologic diagnoses was primarily supervised through a remote observation system and alarms, without a care-planned requirement for direct staff supervision. The resident independently exited his room, opened an emergency stairwell door whose delayed-egress alarm and badge lock had been disabled for months, and proceeded into the stairwell without staff intervention until minutes later, when staff responded to a wander guard alarm and found him face down on the stairs with his wheelchair attached and a scalp hematoma. Multiple staff, including nursing, unit, maintenance, and security personnel, knew or later confirmed that the door was unarmed but did not report or correct it, assuming it was intentional, and there were no documented facility policies or routine checks in place to ensure proper functioning of the door alarm, wander guard, or badge systems, while the remote monitoring technician also failed to follow protocol by leaving the monitoring station and not activating the remote alarm when the resident left his room.
A resident with a history of cerebral infarction, dysphagia, aphasia, gait abnormalities, and weakness, and a BIMS score indicating intact cognition, was placed on a bed alarm that was not included on the signed restraint consent form. The care plan documented a bed alarm but did not specify frequency of use or placement, and the resident reported he had not consented to it, stating it startled him, limited his freedom of movement in bed, disrupted his sleep, and might disturb nearby residents. Although the resident had voiced concerns, several staff, including the RN nurse manager, DON, and medical provider, were unaware of his complaints, and the NP characterized him as very cognitively impaired despite the MDS findings. This conflicted with the facility’s resident rights policy, which guarantees residents the right to participate in person-centered care planning, be informed of and consent to treatments and changes in the plan of care, and request or refuse treatment.
Surveyors found that three neurologically impaired residents were routinely provided lap belt alarms, bed alarms, side rails, and wander guard devices without individualized assessment, documented medical symptoms, or evaluation of less restrictive alternatives. Observations showed that one resident with significant cognitive impairment could not remove a lap belt, did not understand the purpose of side rails, and had additional side rails and a wander guard not reflected in the care plan. Another severely cognitively impaired, aphasic resident had side rails, a seat belt alarm, and a wander guard that were not included in the care plan, despite dependence for mobility and communication. A cognitively intact resident reported not consenting to a bed alarm and feeling restricted by it, yet the device remained part of the care plan, and no less restrictive options were documented. Staff interviews revealed a standard practice of automatically applying lap belts, side rails, and alarms to residents with brain injuries on admission, with nursing not involved in equipment assessments and no clear instructions to routinely release belts. The facility’s restraint policy required interdisciplinary assessment, informed consent, physician orders specifying medical symptoms, and periodic re-evaluation, but requested documentation of these elements for the three residents was not provided.
The facility failed to ensure person-centered care plans accurately reflected all medical devices in use and resident preferences for three residents. One resident with significant cognitive impairment and multiple neurologic conditions had head and foot side rails, a seat belt alarm, and a wander guard in use, but the care plan omitted the foot rails, did not specify when to release the seat belt, and did not list the wander guard. Another severely cognitively impaired resident with extensive ADL needs used bilateral quarter side rails, a seat belt alarm, and a wander guard, none of which were documented on the care plan, while staff relied on general training and common practice rather than individualized care plan guidance. A cognitively intact resident with stroke-related conditions had a care plan listing a bed alarm and wheelchair alarms, but his stated lack of consent and discomfort with the bed alarm, including its impact on his sleep and concern for disturbing others, was not reflected in the care plan, contrary to facility expectations and policy.
Surveyors found that the facility did not conduct or document regular inspections or entrapment assessments of bed frames, mattresses, and bed rails, despite FDA guidance and manufacturer instructions requiring ongoing evaluation of hospital bed systems. Three residents with CVA, hemiplegia, cognitive impairment, and significant ADL dependence had quarter or half side rails in use, but therapy notes, care plans, and MDS assessments did not consistently reflect side rail use or any entrapment evaluations. Staff interviews revealed that the maintenance engineer only addressed side rails when reported broken, a RN was unaware of any side rail safety or inspection procedures, and a PT described routine admission of brain-injured residents with side rails and lap belts while indicating that nursing was responsible for bed safety zoning. The facility’s restraint policy addressed assessment and consent for positioning and safety devices but did not include any schedule or process for device inspection.
The facility did not have a policy or procedure outlining the administrator's responsibilities in the event of a facility closure. When surveyors requested documentation of a closure policy, the facility was unable to provide it. The Administrator later confirmed by email that no such policy or procedure existed, stating this was because there was no intent to close. This deficiency had the potential to affect all residents in the building.
A resident with quadriplegia and a history of spinal cord dysfunction developed a deep tissue pressure injury after staff failed to consistently reassess and implement pressure ulcer interventions, including timely wound assessment, documentation, and daily dressing changes. The resident's refusals of repositioning were not properly documented or addressed, and lapses in communication and care contributed to the progression of the wound.
A resident with a history of spinal cord dysfunction and hemiplegia, assessed as at mild risk for pressure ulcers, developed a new deep tissue pressure injury after refusing overnight repositioning. Staff were aware of the resident's preference to avoid being disturbed at night, but refusals were not consistently documented, and there was no risk versus benefit discussion or notification to the physician. The care plan's interventions were not comprehensively reassessed or adapted in response to the resident's refusals, and family was not informed, leading to the development of the pressure ulcer.
Failure to Maintain Armed Stairwell Door and Adequate Supervision for Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a stairwell emergency exit door was properly secured and alarmed, and to provide adequate supervision for a cognitively impaired resident who was being monitored via a remote observation system. Video surveillance showed the resident, seated in a wheelchair, leaving his room and independently propelling toward the emergency exit door. He pushed the door open with his arm, passed through it, and the door closed behind him. No alarm sounded and no staff intervened until several minutes later, when staff were seen on video approaching the door and then calling for help. Subsequent observation by the surveyor and the maintenance engineer confirmed that the stairwell door could be opened without an alarm sounding and without use of an employee badge. The resident involved had a BIMS score of 6, indicating significant cognitive impairment, and diagnoses including cerebral infarction (stroke), weakness, acute respiratory failure, dysphagia, dysarthria, paralytic gait, and neurological neglect syndrome. He used a wheelchair, required moderate assistance with several ADLs, and had a seat belt alarm ordered for trunk support when in the wheelchair. His care plan at the time did not include staff supervision or note that he had a wander guard, despite his cognitive status and mobility limitations. A post-fall summary documented that staff responded to a wander guard alarm at the stairs and found the resident face down on the stairs with his wheelchair attached, having sustained a hematoma to the frontal scalp and requiring transfer to the ED for evaluation. Multiple staff interviews revealed that the stairwell door alarm had been turned off for months and that several staff, including nursing and unit staff, were aware the door was unarmed but did not report it, assuming it was an intentional change because management and others used the door without badges. The maintenance supervisor stated the alarm had not been in working order for months and believed the door did not need to be secured because residents were monitored by video surveillance or wander guard systems. The security supervisor reported the alarm had been turned off in March and was turned back on the day of the fall, and he was uncertain how the facility verified door function. The offsite remote observation supervisor reported that the technician monitoring the resident walked away from the desk, failed to follow protocol by not sounding the remote alarm when the resident left his room, and instead only called the charge nurse, delaying staff response. Nursing staff described the resident’s supervision as primarily through remote observation and alarms, with no consistent criteria for in-person checks, and some were unaware of the door’s unarmed status. The facility had no provided policies regarding accidents or equipment inspections, and manufacturer manuals for the wander guard and door systems outlined testing procedures but did not specify the facility’s testing frequency or practices.
Failure to Honor Resident’s Right to Refuse Bed Alarm and Participate in Care Planning
Penalty
Summary
The deficiency involves the facility’s failure to honor a cognitively intact resident’s right to dignity, self-determination, and participation in care planning related to the use of a bed alarm. The resident had a signed consent form for restraints dated 2/2/26 that authorized trazodone and side rails, but the bed alarm was not included on this consent form. The resident’s admission MDS showed a BIMS score of 14, indicating he was cognitively intact, with functional limitations including moderate assistance needed for dressing, personal hygiene, and rolling in bed, and dependence for toileting hygiene and transfers. The resident’s care plan dated 2/4/26 documented the use of a bed alarm but did not specify how often it should be used or its placement under his body. The resident reported that he did not consent to the bed alarm, that it startled him, interfered with his sleep, and made him feel he could not move freely in bed, and he expressed concern that the alarm could disturb nearby residents. Despite the resident voicing concerns to staff, multiple facility clinicians and leaders were unaware of his complaints. The NP acknowledged knowing the resident had complained about the bed alarm but stated staff reassured him it was for his safety and described the resident as very cognitively impaired, in contrast to the MDS BIMS score indicating intact cognition. The nurse manager (RN-B), DON, and the medical provider each reported they had not heard of the resident’s bed alarm complaints. The medical director later stated that if the resident had concerns with the bed alarm, the facility should try an alternative and address his concerns while balancing safety and his right to move. The facility’s Resident Rights policy stated that residents have the right to participate in the development, revision, and implementation of a person-centered care plan, to be informed in advance of changes to the plan of care, to be informed of risks and benefits of proposed care and alternatives, and to request or refuse treatment. These rights were not honored in relation to the initiation and continued use of the bed alarm, which the resident stated he had not consented to and found distressing.
Failure to Individually Assess and Care Plan Use of Restraints and Alarms
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from physical restraints unless needed for medical treatment, and to follow required assessment, ordering, care planning, and monitoring processes for restraints. Surveyors found that three residents with significant neurological conditions and cognitive impairment were routinely provided lap belt alarms, bed alarms, side rails, and wander guard devices without individualized assessment of medical symptoms, evaluation of less restrictive alternatives, or clear documentation of ongoing re-evaluation. The facility’s own restraint policy required an interdisciplinary assessment, informed consent, a physician order specifying medical symptoms and circumstances of use, and periodic re-evaluation, but requested documentation of these elements for the three residents was not provided. For one resident with a CVA, significant cognitive impairment (BIMS 6), hemiplegia, impaired mobility, and multiple neurologic deficits, surveyors observed bilateral quarter side rails at the head of the bed, three-quarter side rails at the foot of the bed, a seat belt alarm in the wheelchair, and a wander guard bracelet attached to the wheelchair. The resident could not state the purpose of the side rails, could not remove the lap belt independently, and spoke incoherently. The physical device assessment stated the side rails did not restrict freedom of movement and that the resident understood risks and benefits, listed symptoms such as weakness, impaired mobility, impulsive movements, and cognitive deficits, and documented no less restrictive devices tried. The admission MDS showed significant cognitive impairment and need for moderate assistance with mobility and ADLs. The care plan referenced half side rails for positioning and safety due to spasms and a seat belt alarm for trunk support, but did not address the foot-end side rails, did not specify when staff should release the belt, and did not include the wander guard or related interventions. For a second resident with a CVA, severe cognitive impairment (BIMS 0), aphasia, dysphagia, hemiplegia, and dependence or high assistance needs for mobility and ADLs, surveyors observed bilateral quarter side rails, a seat belt alarm in the wheelchair, and a wander guard bracelet attached to the wheelchair. The resident was unable to move the right arm, could not remove the lap belt independently, and communicated only by nodding. The physical device assessment indicated the resident could use the side rails appropriately, that they did not restrict movement, that the decision maker understood risks and benefits, and that no less restrictive devices were tried. The admission MDS documented severe communication and cognitive deficits and extensive assistance needs. However, the care plan did not include the side rails, seat belt alarm, or wander guard, and contained no interventions related to these devices. For a third resident with a CVA, hemiplegia, dysphagia, aphasia, gait abnormalities, and other cognitive signs but a cognitively intact BIMS score of 14, surveyors found quarter side rails, a bed alarm, and a seat belt alarm. The resident reported being fine with the wheelchair belt and alarm but stated he did not consent to the bed alarm, that it startled him, made him feel unable to move freely in bed, interfered with sleep, and caused concern about disturbing nearby residents. The physical device assessment documented quarter side rails for turning and repositioning, stated the resident could use them appropriately and that they did not restrict movement, but noted that the resident and decision maker did not state they understood risks and benefits, and again showed no less restrictive devices tried. The care plan listed a bed alarm, seat belt alarm for trunk support, and grab bars/bedrails, but did not address the resident’s expressed objection to the bed alarm. Staff interviews revealed that lap belts, side rails, and bed alarms were applied as a standard practice for residents with brain injuries upon admission, rather than based on individualized assessments. Nursing assistants reported they had never been instructed to release lap belts routinely, and that belts for the three residents were only removed for toileting or at bedtime; one aide stated a resident did not understand the purpose of the belt and frequently removed it when agitated. Therapy staff and nurses stated that all residents with brain injuries received lap belts and side rails on admission, with therapy later assessing appropriateness, and described the devices as necessary for safety, impulsiveness, and fall prevention. The NP acknowledged signing orders based on therapy assessments, was unsure what assessments were performed, and did not know whether less restrictive alternatives were attempted or how monitoring occurred. The DON and Administrator confirmed that lap belts, bed alarms, and side rails were considered standard safety practice for this population, while the Medical Director stated she was not aware that these devices were automatically applied on admission and indicated that if a resident felt restricted by a bed alarm, alternatives should have been tried. The facility’s written restraint policy stated that residents have the right to be free from physical restraints, that positioning and safety devices must be determined through individual interdisciplinary assessment and care planning with resident consent and physician order, and that physical restraints are defined as devices attached or adjacent to the body that cannot be easily removed and that restrict freedom of movement or access to the body. The policy required informed consent, documentation of risks and benefits, physician orders specifying medical symptoms and circumstances of use, and periodic re-evaluation. Despite this, when surveyors requested documentation for the three residents regarding medical diagnoses and symptoms supporting restraint use, evaluation of alternatives, and device inspections, the facility did not provide the requested records, demonstrating a failure to implement the policy’s required processes for assessment, determination of medical symptoms, consideration of less restrictive alternatives, and ongoing re-evaluation of restraint use for these residents.
Failure to Include Medical Devices and Resident Preferences in Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain person-centered care plans that included all medical devices in use and appropriate interventions for their safe use for three residents. For one resident with significant cognitive impairment, a history of stroke, weakness, dysphagia, dysarthria, paralytic gait, and neurological neglect syndrome, observations showed bilateral quarter side rails at the head of the bed, three-quarter side rails at the foot of the bed, a seat belt alarm in the wheelchair, and a wander guard bracelet attached to the wheelchair. The care plan dated 3/23/26 only identified the use of half side rails for positioning and safety due to spasms and a seat belt alarm for trunk support, but did not address the side rails at the foot of the bed, did not specify when staff should release the seat belt to allow freedom of movement, and did not include the wander guard or any related interventions. A second resident, who was unable to speak, had severe cognitive impairment (BIMS score of 00), and required moderate to maximum assistance or was dependent for most ADLs, was observed in bed with bilateral quarter side rails at the head of the bed, a seat belt alarm in the wheelchair, and a wander guard bracelet attached to the wheelchair. This resident’s care plan dated 2/27/26 did not document the presence of the side rails, the seat belt alarm, or the wander guard, nor did it include interventions for their use. Despite this, a nursing assistant reported that she relied on her training and the similarity of equipment among residents to guide her use of these devices, stating that side rails were used for positioning, belts were to always be on when residents were in wheelchairs, and wander guards were used to prevent residents from leaving the unit. A third resident, cognitively intact with a BIMS score of 14 and diagnoses including cerebral infarction, dysphagia, aphasia, abnormalities of gait and mobility, weakness, and other signs of cognitive functioning, reported being fine with the alarm belt and wheelchair alarm but objected to the bed alarm. He stated he did not consent to the bed alarm because it startled him, made him feel unable to move freely in bed, interfered with his sleep, and he feared it disturbed nearby residents. His care plan dated 2/4/26 documented a bed alarm, seat belt alarm for trunk support, and grab bars/bedrails, but did not reflect his expressed lack of consent or preferences regarding the bed alarm. The DON acknowledged that all devices should be on the care plan, and the Administrator stated the expectation that all cares, services, and interventions be included on each resident’s care plan, consistent with the facility’s person-centered care planning policy requiring comprehensive, interdisciplinary care plans that include services to meet identified needs and any services refused by the client.
Failure to Inspect and Assess Bed Rails and Bed Systems for Entrapment Risk
Penalty
Summary
The deficiency involves the facility’s failure to conduct and document regular inspections and entrapment assessments of bed frames, mattresses, and bed rails as part of its maintenance and safety program. Surveyors cited FDA guidance and manufacturer instructions that call for ongoing evaluation of hospital bed systems, including reassessment when components are worn, accessories are added or removed, or parts are changed. Despite these expectations, the facility was unable to provide any documentation of routine inspections or entrapment assessments for bed systems in use, including those for three residents reviewed for side rails. For one resident with a history of CVA, weakness, impaired mobility, impulsive movements, cognitive deficits, impaired judgment, hemiplegia, and fatigue, the bed was equipped with bilateral quarter rails at the head and bilateral three-quarter rails at the foot. The resident’s Physical Device assessment documented quarter rails and stated the resident could use the device appropriately and understood risks and benefits, but therapy notes and the MDS did not reflect side rail use or any entrapment assessment. The care plan briefly noted possible use of half side rails for positioning and safety, but there was no further documentation addressing entrapment risks or bed system evaluation. A second resident with CVA, hemiplegia, severe cognitive impairment (BIMS 00), aphasia, dysphagia, and dependence for most ADLs had bilateral quarter rails at the head of the bed and used the rail with her left hand during care, while being unable to move the right side of her body or remove the rails independently. Her Physical Device assessment indicated quarter rails, appropriate use, and understanding of risks and benefits, but there was no documentation of entrapment assessments. Therapy notes, the care plan, and the MDS did not identify side rail use or related safety evaluations. A third resident with CVA, hemiplegia, impaired judgment, and multiple functional limitations had bilateral half rails at the head of the bed and reported using them for repositioning. His Physical Device assessment referenced quarter rails and noted no documented understanding of risks and benefits, with no alternatives tried and no entrapment assessments recorded; therapy notes, care plan, and MDS also did not reflect side rail use. When surveyors requested documentation of side rail assessments or inspections from the maintenance engineer and the administrator, none was provided. The maintenance engineer reported he did not perform any proactive work on side rails and only addressed them when nursing reported they were broken. A RN stated she was unaware of any safety precautions or inspection processes for side rails and believed therapy was responsible for equipment. A PT reported that residents with brain injuries were admitted with side rails and lap belts, with adjustments made later by therapy, and stated that nursing would complete any safety zoning assessments in the bed. The facility’s restraint policy described interdisciplinary assessment, care planning, and informed consent for positioning and safety devices but did not specify any timing or process for inspection of bed rails or other devices.
Lack of Facility Closure Policy and Procedure
Penalty
Summary
The facility failed to develop and maintain a policy and procedure addressing administrator responsibilities in the event of a facility closure. During the survey, surveyors requested a facility closure policy and procedure, but the facility was unable to provide any such documentation. In an email dated 4/7/26 at 8:16 p.m., the Administrator confirmed that the facility did not have a policy or procedure on facility closure, explaining that this was because the facility had no intent to close. This failure had the potential to affect all residents residing in the building.
Failure to Reassess and Implement Pressure Ulcer Interventions
Penalty
Summary
A resident with a history of traumatic spinal cord dysfunction, neurogenic bladder, and quadriplegia, who was cognitively intact and required extensive assistance with all activities of daily living, developed a pressure ulcer after admission to the facility. The resident was identified as being at risk for pressure ulcers and had interventions in place, including regular skin assessments, use of pressure-reducing devices, and scheduled repositioning. Despite these interventions, the resident developed a deep tissue injury (DTI) on the coccyx within 11 days of admission. The resident reported refusing repositioning on the first or second night due to disturbances from staff and feeling unwell, but also stated that staff did not attempt to reposition him or offer assistance during a prolonged period in bed. Documentation and communication lapses were noted, as staff failed to consistently document refusals or the risks and benefits discussed with the resident. The initial identification of the wound was delayed. Although a nursing assistant noticed the sore and informed the nurse, the wound was not assessed by a nurse until several days later. The wound nurse was not notified in a timely manner, and the required documentation, including a progress note and wound tracker form, was not completed at the time the wound was first observed. The wound was eventually assessed and identified as a DTI, but the delay in assessment and documentation contributed to a lack of timely intervention and monitoring. Further deficiencies were observed in the implementation of wound care interventions. The resident's treatment plan required daily dressing changes, but these were not consistently performed over a weekend, as confirmed by both the resident and nursing staff. The nurse responsible for the dressing changes admitted to not completing them due to competing priorities and increased acuity on the unit. The lack of consistent wound care and failure to reassess and update interventions in response to the resident's condition and refusals contributed to the progression of the pressure injury.
Failure to Reassess and Implement Pressure Ulcer Interventions for Resident Refusing Repositioning
Penalty
Summary
The facility failed to comprehensively reassess and update pressure ulcer interventions for a resident who was identified as refusing repositioning during overnight hours and subsequently developed a new pressure injury. The resident, who had a history of spinal cord dysfunction, hemiplegia, and hemiparesis following a stroke, was assessed as being at mild risk for pressure ulcers and required moderate assistance with bed mobility. The care plan included specific interventions such as scheduled repositioning every three hours at night, use of a specialty mattress, and verbal cues to encourage repositioning, but documentation and implementation of these interventions were inconsistent, particularly during the night shift when the resident preferred not to be disturbed. Staff interviews revealed that the resident often refused repositioning at night, preferring to sleep uninterrupted, and that these refusals were not consistently documented in the electronic medical record due to system limitations. Nursing assistants and nurses were aware of the resident's preferences and attempted to encourage repositioning, but there was no formal documentation of refusals or a risk versus benefit discussion regarding the resident's choices. The wound care nurse and other staff noted that after the pressure ulcer was identified, efforts to reposition the resident increased, but prior to the injury, there was a lack of comprehensive reassessment and adaptation of interventions in response to the resident's refusals. Family members were not informed of the resident's refusals to reposition, and the care plan did not reflect a risk versus benefit analysis or notification to the physician regarding the resident's choices. The facility's policy required comprehensive assessment and care planning with input from the interdisciplinary team and family, but this was not fully implemented in the case of this resident. As a result, the resident developed a deep tissue pressure injury that was discovered during a skin assessment, with staff attributing the injury to prolonged pressure during the night and possible contact with an object.
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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