Good Samaritan Society - Blackduck
Inspection history, citations, penalties and survey trends for this long-term care facility in Blackduck, Minnesota.
- Location
- 172 Summit Avenue West, Blackduck, Minnesota 56630
- CMS Provider Number
- 245600
- Inspections on file
- 20
- Latest survey
- October 31, 2025
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Good Samaritan Society - Blackduck during CMS and state inspections, most recent first.
A resident with multiple medical conditions and at moderate risk for pressure sores had inconsistent wound documentation, including varying descriptions and stages of pressure ulcers. An RN coded the MDS based on incomplete and conflicting nursing data, resulting in inaccurate staging of the resident's pressure ulcers.
A resident admitted with a pressure ulcer and at moderate risk for further skin breakdown did not have a baseline care plan developed to address pressure ulcer management. Multiple wounds were documented, but the care plan lacked specific interventions and instructions for pressure-relieving devices and wound care. The DON confirmed that required steps to link assessments to the care plan were not completed, resulting in incomplete care planning.
Two residents at risk for pressure ulcers did not receive ongoing and accurate wound assessments, with incomplete documentation and inconsistent implementation of interventions. One resident with multiple wounds and incontinence was frequently found uncleaned, while another high-risk resident had gaps in wound assessments and lacked regular skin checks. Facility policy requiring weekly evaluations and clear staff direction was not followed.
The facility failed to maintain sanitary conditions in the kitchen's dry storage, affecting all 29 residents. During a tour, a dented can and improperly managed plastic bins with opened bags of food were found. The food service manager acknowledged the lack of proper dating and closure of bags and noted the absence of formal direction for maintaining the dry storage area.
The facility failed to conduct ongoing quality assessment and assurance activities, impacting all 29 residents. It did not track infectious symptoms or implement timely precautions for COVID-19 and human metapneumovirus. The infection preventionist did not maintain the infection control program, and the administrator acknowledged a lack of training for the responsible RN. The QAPI plan lacked a continuous infection prevention program.
The facility failed to track and manage infectious symptoms, leading to inadequate implementation of transmission-based precautions and testing for respiratory illnesses. Several residents with symptoms of COVID-19 and HMPV were not properly isolated or tested, and staff interviews revealed confusion and inconsistency in following infection prevention protocols.
The facility failed to ensure a qualified infection preventionist was in place, affecting all residents, staff, and visitors. The Director of Nursing was on extended leave, and responsibilities were delegated to an RN without adequate training. This led to failures in tracking infectious symptoms and implementing precautions for residents with COVID-19 and HMPV. The administrator assumed tasks were completed based on dashboard presentations, but there was no plan to ensure proper training and support.
A facility failed to notify the Office of Ombudsman for LTC about a resident's hospital transfers. The resident, who had no cognitive impairment, was transferred to the hospital twice and returned without the required notification. The business office coordinator was unaware of the notification requirement, and the director of nursing confirmed the oversight. The facility's policy mandated such notifications.
A resident was hospitalized, and the facility failed to provide a written bed hold policy notice to the resident or their representative. The resident's family was informed of the hospitalization, but there was no documentation of the bed hold policy being communicated. Staff interviews confirmed the lack of verification and documentation, despite the facility's policy requiring such notice at the time of transfer.
Inaccurate MDS Coding for Pressure Ulcer Staging
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) was accurately coded to reflect the correct staging of pressure ulcers for a resident. The resident, who was admitted with diagnoses including dehydration, Parkinson's disease, anxiety, and weakness, was assessed as being at moderate risk for pressure sores according to the Braden Scale. Multiple wound assessments documented varying descriptions and stages of pressure ulcers, including an unstageable ulcer on the left buttock, a wound on the left iliac crest with tunneling and purulent drainage, and a stage I ulcer on the left buttock. There were inconsistencies in the wound documentation, such as incomplete wound characteristics and discrepancies in wound staging and descriptions across different assessments. During an interview, an RN responsible for coding the MDS stated that she relied on the nursing data collection, which indicated an unstageable pressure ulcer on admission, leading her to code it as such. The RN also acknowledged issues with the facility's wound charting. These actions and documentation inconsistencies resulted in the MDS not accurately reflecting the resident's pressure ulcer status, constituting a deficiency in the facility's assessment process.
Failure to Develop Baseline Care Plan for Pressure Ulcers
Penalty
Summary
The facility failed to develop a baseline care plan related to pressure ulcers for one resident who was admitted with an existing pressure ulcer and subsequently developed additional pressure ulcers. Upon admission, the resident had diagnoses including dehydration, Parkinson's disease, anxiety, and weakness, and was assessed as being at moderate risk for pressure sores according to the Braden Scale. Multiple wound assessments documented the presence of an unstageable decubitus ulcer on the left buttock, a wound on the left iliac crest with purulent drainage and tunneling, and later, a stage I pressure ulcer on the left buttock and a wound on the coccyx. The care plan identified a self-care deficit and potential impairment to skin integrity, but lacked specific instructions regarding pressure-relieving devices, their frequency of use, and did not specify interventions for all identified wounds. Interviews and document reviews revealed that the baseline care plan was not properly developed or implemented. The DON acknowledged that the initial care plan was created with assessments, but indicated that nurses did not complete the necessary steps to link interventions to the care plan. The facility's policy required individualized, person-centered care plans to address identified problems and needs, but this was not followed in the resident's case, resulting in incomplete documentation and lack of clear, actionable interventions for pressure ulcer management.
Failure to Perform Ongoing and Accurate Pressure Ulcer Assessment and Prevention
Penalty
Summary
The facility failed to perform ongoing and accurate assessment of pressure ulcers for two residents who were at risk for pressure ulcer development. For one resident with diagnoses including dehydration, Parkinson's disease, anxiety, and weakness, the Braden Scale indicated a moderate risk for pressure ulcers. Upon admission, this resident had multiple wounds, including a dehisced scar, an unstageable ulcer on the left buttock, and a scratch on the arm. Wound assessments documented changes in wound status, including the development of new pressure ulcers and worsening of existing wounds, but lacked consistent and complete documentation of wound characteristics, frequency of assessments, and specific interventions. The care plan and Kardex lacked clear directions for staff regarding mobility, transfers, repositioning, and toileting frequency, despite the resident's incontinence and need for assistance. Progress notes and interviews revealed that the resident was often found incontinent and not cleaned up, with reports of frequent exposure to feces and the development of additional sores during the facility stay. Another resident with diagnoses of dementia, heart disease, pain, and a history of falls was also identified as high risk for pressure ulcers based on the Braden Scale. The care plan directed staff to check for incontinence every two to three hours and to assist with frequent repositioning, but wound assessments were not consistently completed. There was a lack of documented wound assessments for a period of over three weeks, despite the presence of a pressure ulcer on the sacrum and an open area on the coccyx. Staff interviews confirmed that wound charting was inconsistent, and the facility did not have a process for regular wound rounds. The DON acknowledged that skin checks were supposed to be completed weekly but were not being done for this resident. Facility policy required that pressure ulcers be evaluated at least weekly, with RNs responsible for recording wound type and degree of tissue damage, and licensed nurses documenting location, measurements, and characteristics. However, the facility failed to adhere to these requirements, resulting in incomplete and infrequent wound assessments, lack of clear staff direction, and insufficient implementation of interventions to reduce the risk of new or worsening pressure ulcers for residents at risk.
Deficiency in Kitchen Dry Storage Sanitation
Penalty
Summary
The facility failed to maintain clean and sanitary conditions in the dry storage area of the kitchen, which had the potential to affect all 29 residents. During an initial tour, a dented can of tomato juice was found on the shelf, and two large covered plastic bins were improperly managed. One bin contained an opened 50 lb bag of cake mix with a gaping top, and the cover was left open. The second bin had its cover lying on a rack shelf, with two 50 lb opened bags inside, including a bag of biscuit mix with no opening date and a bag of sweet cornbread mix opened on 2/15/24. The kitchen staff member present was unaware of how long the items were good for, how often they were used, or if the cover should be on, and did not know who was responsible for the dry storage area. The food service manager (FSM) confirmed the lack of proper dating and closure of the bags and acknowledged that dented cans should be removed immediately. The FSM, who had been in the role for approximately six months, was working to standardize practices but noted that there was no formal direction for maintaining the dry storage area. The facility's cleaning policies did not include specific procedures for dry storage sanitation, and the existing policies on food supply storage and general sanitation did not adequately address the maintenance of a clean and sanitized dry storage area.
Failure in Infection Prevention and Quality Assurance Activities
Penalty
Summary
The facility failed to conduct ongoing quality assessment and assurance activities, and did not develop or implement appropriate plans of action to correct quality deficiencies identified during the survey. This failure had the potential to adversely affect all 29 residents residing in the facility. Specifically, the facility did not perform timely tracking and trending of potential infectious symptoms to prevent the spread of transmissible organisms. The facility also failed to implement timely transmission-based precautions and testing for COVID-19 according to CDC guidelines for four residents who were displaying COVID-19 symptoms, and did not implement timely precautions for two residents confirmed to have human metapneumovirus. The infection preventionist at the facility did not adequately assess, develop, implement, monitor, and maintain the infection prevention and control program, which had the potential to affect all residents, staff, and visitors. During an interview, the administrator acknowledged that the director of nursing, who was previously responsible for the infection prevention program, had delegated responsibilities to a registered nurse without ensuring the nurse received adequate training or support. The facility's Quality Assurance Performance Improvement plan did not include a plan for a continuous infection prevention program, indicating a disconnect between the assumed and actual understanding of infection prevention responsibilities.
Inadequate Infection Control and Documentation
Penalty
Summary
The facility failed to perform timely tracking and trending of potential infectious symptoms, which led to a deficiency in preventing the spread of transmissible organisms. This included a failure to implement timely transmission-based precautions (TBP) and testing for respiratory illnesses according to CDC guidelines for four residents displaying COVID-19 symptoms and two residents confirmed to have human metapneumovirus (HMPV). The infection logs failed to identify residents not treated with antimicrobials, and there was a lack of documentation regarding confirmatory COVID-19 tests and isolation measures for symptomatic residents. Several residents exhibited symptoms of respiratory illnesses, but their medical records did not reflect appropriate testing or isolation measures. For instance, one resident with a nonproductive cough and afebrile status was not placed in isolation, and there was no record of a confirmatory COVID-19 test. Another resident with cold symptoms and chest congestion was transferred to the emergency department after experiencing hypoxic respiratory failure due to HMPV, yet there was no documentation of isolation upon return to the facility. Similar lapses were noted for other residents, indicating a systemic issue in managing infectious symptoms. Interviews with facility staff revealed confusion and inconsistency in following infection prevention protocols. The Infection Prevention (IP) nurse was unsure of expectations and faced challenges in getting staff to use clinical monitoring forms. The Director of Nursing (DON) was unaware of CDC guidance for confirmatory testing and isolation, and staff interviews highlighted a lack of adherence to facility policies and CDC guidelines. The facility's infection prevention and control program was not effectively implemented, as evidenced by the absence of documentation and tracking of viral illnesses since January 2024.
Inadequate Infection Preventionist Training and Oversight
Penalty
Summary
The facility failed to ensure there was a qualified infection preventionist (IP) to adequately manage the infection prevention and control program, which had the potential to affect all 29 residents, staff, and visitors. The deficiency was identified through interviews and document reviews, revealing that the Director of Nursing (DON), who was initially responsible for the infection prevention program, had been on extended leave. During this period, the responsibilities were delegated to a registered nurse (RN-A) who had not received adequate training or support to fulfill the role effectively. The IP lead was unaware of this delegation and RN-A was not included in the training list, indicating a lack of communication and oversight. The facility's infection prevention and control program policy required the designation of a qualified individual to manage the program, which was not adhered to. The report highlighted specific failures, such as the lack of timely tracking and trending of infectious symptoms and the implementation of transmission-based precautions for residents displaying COVID-19 symptoms and those confirmed with human metapneumovirus (HMPV). Interviews with the DON, RN-A, and the administrator revealed that RN-A's only training was the corporate annual in-service and CDC Nursing Home Infection Preventionist Training, which was insufficient for the role. The administrator assumed infection prevention tasks were completed based on dashboard presentations at quality assurance meetings, but there was no plan to ensure RN-A received necessary training and support.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to notify the Office of Ombudsman for Long-Term Care (OOLTC) regarding a facility-initiated transfer of a resident to the hospital. The resident, identified as R14, had no cognitive impairment according to their quarterly Minimum Data Set. The resident was admitted to the hospital on two occasions, once on 2/29/24 and again on 3/20/24, and returned to the facility each time. However, there was no evidence that the OOLTC was notified of these transfers. During interviews, the business office coordinator (BOC) stated that they were responsible for placing the bed hold form in the resident's chart but were unaware of the requirement to notify the OOLTC about hospital transfers. The director of nursing (DON) confirmed that the OOLTC should be notified of resident transfers and that the BOC was responsible for this task. The facility's Discharge and Transfer policy also indicated that notification to the OOLTC was required when a resident was hospitalized.
Failure to Provide Bed Hold Policy Notice
Penalty
Summary
The facility failed to provide a written bed hold policy to a resident or their representative at the time of hospital transfer. This deficiency was identified for a resident, referred to as R14, who was hospitalized on March 21, 2024. The resident's progress notes indicated that the family was notified of the hospitalization, but there was no documentation regarding the bed hold policy. Interviews with the resident and staff revealed that the resident did not recall receiving a bed hold notice, and the registered nurse responsible for informing the resident or representative could not verify that the bed hold was communicated. Further investigation showed that the business office coordinator was responsible for ensuring bed hold forms were completed and scanned into the resident's chart, but no such documentation was found for R14's hospitalization. The director of nursing stated that it was expected for a bed hold form to be completed and documented for every resident transferred to the hospital. The facility's bed hold policy, dated December 2, 2023, required that a designated individual provide the bed hold policy notice to the resident or their representative at the time of transfer.
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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