Cura Of Onamia
Inspection history, citations, penalties and survey trends for this long-term care facility in Onamia, Minnesota.
- Location
- 200 North Elm Street, Onamia, Minnesota 56359
- CMS Provider Number
- 245127
- Inspections on file
- 23
- Latest survey
- April 23, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Cura Of Onamia during CMS and state inspections, most recent first.
Medication labels for multiple residents were found without an expiration date or beyond use date. An ADON, LPNs, RN, and pharmacists confirmed that labels from both pharmacies did not clearly show when medications should be discarded, and staff were relying on fill dates or general refill timing instead of a visible expiration or BUD on the label.
Medication labels for multiple residents did not include an expiration or beyond use date, and staff relied on fill dates or a one-year rule instead of clear label information. Expired injectable supplies were also found in active stock in the med room, and the ADON confirmed they should have been removed. Pharmacy and nursing staff acknowledged the labels from both pharmacies did not clearly show when meds should be discarded.
The facility failed to ensure residents were offered a substantial evening snack when more than 14 hours separated dinner and breakfast. Mealtimes were set at 8:00 a.m., 12:00 p.m., and 5:00 p.m., and staff reported that evening snacks were only provided to certain residents with orders or if a resident asked for one, rather than as a routine offering for all residents. Two residents stated they were not usually offered snacks in the evening.
Infection control paperwork lacked documentation of resident and staff illness symptoms, symptom trends, or any monitoring for possible outbreak activity. The ADON/IP stated there had been no tracking and trending since taking over the IP program and was not aware it was required, while the RCD stated the facility should have a system to track symptoms and the IP should monitor it frequently. Facility policies stated infection surveillance was intended to identify cases and trends to guide interventions and prevent future infections.
Resident trust funds were not fully covered by adequate surety bond protection. The business office manager confirmed the resident personal funds account balance totaled $40,688.56 for 34 residents, while the CFO confirmed the bond penalty amount was only $10,000 and said it should have been $100,000. Review of the bond and rider showed the lower coverage was in effect before the rider increased it, despite facility policy requiring a surety bond to secure all resident personal funds.
A resident with dementia and inflammatory arthritis was found with a bruise on her hand, which staff failed to assess and report according to the facility's skin integrity process. Despite the care plan requiring weekly skin audits during showers, the bruise was not documented or communicated to the charge nurse, leading to a lapse in monitoring and notification procedures.
A facility failed to monitor medication interactions for a resident with cognitive impairment and multiple diagnoses. The resident was given Allopurinol, Diltiazem, and Carafate together, despite Carafate's potential to decrease Allopurinol's effects if not administered separately. Staff were unaware of this interaction, and the facility's policy for monthly drug regimen reviews was not effectively implemented.
A resident with severe cognitive impairment was found with unexplained bruising, which was not reported to the State Agency and administrator within the required timeframe. The bruising was discovered by a nursing assistant and reported to an LPN, who informed an RN later. The RN filed a report, but the director of nursing and administrator were notified the next day, contrary to facility policy.
A facility failed to thoroughly investigate an injury of unknown origin for a resident with severe cognitive impairment and multiple medical conditions. The resident was found with unexplained bruising, and the DON's investigation did not include interviews with other residents or a complete assessment of the resident's behavior. The facility's policy requires immediate investigation to rule out abuse, but the procedures were not fully followed.
A resident with severe cognitive impairment and multiple health issues was found to have significant bruising, but the facility failed to monitor the bruising as required. Staff interviews revealed a lack of adherence to procedures for monitoring new skin impairments, and the care plan did not include specific instructions for bruising. The Director of Nursing admitted to the oversight, and the facility's policy for skin assessments was not followed.
Medication Labels Missing Expiration or Beyond Use Dates
Penalty
Summary
The facility failed to ensure resident medications were properly labeled with an expiration date or beyond use date. During medication pass observations, multiple residents’ medication labels were reviewed and found to lack either an expiration date or beyond use date, including medications for R17, R7, and R1. The same issue was observed again for R7 during a later medication observation, showing the labeling concern was present across multiple medication carts and at different times during the survey. Two medication carts were reviewed with the ADON, who confirmed that medication labels from both Mille Lacs pharmacy and Onamia Drug store did not include an expiration or beyond use date. During interviews, an LPN stated staff used the fill date and would not use a medication if it was a year past the filled date, while another LPN confirmed the medication cards did not list an expiration or beyond use date. An RN also confirmed that labels from both pharmacies did not include expiration or beyond use dates and stated staff had been told PRN medications expired a year from the fill date and scheduled medications should not be expired because they were refilled every 28 days. The ADON stated they had been working on the medication label concern and had contacted the pharmacy, but was not aware of either pharmacy’s policies or whether the facility had access to them. The Onamia Drug pharmacist confirmed their labels had a place for an expiration date but that it was not currently used, and that nursing staff could not determine from the label whether a medication was expired or should be discarded. The consultant pharmacist and Mille Lacs pharmacist also confirmed the labels did not include a medication expiration or beyond use date, and stated the pharmacy used one year from the fill date unless otherwise labeled.
Medication Labels Lacked Expiration Dates and Expired Supplies Remained in Stock
Penalty
Summary
Medication labels in the facility did not include an expiration date or beyond use date for multiple residents’ medications. During medication pass observations, labels for medications used by R17, R7, and R1 were reviewed and found to lack an expiration or beyond use date. Two medication carts were also reviewed with the ADON, who confirmed that medication cards filled by both Mille Lacs pharmacy and Onamia Drug store did not include an expiration or beyond use date. During review of the medication room, expired injectable supply items were found still stored in active stock, including three boxes of various needle sizes used for injection, a box of safety syringes with a 25-gauge needle, and a bundle of chlamydia swabs. The ADON confirmed these items were expired and stated they should have been discarded when they expired to prevent accidental use on a resident. Nursing staff interviewed during the observations also confirmed that the medication labels did not contain expiration dates and stated they relied on the fill date or a one-year timeframe from the fill date. Further interviews with nursing and pharmacy staff confirmed that the labels from both pharmacies did not provide a clear expiration or beyond use date that nurses could use before administration. The Onamia Drug pharmacist stated their cards had a place for an expiration date but it was not currently used, and that nursing staff would not be able to determine from the label whether a medication was expired or should be discarded. The consultant pharmacist and Mille Lacs pharmacy staff also confirmed that their labels did not include a medication expiration or beyond use date and that nurses were expected to verify expiration before administration, even though the current labels did not clearly show that information.
Failure to Provide Routine Evening Snacks
Penalty
Summary
The facility failed to ensure residents were offered a substantial snack when there were more than 14 hours between the dinner and breakfast meals. The facility-submitted document identified breakfast at 8:00 a.m., lunch at 12:00 p.m., and dinner at 5:00 p.m., creating a span of more than 14 hours between the evening meal and breakfast. The facility’s policy stated there would not be more than a 14-hour span between the substantial evening meal and breakfast unless resident council approved a longer span and a nourishing snack was provided before bed. During interviews, the manager of nutrition services confirmed the mealtimes, and the ADON stated snacks were available in the evening only if a resident asked for one, with no routine evening snack offering. NA-A said evening snacks were sent from the kitchen for specific residents between 6:30 p.m. and 7:00 p.m., labeled with resident names, and not all residents received them, though snacks were available upon request. LPN-A stated dietary brought a snack tray to some residents with orders for an evening snack, and staff were always asking residents if they wanted something to eat. Two residents stated they were not routinely offered snacks in the evening, though one believed staff would provide one if asked.
Infection Control Program Lacked Symptom Tracking and Trending
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program by not tracking and monitoring residents and staff with symptoms of possible illness. During review of the infection control program paperwork, there was no information related to staff and resident illness symptoms reported to the facility, and there was no documentation of symptoms, trends in the facility, or indications that the facility was monitoring to prevent a potential outbreak. During interviews, the assistant director of nursing/infection preventionist stated there had been no tracking and trending of resident or staff symptoms since she took over the IP program in 1/26, and she was not aware that tracking and trending of symptoms needed to be done. The regional clinical director stated the facility should have a way to keep track of resident and staff symptoms and that the IP should monitor that system frequently to know when residents and staff have symptoms that could be contagious to try to prevent an outbreak. The IP also stated the facility should do any monitoring needed to prevent outbreaks and keep residents, visitors, and staff safe. Facility policies for Infection Control and Surveillance for Infections stated the objective was to prevent, detect, investigate, and control infections and to identify individual cases and trends to guide interventions and prevent future infections.
Resident Trust Funds Not Fully Covered by Surety Bond
Penalty
Summary
Assure the security of all personal funds of residents deposited with the facility was not maintained because the facility did not ensure resident personal fund accounts were insured with adequate surety bond coverage to cover the total account balance. During interview and document review, the business office manager confirmed the residents' personal funds accounts totaled $40,688.56 for 34 residents. The CFO confirmed the facility's surety bond for resident personal funds identified a penalty amount of $10,000 and stated the bond should cover $100,000, noting they needed to contact their insurance representative for clarification. Review of surety bond number 2653018 showed a $10,000 bond in effect from 7/23/25 through 7/23/26, and a rider dated 4/23/26 showed the bond increased from $10,000 to $100,000 effective 4/23/26. The facility policy stated it would maintain a surety bond to assure the security of all resident personal funds deposited with the facility.
Failure to Monitor and Report Resident's Bruising
Penalty
Summary
The facility failed to assess and monitor bruising for a resident with impaired skin integrity. The resident, who has moderately impaired cognition and diagnoses including dementia and inflammatory arthritis, was observed with a dark purple bruise on her left hand. Despite the facility's care plan directing weekly skin audits during showers or baths, the bruise was not documented or reported by staff during the resident's shower. The resident stated she bruised easily and did not recall how the bruise occurred. Interviews with staff revealed a lack of adherence to the facility's process for checking and reporting skin issues. A registered nurse and a clinical manager confirmed that skin checks should occur on bath or shower days, and any findings should be reported to the charge nurse for further assessment and notification. However, the nursing assistant and clinical manager who assisted the resident with her shower did not report the bruise, and the clinical manager did not notice it during the shower. The director of nursing acknowledged that the process for reporting and monitoring skin impairments was not followed for this resident.
Failure to Monitor Medication Interactions
Penalty
Summary
The facility failed to ensure that physician-prescribed medications were reviewed and monitored for interactions, specifically for one resident with moderate cognitive impairment and multiple medical diagnoses, including unspecified dementia, anxiety, and major depression. The resident was prescribed several medications, including Allopurinol, Diltiazem, and Carafate. During a medication observation, it was noted that the trained medication assistant administered these medications together, without knowledge of potential interactions, assuming the electronic medication record's schedule was correct. The pharmaceutical reference indicated that Carafate could decrease the effects of Allopurinol if not administered with a time gap. The pharmacy consultant and primary physician confirmed that Carafate should be given separately from other medications to avoid absorption issues. The facility's policy required the consultant pharmacist to review drug regimens monthly and report irregularities, but this was missed in the review of the resident's medications. Interviews with staff revealed a lack of awareness regarding the interaction between Carafate and other medications, leading to the deficiency.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident within the required timeframe to the State Agency and the administrator. The resident, who had a history of stroke, aphasia, dementia, and hemiplegia, was found to have unexplained bruising on the left arm, hand, and fingers. The bruising was discovered by a nursing assistant during morning care and reported to an LPN, who then informed an RN later in the afternoon. The RN filed a report with the Minnesota Adult Abuse Reporting Center, but the facility's director of nursing and the administrator were not notified until the following morning. The facility's policy requires that injuries of unknown origin be reported immediately or within two hours if severe, and within 24 hours if not severe. However, the report to the State Agency was delayed, and the administrator was not informed until the next day. The director of nursing confirmed that reeducation had not been provided to the involved staff regarding timely reporting of such incidents. The facility's policy outlines the conditions under which an injury should be classified as unknown and mandates reporting per federal and state law.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to conduct a thorough investigation into an injury of unknown origin for a resident with severe cognitive impairment and multiple medical conditions, including stroke, aphasia, dementia, and hemiplegia. The resident was found with unexplained bruising on the left arm, forearm, hand, and fingers, which was tender to the touch. The Director of Nursing (DON) attempted to interview the resident, who was unable to communicate effectively due to aphasia, and did not appear fearful. The DON also interviewed staff but did not interview other residents on the unit. The facility's policy on abuse, neglect, and mistreatment requires immediate investigation of injuries of unknown origin to rule out abuse, including interviewing the affected resident and others in the vicinity. However, the DON did not follow these procedures, as she did not interview other residents or fully document the resident's behavior and response to interaction. The policy also mandates providing a safe environment during the investigation, but the report does not indicate that this was ensured. The DON acknowledged uncertainty in ruling out abuse, highlighting a gap in the investigation process.
Failure to Monitor Resident's Bruising
Penalty
Summary
The facility failed to ensure proper monitoring of bruising for a resident with a history of stroke, aphasia, dementia, and hemiplegia. The resident, who had severely impaired cognition and exhibited behavioral symptoms, was reported to have significant bruising on the left forearm and hand. Despite the presence of these bruises, the resident's progress notes lacked any additional monitoring or documentation of the bruising after the initial report. The care plan for the resident, which was revised earlier, did not include specific instructions for monitoring bruising, although it did direct staff to inspect the skin daily. Interviews with facility staff revealed a lack of adherence to procedures for monitoring new skin impairments. An LPN acknowledged not entering an order to monitor the bruising, and an RN was unaware of the facility's procedure for additional monitoring. Another RN confirmed that there was no treatment order for monitoring the bruising, although it was expected. The Director of Nursing admitted to the oversight and confirmed the absence of a treatment order in the resident's record. The facility's policy required nurse aides to inspect the skin every shift and licensed nurses to perform weekly skin assessments, but these procedures were not followed in this case.
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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