Good Samaritan Society - Albert Lea
Inspection history, citations, penalties and survey trends for this long-term care facility in Albert Lea, Minnesota.
- Location
- 75507 240th Street, Albert Lea, Minnesota 56007
- CMS Provider Number
- 245441
- Inspections on file
- 23
- Latest survey
- May 13, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Good Samaritan Society - Albert Lea during CMS and state inspections, most recent first.
Kitchen staff failed to properly date-mark, store, and discard food items, with multiple opened or undated foods found in a walk-in refrigerator past the facility’s 7-day limit or otherwise not labeled. Surveyors also observed wet stacked pans, uncovered utensils with crumbs, and staff personal items such as a cell phone, keys, snacks, and drinks in food prep and storage areas. The MNFS-C stated foods should be dated when opened and discarded after 7 days, and acknowledged concerns about contamination.
Failure to provide adequate visual assistance for meal selection. A resident with severe vision loss, including blindness in one eye and macular degeneration in the other, was observed struggling to read a weekly menu using two very small magnifying glasses. Records showed highly impaired vision, but the care plan did not fully reflect the resident’s blindness, and staff interviews showed inconsistent awareness of his needs. The resident stated no one had offered a larger magnifier or helped him select meals, despite a policy requiring accessible communication and assistance for persons with low vision.
The facility did not ensure the high-temperature dishwashing machine consistently reached the required wash and rinse temperatures, as observed by the dietary manager and confirmed by temperature logs and staff interviews. This failure occurred despite facility policy requiring compliance checks and staff notification when temperatures are out of range.
Staff failed to use required PPE, such as gowns or aprons, when sorting soiled laundry, and transported clean resident clothing in uncovered carts, leaving items exposed to dust and dirt. Facility policy required both PPE for soiled laundry handling and covered carts for clean laundry, but these practices were not followed.
A resident with severely impaired cognition and a high risk for falls was found sitting in a recliner with the call light out of reach, contrary to facility policy and the resident's care plan. Staff confirmed that call lights should be accessible unless otherwise documented, but no such documentation existed for this resident.
A resident with severe cognitive impairment and incontinence was left in urine-soaked sheets for several hours, with staff failing to offer toileting or change incontinence products as required by the care plan. Documentation showed long gaps without care, and staff did not consistently re-approach or document refusals, despite facility policy and expectations.
A male resident with severe cognitive impairment and a history of sexually inappropriate behaviors was not adequately supervised, leading to incidents of sexual abuse involving two female residents. The facility failed to update the care plan or implement effective measures to prevent these incidents, resulting in immediate jeopardy for the affected residents.
A facility failed to report an alleged abuse incident involving two residents with dementia in a timely manner. One resident was found in another's bed, possibly attempting to masturbate. The incident was reported to the DON, family, and provider, but the report to the State Agency was delayed by 40 hours due to an initial assessment that it did not require reporting.
A resident, who required assistance with a gait belt for ambulation, fell and fractured their hip when a nursing assistant let go of the gait belt to secure a wheelchair. The resident, who was legally blind and had diabetes, lost balance and fell, resulting in a need for surgical intervention. The incident was initially reported as a slip, but video evidence later showed the care plan was not followed.
The facility failed to implement enhanced barrier precautions for two residents with implanted medical devices. One resident, dependent on staff for daily activities, was assisted by a nursing assistant without the necessary PPE. Another resident's care plan lacked specific instructions for G-tube care, leading an LPN to administer medications without proper PPE. The director of nursing confirmed the need for PPE, which was not followed.
The facility failed to conduct routine weekly skin assessments for two residents with impaired skin integrity. One resident with severe cognitive impairment had inconsistent wound assessments for a non-healing lesion, while another resident with multiple diagnoses had incomplete wound data for a deep tissue injury and a pressure ulcer. Staff interviews revealed that the required twice-weekly assessments were not consistently performed.
A resident with severe cognitive impairment and a non-healing head lesion experienced a lapse in accurate medical record-keeping. Maggots were found in the wound, but documentation was delayed and incomplete. The resident frequently removed dressings, complicating care. Despite observations and treatment attempts, the facility failed to document the extent of the infestation and subsequent monitoring.
Kitchen Food Storage and Sanitation Deficiencies
Penalty
Summary
Food stored in the kitchen refrigerators was not labeled, dated, or discarded in accordance with facility policy and professional standards. During the kitchen tour, surveyors observed opened foods in a walk-in refrigerator that were past the facility’s seven-day window or were undated, including facility-made strawberry frost dated 3/19, chopped red onion dated 4/25, red grapes dated 10/14 with a cloudy whitish/grayish liquid in the bag, Chef Grade hard boiled peeled eggs dated 4/21, lettuce with no date and brown leaves, and an undated sour cream container that was about half full. A sign on the refrigerator stated that all dated food items must be tossed at the end of 7 days. The MNFS-C removed the items and stated foods were to be dated when opened and prepared foods were to be discarded after seven days. The MNFS-C also stated staff date-mark foods when opened with the month and day and do not include the year. Additional kitchen observations showed two stacked stainless steel pans with water on the inner surfaces, three containers of utensils left uncovered on a wire cart with crumbs in one container, and personal items belonging to staff on or in food preparation counters and storage areas, including a cell phone, car keys, a pink mini wallet, a small bag of chips, plastic water bottles, and a thermal mug. A cell phone was also observed in a drawer with utensils. The MNFS-C stated the pans should have been completely dry before stacking and was unaware utensils should be in a drawer or covered container. The FSA-A stated personal items such as cell phones, keys, and snacks were not appropriate in food prep areas and could lead to distractions. The RD-F stated monthly audits had identified staff not dating opened food, and the administrator stated she expected the MNFS-C to oversee the kitchen and ensure staff adhered to policies and regulations.
Failure to Provide Adequate Visual Assistance for Meal Selection
Penalty
Summary
The facility failed to ensure services and assistance were provided to preserve the independence of a resident with highly impaired vision. The resident’s significant change MDS dated 4/16/26 indicated intact cognition, clear speech, and that he was understood and able to understand, but also showed highly impaired vision. The resident was independent in some ADLs, dependent in others, and able to walk short distances such as to the bathroom. His care plan identified impaired visual function related to macular degeneration and stated he could see very large print/newspaper headlines with a magnifying glass and glasses, but it did not identify blindness in his left eye. Records reviewed showed the resident had age-related macular degeneration in the right eye and blindness in the left eye, with later provider documentation noting progressive vision loss, blindness in the left eye from a prior injury, and severe macular degeneration in the right eye. During a care conference, the resident was noted to have blurry vision even with a magnifying glass. A progress note later documented that the social worker met with the resident about referral options for vision services and that the resident voiced interest in a referral to services for the blind. During observation, the resident was seen holding two very small magnifying glasses up to his right eye while trying to read a weekly menu printed in approximately 11-point font; the menu had to be held close to his nose for him to make out one or two words at a time. The resident stated no one had offered him a larger magnifying glass and that no one had ever asked him or helped him make meal selections before. Staff interviews showed inconsistent awareness of his impairment: one NA said staff were supposed to sit with him and go through the menu, while the cook, manager of nutrition and food services, social worker, and DON stated they were not aware of his visual impairment or how he was being assisted. The RN stated the resident used his own small magnifying glass, had not asked for help, and she had not approached him to ask how staff could assist him with meal selection. The facility’s auxiliary aids policy stated that persons who were blind or had low vision would be provided accessible communication and assistance, but the resident’s menu-reading support was not consistently provided or documented.
Failure to Maintain Proper Dishwashing Temperatures in Kitchen
Penalty
Summary
The facility failed to ensure the high-temperature dishwashing machine operated at the required temperatures for effective sanitization. During an observation, the dietary manager (DM) ran several empty dish racks through the machine and consistently recorded wash and rinse temperatures of approximately 140 degrees Fahrenheit, which is below the required 150 degrees for wash and 180 degrees for rinse. The DM also noted a flashing red light on the booster, which was unusual, and stated that maintenance would be notified. Temperature logs indicated that a dietary aide (DA-A) had documented proper temperatures earlier, but during interview, DA-A referenced the dials on the machine and reported temperatures that did not align with the observed readings. The DA-A also described the process for checking temperatures and the protocol for notifying staff if temperatures were out of range. Further observation on the following day showed the dish machine reaching appropriate temperatures, but the initial failure to meet required standards was not addressed before equipment was used. Facility policy requires compliance checks for wash and rinse cycles at each meal service and mandates staff notification if temperatures are outside acceptable parameters. The policy also references the use of an irreversible registering temperature indicator to ensure proper surface temperature is achieved during the rinse cycle, as per the food code.
Failure to Use Appropriate PPE and Cover Clean Laundry During Transport
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices in the handling of both soiled and clean laundry. Observations showed that a laundry aide transported clean resident clothing in an uncovered metal cart and carried multiple shirts by hand and on her arm into resident rooms. The clean clothing was not protected from dust or dirt during transport and delivery. The laundry aide confirmed that this was the standard practice and that the carts used did not have covers. The Ancillary Department Manager also acknowledged that the carts in use were not laundry carts and lacked covers, and that clean laundry was not being adequately protected during transport. Additionally, the facility did not ensure that appropriate personal protective equipment (PPE) was used when sorting soiled laundry. The laundry aide reported that only gloves were used during sorting, and there was no PPE such as gowns or aprons available nearby in the soiled laundry area. The Infection Preventionist and Ancillary Department Manager were both unsure if gowns were required, despite the facility's policy stating that at a minimum, a disposable apron and gloves should be worn when handling soiled laundry. The policy also directed that clean clothes should be transported and stored in a manner that reasonably protects them from dust and soil, and that clean linen carts should be covered at all times during storage and distribution.
Failure to Ensure Call Light Accessibility for High-Risk Resident
Penalty
Summary
The facility failed to ensure that a resident identified as high risk for falls had their call light within reach, as required by facility policy. The resident had a history of chronic kidney disease, altered mental status, severely impaired cognition, and a history of falls, and was assessed as high risk for falls. The care plan included interventions such as reminding the resident to call for staff assistance and ensuring the call light was accessible. However, during observation, the call light was found removed from the wall and placed on a bedside table, out of the resident's reach while she was sitting in a recliner at the back of the room. Staff interviews confirmed that call lights should always be placed within easy reach of residents unless a specific preference is documented, which was not the case for this resident. The facility's policy also required that call lights be accessible to residents at all times. The failure to ensure the call light was within reach was verified by both nursing and administrative staff, and there was no documentation indicating the resident had requested the call light be placed elsewhere.
Failure to Provide Timely Incontinence Care and Document Refusals
Penalty
Summary
The facility failed to provide timely incontinence care for a resident with severely impaired cognition, dementia, and epilepsy, who was frequently incontinent of bladder and always incontinent of bowel. The resident's care plan required staff to check and change incontinence products every shift and as needed, maintain consistency in ADL routines, and re-approach the resident if care was refused, documenting each refusal. Despite these interventions, continuous observation revealed that the resident remained in urine-soaked sheets for an extended period, with a strong odor of urine present in the room, and staff did not offer toileting or change the resident's clothing or bedding during multiple interactions over several hours. Documentation in the facility's electronic health record indicated that the resident had only been toileted three times during the day in question, with no record of toileting or incontinence care for approximately eight hours. Staff interviews confirmed that the expectation was to offer toileting and check/change incontinence products every two hours, even if the resident refused, and to document each refusal. However, staff failed to follow these protocols, as evidenced by the lack of documented offers and the resident remaining in soiled conditions for an extended period. Family and staff interviews further corroborated that the resident would not have wanted to remain in urine-soaked clothing or bedding, and that staff were aware of the need to re-approach and document refusals. The facility's policy required necessary services for residents unable to perform ADLs, including maintaining personal hygiene. The observed failure to provide timely incontinence care and to document care refusals as required led to the identified deficiency.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect two female residents from sexual abuse and inappropriate behaviors by a male resident. The male resident, who had severe cognitive impairment and a history of wandering, displayed sexually inappropriate behaviors towards staff and other residents. These behaviors included exposing himself, making sexual advances, and inappropriate touching. Despite these behaviors being documented in progress notes, the facility did not notify the physician promptly or update the resident's care plan to address the risk to other residents. The male resident's inappropriate behaviors escalated, leading to two incidents involving female residents. In one incident, the male resident was found in bed with a female resident, possibly attempting to masturbate. In another incident, he was found in a common area touching another female resident inappropriately. Both female residents had severe cognitive impairments and were unable to protect themselves or report the abuse effectively. The facility's interventions, such as placing a mesh stop sign banner and conducting more frequent checks, were insufficient to prevent these incidents. The facility's lack of a comprehensive assessment and failure to implement effective measures to supervise the male resident contributed to the incidents. The interventions in place were not adequately assessed for their effectiveness, and the facility did not ensure that the male resident was supervised to prevent further inappropriate behaviors. The facility's actions were deemed insufficient, resulting in an immediate jeopardy situation for the affected residents.
Removal Plan
- The facility implemented a plan to ensure R3 had direct 1:1 supervision.
- All nursing staff were provided with education and expectations pertaining to R3's care plan interventions and supervision.
- Audits have been initiated to ensure R3 had direct 1:1 supervision.
- Facility updated R1, R2, and R3's care plan and provided education to staff on changes and updates.
Delayed Reporting of Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse in a timely manner to the State Agency for one of the residents reviewed for allegations of abuse. The incident involved two residents, both diagnosed with dementia. One resident was found lying next to another in bed, with the former possibly attempting to masturbate. The incident was discovered by an LPN who responded to a call light and found the resident in question with his pants halfway down. The LPN notified the Director of Nursing (DON), the family, and the provider about the incident. Despite the facility's policy requiring allegations of abuse to be reported within 24 hours if there is no serious bodily injury, the report was submitted approximately 40 hours after the incident. The delay occurred because the DON and regional clinical service nurse initially determined that the incident did not need to be reported due to the absence of willful intent or injury. However, after further discussion, the administrator instructed the DON to submit the report to the State Agency, which was then finalized and submitted two days after the incident.
Failure to Follow Care Plan Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide safe transfers and adhere to the care plan for a resident, resulting in a fall and a left hip fracture that required surgical intervention. The resident, who was legally blind and had diabetes, required one staff assist with a gait belt for ambulation. On the day of the incident, a nursing assistant (NA) was assisting the resident from the bathroom to a wheelchair using a gait belt. The NA let go of the gait belt to secure the wheelchair, causing the resident to lose balance and fall, hitting their head and expressing pain in the hip. The incident was initially reported as a slip by the NA, and the care plan was believed to have been followed. However, a video later revealed that the NA had let go of the gait belt, leading to the fall. The director of nursing (DON) and the administrator reviewed the video with the resident's family, confirming the lapse in following the care plan. The facility's policy required staff to maintain hold of the gait belt until the resident was safely seated, which was not adhered to in this case.
Removal Plan
- Re-educate all staff on safe transfers and expectations for using the gait belt during transfers.
- Check the Kardex/care plan prior to assisting residents with mobility, including transfers and/or ambulation.
- Ensure the Kardex/care plan includes use of gait belt for transfers/ambulation, and staff hold on to the gait belt until the resident is safely seated on the destination surface.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBPs) for two residents with implanted medical devices, leading to a deficiency in infection prevention and control. Resident R4, who was dependent on staff for all activities of daily living and had a supra pubic catheter and ostomy, required staff to wear gowns and gloves during high-contact care activities. However, during an observation, a nursing assistant (NA-E) assisted another nursing assistant (NA-M) in transferring R4 without wearing the necessary personal protective equipment (PPE), despite the supplies being readily available. Similarly, Resident R6, who had an indwelling urinary catheter and a feeding tube, required EBPs during high-contact care activities. However, the care plan did not specify the need for EBPs during G-tube care and medication administration. An LPN was observed administering medications via the feeding tube without wearing a gown and initially without gloves, indicating a lack of awareness of the need for PPE in such situations. The director of nursing confirmed that PPE should be worn as per facility policy, which was not adhered to in these instances.
Failure to Conduct Routine Weekly Skin Assessments
Penalty
Summary
The facility failed to ensure routine weekly skin assessments for two residents with impaired skin integrity. Resident 1, who had severe cognitive impairment and a non-healing lesion on the top of his head, did not receive consistent weekly comprehensive wound assessments. The care plan for Resident 1 included monitoring the location, size, and treatment of the skin injury, but the record showed missed weekly measurements on several dates. The wound data collection lacked initial measurements and descriptions, and the clinical manager acknowledged missing measurements due to her absence. Resident 2, diagnosed with hemiplegia, hemiparesis, and other conditions, had a suspected deep tissue injury on the right great toe and a stage 3 pressure ulcer on the left lower leg. The care plan required daily and weekly wound assessments, but the wound data collection did not consistently include descriptions or measurements. Missed assessments were noted on specific dates. Interviews with staff revealed that wounds were supposed to be assessed twice weekly, but this protocol was not followed consistently, leading to the deficiency.
Failure to Maintain Accurate Medical Records for Wound Management
Penalty
Summary
The facility failed to maintain accurate medical records for a resident with severe cognitive impairment and a non-healing lesion on the head. The resident's care plan required monitoring of the lesion, but a change in the skin condition was identified on July 8, 2024, and not documented until July 10, 2024. During this period, maggots were found in the wound, and the family was notified, but the time of notification was not recorded. The nurse practitioner was informed, and the lesion was irrigated, but there was no documentation of the extent of the maggot infestation or subsequent monitoring. Interviews revealed that the resident frequently removed dressings, complicating wound management. A nursing assistant noted the dressing was intact on the morning of July 8, 2024, but a registered nurse found maggots during a dressing change. The clinical manager confirmed the presence of maggots and attempted treatment without initial orders. Despite these observations, there was a lack of documentation regarding the treatments and findings. The assistant director of nursing acknowledged the importance of timely documentation, which was not adhered to in this case.
Latest citations in Minnesota
A resident with intact cognition and multiple diagnoses, including AFib, HF, stroke, anxiety, and depression, was permitted to self-administer nebulizer treatments after staff setup without an IDT self-administration assessment. The EMR lacked documentation of the resident’s competency and safety to manage the nebulizer, including understanding the medication, following directions, operating the equipment, recognizing side effects, and storing the medication and equipment. Staff and the DON confirmed the assessment had not been completed before the self-administration order was implemented.
Failure to Assess and Monitor Antipsychotic Use: A resident with severe cognitive impairment, dementia, anxiety, and mood disorder received Risperidone for agitation and paranoia, but the EMR did not show an AIMS assessment on admission or timely target behavior monitoring. The RN case manager and DON confirmed that baseline AIMS and ongoing behavior monitoring should have been in place when the antipsychotic was started, but the resident’s record lacked measurable target behaviors and documentation of medication effectiveness.
Incomplete Care Plans for Anticoagulant Therapy and Cardiac-Related Needs: The facility failed to include key diagnoses, devices, and medication-related risks in care plans for two residents. One resident’s plan did not address Eliquis use, cardiac conditions, pacemaker presence, or condom catheter care, and another resident’s plan did not address Eliquis therapy or related bleeding-risk monitoring. The DON and RN case manager confirmed these items should have been care planned.
Failure to provide scheduled bathing and grooming assistance: Two residents with intact cognition and ADL dependence did not receive bathing as documented on a weekly schedule, and one resident also had unaddressed facial hair and greasy, unkempt hair. Records did not show consistent weekly baths, additional refusals, or reasons for missed care, and staff interviews confirmed residents were expected to receive at least weekly bathing unless they refused and that facial hair should be shaved when noticed.
A resident with intact cognition and multiple diagnoses, including BPH and stroke, had a physician order for a condom catheter at bedtime, but the EMR lacked orders or instructions for cleaning, disinfecting, monitoring, or changing the drainage bag. During observation, the bag was seen hanging in the bathroom, and an LPN, RN case manager, and DON all confirmed the absence of documented guidance for the catheter drainage bag care.
Failure to preserve dignity occurred when staff placed a brief on a cognitively intact resident who was continent of bowel and bladder. The resident stated the brief made him feel like a baby, and a NA confirmed she applied it even though he was not incontinent; RN and DON both verified the resident was continent and that briefs should not be placed on continent residents.
Failure to provide restorative ambulation and respond to a decline in mobility: A resident with dementia, weakness, chronic pain, and limited physical mobility was care planned for daily ambulation with a FWW and staff assist of 1, but the rehab record repeatedly showed ambulation as not applicable and staff interviews confirmed the task was often not done. The resident stated she could no longer walk, staff reported she had not walked for weeks and now required a sit-to-stand lift with assist of 2 for transfers, and the chart lacked an ADL decline assessment or revision of the ambulation care plan.
A resident with mild cognitive impairment, hemiplegia, hemiparesis, and limited ROM had restorative orders for PROM, stretching, and hand splints, but staff did not consistently offer or complete the interventions. Documentation showed the splints were sometimes marked not applicable instead of refused, and leg stretches were completed only a few times with no explanation for missed care. Staff interviews confirmed the restorative tasks often were not done, and the DON stated the resident’s restorative program needed to be updated.
Dirty can opener and contaminated dry storage bins: The DCS observed four labeled dry-goods bins with dirty rims, dry matter on the bin walls, and a scoop left inside a flour bin with flour on it. The attached can opener also had dry red matter on the blade, and the cook said it had been used that morning to open cream of corn for lunch. The DCS verified the findings and stated the can opener should be washed after each use and the dry bins and scoops should be kept clean.
Dignified Medication Administration Not Maintained: A resident with severe dementia, hallucinations, anxiety, PTSD, and delusional disorder was observed during med pass in the dining room. An RN attempted to administer meds by pouring them from a plastic cup into the resident’s mouth, continued despite the resident pulling away and moving her head, and then raised her voice and questioned why the resident would not take the meds after one pill was spit out and thrown on the floor. The resident stated the nurse was not being nice, and the RN left with the refused meds.
Missing Self-Administration Assessment for Nebulizer Use
Penalty
Summary
The facility failed to ensure an interdisciplinary team (IDT) assessment was completed before allowing a resident to self-administer nebulizer treatments. The resident had intact cognition and required assistance with ADLs, and diagnoses included atrial fibrillation, heart failure, BPH, stroke, malnutrition, anxiety disorder, and depression. Physician orders showed Ipratropium-Albuterol nebulizer treatments three times daily, and the EMR later included an order permitting the resident to self-administer nebulizer treatments after staff setup, but there was no evidence that an IDT self-administration assessment had been completed first. The record also lacked documentation showing the resident’s competency and safety to self-administer the nebulizer medication and treatment, including the ability to understand the medication purpose, follow directions, safely operate the equipment, recognize side effects or adverse reactions, and ensure safe administration and storage. During observation, the resident had nebulizer equipment and medication available in the room. The resident stated staff set up the medication cup and left while the treatment ran, then returned to ensure the machine was turned off; staff cleaned the nebulizer mask afterward. An LPN and RN confirmed the treatment was set up by staff, and the RN and DON stated a self-administration assessment should have been completed before the resident was permitted to self-administer medications.
Failure to Assess and Monitor Antipsychotic Use
Penalty
Summary
The facility failed to ensure that a resident receiving psychotropic medications was adequately assessed and monitored. R3’s admission MDS identified severe cognitive impairment and the need for assistance with ADLs, with diagnoses including non-traumatic brain dysfunction, unspecified dementia without behavioral, psychological, mood, or anxiety disturbances, non-Alzheimer’s dementia, anxiety disorder, and mood affective disorder. The resident’s physician orders included Risperidone 0.25 mg, two tablets by mouth every four hours PRN for agitation and paranoia, with a maximum of three PRN doses in 24 hours, and Risperidone 0.5 mg, one tablet by mouth three times daily for paranoia/agitation. R3’s EMR did not show that an AIMS assessment was completed upon admission despite the resident receiving antipsychotic medication, and the assessment was only completed after surveyor request. The record also lacked evidence that target behavior monitoring had been initiated for the antipsychotic use, with no measurable target behaviors documented, including frequency, duration, severity, precipitating factors, or response to interventions for agitation and paranoia. Interviews with the RN case manager and DON confirmed that AIMS assessment and behavior monitoring should have been completed upon admission or initiation of antipsychotic medications, and both acknowledged that target behavior monitoring had not been initiated.
Incomplete Care Plans for Anticoagulant Therapy and Cardiac-Related Needs
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents with significant medical conditions and medication-related needs. One resident had intact cognition and diagnoses including atrial fibrillation, heart failure, BPH, stroke, malnutrition, anxiety disorder, depression, and a cardiac pacemaker, and was receiving Eliquis. The resident also had a physician order for a condom catheter at bedtime and removal when getting up for the day. The comprehensive care plan printed 5/20/26 did not identify interventions or monitoring related to anticoagulant use, including bleeding risk, adverse effect monitoring, or staff awareness of anticoagulant precautions, and it also lacked interventions related to the resident’s cardiac conditions, pacemaker, and condom catheter use, including skin integrity monitoring and resident-specific catheter care preferences. A second resident with severe cognitive impairment and diagnoses including non-traumatic brain dysfunction, unspecified dementia, non-Alzheimer’s dementia, anxiety disorder, and mood affective disorder was also receiving Eliquis. The resident’s comprehensive care plan printed 5/19/26 did not include anticoagulant therapy, bleeding risk precautions, monitoring for adverse effects, or other interventions related to anticoagulant medication use. During interviews, the RN case manager and DON confirmed that anticoagulant therapy, the condom catheter, cardiac conditions, and pacemaker presence should have been addressed on the care plans and acknowledged that these items were not included.
Failure to Provide Scheduled Bathing and Grooming Assistance
Penalty
Summary
The facility failed to ensure that two residents who required assistance with activities of daily living received routine bathing and grooming services needed to maintain personal hygiene and dignity. R2’s MDS identified intact cognition and a need for ADL assistance, and the care plan directed staff to assist with dressing, grooming, bathing, and oral care while honoring personal hygiene preferences. R21’s MDS also identified intact cognition and a need for ADL assistance, and the care plan directed staff to assist with dressing, grooming, bathing, and oral care. R2’s bathing record showed a weekly bathing schedule, but the documentation did not show bathing was completed every week as scheduled. Baths were documented on several dates, but the time between some baths exceeded one week, and the record did not show additional refusals or reasons why scheduled baths were missed. During observation, R2’s hair was messy and greasy, and long white chin hairs were present. R2 stated she did not get baths very often because the facility was short staffed and said she did not have access to tweezers, a shaver, or a mirror. The EMR did not document that grooming assistance had been offered or provided for facial hair care. R21’s bathing record also showed a weekly bathing schedule, but the documentation did not show bathing was completed every week as scheduled. The record showed one refusal and several baths, but some intervals between baths exceeded one week, and there was no documentation of additional refusals or reasons for missed baths. R21 stated she had been in the facility since mid-April and had yet to have a bath or shower, and said staff were waiting for physician approval because of wounds, though that had been a while. R21 also stated she had only had her hair washed once with a shampoo shower cap while in bed. Staff interviews confirmed residents were expected to receive at least one bath weekly unless they refused, refusals should be documented, and facial hair should be addressed when noticed.
Missing Orders and Documentation for Condom Catheter Drainage Bag Care
Penalty
Summary
The facility failed to ensure appropriate care and services were provided for management of a resident’s external urinary catheter system. The resident had intact cognition and required assistance with ADLs, and diagnoses included atrial fibrillation, heart failure, BPH, stroke, malnutrition, anxiety disorder, and depression. Physician orders dated 4/29/26 indicated use of a condom catheter at bedtime, but the electronic medical record did not contain physician orders or documented instructions for cleaning, disinfecting, monitoring, or routinely changing the associated catheter drainage bag. During observation on 5/19/26 at 11:57 a.m., the resident’s catheter drainage bag was seen hanging on the side rail in the bathroom. Record review and observation did not identify documentation that the drainage bag was routinely cleaned, disinfected, monitored, or replaced according to accepted standards of practice. An LPN confirmed there were no physician orders addressing when the drainage bag should be changed or instructions for cleaning or disinfecting it. An RN case manager stated the drainage bag should have been changed weekly, but no orders related to changing, cleaning, or disinfecting were present. The DON stated the facility expected clear physician orders and nursing instructions for catheter care, cleaning, monitoring, and replacement schedules, and confirmed the facility could not provide evidence that such orders or guidance were in place for the resident’s condom catheter drainage bag care.
Failure to Preserve Dignity by Placing a Brief on a Continent Resident
Penalty
Summary
The facility failed to provide services in a dignified manner for 1 resident who was cognitively intact and had diagnoses including renal insufficiency, DM, and hypertension. The resident’s MDS identified him as continent of bowel and bladder and needing staff assistance with ADLs including bed mobility, transfers, and toileting. A bowel and bladder assessment also identified the resident as continent, and the care plan stated he was aware of the need to void or defecate and would request to use the toilet as needed. During interview, the resident stated staff put diapers on him even though he was not incontinent and said it made him feel like a baby. During observation, a NA placed a brief on the resident, and the resident showed the surveyor the brief and stated it had just been put on him a few minutes earlier. The NA verified she placed a brief on the resident that morning even though he was not incontinent and said she was unsure why she did so. RN-A confirmed the resident was continent and stated staff put a brief on him out of habit. The DON stated staff should not place a brief on residents who are continent and that it was important to maintain the resident’s dignity.
Failure to Provide Restorative Ambulation and Address Decline in Mobility
Penalty
Summary
The facility failed to provide restorative ambulation services and failed to respond to a decline in ambulation status for one resident who had mild cognitive impairment, dementia, hypertension, diabetes, weakness, and chronic pain. The resident’s care plan and restorative documentation directed daily ambulation with a front wheeled walker and staff assistance of one, and the resident was also identified as having limited physical mobility and being at risk for falls due to weakness, chronic pain, and an unsteadied gait and balance. However, the nursing rehab point-of-care record repeatedly documented ambulation as “not applicable,” with only one entry showing the resident ambulated for 15 minutes and one entry showing refusal. The resident stated she could no longer walk and that staff needed to help her get into bed and her wheelchair. Staff interviews confirmed the ambulation task was not being completed. A nursing assistant stated aides were responsible for ambulation but were not completing it, and another nursing assistant stated ambulation was supposed to be done but was not done very often; that staff documented it as not applicable when it did not get done; and that the resident had not walked at all for several weeks and was using a sit-to-stand lift with assist of two for all transfers. An RN stated the task just did not get done and that no plan had been created to fix it. The DON stated the resident’s condition had changed and a therapy evaluation should have been requested, and also stated the care plan needed revision because the resident would not be transferred with an assist of one. The resident’s medical record lacked an assessment for ADL decline, including any revision to the ambulation care plan.
Failure to Complete and Document Restorative ROM and Splinting
Penalty
Summary
The facility failed to ensure range of motion (ROM) was completed in accordance with therapy recommendations to maintain mobility for one resident with mild cognitive impairment who was dependent on staff for all care areas and had diagnoses including diabetes, hemiplegia, and hemiparesis. The resident’s care plan identified limited physical mobility, fall risk, weakness, contractures, and limited ROM, and included restorative nursing interventions for bilateral lower extremity passive ROM to active ROM, passive hamstring and heel cord stretches, PROM to both hands, and splint use for the hands. The resident’s restorative documentation from 4/20/26 through 5/19/26 showed the hand splints were worn 41 times and marked not applicable 20 times out of 90 opportunities, but the documentation did not identify refusals to wear the splints. The leg stretches were completed 3 times out of 30 opportunities, and the documentation did not identify why the stretches were not performed or whether they were refused. The resident’s untitled nurse aide care sheet also identified a restorative program and encouragement to participate in the Well Fit program. During interviews, a nursing assistant stated staff were supposed to encourage participation in the Well Fit program and complete PROM and AROM, but it did not get done very often and was often documented as not applicable because it was not offered. An RN stated nursing assistants were responsible for restorative programs but they did not get done, and no plan had been created to fix the issue. The DON stated staff should have offered the tasks and documented refusals, but believed staff may have stopped offering after repeated refusals; the DON also stated the restorative program needed to be updated and that staff were documenting tasks as not applicable, which she was unaware of.
Dirty can opener and contaminated dry storage bins
Penalty
Summary
The facility failed to keep 1 of 1 commercial can opener clean and sanitary and failed to store dry goods removed from original packaging in a manner that reduced the risk of cross-contamination. During an initial tour with the Director of Culinary Services (DCS), four white plastic bins in the food preparation area were observed on the floor and labeled for flour, white sugar, rice, and powdered sugar. The flour bin was about one-third full and had a black scoop partially covered with flour, including the handle. The bin labeled white sugar had yellowish-tan dry matter on the right lateral wall, and the front wall had red dry matter measuring 6-7 cm in diameter. The rims around the lids of all four bins were dirty with dark dust-like particles, and the DCS verified these findings and stated the scoop should not be left inside the bins and needed to be clean inside and out. The attached [NAME] brand can opener was also observed with its blade halfway covered with dry, red-colored matter. On a later kitchen tour, the can opener blade still had dry red matter, which had been pushed upward by 0.2 cm, and a small light amber particle was noted below it. The cook stated he had used the can opener that morning to open a can of cream of corn used for lunch. The DCS verified the dry matter on the can opener and stated it should be washed every time it was used to prevent cross contamination. Facility policy stated dry storage areas would be maintained to keep food safe and free of infestation or contamination, and the sample cleaning schedule stated can openers should be clean after each use.
Dignified Medication Administration Not Maintained
Penalty
Summary
The facility failed to provide a dignified experience for 1 of 2 residents, R20, during medication administration. R20’s records showed severely impaired cognition, inattention, disorganized thinking, verbal behaviors toward others, and diagnoses including severe dementia with psychotic disturbance, visual hallucinations, generalized anxiety disorder, PTSD, and delusional disorder. Her care plan identified mood, behavior, and sleep alterations related to Alzheimer’s disease, dementia, generalized anxiety disorder, paranoia, public outbursts, and accusations that people were throwing medications down her throat, and it directed staff to redirect and reapproach when she was resistive or combative, use a calm approach, provide reassurance, and offer comfort items. During observation, RN-A brought medications to R20 in the dining room and attempted to pour them from a small plastic cup into her mouth. When R20 removed one medication, Divalproex, and threw it on the floor, RN-A attempted again to pour the remaining medications into her mouth while R20 moved her head back and forth and tried to pull away. RN-A then raised her voice, stated the resident’s name, told her she needed to take her medications, pulled her chair back from the table, picked up the Divalproex from the floor, placed it in a separate cup, and asked why she would not take her medications. R20 responded that it was because the nurse was not being nice. RN-A then left with the remaining refused medications and stated R20 would take them later and that she always had a behavior when taking her morning medications.
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