Glenoaks Senior Living Campus
Inspection history, citations, penalties and survey trends for this long-term care facility in New London, Minnesota.
- Location
- 100 Glen Oaks Drive, New London, Minnesota 56273
- CMS Provider Number
- 245360
- Inspections on file
- 29
- Latest survey
- September 12, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Glenoaks Senior Living Campus during CMS and state inspections, most recent first.
A resident with impaired mobility and a history of falls sustained a head laceration after falling from a wheelchair lift during transport. The staff member operating the lift did not follow manufacturer safety guidelines, failed to ensure the resident was properly secured, and left the resident unattended on the lift. Incomplete staff training documentation and lack of adherence to facility policy on wheelchair securement contributed to the incident.
Several residents with varying medical and cognitive conditions reported that a nursing assistant provided care in a rushed, rough, and disrespectful manner, leading to increased anxiety, feelings of worthlessness, and avoidance of care. Staff also observed the nursing assistant intentionally agitating residents and using inappropriate language, with prior warnings documented in her employee file.
Multiple residents reported being treated harshly and roughly by a nursing assistant, including being moved in ways that caused pain and being subjected to demeaning remarks. Despite these allegations, facility leadership did not conduct a thorough investigation, failed to document or follow up on complaints, and allowed the nursing assistant to continue working with residents, contrary to facility policy.
The facility did not conduct required annual performance evaluations for four nursing assistants, with employee records and staff interviews confirming the absence of recent evaluations. The DON reported not performing evaluations during her tenure, and the Administrator stated there was no formal policy in place, despite an expectation that evaluations occur.
A resident without cognitive impairment alleged to a physician that staff were physically abusing them. The administrator was informed of the allegation but did not report it to the State Agency, citing lack of specific details from the resident. Later, the DON received a related grievance about rough care but also did not report it, believing it was not a reportable event. Facility policy requires immediate reporting of all abuse allegations, which was not followed.
The facility did not have a formal QAPI plan or documentation to track and measure performance, establish goals, or implement corrective actions, despite holding quarterly meetings attended by the DON. This deficiency had the potential to affect all residents.
The facility did not ensure its QAPI team developed or revised a quality improvement program to address infection control concerns, as shown by incomplete meeting documentation and lack of program focus, benchmarks, or current PIP initiatives. The administrator was unable to provide program-specific information prior to her arrival, and the facility was only beginning to formalize its QAPI process, potentially affecting all residents.
The facility failed to maintain an effective infection prevention and control program, with incomplete infection surveillance logs, lack of antibiotic stewardship practices, and insufficient tracking of staff illnesses. Staff were observed transporting soiled linens without proper bagging and cleaning a glucometer with an inappropriate product. The infection preventionist reported being unable to provide adequate oversight due to multiple responsibilities, and the facility's infection control policy was outdated and lacked necessary procedures.
The facility did not ensure the infection preventionist had adequate time or competency to oversee the infection control program, resulting in incomplete infection surveillance, lack of antibiotic stewardship practices, and insufficient documentation of infection management for residents and staff. Staff also failed to follow proper procedures for handling soiled linens, and the facility lacked updated policies for infection control and employee health.
A bottle of Lysol toilet bowl cleaner was found left out and spilled on the counter in an unlocked soiled utility room, with hazardous chemicals not properly secured as required. The maintenance director could not recall the last inspection of the utility rooms, and staff confirmed that chemicals are expected to be kept locked away from resident areas.
Two residents received medications not in accordance with physician orders or manufacturer guidelines, including one instance where a topical medication was administered in an unmeasured amount and another where multiple oral medications were crushed and given without a provider order. Staff were unsure of the correct procedures, and required documentation and orders were missing from the EMR, resulting in a medication error rate of 26.9%.
The facility did not have an effective antibiotic stewardship program in place, resulting in antibiotics being prescribed and administered without consistent documentation of symptoms, cultures, or antibiotic time outs. Multiple residents received antibiotics without clear indication or follow-up, and staff lacked training and awareness of stewardship practices. Facility policies did not provide specific guidance for monitoring or communicating about antibiotic use, leading to inadequate oversight and documentation.
Two residents with severe cognitive impairment and dependent on staff for ADLs were found with overgrown, unclean nails despite care plans and documentation indicating nail care should be provided. Observations and family reports showed nail care was not performed as required, and staff interviews revealed a lack of oversight by licensed nurses, who relied on nursing assistant documentation without verification.
A resident with severe cognitive impairment and multiple diagnoses was receiving hospice services, but the facility's care plan did not specify the services hospice was to provide during visits. The nurse consultant confirmed the lack of integration between the hospice and facility care plans, which was not in accordance with facility policy.
A resident with multiple diagnoses did not have pharmacy consultant recommendations regarding psychotropic medication reassessment, prednisone dosing, and diagnosis documentation addressed or communicated to the physician in a timely manner. Facility staff confirmed the absence of an organized process and required documentation for following up on these recommendations.
A resident with multiple medical conditions was given Tramadol by an LPN according to a scheduled order, but the medication label incorrectly indicated it was to be given as needed. The LPN and DON confirmed that labels should match current provider orders, but the label did not reflect the scheduled dosing, contrary to facility policy requiring accurate label checks before administration.
The facility did not ensure proper cleanliness, temperature monitoring, and food dating in both a dining room refrigerator and personal refrigerators in resident rooms. Several refrigerators contained undated and unlabeled foods, lacked temperature logs, and in some cases, did not have thermometers. Staff were unclear about their responsibilities for monitoring and cleaning, and the facility's policy did not address personal refrigerators, leading to improper food storage and sanitation practices.
Failure to Follow Wheelchair Lift Safety Protocols Results in Resident Injury
Penalty
Summary
A deficiency occurred when facility staff failed to follow the manufacturer's safety guidelines for operating a wheelchair lift, resulting in a resident falling from the facility transport bus and sustaining a head laceration that required emergency department treatment. The incident took place as the resident, who had a history of falls, impaired mobility, and required staff assistance for activities of daily living, was being loaded onto the bus by a staff member trained to operate the lift. The resident was dependent on staff for self-care, used a manual wheelchair, and had cognitive capacity but exhibited anxiety and behavioral symptoms on the day of the incident. During the transfer, the staff member backed the resident's wheelchair onto the lift, locked the brakes, and began raising the lift. The lift stopped unexpectedly about six inches from the ground. The staff member, while attempting to determine the cause of the stoppage, stepped off the lift, leaving the resident unattended. At this point, the resident's wheelchair rolled forward, and the resident fell off the lift, hitting her head on the ground. The investigation revealed that the front wheels of the wheelchair were not properly positioned behind the yellow foot stop, and the resident was not secured with a seatbelt or torso restraint. Additionally, the staff member did not instruct the resident to hold onto the handrails, and the wheelchair brakes were not fully engaged. Further review found that the facility did not have the owner's manual for the lift on hand, and staff training documentation was incomplete, with skills validation checklists lacking proper markings or evaluations. The facility's policy required staff to be trained in the use of wheelchair lifts and to ensure proper securement of residents during transport, including the use of occupant restraints. However, these procedures were not followed, directly contributing to the resident's fall and injury.
Failure to Ensure Dignified and Respectful Care by Nursing Assistant
Penalty
Summary
The facility failed to ensure that four residents were treated with dignity and respect during care provided by a nursing assistant (NA-P). Multiple grievances and interviews revealed that NA-P performed care too quickly, used a harsh tone, and made inappropriate or demeaning comments. One resident reported increased anxiety and feelings of worthlessness when assisted by NA-P, while another described NA-P as rough and preferred not to receive care from her. Additional residents stated they would avoid requesting assistance from NA-P due to her behavior, which included loud, inappropriate remarks and a lack of bedside manner. Staff interviews corroborated these concerns, with one nursing assistant observing NA-P intentionally agitating residents and reporting this behavior to management. Review of NA-P's employee file showed prior coaching and written warnings for disrespectful, condescending, and rushed care, as well as complaints from both staff and residents about her tone and conduct. Despite these documented issues, management responses focused on coaching NA-P to slow down and treat residents as individuals, but residents and staff did not observe significant improvement. Facility policy defines personal degradation and mental abuse as actions or statements that harm a resident's dignity or cause humiliation, fear, or agitation, which aligns with the behaviors reported in this case.
Failure to Investigate and Protect Residents After Allegations of Abuse
Penalty
Summary
The facility failed to ensure a thorough investigation was completed and to protect residents after allegations of rushed, harsh, and physically abusive care by a nursing assistant were reported. Multiple residents described ongoing inappropriate behavior and treatment by the nursing assistant, including being handled roughly during care, experiencing pain, and being subjected to demeaning or condescending remarks. Despite these complaints, there was no documentation of a comprehensive investigation, no identification of the residents involved in the initial written warning, and no evidence that follow-up with affected residents was completed. Interviews with residents revealed specific concerns about the nursing assistant's conduct, such as being moved too quickly or roughly during transfers, causing pain, and making residents feel anxious, worthless, or angry. Some residents reported avoiding care from the nursing assistant or refusing showers due to discomfort. Staff interviews confirmed that concerns about the nursing assistant's behavior had been reported to facility leadership, but there was no indication that these reports led to a formal investigation or protective measures for the residents. Facility records showed that the nursing assistant continued to work with all residents until the state agency brought the allegations to the attention of the administrator. The facility's own abuse prevention policy requires immediate notification of the administrator, documentation, investigation, and protective actions when abuse is alleged. However, the facility did not follow these procedures, as there was no evidence of resident assessments, witness interviews, or separation of the accused staff member from residents during the investigation period.
Failure to Complete Annual Performance Evaluations for Nursing Assistants
Penalty
Summary
The facility failed to provide annual performance evaluations for four nursing assistants, as required. Employee records showed that one nursing assistant, hired in October 2023, had not received any performance evaluation since hire. Two other nursing assistants, hired in November 2022 and April 2022, each had only one performance evaluation on file from March 2023, with no subsequent evaluations documented. Another nursing assistant, hired in February 2020, had a performance evaluation from 2022 but none after that. Interviews with the nursing assistants confirmed they did not recall receiving recent evaluations. The Director of Nursing stated she had not conducted any performance evaluations for nursing assistants during her three-year tenure, and the Administrator acknowledged there was no policy for annual evaluations, though it was expected they be completed.
Failure to Timely Report Allegation of Abuse to State Agency
Penalty
Summary
The facility failed to timely report an allegation of staff-to-resident physical abuse to the State Agency as required. On 8/28/25, a resident without cognitive impairment made a statement to a physician during a clinic appointment, alleging that staff at the facility were 'beating me up.' The facility scheduler who heard the allegation informed the administrator the same day. However, the administrator did not consider the incident reportable because the resident could not provide specific details or identify the staff member involved and was unwilling to discuss the incident further. As a result, the allegation was not reported to the State Agency at that time. Additionally, the DON became aware of a related grievance from the same resident on 9/5/25, regarding rough care by a nursing assistant. The DON completed a grievance form and spoke with the staff member involved but did not report the incident to the State Agency, as she did not consider rough care to be a reportable event. Facility policy requires that all allegations of abuse be reported immediately to the administrator and to the appropriate state entity within two hours of the allegation. The failure to report the resident's allegation of abuse in a timely manner constitutes a deficiency.
Lack of Formalized QAPI Plan and Documentation
Penalty
Summary
The facility failed to provide a formalized Quality Assurance and Performance Improvement (QAPI) plan that included necessary policies and procedures for identifying and correcting quality deficiencies. During interviews, the administrator acknowledged that there was no QAPI plan in place to track and measure performance, no established goals, and no evidence of corrective action or performance improvement activities. Although attendance rosters for quarterly QAPI meetings were available, there was no documentation reflecting the QAPI process, and the administrator, who was new to the facility, had not yet implemented such a process. Further review revealed that while the director of nursing (DON) attended quarterly quality assurance meetings and provided updates on infection control and facility status, there was no documentation of QAPI presentations or evidence of any current or previous QAPI programs. The only policy provided was a general QAPI/QAA plan updated earlier in the year, which referenced facility-specific goals and documentation that could not be produced for the current year. This deficiency had the potential to affect all 29 residents in the facility.
Failure to Develop and Document Effective QAPI Program for Infection Control
Penalty
Summary
The facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI) team developed and revised a quality improvement program to address infection control concerns identified through tracking and trending, as well as the infection control process presented by the DON during routine QAPI meetings. Review of QAPI meeting attendance rosters and minutes revealed a lack of documentation regarding the program's focus, benchmarks, goals, or current Performance Improvement Plan (PIP) initiatives. Handwritten notes from a meeting referenced infection control but did not provide context or identify patterns of infection, despite noting staff illness and COVID-19 cases. Subsequent meeting records were incomplete, with gaps in documentation and minimal information on infection control activities or action plans. During an interview, the administrator reported being unable to locate any program-specific information about the QAPI program or PIP initiatives prior to her recent arrival. She stated that the facility was only beginning to formalize the QAPI program and develop a PIP, with plans to use current survey results to identify focus areas. The facility's QAPI policy indicated that the program should be ongoing and comprehensive, but the documentation and interviews demonstrated that these requirements were not being met, potentially affecting all 28 residents in the facility.
Infection Control Program Deficiencies and Lapses in Surveillance, Staff Illness Tracking, and Daily Practices
Penalty
Summary
The facility failed to maintain a current and effective infection prevention and control program, as evidenced by incomplete and inconsistent infection surveillance logs, lack of data analysis, and insufficient tracking of infections and staff illnesses. Infection surveillance logs from January to March 2025 were missing critical information such as dates of symptom onset, details of implemented precautions, symptoms, culture results, and documentation of antibiotic time outs (ATO). In several cases, there was no evidence that appropriate cultures were taken, that the appropriateness of antibiotic therapy was evaluated, or that follow-up was conducted to determine if infections resolved or if treatment needed to be altered. The infection preventionist (IP) reported being unable to provide adequate oversight due to multiple competing responsibilities and insufficient time, and the director of nursing (DON) was unaware of the requirement for antibiotic time outs. Employee illness surveillance was also deficient. For example, a staff member diagnosed with Strep throat worked while symptomatic and returned to work without documentation of meeting CDC-recommended criteria for return, such as being fever-free and having received antibiotics for the appropriate duration. The facility lacked a policy specifying when staff should be excluded from work or the criteria for returning to work after illness. The infection control policy had not been updated since 2022 and did not reflect current standards or include necessary procedures for employee health surveillance. Additional infection control lapses were observed in daily practices. Staff were seen transporting soiled linens without proper bagging, allowing them to come into contact with their clothing and the environment, despite being aware of the correct procedure. In another instance, a nurse cleaned a resident's glucometer with an alcohol wipe instead of an EPA-approved disinfectant wipe, contrary to manufacturer recommendations and facility policy. The facility's policy on glucometer cleaning was vague and did not specify the required cleaning product. These failures in infection control practices and oversight had the potential to affect all residents in the facility.
Inadequate Infection Prevention Oversight and Documentation
Penalty
Summary
The facility failed to ensure that the designated infection preventionist (IP) had sufficient time and competency to oversee the infection prevention and control program. The IP was responsible for multiple duties, including wound care, supply ordering, and occasionally working floor shifts, which limited her ability to focus on infection control tasks. The IP reported not having enough time to complete her infection control responsibilities and lacked documentation of competencies related to oversight of the infection control program. Surveillance logs maintained by the IP were incomplete, missing critical information such as infection onset dates, symptoms, culture results, antibiotic time outs (ATO), and follow-up on the effectiveness or appropriateness of prescribed antibiotics. The IP only documented infections treated with medication and did not monitor all infections as required. Multiple instances were identified where residents with infections did not have complete documentation regarding cultures, causative organisms, isolation precautions, or ATOs. For example, one resident was prescribed antibiotics for both a viral and bacterial infection without clear justification, and another resident with a surgical site infection was not placed on enhanced barrier precautions upon return from the hospital. There was also a lack of evidence that the facility followed up on culture results or communicated with providers regarding antibiotic appropriateness. Additionally, the facility's antibiotic stewardship policy did not specify how the IP should monitor or communicate with providers about antibiotic use, and there was no evidence that the policy had been updated since 2022 to reflect current standards. Employee infection surveillance was also deficient. An employee diagnosed with Strep throat worked while symptomatic and returned to work without documentation of meeting criteria for return, such as being fever-free and having received antibiotics for the recommended period. The facility lacked a policy specifying when staff should be excluded from work due to infection. Observations revealed improper handling of soiled linens, with staff failing to bag contaminated items before transport, increasing the risk of cross-contamination. Staff interviews confirmed awareness of proper procedures but admitted to not following them due to being in a hurry. The director of nursing was unaware of the requirement for antibiotic time outs, and the infection preventionist had not performed or documented any such reviews.
Hazardous Chemical Left Unsecured in Unlocked Utility Room
Penalty
Summary
A deficiency was identified when a bottle of Lysol toilet bowl cleaner was found sitting on the counter in an unlocked soiled utility room in hall A, with some of the cleaner spilled on the countertop. This area was accessible and not secured, potentially affecting 16 of 29 residents in that hall. The maintenance director confirmed the presence of the hazardous chemical and was unable to recall the last time the utility rooms were checked, noting that hazardous chemicals are supposed to be stored in a locked closet. The nurse consultant and administrator stated that staff are expected to keep all hazardous chemicals locked away from resident areas. Facility policy requires ongoing assessment for hazards and measures to prevent resident access to hazardous areas.
Failure to Administer Medications per Physician Orders and Manufacturer Guidelines
Penalty
Summary
The facility failed to ensure medications were administered in accordance with physician orders and manufacturer guidelines for two residents, resulting in a medication error rate of 26.9%. In one instance, an LPN administered Voltaren External Gel to a resident without using the required dispensing film to measure the prescribed two grams, instead providing a 'pea-sized' amount at the resident's request. The LPN was unsure how this amount compared to the ordered dose and did not contact the provider for clarification or an alternate order, despite the medication administration record and label specifying the required dosage. For another resident, a TMA prepared and administered multiple medications by crushing them and mixing with applesauce, including medications such as Aspirin, Colace, Furosemide, Metoprolol, Acetaminophen, and Vitamin D3. The Gabapentin capsule was opened and mixed with applesauce, and Potassium Chloride ER was mixed with water. The TMA stated that orders to crush medications typically came from therapy and would be communicated during shift reports or displayed in the electronic medical record (EMR) banner. However, a review of the EMR and order summary revealed no provider order authorizing the crushing of medications for this resident. Interviews with the ADON, DON, and consulting pharmacist confirmed that a provider order is required before medications can be crushed and administered in this manner. The facility's own policies also require physician authorization and documentation for crushing medications. Despite this, medications were administered crushed without the necessary provider order, and the required documentation was not present in the EMR or on the medication administration record.
Failure to Implement Effective Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program to monitor and ensure the appropriate use of antibiotics for all sampled residents. Review of infection surveillance logs from January through March 2025 revealed that antibiotics were prescribed and administered without consistent documentation of symptoms, cultures, or evidence of antibiotic time outs (ATO) to assess the appropriateness of therapy. In several cases, antibiotics were given for viral infections, such as COVID, or without clear indication, and there was no documentation of start and stop dates, symptom resolution, or follow-up on culture results. For example, one resident received antibiotics for both COVID and a urinary tract infection without documentation of symptoms or rationale, and another was treated for pneumonia without evidence of an ATO or follow-up on culture results. Interviews with facility staff, including the director of nursing (DON) and the infection preventionist (IP), revealed a lack of awareness and training regarding antibiotic stewardship practices, specifically the use of ATOs. The IP, who also served as the assistant director of nursing and had multiple other responsibilities, acknowledged missing information in the surveillance logs and not performing ATOs or following professional criteria for antibiotic appropriateness. The IP also reported being unable to provide adequate oversight of the infection control program due to time constraints and competing duties, and only documented infections that were treated with medication, omitting others. Policy review showed that while the facility had an antibiotic stewardship policy and an infection prevention and control program policy, these documents lacked specific processes for monitoring antibiotic use, communicating with prescribers, or performing ATOs. The policies did not outline criteria for determining the appropriateness of antibiotics or require documentation of key elements such as symptoms, culture results, or therapy adjustments. As a result, the facility did not have a functional system in place to ensure antibiotics were used appropriately, and staff were not adequately trained or competent in antibiotic stewardship practices.
Failure to Provide Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate nail care for two residents who were dependent on staff for activities of daily living. One resident, with severe cognitive impairment and multiple diagnoses including Alzheimer's disease and cerebral palsy, was observed on multiple occasions to have untrimmed nails extending beyond the fingertips with a black substance underneath. Despite the care plan specifying nail care twice weekly on bath days, and documentation indicating nail care was completed, direct observation contradicted these records. A family member also reported repeated requests for nail care that were not addressed. Another resident, also with severe cognitive impairment and multiple diagnoses, was observed to have overgrown, unkempt nails with sharp, broken edges and a black dirt-like substance underneath. Documentation for this resident did not indicate that nail care was completed as required. Interviews with nursing staff revealed that while nursing assistants were responsible for documenting nail care on bath sheets, licensed nurses did not verify whether the care was actually provided, relying solely on the documentation submitted. The facility was unable to provide a policy regarding nail care during the survey.
Failure to Integrate Hospice and Facility Care Plans
Penalty
Summary
The facility failed to ensure that the hospice plan of care was integrated with the facility care plan for one resident who was receiving hospice services. The resident had severe cognitive impairment, was dependent on staff for activities of daily living, and had diagnoses including Parkinson's disease, respiratory failure, and diabetes. Review of the resident's care plan showed it noted hospice involvement but did not specify what services hospice was to provide during their visits. The nurse consultant confirmed that the hospice care plan was not integrated with the facility care plan as required. Facility policy stated that care plans for residents on hospice should include the most recent hospice plan of care and delineate the care and services provided by both the facility and hospice.
Failure to Follow Up on Pharmacy Consultant Recommendations
Penalty
Summary
The facility failed to ensure timely follow-up and documentation of pharmacy consultant recommendations for one resident. Multiple monthly drug regimen reviews by the pharmacy consultant included recommendations regarding the continued use and reassessment of divalproex, clarification of prednisone dosing, and the addition of diagnoses for certain medications. In each instance, there was no documentation that the physician had been updated or had addressed the recommendations, nor was there evidence of physician signatures on the pharmacy reviews. The facility was unable to provide records showing that these recommendations were communicated to or acted upon by the physician within the required timeframe. The resident involved had an intact cognitive status and was independent with activities of daily living, with diagnoses including adjustment disorder with depressed mood, hypertension, diabetes, anxiety, orthostatic hypotension, repeated falls, and stroke. Interviews with the DON and nurse consultant confirmed the lack of an effective process for organizing and following up on pharmacy consultant medication reviews, as well as the absence of required documentation in the medical record. No relevant policy was provided by the facility during the survey period.
Medication Labeling Discrepancy for Scheduled Tramadol Administration
Penalty
Summary
A deficiency occurred when a resident with intact cognition and multiple medical diagnoses, including a medically complex condition, was observed receiving medication from an LPN. During the medication pass, the LPN retrieved Tramadol HCl 50 mg from the locked medication cart and stated it was administered every eight hours on a routine basis. However, the medication label indicated it was to be given every eight hours as needed, not as a scheduled dose. Review of the electronic medical record and printed orders confirmed the medication was ordered to be given three times daily, not on an as-needed basis. The LPN acknowledged the discrepancy between the medication label and the physician's order, stating that prescription labels should accurately reflect provider orders. The DON confirmed that medication labels are required to match current orders and that staff are expected to verify and request corrections if discrepancies are found. Facility policy directs staff to check medication labels three times to ensure accuracy before administration. Despite these policies, the medication label did not reflect the current physician-ordered administration instructions, creating a risk for administration error.
Failure to Maintain Cleanliness and Temperature Monitoring in Facility and Personal Refrigerators
Penalty
Summary
The facility failed to ensure proper cleanliness, temperature monitoring, and food dating in both a dining room refrigerator and personal refrigerators located in resident rooms. Observations revealed that several personal refrigerators contained undated and unlabeled leftover foods, lacked temperature logs, and in some cases, did not have thermometers. One resident's refrigerator was found to be dirty, containing uncovered and undated juice and a spoiled banana. The dining room refrigerator had incomplete temperature logs, with many days missing entries, and was observed to be unclean, with substances and debris present in the freezer and on the ice dispenser. Staff were unclear about who was responsible for monitoring and cleaning these refrigerators, and there was no established cleaning schedule for the dining room refrigerator. Interviews with facility staff, including the kitchen manager and DON, revealed confusion regarding responsibility for monitoring and maintaining personal refrigerators in resident rooms. The facility's policy on refrigerator and freezer maintenance required daily temperature checks and regular cleaning, but did not address personal refrigerators in resident rooms. The lack of adherence to these procedures resulted in improper food storage and sanitation practices, as well as inadequate monitoring of refrigerator temperatures and food expiration dates.
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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