Friendship Village Of Bloomington
Inspection history, citations, penalties and survey trends for this long-term care facility in Bloomington, Minnesota.
- Location
- 8130 Highwood Drive, Bloomington, Minnesota 55438
- CMS Provider Number
- 245229
- Inspections on file
- 17
- Latest survey
- May 7, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Friendship Village Of Bloomington during CMS and state inspections, most recent first.
Infection prevention and control practices were not followed during resident care and feeding. A nursing assistant fed two residents at the same time, repeatedly touched his face and eyeglasses, and resumed feeding without hand hygiene. Staff also stood and knelt on a resident’s mattress during transfers, and a resident’s room contained porous pool noodles taped to the bed and windowsill with dust and debris present. The IP, RN, and DON stated these practices did not meet infection control expectations.
A resident’s required annual MDS assessment was not completed on time. Review of the EMR showed the annual assessment was due after the prior quarterly MDS, but there was no evidence it was completed within the required timeframe. The MDS Coordinator/RN stated the facility used a monthly report and due-date schedule to track assessments, but acknowledged the resident fell through the cracks and the annual MDS appeared to have been missed.
A resident’s quarterly MDS failed to code use of a non-invasive ventilatory device, even though a BiPAP machine was observed at bedside and the resident stated staff assisted with it at night. The chart also included orders for CPAP/BiPAP use for OSA, and the MDS coordinator confirmed the assessment was coded incorrectly.
A facility failed to maintain comprehensive care plans for three residents. One resident had documented activity preferences and needs, but no active activities care plan was in place. Another resident used a BiPAP with staff assistance, yet the care plan did not include the device. A third resident had a suprapubic catheter, but the care plan did not identify the catheter or who was responsible for catheter care and bag changes.
Care plans and related care guides were not updated for a resident with pain, a resident with recurrent falls, and a resident with severe cognitive impairment and transfer needs. One resident’s plan lacked individualized nonpharmacological pain interventions, another resident’s plan omitted a motion sensor that staff were using for fall prevention, and a third resident’s plan and Kardex incorrectly stated the resident was independent with transfers despite staff using a transfer belt and Hoyer lift with two-person assistance.
A resident receiving hospice care had a right second toe wound that was not consistently documented in facility skin checks or the EHR, despite hospice wound care orders and hospice notes with detailed assessments. During observation, the DON and RN found an open draining toe wound, and staff stated they had not been notified by hospice for wound rounds. In a separate issue, another resident with significant unilateral left knee swelling had provider-documented pain, drainage, anticoagulation use, and a biopsy-confirmed hemangioma, but the care plan lacked monitoring for changes in the knee and staff were unsure what to track beyond pain.
A resident with severe cognitive impairment, dementia with behavioral disturbances, and fall risk interventions in place was transferred by staff using methods that did not match the care plan and Kardex. Staff used a transfer belt for some transfers, then later used a Hoyer lift from mattresses on the floor to a wheelchair, but used a green sling even though the resident required a yellow sling based on weight. The RN, LPN, DON, and PT verified the resident’s transfer status and sling instructions were not updated to reflect current needs.
A resident with a suprapubic catheter had incomplete orders and unclear care coordination. The care plan did not identify the SP catheter or who was responsible for catheter care and bag changes, and the MAR/TAR contained repeated orders to clarify catheter size without a documented size in the orders. Staff interviews showed uncertainty about the catheter size, who would change the catheter, and whether the listed contact number was available at all times.
A resident with intact cognition and a history of MS had a BiPAP machine at bedside, but the chart lacked resident-specific BiPAP orders, settings, and documentation of staff assistance, mask cleaning, or tubing/filter changes. Staff and the DON confirmed the resident used BiPAP and received help with the mask and machine, while the MAR, task log, care plan, and progress notes did not reflect that care.
Failure to address pharmacist recommendations for melatonin: A resident with moderately impaired cognition and diagnoses including DM, Alzheimer’s disease, and anxiety remained on 6 mg of melatonin at bedtime despite repeated pharmacist recommendations to taper and discontinue it. The provider declined the recommendations and deferred to psychiatry, but the psych note continued the medication without a documented rationale for not following the pharmacist’s advice; the resident also had a fall and was noted to be difficult to wake during a later psych eval.
A resident with severe cognitive impairment and multiple psychiatric diagnoses was prescribed Lexapro, a psychotropic medication, without documented informed consent from the resident or their representative. Staff interviews and facility policy confirmed that informed consent should have been obtained and documented prior to starting the medication, but no such documentation was found in the resident's record.
A resident with multiple risk factors for skin breakdown developed several wounds, including a stage 2 pressure ulcer, but staff failed to consistently assess, document, and report changes in the wounds. Nursing staff were unaware of the current wound status, the wound care team did not include the resident in weekly rounds, and the nurse practitioner was not informed of wound deterioration. Facility policies for prompt notification and evidence-based wound care were not followed.
Staff failed to consistently perform hand hygiene and follow enhanced barrier precautions during personal and wound care for a resident with complex medical needs, including a venous ulcer and indwelling catheter. Nursing assistants did not change gloves or perform hand hygiene when moving from dirty to clean tasks, and a nurse did not wear a gown or consistently perform hand hygiene between glove changes during wound care, contrary to facility policy.
A resident with severe cognitive impairment and a need for assistance with personal hygiene was not properly assisted with shaving, despite documentation indicating the task was completed daily. Observations showed the resident was unshaven for several days, and staff interviews confirmed the task was not performed as required by the care plan and facility policy.
The facility failed to thoroughly investigate injuries of unknown origin for four residents with suspicious bruises. The injuries were not witnessed, and the residents could not explain how they occurred. The facility did not conduct thorough investigations or document the incidents properly, leading to unverified rationales and a failure to implement corrective actions.
The facility failed to recognize and report injuries of unknown origin for four residents with suspicious bruises. Despite multiple staff members identifying the bruises as suspicious, they were not reported to the State Agency as required by the facility's policies.
The facility's administration failed to take timely and appropriate action to address injuries of unknown origin and bruises for four residents. Despite being informed, the DON and administrator did not report the injuries to the state agency, conduct thorough investigations, or implement preventive measures. The facility lacked a formal tool for investigating incidents, and responsibilities were unclear among staff members.
The facility failed to accurately identify a resident's status on the MDS assessment. Despite the resident displaying behaviors such as repetitive calling out and receiving Lorazepam for anxiety, the MDS did not reflect these behaviors. Documentation and interviews confirmed the discrepancy, highlighting a failure in accurately assessing and documenting the resident's behavioral symptoms.
The facility failed to consistently implement transfer interventions for a cognitively impaired resident and did not properly monitor and document bruising for two residents, leading to discrepancies in care and incomplete documentation.
The facility failed to properly assess and monitor bruises on multiple residents, leading to inconsistencies in documentation and lack of follow-up care. For one resident, the measurements and location of a bruise were inconsistent among different nursing staff, and there was no further investigation to determine the cause. Another resident had multiple bruises that were not properly documented or monitored, and the care plan was not revised to address risks. A third resident had a bruise that was not consistently assessed or monitored, and the facility lacked a policy for monitoring bruises.
The facility failed to provide timely assistance with repositioning for a resident with severe cognitive impairment and multiple diagnoses, leading to a risk of pressure ulcer development. The care plan directed repositioning every two hours while in bed but did not specify frequency while in a chair. Observations and staff interviews confirmed that the resident was not repositioned as required.
The facility failed to provide adequate supervision and appropriate transfer techniques for a resident with severe cognitive impairment, resulting in a significant bruise. Another resident at high risk of falls experienced multiple falls due to an unlocked wheelchair, with inconsistent use of an anti-rollback device. The facility's failure to adhere to care plans and ensure proper transfer methods led to injuries and potential harm.
A resident with severe cognitive impairment and multiple diagnoses did not receive timely incontinence care as per their care plan, resulting in a period of four hours and thirty minutes without assistance. Staff interviews confirmed the resident should have been assisted every 2-3 hours.
The facility failed to provide nonpharmacological interventions before administering as-needed antianxiety medications to a resident with severe cognitive impairment and multiple diagnoses. The care plan and clinical records lacked documentation of such interventions, and staff did not consistently implement or document them, despite the resident frequently calling out and displaying distress.
The facility failed to notify the Office of Ombudsman for Long-Term Care (OOLTC) of facility-initiated transfers for 12 residents who had been hospitalized. The deficiency was identified through an email correspondence with the OOLTC, which indicated that the facility had not completed monthly reporting of transfers and discharges as required. Interviews with the director of health center sales and services (DHCSS) and the administrator confirmed that the notifications had not been sent and that the facility policy did not include a timeframe for reporting emergency transfers to the OOLTC monthly or within 30 days prior to the discharge or as soon as practicable.
Infection prevention and control practices were not followed during feeding, transfers, and cleaning of resident care items
Penalty
Summary
The facility failed to ensure staff followed infection prevention and control practices during resident care and feeding. During observation, a nursing assistant assisted two residents with eating at the same time, repeatedly touched his face and eyes, scratched his face, touched the counter, obtained straws, moved a wheelchair, and continued feeding both residents without performing hand hygiene. He also cleaned his eyeglasses at the dining table with a disposable wipe and then resumed feeding without hand hygiene. The Infection Preventionist stated staff should perform proper hand hygiene, prevent cross contamination, and should not feed more than one resident at a time because it created a significant contamination risk. The facility also failed to maintain a clean resident care environment when staff stood on a resident’s mattress during transfers. R6’s quarterly MDS identified severe cognitive impairment, delusions, behaviors directed at others, and diagnoses including dementia with behavioral disturbances, anxiety, affective disorder, diabetes, and hearing loss. During observations, nursing assistants transferred R6 between a wheelchair, toilet, and a bed made of two twin mattresses on the floor. Staff stepped onto and knelt on the mattresses while assisting with transfers and positioning a Hoyer sling, and one aide stated she did not know another way to help without stepping on the mattresses. RN-A and the DON stated staff should not have feet on the mattress due to infection control. The facility further failed to ensure resident care items were cleanable and disinfected for R1. R1’s quarterly MDS identified severely impaired cognition and diagnoses of cancer, kidney disease, and respiratory failure, with dependence for activities of daily living. In R1’s room, pool noodles with slits cut down one side were taped to the windowsill, headboard, and footboard, with curling tape, brown/black matter under the edges, and dust on the surfaces. The Infection Preventionist stated the pool noodles were wiped with disinfectant and left wet for the recommended contact time even though they were porous and not a cleanable hard surface. The housekeeper stated she used a bleach solution on the noodles but did not saturate them and left the solution on for less than a minute.
Missed Annual MDS Assessment
Penalty
Summary
The facility failed to ensure timely completion of a required annual MDS assessment for one resident, R7. R7’s most recent MDS was a quarterly assessment dated [DATE], and based on the assessment schedule, an annual MDS was required after the 12/2/25 quarterly assessment. Review of R7’s EMR and MDS records showed no evidence that the annual assessment was completed within the federally required timeframe. During interview, the MDS Coordinator and RN-B stated that the EMR system generated a monthly report on the 15th to track upcoming MDS assessments and that a schedule with due dates was then completed for nursing staff to gather data and identify ARDs. RN-B stated he was unsure how R7 fell through the cracks, acknowledged that the annual assessment appeared to have been missed, and said he would complete it immediately.
MDS Incorrectly Omitted BiPAP Use
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessment for one resident who used a non-invasive ventilatory device. The resident’s quarterly MDS dated [DATE] identified intact cognition with no hallucinations or delusions, but in Section O, the item for non-invasive mechanical ventilator use, including BiPAP and CPAP, was not checked, and Section Z1, “none of the above,” was marked instead. During observation, a BiPAP machine was seen on the resident’s bedside table with a gallon of water next to it, and the resident stated staff assisted with the machine at night. The resident later stated she had previously used CPAP and had been changed to BiPAP. The medical record included an order to resume CPAP with home settings and an after-visit summary documenting BiPAP home use with specified pressure settings for obstructive sleep apnea. An LPN stated staff assisted the resident with a CPAP machine, and the MDS coordinator confirmed the quarterly MDS was coded incorrectly because the resident did use a non-invasive ventilatory device.
Incomplete Care Plans for Activity Needs, BiPAP Use, and Catheter Care
Penalty
Summary
The facility failed to ensure comprehensive care plans were developed and maintained for three residents reviewed for care planning. For one resident, a significant change MDS showed severe cognitive impairment and extensive to total assistance for all ADLs, along with preferences for books, newspapers, music, animals, news, groups of people, going outside, and religious services. An activity assessment also documented preferences for individual and group leisure, outings, worship services, nature, prayer, modern music, games, reading, group discussions, news, social activities, and connecting with team members, but the resident’s care plan did not include activity goals, participation, or interventions to address those needs. An activities lead confirmed the resident did not have an active activities care plan, and the administrator stated residents would be expected to have one. For another resident, the quarterly MDS identified intact cognition and use of a BiPAP machine was observed at the bedside with water next to it. The resident stated staff assisted with putting the mask on and off and turning the machine on and off at night. Nursing staff confirmed assistance was provided with the mask, machine, and water chamber, and that the water chamber should be filled weekly with mask and tubing changes documented on the MAR. However, the resident’s care plan addressed ADL deficits related to multiple sclerosis and impaired balance, but did not include any evidence that the resident required or used a BiPAP machine. The RN manager and DON both verified that BiPAP use should have been included on the care plan. For the third resident, the admission MDS identified intact cognition and an indwelling catheter. The resident stated he had a catheter prior to admission and that it had been changed to a suprapubic catheter because of infections, and he verified staff assisted with catheter care. The care plan addressed bladder incontinence with brief use, peri-care, scheduled checks, and monitoring for UTI signs, but did not identify the suprapubic catheter or specify who was responsible for catheter care and changing the catheter bag. The RN manager and DON both stated that catheter information should have been included on the care plan for coordination of care.
Care plans not updated for pain interventions, fall precautions, and transfer needs
Penalty
Summary
The facility failed to update care plans and related care guides to reflect current, individualized interventions for three residents. For one resident with quadriplegia related to a spinal injury and ongoing pain, the admission MDS showed intact cognition, scheduled pain medication, and no non-medication pain interventions. The resident stated he had a lot of pain and had been seen by a pain doctor, but the care plan only listed general pain management and comfort measures without identifying the resident’s preferences for nonpharmacological interventions or documenting whether any had been attempted, effective, ineffective, or preferred. The MAR/TAR and progress notes also lacked identification of nonpharmacological pain interventions. For another resident with moderately impaired cognition and a history of multiple falls, the quarterly MDS documented two or more falls with no injury and one fall with nonmajor injury. The care plan included several fall precautions such as frequent safety checks, a low bed, a floor mat, and non-slip footwear, but it did not include the motion sensor with automated auditory reminders that staff were using. Staff observed the resident with the motion sensor in place, and nursing staff stated the device had been used since after a fall in November 2025. The care plan did not identify when the motion sensor should be used or what adverse effects should be monitored. For a third resident with severe cognitive impairment, delusions, behavioral symptoms, and diagnoses including dementia with behavioral disturbances, anxiety, affective disorder, diabetes, and hearing loss, the care plan and Kardex stated the resident was independent with transfers. However, staff observed the resident being transferred with a transfer belt, requiring assistance from two nursing assistants, and later being moved to and from twin mattresses placed on the floor using a Hoyer lift with two staff. Staff confirmed the resident was not independent with transfers and that the care plan and Kardex had not been revised to reflect the resident’s current transfer ability or the use of the Hoyer lift and mattresses on the floor.
Failure to Coordinate Hospice Skin Monitoring and Monitor Knee Swelling
Penalty
Summary
The facility failed to develop and/or implement a process to coordinate with hospice and ensure skin was accurately evaluated and monitored for a resident receiving hospice services who had severe cognitive impairment, arthritis, heart failure, and malnutrition. The resident’s care plan addressed an open coccyx area, a left lower extremity skin tear, and a bruise to the left shin, but did not include the right second toe wound. Although hospice reported redness on the toe and wound care orders were entered, facility skin checks and non-hospice EHR assessments did not document the toe wound, and a comprehensive assessment of the wound was not found in the resident’s EHR or hospice communication notes. The resident’s medication and treatment records showed wound care orders for the right second toe that changed over time, and the hard chart contained hospice interdisciplinary group meeting notes with detailed wound assessments on multiple dates. However, an assessment for one of the later dates was not found, and facility staff were unable to locate documentation of the wound in the EHR during interview. During observation, the resident’s right second toe dressing was removed and an open red wound with drainage and elevated, shiny edges was seen. The RN stated the wound appeared infected and that it was not being seen during wound rounds because hospice had not notified the facility. The facility also failed to ensure comprehensive monitoring was developed and completed for a resident with extensive unilateral left knee swelling. The resident had diagnoses including heart failure and asthma, and provider notes documented increased pain and swelling, prior drainage of fluid from the knee, recurrent steroid injections, anticoagulation use, and later a biopsy-confirmed hemangioma with surgery planned. Before survey entrance, the care plan did not include monitoring for increase in size, discoloration, or other changes to the left knee, and staff interviews showed uncertainty about what should be monitored beyond pain. During observation, the left knee was notably larger than the right knee, and the resident stated it had been swollen for a while and had been drained.
Failure to Follow Transfer and Sling Size Interventions
Penalty
Summary
The facility failed to ensure staff followed fall risk interventions for one resident identified as at risk for falls. The resident had severe cognitive impairment, delusions, behaviors directed at others, dementia with behavioral disturbances, anxiety, an affective disorder, diabetes, and hearing loss. The resident’s care plan and Kardex identified the resident as a fall risk and stated the resident was independent for transfers, while also noting that if a Hoyer transfer was required, a yellow/medium sling was to be used. During observation, nursing assistants transferred the resident from a wheelchair to the toilet using a transfer belt, then later transferred the resident from the wheelchair to mattresses on the floor using a transfer belt and two staff members. Staff stated they normally used a Hoyer lift to lift the resident from the mattresses on the floor, but the resident’s Kardex did not identify the mattresses on the floor or clarify when a Hoyer should be used for transfers. Staff also stated the resident was not independent with transfers and required one to two staff for wheelchair-to-toilet transfers and two staff with a Hoyer for transfers to and from the mattresses on the floor. On a later observation, two nursing assistants used a Hoyer lift to transfer the resident from the mattresses on the floor to a wheelchair, but used a green sling even though the resident weighed 155 pounds and the manufacturer’s chart indicated a yellow sling was required. Staff stated the green sling was too big for the resident and that the correct sling size was important for safety. The RN, LPN, DON, and PT all verified that the resident’s care plan and Kardex were not revised to reflect the resident’s current transfer abilities and the correct sling size and transfer method for the resident’s current setup.
Incomplete Suprapubic Catheter Orders and Care Coordination
Penalty
Summary
The facility failed to ensure proper orders were obtained and adequate coordination was in place for a resident with a suprapubic catheter. The resident’s admission MDS identified intact cognition and an indwelling catheter. During interview, the resident stated he had a catheter before admission and that it was changed to a suprapubic catheter after moving to the facility because of infections. The resident also stated staff assisted with the catheter. The resident’s care plan addressed bladder incontinence and included brief use, perineal care, incontinence checks, and monitoring for signs and symptoms of UTI, but it did not identify that the resident had a suprapubic catheter or who was responsible for catheter care and changing the drainage bag. The MAR/TAR contained multiple catheter-related orders, including orders to clarify catheter size, change the drainage bag and tubing, clean around the suprapubic catheter exit site, monitor for leakage and infection, and flush the catheter if not draining properly. Several of these orders were left blank on some shifts or days, and the record showed repeated orders to clarify the catheter size without a documented size in the orders. Progress notes showed catheter-related documentation, including a resident refusal of catheter care, a successful suprapubic catheter exchange at the urologist office, and later documentation that the catheter was patent and sized at 16 fr. Staff interviews showed uncertainty about the current catheter size, whether the facility was responsible for catheter changes, and whether the contact number listed for catheter problems was available 24 hours a day. The DON stated orders should include the catheter size and clear responsibility for catheter changes in case of emergency, and the facility policy titled Indwelling Catheter Use and Removal did not address suprapubic catheters.
Incomplete BiPAP Orders and Documentation
Penalty
Summary
The facility failed to ensure accurate orders, complete respiratory care documentation, and resident-specific settings for a BiPAP device for a resident with intact cognition and a history of multiple sclerosis and impaired balance. The resident’s quarterly MDS did not indicate use of a non-invasive mechanical ventilator, and the care plan lacked evidence that the resident required or used a BiPAP machine. The resident’s order summary also lacked orders for BiPAP use, specific settings, when to use the device, cleaning of the mask and machine, and tubing or filter changes. Although a BiPAP machine was observed at the resident’s bedside and the resident stated staff assisted with the machine at night, the MAR, task log, and progress notes lacked documentation of BiPAP use, assistance with the mask, cleaning, or equipment changes. The resident’s after-visit summary included BiPAP settings for home use, but the facility’s current orders reflected CPAP with home settings and did not include BiPAP settings. Interviews with nursing staff, the RN manager, the DON, and clinic staff confirmed the resident used a BiPAP machine and that staff were assisting with it, but the record did not show monitoring or documentation of those activities.
Failure to Address Pharmacist Recommendations for Melatonin
Penalty
Summary
The facility failed to ensure that the consulting pharmacist’s recommendations from the monthly drug regimen review were fully addressed for one resident with moderately impaired cognition who had diagnoses of diabetes, Alzheimer’s disease, and anxiety. The resident had been receiving 6 mg of melatonin at bedtime since 7/21/23 for insomnia. In the pharmacist’s 11/5/25 consultation report, melatonin was identified as not recommended for sleep onset or sleep maintenance insomnia in adults, with adverse reactions including confusion, daytime drowsiness, dizziness, vivid dreams or nightmares, and increased bed wetting. The pharmacist recommended tapering the melatonin to 3 mg at bedtime for seven days and then discontinuing it, but the provider signed the report on 11/10/25 and declined the recommendation with a handwritten rationale stating the need to review with psychiatry. A second pharmacist consultation report dated 12/2/25 again noted the resident was receiving 6 mg of melatonin at bedtime and had experienced a fall on 11/22/25. The pharmacist again recommended discontinuing melatonin, but the provider signed on 12/11/25 and declined the recommendation, writing that psychiatry was following. A psychiatric evaluation note dated 1/12/26 documented the resident lying in bed sleeping and being difficult to wake, with the note stating to continue melatonin 6 mg at bedtime but without a rationale for not following the pharmacist’s recommendation. During interviews, the consultant pharmacist stated he believed the psychiatry note was a response to his recommendation, and the DON stated she did not believe the medical director had been notified regarding the melatonin recommendations.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to inform a resident or their representative in advance and obtain consent for the use of a psychotropic medication, specifically Escitalopram Oxalate (Lexapro). The resident in question had severe cognitive impairment, a history of depression, Alzheimer's, dementia, and hallucinations, and was taking both antipsychotic and antidepressant medications. The care plan and medication administration record documented the use of Lexapro for anxiety and related symptoms, with the medication originally started several months prior to the review. Upon review of the resident's electronic medical record, there was no evidence of informed consent for Lexapro. Interviews with facility staff, including an LPN, the DON, and the consultant pharmacist, confirmed that informed consent should have been obtained and documented prior to starting the psychotropic medication. The facility's own policy required that residents or their representatives be informed of the recommendation, risks, benefits, purpose, and potential adverse consequences of antipsychotic medication use, but this process was not followed in this case.
Failure to Accurately Assess and Report Wound Deterioration
Penalty
Summary
The facility failed to ensure that wounds were accurately assessed and reported for a resident with multiple risk factors, including severe cognitive impairment, immobility, incontinence, diabetes, congestive heart failure, and kidney disease. The resident was identified as being at moderate risk for pressure ulcers and had a care plan instructing staff to monitor, document, and report any changes in skin status. Despite this, documentation showed inconsistencies and a lack of clarity regarding the identification, assessment, and monitoring of wounds, including a stage 2 pressure ulcer and other skin issues such as bruising, skin tears, and abrasions. Observations and interviews revealed that staff were not consistently aware of the resident's current wound status, with some staff unable to explain missing dressings or the duration of open wounds. Nursing staff admitted to not having recently assessed the resident's wounds and were unaware of open areas, while the wound care team had not included the resident in weekly rounds or provided documentation of wound assessments. The treatment administration record lacked evidence of updated or discontinued wound care orders for the resident's ongoing skin issues. Further, the nurse practitioner was not notified of changes or deterioration in the resident's wounds, and the director of nursing was unaware of open areas that required attention. Facility policies required prompt notification of changes in a resident's condition and evidence-based wound care practices, but these were not followed, resulting in a failure to provide appropriate treatment and care according to orders, resident preferences, and goals.
Failure to Perform Hand Hygiene and Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to ensure proper hand hygiene and adherence to enhanced barrier precautions (EBP) during personal and wound care for a resident with significant medical needs. During personal care, two nursing assistants wore gowns and gloves but did not change gloves or perform hand hygiene when moving from dirty to clean areas, such as after cleansing the peri-area and before assisting with other tasks. One assistant applied cream and handled linens with the same gloves, and after removing gloves, donned new gloves without performing hand hygiene. The resident was only given a washcloth to wash his own hands at the end of care. During wound care, a registered nurse did not wear a gown as required for EBP and inconsistently performed hand hygiene between glove changes. The nurse handled wound dressings, performed wound cleansing, and assisted the resident with personal items such as a water pitcher, all while wearing the same gloves. At one point, the nurse picked up a dressing that had fallen on the floor and continued care without changing gloves. Hand hygiene was not performed between all glove changes, and the nurse acknowledged missing these steps during an interview. The resident involved had a history of kidney failure, hypertension, depression, chronic pain, an indwelling urinary catheter, and a venous ulcer. The care plan specified the need for EBP and extensive assistance with personal hygiene due to limited mobility and a left leg amputation. Facility policy required hand hygiene before and after resident contact, between glove changes, and the use of appropriate PPE for residents on EBP, but these protocols were not consistently followed during the observed care events.
Failure to Provide Required Assistance with Grooming for Cognitively Impaired Resident
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment, Alzheimer's disease, dementia, and impaired balance was not assisted with shaving as required by his care plan and personal preferences. The resident's care plan and Kardex both indicated the need for staff assistance with personal hygiene, including shaving, and instructed staff to maintain a consistent routine. Documentation in the resident's task sheets and treatment administration record (TAR) showed that staff had marked the shaving task as completed daily, despite observations on two consecutive days revealing the resident had several days' growth of facial hair and was not clean shaven. Interviews with nursing staff and the director of nursing confirmed that nursing assistants were responsible for assisting with shaving and that tasks should only be signed off as completed if actually performed. Staff could not explain why the task was documented as completed when it had not been done, and there was no documentation of care refusal or other reasons for the omission. Facility policy required that residents unable to perform activities of daily living independently receive necessary services to maintain good grooming and personal hygiene.
Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate injuries of unknown origin for four residents who had suspicious bruises. These residents included one with mild cognitive impairment and dementia, another with severe cognitive impairment and Parkinson's disease, a third with severe cognitive impairment and Alzheimer's disease, and a fourth with severe cognitive impairment and dementia. The injuries were not witnessed, and the residents could not explain how they occurred. The facility's failure to investigate these injuries constituted an immediate jeopardy situation, which began when the first resident was identified with a bruise on the inner thigh and continued as additional residents were found with unexplained bruises on their face, calf, and wrist. For each resident, the facility did not conduct a thorough investigation to determine the root cause of the injuries. For example, one resident was found with multiple bruises after a fall, but no investigation was done to rule out the cause. Another resident had a large facial bruise, but the facility did not interview staff or investigate the possibility of abuse. Similarly, a resident with a wrist bruise and another with a calf bruise did not have their injuries thoroughly investigated, and the facility did not use a formal tool to document or analyze the incidents. The facility's policies required a thorough investigation of injuries of unknown origin, including reviewing documentation, interviewing staff and residents, and observing interactions. However, these steps were not followed, and the facility did not document the investigations properly. The lack of thorough investigations and documentation led to unverified rationales for the injuries and a failure to implement corrective actions to protect residents from further harm. The immediate jeopardy was removed after the facility took corrective actions, but non-compliance remained at a lower scope and severity level.
Removal Plan
- Conducted interviews with all interviewable residents regarding their perception of safety in the facility
- Completed a physical assessment of all residents to identify any injuries of unknown origin
- Nursing leadership, including the facility unit managers, DON and administrator, were educated on investigating injuries of unknown origin by the facility's regional director of health services
- Reviewed the facility's policy regarding injuries of unknown source
- Educated all staff on identification of injuries of unknown source
- Administrator will monitor compliance to ensure complete investigation practices are followed
- Administrator will complete an audit of incidents of unknown source or bruising
- Any identified concerns will be addressed
- If trends or patterns are identified, the facility will conduct an ad-hoc Quality Assurance and Performance Improvement meeting to address any additional interventions needed to ensure compliance
Failure to Report Injuries of Unknown Origin
Penalty
Summary
The facility failed to recognize and report injuries of unknown origin to the administrator and/or the State Agency (SA) for four residents with suspicious bruises. Resident 18 was observed with a large bruise on the left side of the chin and neck area, which was not reported to the SA despite being identified as suspicious by multiple staff members. The facility's investigation concluded that the bruise was likely due to dental issues or the resident's habitual head positioning, but this was not verified, and the injury was not reported to the SA as required. Resident 57 was found with a bruise on the left wrist, which was not reported to the SA. The bruise was initially assessed by an LPN who did not find it suspicious, but a nursing assistant later described the bruise as looking like thumb marks. Despite this, the bruise was not reported to the SA, and the facility's incident report did not identify the bruise as suspicious. The DON confirmed that such a description should have prompted a report to the SA. Resident 30 had a bruise on the left lower extremity, which was not reported to the SA. The bruise was believed to be caused by the resident kicking or bumping into something, but there was no incident report to support this. Similarly, Resident 46 was found with multiple bruises after a fall, but the cause of the bruises was unknown, and they were not reported to the SA. The facility's policies directed staff to report injuries of unknown origin immediately, but this was not followed in these cases.
Failure to Address Injuries of Unknown Origin
Penalty
Summary
The facility's administration failed to take timely and appropriate action to address injuries of unknown origin and bruises for four residents. For Resident 18, a facial bruise was reported by a nursing assistant and confirmed by a registered nurse. Despite the Director of Nursing (DON) and the administrator being informed, the incident was not reported to the state agency, and no thorough investigation or preventive measures were taken. The DON did not assess the resident, and the facility lacked a formal tool for investigating the root causes of incidents. Resident 30's progress notes revealed a bruise on the left calf and foot, reported by the resident's daughter and confirmed by a nurse. The DON and administrator were notified, but the injury was not reported to the state agency, and no thorough investigation or preventive actions were implemented. Similarly, Resident 46 was found on the floor with multiple bruises, and although the DON and administrator were aware, the facility failed to report the injury to the state agency and did not conduct a thorough investigation or take preventive measures. Resident 57 sustained a bruise around the left wrist, which was reported by a nurse's aide and assessed by a nurse manager. The DON and administrator were informed, but the injury was not reported to the state agency, and no thorough investigation or preventive actions were taken. The facility's process for identifying, reporting, and investigating injuries of unknown origin was inadequate, with no formal tool or process in place, and responsibilities were unclear among staff members.
Inaccurate MDS Assessment for Resident with Behavioral Symptoms
Penalty
Summary
The facility failed to ensure the resident status was accurately identified on the Minimum Data Set (MDS) assessment for one resident (R18) reviewed for behaviors. R18, who had moderate cognitive impairment and diagnoses including dementia, Parkinson's disease, and anxiety disorder, was noted to have received Lorazepam for anxiety. Despite the care plan indicating behaviors such as pulling hair, biting nails, and yelling out, the MDS assessment did not reflect any behaviors during the seven-day look-back period. Documentation in the progress notes and interviews with staff and family members confirmed that R18 frequently called out repetitive phrases and displayed behaviors that required intervention, which were not accurately captured in the MDS assessment. Observations and interviews revealed that R18 repeatedly called out phrases like 'Please help me, I am stuck,' and staff responded by offering comfort measures and administering Lorazepam as needed. However, the Behavior Monitoring and Intervention Reports did not document these behaviors, leading to an inaccurate MDS assessment. The facility's MDS coordinator and licensed social workers acknowledged the discrepancy, confirming that the MDS did not accurately reflect R18's behaviors during the look-back period. The administrator verified that the MDS should be completed according to CMS instructions, highlighting a failure in accurately assessing and documenting the resident's behavioral symptoms.
Failure to Implement Transfer and Bruising Interventions
Penalty
Summary
The facility failed to ensure transfer interventions were consistently implemented for a resident with severe cognitive impairment and multiple diagnoses, including dementia and Parkinson's disease. The resident's care plan required extensive assistance of two staff members for transfers. However, observations revealed that staff members frequently transferred the resident without using a gait belt or the assistance of a second staff member, contrary to the care plan directives. Interviews with staff confirmed these deviations from the care plan, with some staff members stating they believed the resident was light enough to transfer alone without a gait belt. Additionally, the facility failed to implement interventions for monitoring and documenting bruising for two residents. One resident, who was on anticoagulant therapy, had a bruise identified by a family member, but the facility did not document the bruise's width or color, nor did they monitor and document the bruise until it resolved. Another resident with fragile skin had multiple bruises documented, but the facility failed to record the color of the bruises, and the size of the bruises remained unchanged over several weeks without resolution. Interviews with staff and review of care plans revealed discrepancies in the implementation of care directives, including the use of gait belts and the number of staff required for transfers. The facility's documentation practices for monitoring and documenting bruises were also found to be inconsistent and incomplete, failing to adhere to the care plans established for the residents. These deficiencies were confirmed through observations, interviews, and record reviews conducted by the surveyors.
Failure to Properly Assess and Monitor Resident Bruises
Penalty
Summary
The facility failed to properly assess and monitor bruises on multiple residents, leading to inconsistencies in documentation and lack of follow-up care. For Resident 30, a bruise was noted on the left lower extremity, but the measurements and location of the bruise were inconsistent among different nursing staff. There was no further investigation to determine the cause of the bruise, and the facility failed to monitor the bruise over time, making it unclear when the bruise resolved. Additionally, the care plan related to anticoagulant therapy required monitoring and documenting bruising, which was not adequately followed. Resident 46 was found with multiple bruises on the right forearm, lower arm, anterior elbow, and medial thigh. The color of the bruises was not documented, and the size of the bruises remained the same over time without resolving. The facility did not revise the care plan to address the risks associated with the use of a Hoyer lift sling, which was suspected to cause some of the bruises. The facility also failed to monitor and document the bruises consistently, leading to a lack of clarity on the resident's condition. Resident 18 had a bruise on the left side of the chin and neck area, but the facility did not continue to assess and monitor the bruise for healing, worsening, or pain. The care plan required monitoring and documenting the location, size, and treatment of skin injuries, but this was not followed. The facility's internal incident report suggested possible causes for the bruise, but there was no routine monitoring or assessment documented. The facility did not have a policy for monitoring resident bruises, leading to inconsistent care and documentation.
Failure to Provide Timely Repositioning for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to provide timely assistance with repositioning to minimize the development of pressure ulcer risk for a resident with severe cognitive impairment and multiple diagnoses, including dementia, Parkinson's disease, and anxiety disorder. The resident's care plan directed staff to reposition the resident every two hours while in bed, but did not specify the frequency for repositioning while in a chair. Observations revealed that the resident was seated in a Broda chair for over four hours without being repositioned, contrary to the care plan's directives. Interviews with staff confirmed that the resident had not been repositioned as required during this period. The resident's skin was observed to be bright pink and blanchable, indicating adequate blood perfusion, but the lack of timely repositioning posed a risk for pressure ulcer development. The facility's wound care policy did not provide specific guidance on the frequency of repositioning for dependent residents, contributing to the deficiency. The administrator and staff acknowledged that repositioning should be done in accordance with the care plan, but this was not consistently implemented, leading to the observed deficiency.
Inadequate Supervision and Transfer Techniques Lead to Resident Injuries
Penalty
Summary
The facility failed to provide adequate supervision and appropriate transfer techniques for a resident (R18) with severe cognitive impairment and multiple diagnoses, including dementia and Parkinson's disease. Despite the care plan directing staff to provide extensive assistance of two staff members for transfers, observations revealed that a nursing assistant (NA-A) transferred R18 alone without using a gait belt. This inappropriate transfer method was confirmed by multiple staff members, including a registered nurse (RN-A) and a licensed practical nurse (LPN-A), who acknowledged that the care plan was not followed. Additionally, the facility did not conduct a comprehensive transfer assessment for R18, and the origin of a significant bruise on R18's chin remained undetermined despite an investigation and nurse practitioner assessment ruling out dental issues as the cause. The facility's director of nursing (DON) admitted that discrepancies in transfer styles among staff could have contributed to the injury and that the facility would have approached the investigation differently if they had been aware of these discrepancies earlier. Another resident (R46) was identified as being at high risk of falls and had a care plan in place for fall prevention, which included reminders to lock the wheelchair when completing activities of daily living (ADLs) independently. Despite this, R46 experienced multiple falls due to an unlocked wheelchair. On one occasion, R46 was found on the floor after attempting to self-transfer, and the wheelchair was found unlocked. The facility staff documented reminders to lock the wheelchair but did not implement additional preventative measures until an anti-rollback device was installed. However, observations revealed that the anti-rollback device was not consistently used, and R46 continued to use a wheelchair without the device, leading to further falls and injuries. The facility's failure to adhere to individualized care plans and ensure consistent use of assistive devices and proper transfer techniques resulted in injuries and potential harm to residents. The discrepancies in staff practices and lack of comprehensive assessments and investigations highlight significant deficiencies in the facility's supervision and care provision. The DON acknowledged the potential for personal injury due to improper transfer methods and the need for consistent adherence to care plans to prevent accidents and injuries.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely assistance with incontinence care for a resident (R18) who was identified with severe cognitive impairment and diagnoses including dementia, Parkinson's disease, and anxiety disorder. The resident was dependent on staff for toileting hygiene, frequently incontinent of bowel and bladder, and required substantial assistance with transfers. The care plan directed staff to check the resident every two hours and assist with toileting as needed. However, observations on the specified date revealed that the resident was not assisted with toileting for a period of four hours and thirty minutes, contrary to the care plan directives. During the observation period, the resident was seen in various locations within the facility, including the dining room, her room, and the activity room, without receiving the required incontinence care. Interviews with the nursing assistant (NA-A) and licensed practical nurse (LPN-A) confirmed that the resident was supposed to receive assistance with incontinence care every 2-3 hours. The administrator also confirmed that staff were expected to follow the care plan. Despite these directives, the resident was found to be incontinent of urine when finally assisted with incontinence care after the prolonged period without assistance.
Failure to Implement Nonpharmacological Interventions Before Administering Antianxiety Medications
Penalty
Summary
The facility failed to provide nonpharmacological interventions prior to administering as-needed antianxiety medications to a resident with severe cognitive impairment and multiple diagnoses, including dementia, Parkinson's disease, and anxiety disorder. The resident's care plan and clinical records lacked documentation of nonpharmacological interventions attempted before administering Lorazepam, despite the resident frequently calling out repetitive phrases and displaying behaviors such as pulling hair, biting nails, and yelling out. Observations and interviews with staff confirmed that nonpharmacological interventions were not implemented or documented as required. The resident's medication administration records indicated multiple instances of Lorazepam administration without prior nonpharmacological interventions from January to April. The resident's behavior monitoring reports also lacked evidence of nonpharmacological interventions before medication administration. Interviews with family members and staff revealed that the resident frequently called out for help and displayed distress, but staff did not consistently provide or document nonpharmacological interventions to address these behaviors. The facility's behavior committee meetings discussed the resident's medication but did not include specific nonpharmacological interventions in the meeting minutes. The administrator and director of health services confirmed that nonpharmacological interventions were not included in the care plan or implemented before administering antianxiety medications. The facility also lacked a policy related to antianxiety medication, further contributing to the deficiency in care for the resident.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the Office of Ombudsman for Long-Term Care (OOLTC) of facility-initiated transfers for 12 residents who had been hospitalized. The deficiency was identified through an email correspondence with the OOLTC, which indicated that the facility had not completed monthly reporting of transfers and discharges as required. Specific instances included residents being transferred to the hospital for various medical reasons such as unresponsiveness, low oxygen saturation, family requests, infections, falls with injury, increased respirations, pleural effusion, pneumonia, low hemoglobin, and chest pain. The medical records for these residents lacked evidence that notice of the transfers was provided to the OOLTC. Interviews with the director of health center sales and services (DHCSS) and the administrator confirmed that the notifications had not been sent and that the facility policy did not include a timeframe for reporting emergency transfers to the OOLTC monthly or within 30 days prior to the discharge or as soon as practicable. During the interviews, the DHCSS admitted that she had let the notifications accumulate for about three months before sending them and was not aware that they should be sent monthly. The administrator verified that transfer notices should be sent to the OOLTC monthly and acknowledged that the facility policy needed to be updated to include a specific timeframe for reporting. The facility's Transfer and Discharge (30 Day Notice) policy dated 1/13/20 directed that a copy of the notice be sent to a representative of the Office of the State Long-Term Care Ombudsman before transferring or discharging a resident, but it lacked a specific timeframe for reporting emergency transfers and facility-initiated transfers to the OOLTC.
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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