Franklin Restorative Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Franklin, Minnesota.
- Location
- 900 3rd Street South, Franklin, Minnesota 55333
- CMS Provider Number
- 245273
- Inspections on file
- 32
- Latest survey
- April 23, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Franklin Restorative Care Center during CMS and state inspections, most recent first.
The facility failed to maintain an infection prevention program with ongoing surveillance, analysis, and trending of resident and staff infections, and staff lacked knowledge of reportable communicable diseases and reporting procedures. The infection surveillance and employee illness logs contained missing data and no evidence of trend analysis or interventions. The facility also failed to ensure EBP compliance for two residents with wounds and catheter or wound care needs, as staff did not consistently have PPE available and an LPN provided wound care without a gown.
Failure to Track Antibiotic Use and Culture Results: The facility did not maintain an effective antibiotic stewardship process within its IPC program. The IPC log tracked infection details, but it did not include culture dates, identified organisms, or antibiotic resistance, and antibiotic use, indications, dosage, duration, and timely discontinuation were not tracked. The infection prevention nurse and DON confirmed there was no formal process to monitor antibiotic starts, culture follow-up, or resistance patterns, and providers were expected to track and communicate culture results without a facility process to ensure they were received or addressed.
Locked exit doors prevented residents from freely leaving the facility without individualized assessment, clinical justification, or care planning. Surveyors found that multiple residents were cognitively intact or only mildly impaired, independent with mobility, and documented as not being at risk for elopement, yet all doors were locked and only staff had the codes. The administrator confirmed residents could not independently exit and that no waivers or individualized assessments had been completed to support the restriction.
Incorrect MDS Coding for Anticoagulant Use: Two residents had MDS assessments that coded them as taking an anticoagulant, but their physician orders showed aspirin 81 mg daily and no anticoagulant medication. RN-A initially believed aspirin could be coded as an anticoagulant, then clarified it should be coded as an antiplatelet, and stated the MDS was coded incorrectly. The DON stated the MDS should be coded correctly based on RAI directions.
The facility failed to notify the provider of a resident’s critical blood glucose readings, and staff could not show that glucometer calibration checks were being completed per manufacturer instructions. In a separate issue, a resident with a skin-picking disorder had multiple scabs on both arms that were observed and reported by staff and the resident, but there was no evidence of ongoing monitoring or treatment documentation.
Pharmacy recommendations were not consistently addressed or documented for two residents reviewed for unnecessary meds. One resident had multiple chronic conditions, was dependent for ADLs, did not walk, and had 28 meds ordered; another had Alzheimer’s disease and dementia, severe cognitive impairment, was on hospice, and had 8 meds ordered. Monthly pharmacist reviews identified irregularities over several months, but provider responses were missing or could not be produced, and interviews showed the DON, CP, and MD were aware the process had not been sustained.
Failure to Perform Ordered Wound Care Dressing Changes: A resident with paraplegia and a stage 4 sacral pressure injury had provider-ordered wound care changed to BID cleansing, calcium alginate, barrier cream, and ABD dressing, but the TAR showed the dressing was not changed at all on one day and another change was also undocumented. The resident said he rarely refused care and did not mind being awakened for dressing changes, while an LPN verified the missed documentation and the wound provider expected the ordered care to be completed.
RN coverage was not maintained for 5 of 7 days reviewed, with no RN scheduled on several days. The administrator stated the facility had a waiver, was using agency nursing staff, and was actively recruiting RNs while acknowledging that not all days had a scheduled RN.
The facility did not ensure RN coverage for at least eight consecutive hours daily, as required. Staffing reports and timecard logs confirmed the absence of RN coverage on certain days, and interviews with administration acknowledged ongoing scheduling challenges. This deficiency had the potential to affect all residents in the facility.
The facility did not consistently include all required information on daily nurse staffing postings, with missing elements such as facility name, date, census, and staff details on multiple occasions. This was confirmed by administrative staff, and no policy for staff posting was available when requested.
Surveyors found that the facility did not ensure the dishwasher reached the required rinse temperature for proper sanitization, with staff failing to notice or document the issue during routine checks. Additionally, temperature logs for all kitchen refrigerators and freezers were inconsistently completed, with many missed entries and some logs missing entirely, contrary to facility policy and expectations.
The facility did not maintain effective QAPI monitoring, resulting in a repeat deficiency for failing to offer or provide the pneumococcal vaccine series to several residents as recommended by the CDC. QAA committee meeting minutes lacked ongoing data or monitoring related to this issue.
The facility did not obtain or document informed consent, including discussion of risks and benefits, before administering psychotropic medications to several residents with cognitive and psychiatric conditions. Medical records lacked evidence of completed consent forms or documentation that residents or their representatives were informed, despite facility policy and staff expectations requiring this process.
The facility did not maintain an effective system for tracking and monitoring stored narcotics, as staff no longer used the narcotic record index pages and relied on memory to identify which controlled substances should be present. During narcotic counts, nurses matched medication cards to the narcotic book but lacked a comprehensive list or updated index, and a handwritten list of controlled medications did not include necessary details for tracking. The DON confirmed that no refined system was in place to prevent diversion of controlled substances.
The facility did not act on pharmacist consultant recommendations for five residents, including requests for lab work, medication order clarifications, and clinical rationales for continued medication use. Despite repeated monthly recommendations, there was no evidence that staff communicated these findings to providers or updated medical records, as confirmed by both the consulting pharmacist and DON.
Surveyors found that a shared resident refrigerator contained open, undated food items and a freezer with melted popsicles and sticky residue, with no recent cleaning documented. The medication refrigerator had water inside insulin storage containers due to ice buildup and leaking, and temperature logs for both refrigerators were incomplete for several months. The CDM, LPN, DON, and administrator confirmed these unsanitary conditions and lapses in required monitoring.
A resident with multiple chronic conditions was found with an Advair inhaler at bedside without a completed self-administration of medications (SAM) assessment or physician order authorizing this. Staff discovered the inhaler was not stored in the medication cart and confirmed that only certain items were approved for bedside use per the SAM assessment. The DON acknowledged the oversight, noting that only medications deemed safe after nurse evaluation should be left at bedside.
A resident was not given the required SNFABN (CMS-10055) notice at least 48 hours before Medicare Part A services ended. Instead, the notice was provided on the same day services ended, contrary to facility policy and federal requirements. Staff interviews confirmed the lapse in timely notification.
The facility did not control persistent, loud noise from the call light system, which repeatedly sounded for extended periods in resident areas. Cognitively intact residents with various psychiatric and medical diagnoses reported the noise was irritating and disrupted sleep, while staff described difficulty concentrating and increased frustration. Despite staff raising concerns, the outdated call light system continued to negatively affect both residents and staff, contrary to facility policies on maintaining a comfortable and quiet environment.
Two residents were prescribed PRN psychotropic medications beyond the required 14-day period without documented clinical rationale or evidence of gradual dose reduction, despite repeated requests from the consulting pharmacist. The facility did not respond to pharmacy recommendations, and the DON confirmed missing documentation and uncertainty about responsibility for pharmacy reviews.
A resident with multiple diagnoses, including malnutrition and osteoporosis, had a care plan that was not updated to reflect the discontinuation of a nutritional supplement intended for wound healing. The supplement order was discontinued, but the care plan continued to list it as an active intervention. Staff interviews confirmed that care plan updates were not completed in a timely manner, and the facility could not provide a policy on care plan updates.
A resident with multiple medical conditions, including malnutrition and paraplegia, did not have weekly weights monitored as ordered by the physician. Despite an active order and care plan instructions, no weights were documented for several months. Staff interviews confirmed the lapse, and facility policy required regular weight monitoring to ensure nutritional status.
A vial of Lorazepam Oral Concentrate, a Schedule IV controlled substance, was found stored in the refrigerator door outside of the double lock box, which was not permanently affixed and had its key left in the lock. An LPN confirmed this storage practice had been ongoing, and the DON verified that the medication was not properly double locked as required. Both the consultant pharmacist and DON stated that controlled substances should be stored double locked in a permanently affixed compartment, in accordance with facility policy.
Three residents with multiple chronic conditions were not offered or provided the recommended pneumococcal vaccine series as outlined by CDC guidelines, despite having signed consents and facility policy requiring immunizations. The DON confirmed that the required vaccines were not administered or offered as appropriate.
A resident with cognitive and cardiovascular conditions consented to receive the COVID-19 vaccine, but facility records showed the vaccine was not administered and there was no documentation of vaccination, as confirmed by the DON.
The facility did not consistently follow physician orders for pressure ulcer wound care, as evidenced by multiple instances where dressing changes for several residents with stage III and IV pressure ulcers were not completed or documented. Residents and staff confirmed that wound care was missed on several occasions, and staff reported these lapses to the DON. The facility's policy required adherence to provider orders, but this was not maintained.
During wound care for two residents requiring extensive assistance, an infection preventionist did not remove gloves and perform hand hygiene after cleansing wounds and before applying new dressings, contrary to facility policy and expectations. Both the IP and interim DON confirmed that hand hygiene should have been performed at these points during the dressing change process.
Two residents with significant cognitive and physical impairments experienced multiple falls, including one resulting in a rib fracture, due to the facility's failure to investigate falls, update care plans, and implement or communicate fall prevention interventions. Staff were unaware of current interventions, required signage and appropriate footwear were not consistently provided, and documentation lacked evidence of IDT review or root cause analysis after each fall.
The facility failed to ensure RN coverage for 8 consecutive hours a day, 7 days a week, as required. A review of the nursing schedule identified 8 days without RN coverage on weekends. The administrator acknowledged the issue and mentioned efforts to stagger hours and utilize an RN from a sister facility. The facility was actively advertising for full-time RN positions to achieve compliance.
The facility failed to submit accurate direct care staffing information to CMS for Quarter 1 of 2024. The PBJ Report identified dates with no licensed nurse coverage for 24 hours, but staffing schedules and timecards showed otherwise. The administrator noted that an offsite person enters the PBJ data, but no further information or policy was provided.
The facility failed to ensure proper documentation and analysis of data submitted to the QAPI committee, lacking benchmarks, action plans, and data analysis. The administrator acknowledged the issue, noting a format change about a year ago that led to these deficiencies.
The facility failed to have a formal Performance Improvement Project (PIP) focusing on high-risk or problem-prone areas, affecting all 34 residents. Interviews revealed that each department handled issues independently, and staff were not informed about QAPI activities. No policy related to QAPI or a PIP was provided by the end of the survey.
The facility failed to provide mandatory training on its specific QAPI Program. Staff interviews revealed a lack of specific training and awareness about the QAPI plan and their roles within it. The administrator confirmed that only general training was provided, and no policy related to QAPI training was available.
The facility failed to offer and administer the most recent CDC-recommended pneumococcal vaccines to two residents. One resident with multiple health conditions did not receive the PCV-20 vaccine at least five years after receiving the PPSV-23 vaccine. Another resident with various diagnoses did not receive the PCV-20 vaccine at least five years after the last pneumococcal vaccine dose. The facility's records lacked evidence of physician consultation or resident education about the updated vaccine.
The facility failed to notify the county's designated State Mental Health Authority (SMHA) when a resident exhibited a new onset of mental illness, including PTSD and Paranoid Personality Disorder. The social service designee did not review the Pre-Admission Screening for accuracy or refer it to the SMHA.
Infection Surveillance and EBP Deficiencies
Penalty
Summary
The infection prevention and control program failed to include ongoing surveillance, analysis, and trending of resident and staff infections. Review of the infection surveillance report for 1/1/26 through 3/31/26 showed resident name, room number, infection onset date, signs and symptoms, status, and pharmacy orders, but the report had missing signs and symptoms data and no evidence of analysis, identification of patterns or trends, implemented interventions, or required precautions. Review of the employee line list printed 4/22/26 also showed employee name, department, title, date, and symptoms, but it likewise lacked evidence of analysis, patterns or trends, interventions, or precautions. The facility could not provide documentation showing analysis, trending, or evaluation of infection data. The infection preventionist, an RN employed at the facility for about one month, stated infections were tracked in the EMR, but the data reviewed for February and March 2026 did not include comprehensive information such as signs and symptoms and primarily included infections associated with medication orders. The RN confirmed gaps in the surveillance process and stated monthly analysis is important to identify trends or patterns and initiate interventions. The RN also stated there was no awareness of a current list of reportable communicable diseases and could not describe the reporting protocol for communicable diseases, healthcare-associated infections, or potential outbreaks. The interim DON and the RN stated they were not aware of employee illness tracking processes, while the administrator stated the facility had a document tracking employee illnesses but it had not been shared with the infection preventionist and was not used for trending or analysis. The facility also failed to ensure adherence to enhanced barrier precautions for two residents with wounds and device-related care needs. One resident had paraplegia, pressure ulcers to the buttocks and sacral area, and a suprapubic catheter with a history of chronic infections and ESBL in urine. Although an EBP sign was observed on the resident’s door, staff repeatedly could not locate a PPE cart or gowns in the room, and the doffing receptacle was placed on top of a drawer unit and was hard to reach. The resident stated staff did not wear gowns when emptying the catheter or changing the dressing. Nursing staff and the infection preventionist confirmed the lack of gowns and the absence of the PPE cart, and the infection preventionist stated the resident should have had a PPE cart outside the door and that staff were not being monitored for EBP adherence. A second resident had a coccyx wound and required wound care. During observation, an LPN completed wound care without wearing a gown and stated she was unsure whether a gown was required and did not see an EBP sign or supply cart outside the room. The resident stated she did not recall staff wearing gowns when changing her brief or providing wound care. Later, the room had an EBP sign and a cart with gowns outside the door. The interim DON stated EBP would be expected for wounds requiring a dressing to prevent spread of infection.
Failure to Track Antibiotic Use and Culture Results
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program specific to antibiotic stewardship. Review of the Infection Prevention and Control case list dated 1/1/26-3/31/26 showed resident names, room numbers, onset dates, signs and symptoms, current prescriptions, prescribers, infection types, organisms, diagnoses, and categories, but it did not include the date cultures were obtained, the organisms identified from culture results, or whether organisms were resistant to the prescribed antibiotics. The facility’s antibiotic use was not tracked, and there was no current process for antibiotic stewardship. On 4/21/26, the infection prevention nurse stated the facility completed a log to monitor possible infections, but antibiotic tracking was identified as a gap to ensure residents were on the correct antibiotic. She stated follow-up of cultures and ensuring residents were prescribed the correct antibiotic was a gap, and that the facility did not track antibiotic indications for use, dosage, duration, culture results, or whether antibiotics were discontinued timely. She further stated that if a resident had a UTI and a urine culture was obtained, the provider was expected to track and communicate results to the facility, and the facility did not have a process to ensure culture results were received or addressed. On 4/22/26, the interim DON and the infection prevention nurse verified that infection surveillance related to antibiotic use and resistance was not tracked on the IPC log and that the facility did not have a formal antibiotic stewardship process as expected.
Locked Exit Doors Restricted Resident Freedom
Penalty
Summary
The facility failed to ensure residents were free from involuntary seclusion when it maintained locked exit doors that prevented residents from freely exiting the building without individualized assessments, clinical justification, physician orders, or care planning to support the restriction. Surveyors identified this issue as affecting 8 of 34 residents, including residents who were cognitively intact, independent with mobility, and documented as not being at risk for elopement or wandering. Record review showed that multiple residents had assessments and care plans indicating they were able to move about independently, use wheelchairs or walkers, go outside, and were not elopement risks. For example, residents were documented as having intact or moderately impaired cognition, independent transfers, independent wheelchair propulsion, and in some cases a desire to go outside for fresh air. Elopement risk evaluations for these residents repeatedly indicated they were not at risk for elopement. Despite this, the facility had no individualized assessments, care plans, physician orders, or other clinical justification in the records to support restricting their ability to leave the building. During interviews and observations, the administrator stated the doors were locked from the inside and outside for safety and security and that only staff had access to the codes. The administrator confirmed residents, including those who were independent and without cognitive impairment, could not leave the building without staff assistance and that no individualized assessments or waivers had been completed to support the restriction. Staff confirmed all facility doors were locked and residents could not independently exit. Surveyors observed several exit doors with keypads and push bars that remained locked when pressed, and one resident stated the locked doors made the facility feel "almost like jail." The medical director stated that individualized assessment, including elopement risk, cognition, physical ability, and decision-making capacity, would be expected before restricting a resident's ability to leave freely, and that a generalized safety concern could not be applied to all residents.
Incorrect MDS Coding for Anticoagulant Use
Penalty
Summary
The facility failed to ensure medications were coded accurately on the Minimum Data Set (MDS) assessments for 2 residents reviewed for unnecessary medications. R11’s quarterly MDS identified that the resident took an anticoagulant, but the physician’s orders did not include an anticoagulant and instead included aspirin 81 mg by mouth daily. R11’s care plan also did not mention an anticoagulant medication. R11’s face sheet listed diagnoses of type two diabetes with complications, alcohol abuse, and weakness. R29’s quarterly MDS also identified that the resident took an anticoagulant, but the physician’s orders did not include an anticoagulant medication and instead included aspirin 81 mg by mouth daily. R29’s care plan did not mention an anticoagulant medication. R29’s face sheet listed diagnoses of chronic respiratory failure, repeated falls, and systolic heart failure. During interview, RN-A stated she initially thought aspirin could be counted as an anticoagulant on the MDS, then clarified that aspirin should be coded as an antiplatelet medication, not an anticoagulant, and stated the MDS was coded incorrectly. The interim DON stated he would expect the MDS to be coded correctly based on the RAI directions.
Failure to Report Critical Blood Sugars, Calibrate Glucometers, and Monitor Skin Scabs
Penalty
Summary
The facility failed to report elevated blood glucose levels per provider order for one resident with diabetes and hyperglycemia. The resident’s orders included blood sugar checks twice daily and notification of the provider if blood sugar was less than 70 or greater than 400. Review of the electronic medical record showed two fingerstick blood sugars above 400 mg/dl, including 536 mg/dl and 421 mg/dl, with no documentation that the provider had been notified. A provider note before those readings indicated the resident had type 2 diabetes, an A1c of 8.8%, and recent medication adjustments with close monitoring planned. During interviews, the regional clinical consultant verified the elevated readings and confirmed there was no sliding scale order and no documentation that nursing staff notified a provider of the blood sugars greater than 400 mg/dl. A licensed practical nurse stated she did not call the provider when the resident’s blood sugar was greater than 500 mg/dl, though she may have sent an electronic message and could not say for certain. The advanced practice registered nurse did not recall being informed of the elevated blood sugars and stated notification was important so action such as a one-time insulin dose could be taken. The facility’s blood glucose monitoring policy stated critical test results were to be reported timely. The facility also failed to ensure glucometer calibration checks were being performed according to manufacturer instructions. Staff stated they did not know about glucometer calibration, and when the glucometer was examined, unopened control solution boxes were found but no binder or documentation showing calibration was being done. The manufacturer instructions for the Arkray Assure Platinum glucometer required control solution testing under specific circumstances, including before first use, when opening a new bottle of test strips, and when results appeared abnormally high or low. In a separate finding, the facility failed to monitor a resident with a skin-picking disorder and multiple scabs on both arms. The resident was observed with several scabs, including one actively being picked open, and stated nurses did not check, treat, or ask about them. Staff interviews indicated the scabs were no longer being monitored or documented, and the interim DON stated he was not sure they were being monitored or treated and did not think anything was being done for them.
Pharmacy Recommendations Not Addressed
Penalty
Summary
The facility failed to ensure consulting pharmacist recommendations were addressed or acted upon for 2 of 5 residents reviewed for unnecessary medications. For one resident, the record showed monthly pharmacy reviews were completed over multiple months, with pharmacist recommendations noted in nine months, but only one recommendation with a provider response was produced when requested. For the second resident, monthly pharmacy reviews were also documented over several months, with pharmacist recommendations noted in four months, but no copies of the recommendations with provider responses were provided. The facility medication regimen policy required the licensed pharmacist to review each resident’s drug regimen at least monthly, including the medical chart, and for staff to act upon recommendations according to procedures for medication regimen review irregularities. The first resident had diagnoses including wedge compression fracture of the lumbar vertebrae, HTN, dependence on renal dialysis, hyperlipidemia, depression, DM, CHF, and anemia, was dependent on staff for ADLs, did not walk, and had 28 medications ordered. The second resident had Alzheimer’s disease and dementia, severe cognitive impairment, unclear speech, was rarely or never understood and rarely or never understood others, was dependent on staff for ADLs, did not walk, and was receiving hospice care with eight medications ordered. Interviews with the regional clinical consultant, consultant pharmacist, interim DON, and medical director indicated the lack of provider responses and follow-through on pharmacy recommendations was an ongoing issue, with staff changes and an unsustained process contributing to the problem.
Failure to Perform Ordered Wound Care Dressing Changes
Penalty
Summary
The facility failed to follow provider orders for wound care dressing changes for a resident with paraplegia and pressure ulcers to the buttocks and sacral region. The resident’s face sheet listed diagnoses of paraplegia and pressure ulcers to the right and left buttock, and the MDS indicated intact cognition, clear speech, independence with most ADLs, and mobility by motorized wheelchair. The care plan identified a stage 4 pressure injury to the coccyx and directed staff to administer treatments as ordered and monitor effectiveness. On 4/21/26, the wound care provider documented a stage 4 sacral pressure ulcer with moderate seropurulent drainage and changed the wound care orders to cleanse the coccyx wound twice daily, apply calcium alginate to the wound bed, barrier cream around the peri-wound, and cover with ABD and tape. The treatment administration record showed the ordered dressing change was not completed at all on 4/22/26, and another dressing change to the coccyx had not been documented on 4/15/26. During interview, the LPN verified the missed documentation and stated she could not speculate why the dressing changes had not been done. The resident stated the dressing had not been changed since the provider changed it on 4/21/26 and said he rarely refused care and did not mind being awakened for dressing changes. The wound care provider stated he expected staff to perform the dressing changes as ordered, and the regional clinical consultant stated staff should have completed the twice-daily dressing changes, especially after the provider changed the wound care orders because the wound had plateaued in healing.
RN Coverage Not Maintained
Penalty
Summary
The facility failed to ensure an RN was on duty a minimum of 8 consecutive hours per day for 5 of 7 days reviewed. Review of the nursing schedule for the last 30 days showed that no RN had been scheduled on 3/15/26, 3/16/26, and 4/5/26. During an interview on 4/22/26 at 11:54 a.m., the administrator stated the facility had obtained a waiver for RN coverage, was actively recruiting RN staff and offering incentives, and was using agency nursing staff to fill RN coverage. The administrator also stated the facility was aware that not all days had a scheduled RN and explained that finding RNs in the rural area was difficult because the facility was competing with other employers such as homecare, hospice, and hospitals.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was scheduled for at least eight consecutive hours a day, seven days a week, as required. Review of the Payroll-Based Journal (PBJ) Staffing report for the first quarter of 2025 revealed several staffing concerns, including a one-star staffing rating, excessively low weekend staffing, and no RN hours reported. Examination of the licensed staff schedule and daily timecard logs confirmed that there was no consecutive eight-hour RN coverage on specific dates, and there was no RN coverage at all on two identified days. Interviews with the administrator and health unit coordinator (HUC) revealed that both were responsible for scheduling and acknowledged difficulties in maintaining RN coverage due to call-ins and scheduling challenges. They confirmed that on the days in question, there was no RN coverage, and also stated that having RN coverage is a requirement for skilled nursing. Additionally, when requested, the facility was unable to provide a staffing policy. This deficiency had the potential to affect all 35 residents residing in the facility.
Incomplete Daily Nurse Staffing Information Posting
Penalty
Summary
The facility failed to ensure that all required data were included on the daily nurse staffing information postings. Record review of the PBJ Staffing report and staff schedule documentation revealed that, on multiple dates from October 2024 through May 2025, the postings were missing one or more of the following required elements: facility name, current date, facility census, total number and actual hours worked by licensed staff, and total number of licensed staff with their designation or title. This omission was identified through review of posted schedules and confirmed by both the administrator and the health unit coordinator (HUC), who acknowledged that the postings were incomplete on the specified dates. Additionally, the facility's PBJ Staffing report indicated concerns such as a one-star staffing rating, excessively low weekend staffing, and no RN hours. During interviews, the administrator and HUC explained that the HUC prepared the staff posting and night nurses were responsible for updating and posting it in the morning. They confirmed their understanding of the posting requirements but acknowledged the deficiencies in the posted information. No staff posting policy was provided when requested.
Failure to Maintain Dishwasher and Cold Storage Temperatures
Penalty
Summary
Surveyors observed that the facility failed to ensure the dishwasher reached the manufacturer's required minimum rinse temperature of 180 degrees Fahrenheit during multiple cycles, with actual rinse temperatures recorded between 160 and 170 degrees Fahrenheit. The nursing assistant responsible for monitoring the dishwasher temperatures did not notice the low rinse temperatures until pointed out by the surveyor, despite being responsible for checking the machine at each mealtime or at least three times daily. The certified dietary manager confirmed the dishwasher was not reaching the required temperatures and that maintenance had been notified. Additionally, the facility failed to consistently monitor and document temperatures for all kitchen refrigerators and freezers. Review of temperature logs for two freezers and four refrigerators revealed numerous missed opportunities for documentation over several months, with some logs missing entirely for certain periods. The certified dietary manager and administrator both confirmed that temperature logs were incomplete and that staff were expected to record temperatures twice daily to ensure food safety.
Repeat Deficiency in Immunization Compliance Due to Ineffective QAPI Monitoring
Penalty
Summary
The facility failed to ensure its Quality Assurance and Performance Improvement (QAPI) program effectively maintained ongoing compliance regarding immunization requirements, resulting in a repeat citation for influenza and pneumococcal immunizations. Specifically, review of records showed that three out of five residents reviewed for immunizations were not offered or provided the pneumococcal vaccine series as recommended by the CDC. Additionally, the Quality Assessment and Assurance (QAA) committee meeting minutes from April 2024 through May 2025 did not include ongoing data or monitoring related to this repeat citation, despite the facility's policy stating that performance improvement activities should be monitored for effectiveness and sustainability.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain and document informed consent, including discussion of risks and benefits, for the use of psychotropic medications for four residents reviewed. For each of these residents, medical records showed prescriptions for various psychotropic drugs such as antidepressants, antipsychotics, and benzodiazepines, but lacked evidence that informed consent was obtained prior to administration. The records did not contain completed consent forms or documentation that residents or their representatives were informed about the risks, benefits, or alternatives to these medications, as required by facility policy. Interviews with facility staff, including the regional director of nursing, consulting pharmacist, and director of nursing, confirmed that consents for psychotropic medications had not been completed and that it was an expectation for such consents to be obtained. The facility's own policy required that residents, families, or representatives be informed of the benefits, risks, and alternatives to psychotropic medications before initiation or dose increases, and that this information be documented. Despite this, the review found no such documentation for the residents in question, all of whom had significant medical and psychiatric diagnoses and were prescribed multiple psychotropic medications.
Failure to Maintain System for Monitoring and Tracking Stored Narcotics
Penalty
Summary
The facility failed to implement an effective system to monitor and track stored narcotics, which had the potential to affect all 16 residents prescribed Schedule II-V medications. Observations and interviews revealed that the narcotic record index pages in both the West and East medication carts were not updated beyond page 55, despite the narcotic books containing documentation through page 127. Staff confirmed that the index pages were no longer used to log new medications or to guide shift change narcotic counts. Instead, staff relied on memory and routine to identify which medications should be present, without a formal list or tracking method. During a medication cart narcotic count, nurses verified the number of doses by matching the medication card with the narcotic book, but did not reference an updated index or comprehensive list. The DON acknowledged that there was no refined system or alternative method in place to account for every narcotic in the facility. Additionally, a handwritten document listing controlled medications did not include corresponding narcotic book page numbers, further limiting the ability to accurately track and monitor controlled substances. The facility's policy required safeguards to prevent diversion, but these were not effectively implemented.
Failure to Act on Pharmacist Medication Review Recommendations
Penalty
Summary
The facility failed to ensure that pharmacist consultant recommendations were acted upon for all five residents reviewed for unnecessary medications. Each resident's monthly pharmacy reconciliation included specific recommendations from the consulting pharmacist, such as requests for laboratory workups, order clarifications, clinical rationales for continued medication use, and suggestions for medication adjustments or discontinuations. Despite these recommendations, there was no evidence in the medical records that the facility responded to or updated the physicians regarding the pharmacist's findings for any of the residents involved. For example, one resident with multiple diagnoses including hypertension, dementia, and depression had recommendations for a laboratory workup for an antipsychotic and clarification of an antidepressant order, but no follow-up was documented. Another resident with heart failure, renal insufficiency, and anxiety had repeated requests from the pharmacist for clinical rationales for continued use of certain medications, which were not addressed. Additional residents had recommendations related to medication schedule changes, laboratory monitoring, and dose reductions, none of which were documented as having been communicated to the prescribing providers. Interviews with the consulting pharmacist and the DON confirmed that the facility was expected to resolve medication review recommendations prior to the next monthly pharmacist visit, but this was not done. The facility's own policy required staff to act upon all pharmacist recommendations according to established procedures, yet records showed a consistent lack of follow-through, leaving the recommendations unaddressed for multiple residents over several months.
Failure to Maintain Sanitary and Temperature-Controlled Storage for Food and Medications
Penalty
Summary
The facility failed to maintain sanitary conditions and proper temperature monitoring for both a shared resident refrigerator and a medication refrigerator. Surveyors observed the shared resident refrigerator containing multiple open and undated bottles and containers, including milk and beverages, as well as a freezer section with melted popsicles and a sticky orange substance affixing a Tupperware container to the freezer floor. The certified dietary manager was unable to confirm when the refrigerator was last cleaned, and temperature logs for the refrigerator were missing significant entries for the month reviewed. The cleaning schedule also lacked documentation of the last cleaning date, and the administrator confirmed there was no evidence of recent cleaning. Additionally, the medication refrigerator was found to have water inside the containers and bags storing insulin pens, with a freezer compartment covered in ice and leaking into the storage area. Temperature logs for the medication refrigerator were incomplete for several months, with numerous shifts lacking recorded temperatures. Both the LPN and DON confirmed that water should not be present in medication storage and that the refrigerator required defrosting. The facility's policies required daily temperature checks and documentation, which were not followed, and the pharmacist emphasized the importance of proper storage conditions for medication effectiveness.
Failure to Complete Self-Administration Assessment for Bedside Medication
Penalty
Summary
The facility failed to ensure that a self-administration of medications (SAM) assessment was completed and appropriate orders were obtained for all medications kept at bedside for a resident. Specifically, a resident with diagnoses including diabetes, heart failure, and COPD was observed with an Advair inhaler at their bedside, which had not been documented as safe for self-administration in the resident's SAM assessment. The assessment only indicated that Bio Freeze and nicotine gum were approved for bedside self-administration, not the Advair inhaler. During medication administration, staff were unable to locate the resident's Advair inhaler in the medication cart and subsequently found it on the resident's bedside table, accessible to the resident. The director of nursing confirmed that the SAM assessment did not authorize the resident to keep Advair at bedside and stated that only medications identified as safe in the SAM assessment should be left at bedside. The facility's policy required that resident choices regarding medication administration be evaluated for safety, but this process was not followed for the Advair inhaler.
Failure to Provide Timely Medicare Coverage Termination Notice
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN-CMS-10055) to a resident within the mandated timeframe. Specifically, the resident was admitted and later discharged, with their Medicare Part A services ending on a specified date. The SNFABN, which informs residents of the end of Medicare coverage and their potential financial responsibility, was given to the resident on the same day that services ended, rather than at least 48 hours in advance as required by both facility policy and federal guidelines. Interviews with the office manager and administrator confirmed that the notice was not provided within the required timeframe. The office manager acknowledged responsibility for completing the SNFABN forms and stated that they typically rely on notifications from therapy or the MDS nurse regarding the end of services. Both the office manager and administrator recognized the importance of timely notification to allow residents to make informed decisions about their care and financial obligations. Review of facility policy further confirmed the expectation that such notices be provided at least two days before the end of Medicare coverage.
Failure to Control Excessive Call Light Noise in Resident Areas
Penalty
Summary
The facility failed to maintain a safe, comfortable, and homelike environment by not controlling excessive and persistent noise from the call light system in resident living areas. Observations revealed that the call light alarm, located at the nurses' station in a central area, produced a continuous, loud, high-pitched noise that could be heard throughout the resident hallways and common areas. The alarm frequently sounded for extended periods, with documented instances ranging from 8 to 34 minutes at a time, occurring multiple times over several days. Residents who were cognitively intact and had diagnoses such as schizophrenia, anxiety disorder, major depressive disorder, bipolar disorder, delusional disorders, mood affective disorder, diabetes, and chronic tension-type headache reported that the noise was irritating and disruptive, with one resident specifically stating it affected their sleep. Staff, including a TMA, RN, LPN, DON, and the administrator, acknowledged the negative impact of the persistent noise on both residents and staff. Staff reported difficulty concentrating and increased frustration, while residents expressed their annoyance and distress, sometimes resulting in negative behaviors. The DON and administrator recognized that the loud environment could trigger challenging behaviors and negatively affect quality of life, especially for residents with dementia. Despite staff reporting concerns about the noise, they were told that nothing could be done due to the age and design of the call light system, which continued to ring until manually turned off. Facility policies indicated a commitment to providing a quiet, comfortable environment, but these were not upheld in practice.
Failure to Document Rationale and Gradual Dose Reduction for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that as-needed (PRN) antipsychotic medications were limited to a 14-day period and that clinical rationale was documented for continuation beyond this timeframe. For two residents, there was no evidence in the medical records to support the ongoing use of PRN psychotropic medications past 14 days, nor was there documentation of a gradual dose reduction (GDR) or appropriate indication for use. Pharmacy reconciliation reports repeatedly requested clinical rationale and GDRs, but the facility did not respond or provide the required documentation. One resident, who was moderately cognitively impaired and had multiple diagnoses including anemia, heart failure, renal insufficiency, diabetes, hyperlipidemia, and anxiety, was prescribed alprazolam PRN with no documented rationale for use beyond 14 days. Another resident, who was severely cognitively impaired with diagnoses including peripheral vascular disease, arthritis, Alzheimer's, and anxiety, was prescribed multiple psychotropic medications, including haloperidol and olanzapine, with no clinical rationale for their continued use past 14 days. Additionally, there was no evidence of a GDR for the resident's antidepressant, and morphine was prescribed with an inappropriate indication of dementia. The consulting pharmacist confirmed that the required clinical rationales and GDRs were missing from the medical records and that multiple requests for this information had gone unanswered. The DON also confirmed the lack of documentation and was unsure who was responsible for completing pharmacy reviews, as the previous DON had left unexpectedly. Facility policy required documentation of rationale for extended psychotropic use and GDRs, but these requirements were not met for the residents reviewed.
Failure to Update Care Plan Following Discontinued Pressure Ulcer Intervention
Penalty
Summary
The facility failed to update the care plan for a resident with pressure ulcer interventions after a significant change in condition. The resident, who was cognitively intact and had diagnoses including osteoporosis, thyroid disorder, malnutrition, and depression, had an order for Arginaid Oral Packet to aid with wound healing, which was discontinued in August 2024. However, the care plan, last reviewed in April 2025, still listed the discontinued supplement as an active intervention. Interviews with staff revealed that care plan updates were typically done the same day or as soon as possible after changes, but there was no set schedule. The director of nursing confirmed that care plans should be updated at least quarterly and with any change of condition, and acknowledged that the care plan should have been updated when the order was discontinued. The facility was unable to provide a policy regarding care plan updates.
Failure to Follow Physician Orders for Weekly Weight Monitoring
Penalty
Summary
The facility failed to implement physician orders for weekly weight monitoring for a resident who was cognitively intact and had diagnoses including neurogenic bladder, paraplegia, malnutrition, and depression. The physician order, active since late December, required weekly weights and vitals to be taken on bath day. The resident's care plan also identified a risk for nutrition and hydration problems, specifying that weights should be monitored per medical orders or facility policy. However, a review of the electronic medical and treatment administration records showed that the last documented weight for the resident was in December, with no further weights recorded through May. Interviews with facility staff confirmed that the responsibility for obtaining weights fell to the nurse on duty or could be delegated to a CNA, and that the process was tracked through the MAR, TAR, or by requests from dietary staff. The LPN confirmed no weights had been charted since December and was unsure of the reason. The DON also confirmed the lack of documented weights and emphasized the importance of following physician orders as part of the nurse's scope of practice and the resident's care plan. Facility policy required monitoring of residents' weights to maintain acceptable nutritional status.
Improper Storage of Controlled Substance in Medication Room Refrigerator
Penalty
Summary
A vial of Lorazepam Oral Concentrate USP 2 mg/ml, a Schedule IV controlled substance, was found stored in the door of the medication room refrigerator, outside of the designated double lock box. The lock box intended for controlled substances was not permanently affixed to the refrigerator and had a key left in the lock. An LPN, who was agency staff, confirmed that the lock box had been unaffixed and the key left in place since they began working at the facility. The LPN also confirmed that the Ativan should have been stored and locked in the lock box, and that the key should not have been left in the box. The medication count for Ativan was verified as correct in the narcotic box. The DON confirmed that the Ativan was inappropriately stored and not double locked as required, and that the key should have been kept with the charge nurse rather than left in the box. Both the consultant pharmacist and the DON stated that the expectation was for Lorazepam Oral Concentrate to be stored double locked in a permanently affixed compartment within the refrigerator. The facility's medication policy indicated that Schedule II drugs and backup stock of Schedule III, IV, and V medications are to be stored under double lock and key, with Schedule II medications specifically requiring storage in a separately locked, permanently affixed compartment when stored with other medications.
Failure to Offer and Administer Pneumococcal Vaccines per CDC Guidelines
Penalty
Summary
The facility failed to ensure that three out of five residents reviewed for immunizations were offered and/or provided the recommended pneumococcal vaccine series according to CDC guidelines. Specifically, one resident with diagnoses including dementia, diabetes, rheumatoid arthritis, and epilepsy had received PPSV23 and PCV13 in previous years and had a signed consent for further pneumococcal vaccination, but there was no evidence that the PCV20 or PCV21 vaccine was administered. Another resident with Alzheimer's disease, anxiety disorder, and peripheral vascular disease had received PCV15 and had a signed consent for additional pneumococcal vaccination, but there was no documentation of receiving PPSV23, PCV20, or PCV21. A third resident with adult failure to thrive, depression, and osteoporosis had not received any pneumococcal vaccinations, nor was there evidence that the vaccine was offered. The director of nursing confirmed that the facility did not administer the requested or consented pneumococcal vaccinations to two residents and failed to offer the vaccine to a third resident. The facility's policy stated that immunizations should be offered in accordance with current CDC guidelines, but documentation and interviews revealed that this was not consistently followed for the residents reviewed.
Failure to Administer COVID-19 Vaccine After Consent
Penalty
Summary
The facility failed to ensure that a resident with diagnoses including mild cognitive impairment, transient ischemic attack, cerebral infarction, and aortic valve stenosis was provided the COVID-19 vaccine after consenting to receive it. Documentation showed that the resident had not received any COVID-19 vaccinations as of the date reviewed, despite having signed a consent form to receive the vaccine. The resident's clinical record lacked evidence that the vaccine was administered, and this was confirmed by the DON, who acknowledged the absence of documentation and stated that staff are expected to review and offer immunizations upon admission and at quarterly care conferences.
Failure to Follow Physician Orders for Pressure Ulcer Wound Care
Penalty
Summary
The facility failed to ensure physician orders for pressure ulcer wound care were followed for three residents with documented pressure ulcers. Each resident had specific wound care orders, including cleansing, application of wound care products, and dressing changes at prescribed intervals. However, treatment administration records showed multiple dates where there was no documentation that the required dressing changes were completed for various wounds, including stage III and IV pressure ulcers on the sacrum, heel, gluteal area, ischial tuberosity, and elbow. Residents involved had significant medical histories, such as paraplegia, protein-calorie malnutrition, adult failure to thrive, muscle weakness, and type 2 diabetes mellitus. Their care plans and provider orders detailed the necessary wound care interventions, but the records indicated repeated lapses in performing or documenting these treatments. Interviews with the residents confirmed that there were several occasions when their dressings were not changed as ordered, though they could not specify exact dates or reasons. Staff interviews revealed that LPNs and the infection preventionist acknowledged there were times when dressing changes were not completed and that these instances were reported to the DON. Staff consistently stated that if a dressing change was not documented, it was not done. The interim DON confirmed that staff were expected to follow provider orders for wound care. The facility's wound treatment management policy required treatments to be completed according to physician orders, but this was not consistently followed.
Failure to Perform Proper Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to ensure proper hand hygiene was performed during wound care for two residents who required extensive assistance with bed mobility and personal hygiene. For both residents, the infection preventionist (IP) did not remove gloves and perform hand hygiene after cleansing wounds and before applying new dressings, as observed during dressing changes. The IP initially sanitized or washed hands and donned appropriate personal protective equipment before starting the procedures, but did not follow hand hygiene protocols between the removal of soiled dressings, cleansing of wounds, and application of clean dressings. Interviews with the IP and the interim director of nursing confirmed that facility policy and expectations required staff to perform hand hygiene before and after handling dressings, and specifically after removing soiled dressings and cleansing wounds. The facility's hand hygiene policy, reviewed in February 2025, also indicated that hand hygiene should be completed before and after handling clean or soiled dressings and when moving from a contaminated to a clean body site. The IP acknowledged not following these procedures during the observed wound care for both residents.
Failure to Investigate Falls and Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to thoroughly investigate falls, implement adequate fall prevention interventions, and follow care planned fall interventions for two residents identified as high risk for falls. One resident with hemiplegia, dementia, disorientation, and muscle weakness experienced multiple falls, including both witnessed and unwitnessed incidents, with documentation repeatedly lacking identification or implementation of new interventions. After several falls, the resident suffered a fractured rib following an unwitnessed fall while attempting to use the bathroom, and the care plan and care sheets did not reflect any updated fall interventions. Another resident with Alzheimer's disease, dementia, and muscle weakness, also assessed as high risk for falls, experienced several falls, including one with a suspected head injury. Documentation for these incidents similarly lacked identification or implementation of new interventions, and the resident's care sheet did not include any fall interventions. In both cases, there was no evidence of interdisciplinary team (IDT) review, root cause analysis, or appropriate updates to the care plan after each fall. Observations revealed that required signage and appropriate footwear were not consistently provided, and staff interviews indicated a lack of awareness regarding current fall interventions for these residents. Staff were unclear about who was responsible for updating care plans with fall interventions, and the facility's fall prevention policy, which required review and update of care plans after a fall, was not followed.
Failure to Ensure RN Coverage 8 Hours a Day, 7 Days a Week
Penalty
Summary
The facility failed to ensure registered nurse (RN) coverage for 8 consecutive hours a day, 7 days a week, as required by CFR 483.35 (b)(1). A review of the nursing schedule from 10/1/2023 through 3/15/2024 identified 8 days where no RN was scheduled on Saturdays or Sundays. During an interview on 3/28/2024, the administrator acknowledged the lack of coverage and mentioned efforts to stagger hours and utilize an RN from a sister facility to meet the requirement. The facility was actively advertising for full-time RN positions to achieve compliance.
Inaccurate Staffing Data Submission to CMS
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to CMS for Quarter 1 of 2024. Specifically, the Payroll Based Journal (PBJ) Report identified several dates where there was a failure to have licensed nurse coverage for 24 hours per day. However, a review of staffing schedules and staff timecards showed that there were licensed nursing staff present on those dates, indicating that the data submitted was inaccurate. During an interview, the administrator mentioned that an offsite person enters the PBJ data, but no further information or policy was provided by the end of the survey.
Failure to Document and Analyze QAPI Data
Penalty
Summary
The facility failed to ensure that data submitted to the Quality Assurance and Performance Improvement (QAPI) committee was properly analyzed and documented. This deficiency was identified through a review of the monthly QAPI meeting minutes from June 2023 through March 2024, which showed that while department heads brought data on various topics such as infection control, falls, grievance reports, and incident reports, there were no documented benchmarks for goals, analysis of the data, or action plans to achieve these goals. An interview with the administrator revealed that the facility had changed their QAPI meeting format about a year ago, resulting in a lack of documentation for goals, action plans, and data analysis. The administrator acknowledged that the previous format, which included a table for goals, action plans, and analysis results, was more effective. The March 2020 QAPI Program indicated that the committee should oversee areas for improvement, develop action plans, and analyze the results, but this was not being followed.
Lack of Formal Performance Improvement Project
Penalty
Summary
The facility failed to have evidence of a Performance Improvement Project (PIP) that focused on high-risk or problem-prone areas identified through appropriate data collection, analysis, and evaluation during Quality Assurance and Performance Improvement (QAPI). This deficiency had the potential to affect all 34 residents. Interviews with the Director of Nursing, a trained medication aide, and the administrator revealed that the facility did not have a formal PIP in place. Each department was handling issues independently, and staff were not informed about the QAPI committee's activities. Additionally, there was no policy related to QAPI or a PIP provided by the end of the survey.
Failure to Provide Specific QAPI Training
Penalty
Summary
The facility failed to provide mandatory training on its specific Quality Assurance Performance Improvement (QAPI) Program. During interviews, a dietary aide and a trained medication aide (TMA) revealed they had either no training or only general training on QAPI, and were unaware of how to communicate concerns to the QAPI committee or what issues the facility was addressing. The administrator confirmed that staff had only received general online training through Relias and brief mentions during stand-up meetings, but not specific training on the facility's QAPI plan or their roles within it. There was no policy related to QAPI training provided by the end of the survey.
Failure to Administer CDC-Recommended Pneumococcal Vaccines
Penalty
Summary
The facility failed to offer and/or administer the most recent CDC-recommended pneumococcal vaccine for two residents reviewed for immunizations. Specifically, the facility did not provide the PCV-20 vaccine to residents who had previously received the PPSV-23 vaccine, as required by CDC guidelines. Resident 22, who had a history of stroke, hyperlipidemia, spinal stenosis, iron deficiency anemia, hypotension, bipolar disorder, and major depressive disorder, received the PPSV-23 vaccine in 2017 but was not offered the PCV-20 vaccine at least five years later. Similarly, Resident 32, with diagnoses including type 2 diabetes mellitus, cirrhosis of the liver, chronic viral hepatitis C, traumatic brain injury, muscle weakness, peripheral vascular disease, and major depressive disorder, received the PCV-13 vaccine in 2019 and the PPSV-23 vaccine in 2000 but was not offered the PCV-20 vaccine at least five years after the last pneumococcal vaccine dose, as per CDC guidelines. The medical records for both residents lacked evidence of physician consultation or documentation that the residents or their representatives were educated about the need for the updated vaccine. An interview with the Director of Nursing confirmed that the facility had not been offering the PCV-15 or PCV-20 vaccines but planned to do so in the future. The facility's October 2019 Pneumococcal Vaccine policy stated that all residents would be offered pneumococcal vaccines in accordance with current CDC recommendations, but this was not followed in practice.
Failure to Notify SMHA of New Mental Illness Diagnosis
Penalty
Summary
The facility failed to notify the county's designated State Mental Health Authority (SMHA) when a resident (R15) exhibited a new onset of mental illness. R15 required law enforcement and emergency medical services to transport him to a local hospital for behavioral issues, and he was later moved to a mental health inpatient facility. Upon re-entering the facility, R15 had new diagnoses of Post Traumatic Stress Disorder (PTSD) and Paranoid Personality Disorder, which were not identified in the Pre-Admission Screening (PAS) conducted on 6/21/23. The social service designee (SSD) admitted to not reviewing R15's PAS for accuracy or referring it to the SMHA for review. No policy was provided by the facility by the end of the survey.
Latest citations in Minnesota
A resident with intact cognition and multiple diagnoses, including AFib, HF, stroke, anxiety, and depression, was permitted to self-administer nebulizer treatments after staff setup without an IDT self-administration assessment. The EMR lacked documentation of the resident’s competency and safety to manage the nebulizer, including understanding the medication, following directions, operating the equipment, recognizing side effects, and storing the medication and equipment. Staff and the DON confirmed the assessment had not been completed before the self-administration order was implemented.
Failure to Assess and Monitor Antipsychotic Use: A resident with severe cognitive impairment, dementia, anxiety, and mood disorder received Risperidone for agitation and paranoia, but the EMR did not show an AIMS assessment on admission or timely target behavior monitoring. The RN case manager and DON confirmed that baseline AIMS and ongoing behavior monitoring should have been in place when the antipsychotic was started, but the resident’s record lacked measurable target behaviors and documentation of medication effectiveness.
Incomplete Care Plans for Anticoagulant Therapy and Cardiac-Related Needs: The facility failed to include key diagnoses, devices, and medication-related risks in care plans for two residents. One resident’s plan did not address Eliquis use, cardiac conditions, pacemaker presence, or condom catheter care, and another resident’s plan did not address Eliquis therapy or related bleeding-risk monitoring. The DON and RN case manager confirmed these items should have been care planned.
Failure to provide scheduled bathing and grooming assistance: Two residents with intact cognition and ADL dependence did not receive bathing as documented on a weekly schedule, and one resident also had unaddressed facial hair and greasy, unkempt hair. Records did not show consistent weekly baths, additional refusals, or reasons for missed care, and staff interviews confirmed residents were expected to receive at least weekly bathing unless they refused and that facial hair should be shaved when noticed.
A resident with intact cognition and multiple diagnoses, including BPH and stroke, had a physician order for a condom catheter at bedtime, but the EMR lacked orders or instructions for cleaning, disinfecting, monitoring, or changing the drainage bag. During observation, the bag was seen hanging in the bathroom, and an LPN, RN case manager, and DON all confirmed the absence of documented guidance for the catheter drainage bag care.
Failure to preserve dignity occurred when staff placed a brief on a cognitively intact resident who was continent of bowel and bladder. The resident stated the brief made him feel like a baby, and a NA confirmed she applied it even though he was not incontinent; RN and DON both verified the resident was continent and that briefs should not be placed on continent residents.
Failure to provide restorative ambulation and respond to a decline in mobility: A resident with dementia, weakness, chronic pain, and limited physical mobility was care planned for daily ambulation with a FWW and staff assist of 1, but the rehab record repeatedly showed ambulation as not applicable and staff interviews confirmed the task was often not done. The resident stated she could no longer walk, staff reported she had not walked for weeks and now required a sit-to-stand lift with assist of 2 for transfers, and the chart lacked an ADL decline assessment or revision of the ambulation care plan.
A resident with mild cognitive impairment, hemiplegia, hemiparesis, and limited ROM had restorative orders for PROM, stretching, and hand splints, but staff did not consistently offer or complete the interventions. Documentation showed the splints were sometimes marked not applicable instead of refused, and leg stretches were completed only a few times with no explanation for missed care. Staff interviews confirmed the restorative tasks often were not done, and the DON stated the resident’s restorative program needed to be updated.
Dirty can opener and contaminated dry storage bins: The DCS observed four labeled dry-goods bins with dirty rims, dry matter on the bin walls, and a scoop left inside a flour bin with flour on it. The attached can opener also had dry red matter on the blade, and the cook said it had been used that morning to open cream of corn for lunch. The DCS verified the findings and stated the can opener should be washed after each use and the dry bins and scoops should be kept clean.
Dignified Medication Administration Not Maintained: A resident with severe dementia, hallucinations, anxiety, PTSD, and delusional disorder was observed during med pass in the dining room. An RN attempted to administer meds by pouring them from a plastic cup into the resident’s mouth, continued despite the resident pulling away and moving her head, and then raised her voice and questioned why the resident would not take the meds after one pill was spit out and thrown on the floor. The resident stated the nurse was not being nice, and the RN left with the refused meds.
Missing Self-Administration Assessment for Nebulizer Use
Penalty
Summary
The facility failed to ensure an interdisciplinary team (IDT) assessment was completed before allowing a resident to self-administer nebulizer treatments. The resident had intact cognition and required assistance with ADLs, and diagnoses included atrial fibrillation, heart failure, BPH, stroke, malnutrition, anxiety disorder, and depression. Physician orders showed Ipratropium-Albuterol nebulizer treatments three times daily, and the EMR later included an order permitting the resident to self-administer nebulizer treatments after staff setup, but there was no evidence that an IDT self-administration assessment had been completed first. The record also lacked documentation showing the resident’s competency and safety to self-administer the nebulizer medication and treatment, including the ability to understand the medication purpose, follow directions, safely operate the equipment, recognize side effects or adverse reactions, and ensure safe administration and storage. During observation, the resident had nebulizer equipment and medication available in the room. The resident stated staff set up the medication cup and left while the treatment ran, then returned to ensure the machine was turned off; staff cleaned the nebulizer mask afterward. An LPN and RN confirmed the treatment was set up by staff, and the RN and DON stated a self-administration assessment should have been completed before the resident was permitted to self-administer medications.
Failure to Assess and Monitor Antipsychotic Use
Penalty
Summary
The facility failed to ensure that a resident receiving psychotropic medications was adequately assessed and monitored. R3’s admission MDS identified severe cognitive impairment and the need for assistance with ADLs, with diagnoses including non-traumatic brain dysfunction, unspecified dementia without behavioral, psychological, mood, or anxiety disturbances, non-Alzheimer’s dementia, anxiety disorder, and mood affective disorder. The resident’s physician orders included Risperidone 0.25 mg, two tablets by mouth every four hours PRN for agitation and paranoia, with a maximum of three PRN doses in 24 hours, and Risperidone 0.5 mg, one tablet by mouth three times daily for paranoia/agitation. R3’s EMR did not show that an AIMS assessment was completed upon admission despite the resident receiving antipsychotic medication, and the assessment was only completed after surveyor request. The record also lacked evidence that target behavior monitoring had been initiated for the antipsychotic use, with no measurable target behaviors documented, including frequency, duration, severity, precipitating factors, or response to interventions for agitation and paranoia. Interviews with the RN case manager and DON confirmed that AIMS assessment and behavior monitoring should have been completed upon admission or initiation of antipsychotic medications, and both acknowledged that target behavior monitoring had not been initiated.
Incomplete Care Plans for Anticoagulant Therapy and Cardiac-Related Needs
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents with significant medical conditions and medication-related needs. One resident had intact cognition and diagnoses including atrial fibrillation, heart failure, BPH, stroke, malnutrition, anxiety disorder, depression, and a cardiac pacemaker, and was receiving Eliquis. The resident also had a physician order for a condom catheter at bedtime and removal when getting up for the day. The comprehensive care plan printed 5/20/26 did not identify interventions or monitoring related to anticoagulant use, including bleeding risk, adverse effect monitoring, or staff awareness of anticoagulant precautions, and it also lacked interventions related to the resident’s cardiac conditions, pacemaker, and condom catheter use, including skin integrity monitoring and resident-specific catheter care preferences. A second resident with severe cognitive impairment and diagnoses including non-traumatic brain dysfunction, unspecified dementia, non-Alzheimer’s dementia, anxiety disorder, and mood affective disorder was also receiving Eliquis. The resident’s comprehensive care plan printed 5/19/26 did not include anticoagulant therapy, bleeding risk precautions, monitoring for adverse effects, or other interventions related to anticoagulant medication use. During interviews, the RN case manager and DON confirmed that anticoagulant therapy, the condom catheter, cardiac conditions, and pacemaker presence should have been addressed on the care plans and acknowledged that these items were not included.
Failure to Provide Scheduled Bathing and Grooming Assistance
Penalty
Summary
The facility failed to ensure that two residents who required assistance with activities of daily living received routine bathing and grooming services needed to maintain personal hygiene and dignity. R2’s MDS identified intact cognition and a need for ADL assistance, and the care plan directed staff to assist with dressing, grooming, bathing, and oral care while honoring personal hygiene preferences. R21’s MDS also identified intact cognition and a need for ADL assistance, and the care plan directed staff to assist with dressing, grooming, bathing, and oral care. R2’s bathing record showed a weekly bathing schedule, but the documentation did not show bathing was completed every week as scheduled. Baths were documented on several dates, but the time between some baths exceeded one week, and the record did not show additional refusals or reasons why scheduled baths were missed. During observation, R2’s hair was messy and greasy, and long white chin hairs were present. R2 stated she did not get baths very often because the facility was short staffed and said she did not have access to tweezers, a shaver, or a mirror. The EMR did not document that grooming assistance had been offered or provided for facial hair care. R21’s bathing record also showed a weekly bathing schedule, but the documentation did not show bathing was completed every week as scheduled. The record showed one refusal and several baths, but some intervals between baths exceeded one week, and there was no documentation of additional refusals or reasons for missed baths. R21 stated she had been in the facility since mid-April and had yet to have a bath or shower, and said staff were waiting for physician approval because of wounds, though that had been a while. R21 also stated she had only had her hair washed once with a shampoo shower cap while in bed. Staff interviews confirmed residents were expected to receive at least one bath weekly unless they refused, refusals should be documented, and facial hair should be addressed when noticed.
Missing Orders and Documentation for Condom Catheter Drainage Bag Care
Penalty
Summary
The facility failed to ensure appropriate care and services were provided for management of a resident’s external urinary catheter system. The resident had intact cognition and required assistance with ADLs, and diagnoses included atrial fibrillation, heart failure, BPH, stroke, malnutrition, anxiety disorder, and depression. Physician orders dated 4/29/26 indicated use of a condom catheter at bedtime, but the electronic medical record did not contain physician orders or documented instructions for cleaning, disinfecting, monitoring, or routinely changing the associated catheter drainage bag. During observation on 5/19/26 at 11:57 a.m., the resident’s catheter drainage bag was seen hanging on the side rail in the bathroom. Record review and observation did not identify documentation that the drainage bag was routinely cleaned, disinfected, monitored, or replaced according to accepted standards of practice. An LPN confirmed there were no physician orders addressing when the drainage bag should be changed or instructions for cleaning or disinfecting it. An RN case manager stated the drainage bag should have been changed weekly, but no orders related to changing, cleaning, or disinfecting were present. The DON stated the facility expected clear physician orders and nursing instructions for catheter care, cleaning, monitoring, and replacement schedules, and confirmed the facility could not provide evidence that such orders or guidance were in place for the resident’s condom catheter drainage bag care.
Failure to Preserve Dignity by Placing a Brief on a Continent Resident
Penalty
Summary
The facility failed to provide services in a dignified manner for 1 resident who was cognitively intact and had diagnoses including renal insufficiency, DM, and hypertension. The resident’s MDS identified him as continent of bowel and bladder and needing staff assistance with ADLs including bed mobility, transfers, and toileting. A bowel and bladder assessment also identified the resident as continent, and the care plan stated he was aware of the need to void or defecate and would request to use the toilet as needed. During interview, the resident stated staff put diapers on him even though he was not incontinent and said it made him feel like a baby. During observation, a NA placed a brief on the resident, and the resident showed the surveyor the brief and stated it had just been put on him a few minutes earlier. The NA verified she placed a brief on the resident that morning even though he was not incontinent and said she was unsure why she did so. RN-A confirmed the resident was continent and stated staff put a brief on him out of habit. The DON stated staff should not place a brief on residents who are continent and that it was important to maintain the resident’s dignity.
Failure to Provide Restorative Ambulation and Address Decline in Mobility
Penalty
Summary
The facility failed to provide restorative ambulation services and failed to respond to a decline in ambulation status for one resident who had mild cognitive impairment, dementia, hypertension, diabetes, weakness, and chronic pain. The resident’s care plan and restorative documentation directed daily ambulation with a front wheeled walker and staff assistance of one, and the resident was also identified as having limited physical mobility and being at risk for falls due to weakness, chronic pain, and an unsteadied gait and balance. However, the nursing rehab point-of-care record repeatedly documented ambulation as “not applicable,” with only one entry showing the resident ambulated for 15 minutes and one entry showing refusal. The resident stated she could no longer walk and that staff needed to help her get into bed and her wheelchair. Staff interviews confirmed the ambulation task was not being completed. A nursing assistant stated aides were responsible for ambulation but were not completing it, and another nursing assistant stated ambulation was supposed to be done but was not done very often; that staff documented it as not applicable when it did not get done; and that the resident had not walked at all for several weeks and was using a sit-to-stand lift with assist of two for all transfers. An RN stated the task just did not get done and that no plan had been created to fix it. The DON stated the resident’s condition had changed and a therapy evaluation should have been requested, and also stated the care plan needed revision because the resident would not be transferred with an assist of one. The resident’s medical record lacked an assessment for ADL decline, including any revision to the ambulation care plan.
Failure to Complete and Document Restorative ROM and Splinting
Penalty
Summary
The facility failed to ensure range of motion (ROM) was completed in accordance with therapy recommendations to maintain mobility for one resident with mild cognitive impairment who was dependent on staff for all care areas and had diagnoses including diabetes, hemiplegia, and hemiparesis. The resident’s care plan identified limited physical mobility, fall risk, weakness, contractures, and limited ROM, and included restorative nursing interventions for bilateral lower extremity passive ROM to active ROM, passive hamstring and heel cord stretches, PROM to both hands, and splint use for the hands. The resident’s restorative documentation from 4/20/26 through 5/19/26 showed the hand splints were worn 41 times and marked not applicable 20 times out of 90 opportunities, but the documentation did not identify refusals to wear the splints. The leg stretches were completed 3 times out of 30 opportunities, and the documentation did not identify why the stretches were not performed or whether they were refused. The resident’s untitled nurse aide care sheet also identified a restorative program and encouragement to participate in the Well Fit program. During interviews, a nursing assistant stated staff were supposed to encourage participation in the Well Fit program and complete PROM and AROM, but it did not get done very often and was often documented as not applicable because it was not offered. An RN stated nursing assistants were responsible for restorative programs but they did not get done, and no plan had been created to fix the issue. The DON stated staff should have offered the tasks and documented refusals, but believed staff may have stopped offering after repeated refusals; the DON also stated the restorative program needed to be updated and that staff were documenting tasks as not applicable, which she was unaware of.
Dirty can opener and contaminated dry storage bins
Penalty
Summary
The facility failed to keep 1 of 1 commercial can opener clean and sanitary and failed to store dry goods removed from original packaging in a manner that reduced the risk of cross-contamination. During an initial tour with the Director of Culinary Services (DCS), four white plastic bins in the food preparation area were observed on the floor and labeled for flour, white sugar, rice, and powdered sugar. The flour bin was about one-third full and had a black scoop partially covered with flour, including the handle. The bin labeled white sugar had yellowish-tan dry matter on the right lateral wall, and the front wall had red dry matter measuring 6-7 cm in diameter. The rims around the lids of all four bins were dirty with dark dust-like particles, and the DCS verified these findings and stated the scoop should not be left inside the bins and needed to be clean inside and out. The attached [NAME] brand can opener was also observed with its blade halfway covered with dry, red-colored matter. On a later kitchen tour, the can opener blade still had dry red matter, which had been pushed upward by 0.2 cm, and a small light amber particle was noted below it. The cook stated he had used the can opener that morning to open a can of cream of corn used for lunch. The DCS verified the dry matter on the can opener and stated it should be washed every time it was used to prevent cross contamination. Facility policy stated dry storage areas would be maintained to keep food safe and free of infestation or contamination, and the sample cleaning schedule stated can openers should be clean after each use.
Dignified Medication Administration Not Maintained
Penalty
Summary
The facility failed to provide a dignified experience for 1 of 2 residents, R20, during medication administration. R20’s records showed severely impaired cognition, inattention, disorganized thinking, verbal behaviors toward others, and diagnoses including severe dementia with psychotic disturbance, visual hallucinations, generalized anxiety disorder, PTSD, and delusional disorder. Her care plan identified mood, behavior, and sleep alterations related to Alzheimer’s disease, dementia, generalized anxiety disorder, paranoia, public outbursts, and accusations that people were throwing medications down her throat, and it directed staff to redirect and reapproach when she was resistive or combative, use a calm approach, provide reassurance, and offer comfort items. During observation, RN-A brought medications to R20 in the dining room and attempted to pour them from a small plastic cup into her mouth. When R20 removed one medication, Divalproex, and threw it on the floor, RN-A attempted again to pour the remaining medications into her mouth while R20 moved her head back and forth and tried to pull away. RN-A then raised her voice, stated the resident’s name, told her she needed to take her medications, pulled her chair back from the table, picked up the Divalproex from the floor, placed it in a separate cup, and asked why she would not take her medications. R20 responded that it was because the nurse was not being nice. RN-A then left with the remaining refused medications and stated R20 would take them later and that she always had a behavior when taking her morning medications.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
