Gil-mor Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Morgan, Minnesota.
- Location
- 96 Third Street East, Morgan, Minnesota 56266
- CMS Provider Number
- 245594
- Inspections on file
- 17
- Latest survey
- December 16, 2025
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Gil-mor Manor during CMS and state inspections, most recent first.
A resident with Alzheimer's, diabetes, and Parkinson's experienced multiple falls, and the facility did not promptly update the care plan with new fall prevention interventions discussed by the IDT. Despite repeated incidents and discussions about additional measures such as closer monitoring, alarm adjustments, and increased toileting, these were not timely reflected in the care plan. Staff interviews confirmed a lack of awareness of updated interventions, and the facility's policy for care plan updates was not followed.
A resident with Alzheimer's, diabetes, and Parkinson's experienced multiple falls due to the facility's failure to conduct timely root cause analyses and update the care plan with effective interventions. Despite repeated incidents involving impulsivity, incontinence, and malfunctioning alarms, staff did not consistently investigate or address the underlying causes, resulting in ongoing fall risks.
Staff failed to use required Enhanced Barrier Precautions (EBP), including gowns and gloves, during high-contact care activities such as transferring and toileting for a resident with a weeping foot wound. Despite clear signage and facility policy, both a nursing assistant and the DON did not follow EBP protocols, and interviews revealed confusion among staff about when EBP was necessary.
Surveyors found that emergency medications, including morphine syringes, in the E-kit were expired and not clearly labeled, leading to confusion among staff about which expiration dates to follow. The LPN, pharmacy contact, DON, and administrator all acknowledged the presence of expired medications and unclear labeling, and no relevant policy was provided during the survey.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
The designated infection preventionist did not provide effective oversight of the infection prevention and control or antibiotic stewardship programs. Surveillance forms for residents and staff were incomplete, with missing documentation and failure to track all relevant cases. The IP was unclear about her responsibilities, did not document follow-up on protocol breaches, and was not overseen by an infection control committee as required. The DON was unaware of these lapses, and facility policy requirements for surveillance and reporting were not met.
A resident with dementia and depression, who was cognitively intact and receiving citalopram for major depressive disorder, did not have a documented informed consent for psychotropic medication use. Staff interviews and policy review confirmed that the required process of providing information on risks, benefits, and alternatives, and obtaining a signed consent, was not completed.
A resident who was receiving Medicare-covered skilled services was not given the required Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) at least 48 hours before coverage ended. The responsible RN and facility leadership confirmed the notice was provided late, contrary to facility policy.
Two residents receiving PRN antianxiety medications were not assessed by a physician for continued need, with no documentation of rationale, frequency, or effectiveness of use. Pharmacy reviews did not identify the lack of reassessment, and nursing staff confirmed that required 14-day reviews were not completed. No facility policy on PRN psychotropic medication reassessment was provided.
A consulting pharmacist did not identify or report irregularities in medication orders for three residents, including PRN psychotropic and antibiotic medications lacking end dates or reassessment. Despite monthly reviews and facility expectations, these issues were not brought to the attention of the facility or documented for follow-up.
A resident was maintained on a long-term antibiotic regimen without documented reassessment or an identified end date, as required by facility policy. The ongoing use of Minocycline HCI for infection and inflammatory reaction related to a knee prosthesis was not reviewed by the infection preventionist, consulting pharmacist, or DON, resulting in the medication being administered for an extended period without evaluation of its continued necessity.
An E-kit was observed unsecured on the medication room counter, with a red numbered zip tie loosely placed and easily removed without cutting. An LPN was unaware of the improper securing, despite facility policy requiring the E-kit to be locked and checked at each shift change by two licensed nurses. The DON and administrator confirmed the expectation for proper security and shift checks.
The facility did not conduct required antibiotic assessments (time-outs) within 48-72 hours after starting antibiotics for two residents, as recommended by CDC guidelines. Documentation lacked evidence that the need for continued antibiotic use was evaluated, and there was no indication of provider communication regarding these assessments. Leadership was aware of the issue but had not addressed it with the medical director or at QAPI meetings, and the facility's policy did not include the required time-out process.
The facility failed to ensure proper training for nurse aides and medication aides in cleaning and disinfecting a whirlpool tub, leading to improper procedures and potential cross-contamination. Staff were observed not following manufacturer's guidelines, and the director of nursing and infection preventionist were unaware of the deficiencies. No specific policy or documented maintenance was in place.
The facility failed to submit accurate staffing data to CMS for a quarter. A review showed missing 24-hour nursing coverage on certain dates, but schedules confirmed coverage. The administrator noted agency staff hours were incorrectly reported, causing the data inaccuracy.
The facility failed to ensure proper cleaning and disinfection of a whirlpool tub by staff, as well as baseline TB screenings and testing for two staff members and three residents. Staff did not follow the manufacturer's guidelines for cleaning the tub, leading to visible dirt and debris. The DON and IP were unaware of these lapses, and there was no documented preventative maintenance or specific cleaning policy. Additionally, the facility did not provide required TB screenings and testing, as outlined in their TB Exposure Control Plan.
A resident with moderately impaired cognition eloped from the facility, crossing a busy highway, due to the facility's failure to comprehensively assess elopement risk and maintain a WanderGuard device. The facility did not conduct regular elopement risk assessments or report the incident to the State Agency. Staff were unaware of the WanderGuard system being turned off in a specific wing, and the device was discontinued without a physician's order.
A resident with moderately impaired cognition eloped from the facility, leading to the application of a WanderGuard device. The device was later removed without a physician's order, contrary to protocol. Interviews revealed a lack of communication and adherence to procedures, with the DON and MDS nurse acknowledging the oversight. The physician was not informed of the removal, and no specific policy on WanderGuard use was provided.
A resident with a history of elopement and cognitive impairment was allowed to go outside unsupervised, leading to an incident where the resident crossed a busy highway. The facility failed to reassess the resident's elopement risk and did not maintain an active WanderGuard system. Staff interviews revealed a lack of awareness and adherence to policies, and the incident was not reported to the State Agency.
A facility failed to prevent the administration of expired medication to a resident. A nurse discovered a blister pack of expired oxycodone in the locked narcotic medication box, which had been administered to a resident. The DON expected expired narcotics to be discarded immediately and not stored with in-use medications. Facility policies stated that medications should not be used after expiration and outdated controlled substances should be disposed of according to law.
Failure to Timely Revise Care Plan with Fall Interventions After Multiple Falls
Penalty
Summary
The facility failed to timely revise the care plan with appropriate fall interventions for a resident with a history of falls and multiple risk factors. The resident, diagnosed with Alzheimer's disease, diabetes mellitus, and Parkinson's disease, required moderate assistance for transfers, had severe cognitive impairment, and had experienced two or more falls since admission. Despite being identified as high risk for falls, the care plan was not updated promptly after several fall incidents to reflect new interventions discussed by the interdisciplinary team (IDT). Multiple fall incidents occurred over several days, including the resident being found on the floor in various locations such as the dining room, next to the bed, and in front of a recliner. In some cases, alarms intended to alert staff did not function as intended, such as a wheelchair alarm with a string that was too long. The IDT discussed interventions like placing the resident near the nursing station with a tray table, shortening alarm strings, involving family for supervision, and increasing toileting and repositioning frequency. However, these interventions were not promptly incorporated into the resident's care plan. Interviews with nursing staff and the DON revealed that staff were unable to clearly articulate additional fall prevention interventions beyond the use of alarms, and acknowledged that the care plan had not been revised in a timely manner to reflect the interventions discussed after each fall. The facility's policy requires care plans to be updated when there is a significant change in the resident's condition or when desired outcomes are not met, but this was not followed in the resident's case.
Failure to Assess and Address Root Causes of Repeated Falls
Penalty
Summary
The facility failed to comprehensively assess and address the root causes of repeated falls for a resident with significant cognitive and physical impairments. The resident had diagnoses including Alzheimer's disease, diabetes mellitus, and Parkinson's disease, and was identified as high risk for falls due to a history of falls, psychoactive drug use, severe cognitive impairment, and incontinence. Despite multiple documented falls, the facility did not consistently conduct timely or thorough investigations into the causes of each incident, nor did they promptly revise the care plan to implement effective, ongoing interventions tailored to the resident's needs. Several fall incidents occurred, with reports indicating issues such as alarms not functioning properly, the resident's impulsivity, self-transfers, and incontinence. In multiple cases, immediate interventions were either not developed or not implemented, and care plan revisions were delayed. The interdisciplinary team (IDT) reviews often lacked comprehensive analysis of causal factors, particularly regarding the resident's impulsivity, compulsiveness, and failure to use the call light. Although some interventions were eventually added, such as family assistance and changes to alarm placement, these were not implemented in a timely manner and did not always address the underlying causes identified in the incident reviews. Interviews with staff, including an LPN and the DON, revealed a lack of awareness and understanding regarding the need for comprehensive root cause analysis and timely care plan updates following each fall. The facility's own protocol required identification of fall causes within 24 hours and ongoing evaluation of intervention effectiveness, but these procedures were not consistently followed. As a result, the resident continued to experience repeated falls without adequate assessment or modification of interventions to prevent recurrence.
Failure to Implement Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) as required during high-contact care activities for a resident with a weeping wound on the left foot. Despite clear signage outside the resident's room indicating the need for EBP, including the use of gowns and gloves for activities such as transferring and toileting, staff members including a nursing assistant and the director of nursing entered the room and provided care without donning the appropriate personal protective equipment. The nursing assistant only wore gloves while changing the resident's brief and pants, and the director of nursing applied a gait belt without any PPE, even though her body was in direct contact with the resident. Interviews with staff revealed a lack of understanding regarding when EBP should be used, with both the nursing assistant and the director of nursing incorrectly believing that EBP was only necessary for wound or catheter care, not for transfers or toileting. The infection preventionist and another LPN confirmed that EBP should have been used for all high-contact care activities due to the resident's wound. Review of the facility's policy and the resident's care plan further indicated that the need for EBP during high-risk care was not properly identified or communicated, contributing to the failure to follow infection control protocols.
Expired Emergency Medications Found in E-Kit
Penalty
Summary
Surveyors observed that the facility failed to ensure that emergency medications stored in the medication storage room were not expired. During an observation with an LPN, the emergency medication kit (E-kit) was found on the counter with a sticker indicating an expiration date of 6/27, which was unclear as to whether it referred to June 2025 or June 2027. Upon further inspection, two morphine pre-filled syringes inside the E-kit were found to have a manufacturer’s expiration date of June 2025, which had already passed. Additional medications in the E-kit also had printed expiration dates indicating they were expired, while some had handwritten expiration dates that were not expired, leading to confusion about which date should be used to determine if a medication was expired. The LPN acknowledged the presence of expired medications but was uncertain about which expiration date to follow. The pharmacy contact person confirmed that the morphine syringes were expired and agreed that the labeling on other medications was unclear, though she stated that staff were generally aware of the process. The DON and administrator also agreed with the findings and expected the pharmacy to remove expired medications from the E-kit. No policy regarding the management of expired medications was provided by the facility during the survey.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures for infection prevention and control were not established or maintained as expected. The report notes the absence or inadequacy of a program designed to prevent and control infections within the facility, but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Inadequate Oversight of Infection Prevention and Control Program
Penalty
Summary
The facility failed to ensure that the designated infection preventionist (IP) provided adequate oversight of the infection prevention and control program, as well as the antibiotic stewardship program. Review of monthly resident surveillance forms revealed incomplete documentation, including missing resolved dates and lack of columns for antibiotic time-outs or implementation of precautions. The IP only documented residents on antibiotics and did not include those who were ill but not receiving antibiotics. For staff surveillance, records showed that eight staff members returned to work before the recommended work restrictions for potential norovirus symptoms, and the required call-in forms were not consistently completed by charge nurses. The IP was unsure of her oversight responsibilities and had no documentation of follow-up when protocols were not followed. Interviews with the IP and the DON confirmed that the IP was not effectively monitoring or ensuring adherence to infection control policies and protocols. The DON expected the IP to provide oversight and education when protocols were not followed but was unaware that these duties were not being performed. Additionally, there was no evidence that the IP was being overseen by an infection control committee, as required by facility policy. The facility's infection prevention and control manual outlined specific surveillance and oversight responsibilities that were not being met, including comprehensive data collection, analysis, and reporting to the appropriate committees.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain and document informed consent for the use of a psychotropic medication for one resident. Specifically, a resident with diagnoses of dementia and depression, who was cognitively intact and required assistance with activities of daily living, was routinely administered citalopram for major depressive disorder. The resident's quarterly assessment indicated no significant depression or behavioral issues. Despite this, there was no signed consent form in the resident's medical record outlining the risks, benefits, and alternative treatments associated with the psychotropic medication. Interviews with facility staff, including a registered nurse, the DON, and the administrator, confirmed that the required consent process had not been completed for this resident. Facility policy requires that staff provide residents or their representatives with information about the indication, dose, side effects, adverse consequences, and treatment goals for psychotropic medications, and that informed consent be obtained and documented in the medical record. This process was not followed in this instance.
Failure to Provide Timely SNFABN Notice to Resident
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) CMS-10055 to a resident who was receiving Medicare-covered skilled services. The resident received skilled services from early November through early February, and the facility discontinued these services before the Medicare benefit days were exhausted. The resident was notified of the end of coverage only one day prior to the last covered day, rather than the required minimum of two days' notice. Interviews with the responsible RN and facility leadership confirmed that the notice was not provided within the required timeframe, and the facility's policy mandates that such notices be given at least 48 hours in advance and documented in the medical record.
Failure to Reassess PRN Psychotropic Medications by Physician
Penalty
Summary
The facility failed to ensure that two residents receiving as-needed (PRN) antianxiety medications were properly assessed by a physician for the continued need of these medications. One resident, with diagnoses including anxiety disorder, COPD, major depressive disorder, and alcohol dependence, had an order for Ativan PRN that was not reviewed or reassessed by a physician since its initiation. Physician visit notes did not document a rationale for continued use, frequency of administration, or effectiveness of the medication. Similarly, another resident with anxiety disorder and moderate cognitive impairment had a PRN order for clonazepam that was not reviewed or reassessed by a physician for several months, with no documentation supporting ongoing need or effectiveness. Pharmacy reviews conducted during this period did not identify the lack of physician reassessment or the absence of end or review dates for the PRN psychotropic medications. Nursing staff interviews confirmed that PRN psychotropic medications should be reassessed every 14 days unless otherwise documented, but this process was not followed. The consulting pharmacist reported reviewing PRN psychotropic medications during monthly reviews but did not notify the provider directly about the need for reassessment, relying on the facility to ensure compliance. No facility policy on PRN psychotropic medication reassessment was provided during the survey.
Pharmacist Failed to Identify and Report Medication Irregularities
Penalty
Summary
A licensed pharmacist failed to identify and report medication irregularities for three of eight sampled residents during monthly drug regimen reviews. For one resident with intact cognition and multiple diagnoses, including anxiety disorder and major depressive disorder, a PRN order for Ativan was initiated without an end date, and pharmacy reviews over several months did not note this irregularity or recommend provider follow-up. Another resident with moderate cognitive impairment and anxiety disorder had a PRN order for Clonazepam without an end date, which also went unaddressed in pharmacy reviews. A third resident, cognitively intact but requiring extensive assistance, had a long-standing antibiotic order for Minocycline without an end date or documented reassessment, and this was not identified as an irregularity by the pharmacist in monthly reviews. Interviews with the consulting pharmacist confirmed that these PRN psychotropic and antibiotic orders had not been reviewed for appropriate end dates or continued need, despite facility expectations and contractual obligations for the pharmacist to identify and report such irregularities. The facility's director of nursing and administrator stated that they rely on the pharmacist to bring such issues to their attention and to provide written documentation of any findings or recommendations, which did not occur in these cases.
Failure to Assess Continued Need for Long-Term Antibiotic Therapy
Penalty
Summary
A deficiency was identified when a resident's drug regimen included an antibiotic, Minocycline HCI 100 mg, that had been ordered for infection and inflammatory reaction due to an internal right knee prosthesis. The antibiotic order, which began in early 2023, did not have an identified end date and had not been reassessed for continued need. The resident, who was cognitively intact and required extensive assistance with care, was also taking a diuretic and an opioid. The infection preventionist was unaware that the resident was still receiving the antibiotic and had not reviewed its ongoing necessity, as the medication was being administered by a trained medication aide rather than the charge nurse, which contributed to the oversight. Further interviews revealed that the consulting pharmacist was also unaware of any reassessment for the continued use of the antibiotic and noted that while long-term use of Minocycline is not uncommon, the lack of an end date should have prompted a review. The director of nursing acknowledged that the antibiotic order should not have been overlooked for such an extended period and that orders are expected to be reviewed by nursing staff, the pharmacist, and the provider. The facility's antibiotic stewardship policy requires all antibiotic orders to include a diagnosis, medication, dose, route, and duration, and limits prophylactic use based on physician documentation, but these procedures were not followed in this case.
Emergency Medication Kit Not Properly Secured
Penalty
Summary
The facility failed to ensure that the emergency medication kit (E-kit) was properly secured in accordance with facility policy and professional standards. During an observation in the medication room, the E-kit was found sitting on the counter with a black zip tie on the closure and a red numbered zip tie, which is the standard security measure, loosely placed over it. The red zip tie could be easily removed without being cut, indicating it was not securely fastened. An LPN present was unaware of why the red zip tie was not properly secured, despite facility policy requiring the E-kit to be locked with a red numbered zip tie and checked at each shift change by two licensed nurses. The number on the zip tie matched the documentation in the E-kit count book, and a count confirmed all medications were present. The director of nursing and administrator acknowledged the findings and confirmed that staff are expected to ensure the E-kit is properly secured at each shift change.
Failure to Complete Antibiotic Time-Outs for Continued Use
Penalty
Summary
The facility failed to complete comprehensive assessments for continued use of antibiotics for two of three sampled residents reviewed for antibiotic stewardship. Specifically, after antibiotics were initiated for these residents, there was no evidence that an antibiotic assessment (time-out) was conducted within 48-72 hours to determine if criteria for continuation of the antibiotic were met, as recommended by CDC guidelines. The surveillance logs for the relevant months included documentation of infection onset, type of illness, signs and symptoms, and treatment, but lacked evidence that the effectiveness of the antibiotic or the need for its continuation was evaluated. For one resident prescribed Azithromycin, there was no documentation of an antibiotic time-out or communication with the provider after starting the medication. For another resident prescribed Doxycycline, while some clinical assessments were documented, there was no evidence of provider communication regarding the assessment. Interviews with facility leadership revealed that the administrator was aware of issues with providers not responding to antibiotic time-outs, but this concern had not been addressed with the medical director or at QAPI meetings. The DON stated that her expectation was for antibiotic stewardship monitoring to occur with each antibiotic started. However, the facility's antibiotic stewardship policy did not include a requirement for an antibiotic assessment (time-out) 48-72 hours after initiation to determine if continuation criteria were met.
Inadequate Training and Procedure for Whirlpool Tub Cleaning
Penalty
Summary
The facility failed to ensure that all 20 nurse aides and 3 trained medication aides were appropriately trained in the cleaning and disinfection of a whirlpool tub according to the manufacturer's instructions. During an observation, it was noted that the staff did not follow the correct procedure for cleaning and disinfecting the tub, as they did not remove dirt and debris before the disinfection process. The jets of the tub were observed to be heavily soiled with dirt-like debris. The staff, including NA-C who had been employed for three years, were unsure of the correct amount of disinfectant required and had been following incorrect guidelines posted by the facility. The director of nursing and the infection preventionist were unaware that the staff were not following the manufacturer's guidelines. The infection preventionist admitted to not performing environmental rounds or training on the whirlpool tub cleaning and disinfection. Additionally, there was no documented preventative maintenance performed by the maintenance supervisor, and no specific policy related to staff competencies or cleaning the whirlpool tubs was provided by the end of the survey.
Inaccurate Staffing Data Submission to CMS
Penalty
Summary
The facility failed to submit accurate and complete staffing data to the Centers for Medicare and Medicaid Services (CMS) for the second quarter. The deficiency was identified through a review of the payroll-based journal (PBJ) report, which showed that the facility did not have 24-hour nursing coverage on specific dates. However, further review of staffing schedules and time punches revealed that the facility did have 24-hour licensed staffing on those dates. An interview with the administrator on June 11, 2024, revealed that the hours worked by agency staff were not being reported correctly by the staffing company, leading to the inaccurate data submission to the PBJ.
Deficiencies in Whirlpool Tub Cleaning and TB Screening
Penalty
Summary
The facility failed to ensure proper cleaning and disinfection of a whirlpool tub by two staff members, NA-C and NA-D, according to the manufacturer's guidelines. During an observation, it was noted that the staff did not follow the correct procedure for cleaning and disinfecting the tub, as they did not remove dirt and debris before disinfection. The jets of the tub were observed to be heavily soiled with dirt-like debris. NA-C, who had been employed for three years, stated that they used to remove and scrub the jets but stopped due to management's orders. The staff were unsure of the correct amount of disinfectant required, and the posted guidelines were not being followed correctly. The director of nursing (DON) and the infection preventionist (IP) were unaware that the staff were not following the manufacturer's guidelines for cleaning and disinfecting the whirlpool tub. The IP admitted to not performing environmental rounds or training and competencies related to the whirlpool tub cleaning and disinfection. The maintenance supervisor also confirmed that there was no documented preventative maintenance performed on the whirlpool tubs, and there was no specific policy for cleaning the tubs apart from the manufacturer's instructions. Additionally, the facility failed to provide baseline screenings and/or testing for tuberculosis (TB) for two staff members and three residents. The immunization records showed that two residents admitted in 2023 and 2024 had no baseline screenings for TB, and another resident had a baseline screening but no TB testing. Similarly, one staff member had a baseline screening but no TB testing, and another had neither. The DON acknowledged the lack of TB screening and testing but had not taken steps to correct the issue. The 2020 TB Exposure Control Plan required screening and testing, with the IP responsible for oversight in collaboration with the administrator and DON.
Failure to Assess and Monitor Elopement Risk
Penalty
Summary
The facility failed to comprehensively assess a resident, identified as R15, for risk of elopement and the need for a WanderGuard device. R15, who had moderately impaired cognition and a history of wandering, was allowed to go outside unsupervised, leading to an elopement incident where he crossed a busy highway and entered a field. The facility's Quality Assurance Performance Improvement (QAPI) committee identified the elopement but did not document the resident's name or date in the meeting minutes. Despite R15's history of wandering and cognitive impairment, the facility did not reassess his elopement risk quarterly, annually, or as needed, and failed to maintain consistent use of the WanderGuard device. The facility's staff, including the Director of Nursing (DON) and the Minimum Data Set (MDS) nurse, were unaware of the WanderGuard system being turned off in a specific wing, which could have affected residents with WanderGuard devices. The MDS nurse admitted to not conducting regular elopement risk assessments as required, and the DON acknowledged that the WanderGuard was discontinued without a physician's order. The facility also failed to report the elopement incident to the State Agency, and there was no documentation of a comprehensive assessment or increased supervision for R15 after the incident, despite his frequent falls and cognitive decline. Interviews with staff revealed a lack of awareness and adherence to policies regarding elopement risk assessment and WanderGuard usage. The facility's procedures for elopement risk assessment and precautions were not followed, as evidenced by the lack of regular assessments and the unauthorized removal of the WanderGuard device. The facility's failure to perform a root cause analysis or implement measures to prevent future elopements further highlights the deficiency in ensuring resident safety.
Failure to Obtain Physician's Order for WanderGuard Discontinuation
Penalty
Summary
The facility failed to obtain a physician's order before discontinuing a WanderGuard device for a resident who had previously eloped. The resident, identified as having moderately impaired cognition, was allowed to go outside by a nurse and subsequently crossed a highway to observe field work, which was not explicitly prohibited by the nurse. After being returned to the facility, a WanderGuard was applied to the resident's walker and wheelchair, and the physician was informed and agreed to its use. However, the WanderGuard was later removed without notifying the physician or obtaining an order for its discontinuation. Interviews with the Director of Nursing (DON), MDS nurse, and the facility administrator revealed a lack of communication and adherence to protocol regarding the removal of the WanderGuard. The DON acknowledged the failure to secure a physician's order for the removal and the need for reassessment of the resident's wandering risk. The MDS nurse was unsure of the policy for WanderGuard removal and did not recall any standing orders. The physician confirmed he was not informed of the device's removal and expected to be notified of such decisions. The facility did not provide a specific policy related to WanderGuard use by the end of the survey.
Failure to Supervise and Assess Elopement Risk
Penalty
Summary
The facility failed to ensure adequate supervision and assessment for a resident with a history of elopement, leading to an incident where the resident left the premises unsupervised. The resident, who had moderately impaired cognition and a history of wandering, was allowed to go outside by nursing staff. Subsequently, the resident crossed a busy highway and entered a field where farm machinery was operating. The resident's WanderGuard system was not active at the time, as it had been removed previously without proper reassessment or physician orders. The resident's care plan and elopement risk assessments were not adequately updated or followed. Despite previous incidents of wandering and cognitive decline, the facility did not reassess the resident's risk for elopement with each Minimum Data Set (MDS) assessment or after significant changes in the resident's condition. The WanderGuard system was also found to be disengaged in certain areas of the facility, further compromising resident safety. Interviews with facility staff, including the Director of Nursing and the MDS nurse, revealed a lack of awareness and adherence to policies regarding elopement risk assessment and WanderGuard usage. The facility also failed to report the elopement incident to the State Agency, and there was no documentation of a comprehensive assessment or root cause analysis following the incident.
Expired Medication Administered to Resident
Penalty
Summary
The facility failed to ensure that expired medications were not stored with in-use medications and that expired medications were not administered to residents. During an observation and interview, a registered nurse identified a blister pack of oxycodone, a narcotic pain medication, with an expiration date that had passed. This expired medication was found in the locked narcotic medication box and had been administered to a resident. The nurse confirmed that the expired oxycodone had been given to the resident as recorded in the log book. The nurse also acknowledged that expired medications should be discarded promptly and not stored with current medications. The Director of Nursing (DON) stated that her expectations were for nursing staff to discard expired narcotics immediately upon discovery and not store them with in-use medications. The expired medication should have been identified during the routine narcotic medication count and verified as part of the five medication rights before administration. The facility's policies on Dispensing, Storage & Labeling of Medications and Controlled Substances also indicated that medications should not be used after their expiration date and that outdated controlled substances should be detected and disposed of according to state and federal law.
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.
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