Green Lea Senior Living
Inspection history, citations, penalties and survey trends for this long-term care facility in Mabel, Minnesota.
- Location
- 115 North Lyndale, Rr 2 Box 49, Mabel, Minnesota 55954
- CMS Provider Number
- 245536
- Inspections on file
- 25
- Latest survey
- April 8, 2026
- Citations (last 12 mo.)
- 12 (2 serious)
Citation history
Health deficiencies cited at Green Lea Senior Living during CMS and state inspections, most recent first.
A resident with a right BKA and multiple comorbidities had an ordered wound care regimen and a care plan calling for regular incision inspection and dressing changes, but the facility failed to complete and document comprehensive weekly wound assessments with measurements. Staff reported that wounds were to be measured weekly by an RN and recorded in a wound binder, yet the resident’s wound page lacked measurements and characteristics, and the resident could not recall the last time facility staff measured the wound. An RN stated she was unsure about measuring the wound because an outside wound provider assessed it every other week, while the MD expected at least weekly measurements and descriptive documentation, which were not present in the chart, contrary to facility policy requiring detailed assessment data for wounds.
Surveyors found that staff did not consistently follow a systematic process to account for controlled medications in the emergency kit and for residents’ home medications stored in the medication room. An RN described using breakaway locks, a binder of lock numbers, and pharmacy usage forms when removing controlled drugs from the e‑kit, but there was no evidence of the every‑shift controlled substance inventory required by policy, and the pharmacist stated the facility should be completing such inventories. Staff, including an RN, an LPN, and a TMA, gave differing accounts of how home medications were handled, often involving placing medications in bags and cabinets, sometimes unlocked, without a standardized method to document all medications and pill counts. These practices did not align with facility policies requiring shift‑to‑shift controlled substance counts by two licensed nurses and proper documentation of medications brought in by residents or responsible parties.
Two residents with significant fall risk factors experienced multiple unwitnessed falls, including one resulting in a subarachnoid hemorrhage, due to the facility's failure to conduct root cause analyses, implement appropriate interventions, and update care plans. Staff were often unaware of current fall prevention measures, and documentation was inconsistent, leading to repeated incidents without effective prevention.
Four nursing assistants worked with expired certifications, as the facility did not have a process to verify current credentials. The DON and administrator were unaware of the expired statuses, and the policy assigning responsibility to Human Resources was not followed, potentially affecting all residents.
The facility did not ensure its QAPI committee properly identified, investigated, or responded to a significant increase in resident falls, including multiple falls by a resident that led to a subarachnoid hemorrhage and hospitalization. Despite documentation of the rise in falls and concerns raised by the medical director, the committee failed to conduct a root cause analysis or develop an action plan, and meeting minutes contained inaccuracies regarding the number and nature of falls.
Two residents with severe cognitive impairment and mobility limitations did not have their call lights within reach, as observed during surveyor visits. Both residents required assistance for transfers and were at risk for falls, yet their call lights were found on the floor and inaccessible. Staff confirmed that call lights should have been within reach, in accordance with facility policy.
A resident with a history of multiple falls and neurological impairment suffered a fall resulting in a brain bleed, but the facility did not complete a comprehensive fall investigation or report the serious injury to the State Agency within the required timeframe. Staff interviews revealed confusion about reporting responsibilities, and the facility's policy for prompt reporting of serious injuries was not followed.
A resident with hemiplegia and hemiparesis experienced multiple documented falls after admission, but the 5-day MDS assessment was inaccurately coded to indicate no falls had occurred. The MDS-RN acknowledged missing the falls during the assessment process, despite facility policy requiring consistency between MDS data and resident records.
A resident with hemiplegia and hemiparesis following a stroke was admitted and assessed as being at moderate risk for falls, but the baseline care plan did not include fall prevention interventions or specify transfer status. Therapy recommendations for transfer assistance were not promptly incorporated into the care plan, leading to staff confusion and lack of clear instructions. The facility's policy requiring a baseline care plan within 48 hours was not followed, resulting in missing essential safety information.
A resident with Huntington's disease, initially continent on admission, experienced fluctuating urinary incontinence and urgency. The facility did not conduct a comprehensive bladder assessment, failed to develop or implement an individualized toileting program, and delayed updating the care plan to address the resident's changing continence status. Staff interviews revealed a lack of awareness of the resident's specific needs, and the resident reported inadequate toileting assistance, leading to distress and falls.
A nursing assistant did not follow hand hygiene protocols during toileting and incontinence care for a resident with hemiplegia and hemiparesis. The NA applied gloves without hand hygiene, performed peri care, then pulled up the resident's pants and handled the wheelchair with the same gloves, only washing hands after all tasks were completed. This was contrary to facility policy and staff expectations.
A resident with significant mobility limitations was injured during a transfer when staff failed to follow proper procedures for mechanical lift use, including using two slings and not ensuring all straps were securely attached. This resulted in the resident falling and sustaining a head hematoma, multiple rib fractures, and a spinal compression fracture. Staff interviews and documentation confirmed that facility protocols and manufacturer instructions were not followed, leading to an Immediate Jeopardy situation.
The facility did not ensure an RN was onsite for at least 8 consecutive hours each day, as required by policy. Staffing records and interviews confirmed multiple days with either no RN coverage or insufficient hours, with staff acknowledging ongoing challenges in maintaining adequate RN presence, especially on weekends.
A resident's room was searched and personal items were removed by a previous administrator without the resident's consent, based on suspicions of prohibited activity. The resident, who was cognitively intact and largely independent, reported feeling mistrustful and socially isolated as a result. Staff and documentation confirmed the unauthorized entry and removal of property, which was not in accordance with facility policy requiring respect for residents' privacy and belongings.
A resident with intact cognition and a need for substantial assistance was not provided showers or baths according to their stated preference of three specific days per week, despite assurances from staff. Documentation and care planning failed to include the resident's bathing preferences, and staff interviews revealed confusion about responsibility for recording such preferences, resulting in the resident receiving showers or baths on a different schedule than requested.
Two residents with complex medical and functional needs did not have person-centered, comprehensive care plans developed as required. Although baseline and temporary care plans were in place, they lacked the necessary detail and scope to address all triggered care areas. Staff interviews confirmed that comprehensive care plans had not been completed for these residents.
The facility did not provide required quarterly statements for resident trust accounts, as confirmed by both the business office manager and the administrator, despite facility policy mandating this practice. This failure was identified during a survey following a complaint about access to funds and had the potential to affect all residents with trust accounts.
The facility failed to maintain two mechanical lifts in proper working condition. A sit-to-stand lift had non-functional switches and clogged wheels, while a full-body lift had a remote with buttons held by tape and similarly clogged wheels. Despite these issues, the lifts were still in use. Maintenance records showed weekly checks but lacked details on repairs or cleaning, and the last inspection by the lift company was in June 2021.
The facility's assessment failed to accurately identify staffing needs based on resident care requirements. The assessment lacked details on necessary nursing roles and staffing ratios, leading to incomplete documentation. The administrator admitted to misunderstanding the staffing plans, resulting in an inability to provide evidence of sufficient staffing to meet resident needs.
A facility failed to implement an ambulation program for a resident with a history of falls, as ordered by physical therapy. Despite recommendations for ambulation three times a day, there was no documentation of the program being completed. Interviews revealed that staff were too busy to assist with walking, and there was a lack of awareness about the program. The facility's Walking Program policy was not provided.
A facility failed to maintain complete and accurate medical records for a resident, as required by professional standards. The resident's treatment administration record (TAR) indicated that weekly Body Audit assessments were completed, but the electronic health record (EHR) lacked documentation for several dates. Interviews with staff, including an LPN and the DON, confirmed the discrepancy, and the facility's policy did not adequately address the maintenance of accurate medical records.
The facility failed to follow enhanced barrier precautions (EBP) for two residents with chronic wounds and indwelling devices. Staff, including an LPN and nursing assistants, did not wear gowns during high-contact care activities despite the presence of signage and training. The director of infection prevention confirmed the necessity of EBP for such conditions.
The facility failed to submit accurate staffing data to CMS for Q1 of FY 2024, leading to a report of excessively low weekend staffing. The error was due to the exclusion of agency pool staff hours and miscoded staffing hours.
The facility failed to offer pneumococcal and influenza vaccinations to eligible residents, as required by CDC guidelines and facility policies. The infection preventionist and director of nursing acknowledged the oversight and confirmed that necessary consents and declinations were missing from the records.
The facility failed to provide a written notification of the bed hold policy to a resident or their representative during a hospitalization. Despite attempts to contact the representative and a stated procedure for mailing the form, there was no evidence that the form was ever provided or signed.
A resident with severe cognitive impairment and dementia was observed multiple times with unshaven facial hair, despite expressing a preference to be clean-shaven. The facility failed to provide consistent grooming care due to a broken shaver and inconsistent staff assignments. Staff and family confirmed the resident's usual preference for being clean-shaven, highlighting a deficiency in meeting the resident's personal hygiene needs.
The facility failed to offer the COVID-19 vaccine to an eligible resident with medically complex conditions, including diabetes and a pulmonary disease. Despite the facility's policy requiring vaccination opportunities upon admission, the infection preventionist and director of nursing confirmed that the necessary steps for offering and documenting the vaccine were not followed for this resident.
The facility failed to notify a physician of a resident's skin injury, leading to delayed treatment and significant pain during wound care. The wound was initially observed by staff but not documented or reported, and the resident's family member eventually brought it to the physician's attention. Staff interviews revealed that protocols for documenting and reporting skin alterations were not consistently followed.
The facility failed to revise the care plan for a resident who developed substantial bruising due to a new diagnosis of nonthrombocytopenic purpura. Despite multiple progress notes and body audits documenting significant bruising and other skin issues, the care plan was not updated to include new interventions. Interviews with staff revealed a lack of awareness and responsibility for updating the care plan.
The facility failed to complete comprehensive pressure ulcer risk assessments, monitor pressure ulcers, notify the physician, and follow physician orders for a resident with multiple skin conditions. Despite the resident's history of chronic right heart failure, acute respiratory failure, type 2 diabetes, and pressure ulcers, the care plan was not updated, and weekly comprehensive assessments were not conducted. Staff interviews revealed a lack of adherence to protocols and policies, leading to inadequate care and monitoring.
Failure to Perform and Document Comprehensive Weekly Wound Assessments
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess and monitor a surgical stump wound for a resident with a right below-knee amputation and multiple comorbidities, including PVD, diabetes mellitus type 2, and hypertensive heart disease with chronic kidney disease. The resident’s care plan identified risk for impaired skin integrity and included interventions such as daily incision inspection and dressing changes every other day, and an outside wound care provider ordered specific wound care, including packing the wound with Mesalt ribbon and covering with a Mepilex border. A progress note documented that wound care was provided with findings of moderate sanguineous and purulent drainage, tunneling of approximately 7–7.5 cm, saturated peri-wound with brown, yellow, and green drainage, and surrounding pink tissue, but did not include wound measurements. Review of wound documentation from early March through early April showed mentions and descriptions of the wound but no evidence of comprehensive assessments with measurements to determine improvement or deterioration. During interviews and record review, staff described a process in which wounds were to be measured weekly by an RN and recorded in a wound book, with wound characteristics documented in wound notes. However, the resident’s wound page in the binder contained only weekly dates and dressing change orders, without measurements or wound characteristics, and the RN acknowledged uncertainty about whether to measure this resident’s wound weekly because an outside wound care provider measured it every other week. The resident could not recall the last time facility staff measured the wound, and the MD stated that nurses should document wound appearance with every dressing change, measure at least weekly, and notify the MD if the wound deteriorated, but could not rely on the chart for wound descriptions. The nurse consultant confirmed that the resident’s record lacked weekly wound assessments with measurements in March and April, despite facility policy requiring documentation of all assessment data, including wound size and characteristics, at least weekly and as needed.
Failure to Maintain Accurate Accounting for E‑Kit Controlled Drugs and Residents’ Home Medications
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate, systematic accounting for controlled medications in the emergency medication kit (e‑kit) and for residents’ home medications stored in the medication room. Surveyors observed an RN accessing the controlled and non‑controlled e‑kits, which were secured with numbered breakaway locks and tracked in a binder. The RN explained that when removing a controlled medication, the nurse checked provider orders, broke the lock, completed a pharmacy usage form, removed the medication, applied a new lock, and recorded the new lock number. If the pill count did not match the number listed on the e‑kit cover, the RN would contact the pharmacy. However, there was no mention of a routine, documented, every‑shift inventory of the controlled e‑kit contents, and the pharmacist later stated the facility should be accounting for all medications removed and completing an inventory every shift. The DON described a process where a nurse should count pills before removal and compare to the stocked amount, then review usage sheets or call the pharmacy if counts differed, but this process was not supported by documentation of consistent shift‑to‑shift inventory as required by policy. The facility also lacked a consistent system to account for residents’ home medications stored in the medication room. An RN stated that when residents were admitted with home medications, staff would ask family to take them home; if that was not possible, the medications were stored in the medication room until discharge or destruction, and the RN did not know of a procedure to account for these non‑controlled medications. An LPN reported that if family could not take medications home, the medications were written on a piece of paper, placed in a plastic bag with the list attached, and stored in the medication room. A TMA described receiving bags of home medications from nurses, checking only for controlled substances, and then placing the bags in an unlocked cabinet, and did not know the procedure to account for all non‑controlled medications. The nurse consultant stated that when family could not remove home medications, a nurse should document all medications and pill counts in a nurse’s note in the electronic medical record. These practices were inconsistent with the facility’s written policies, which required a physical inventory of all controlled substances at each shift change by two licensed nurses and documentation of medications brought to the facility on the appropriate form or chart.
Failure to Assess and Prevent Falls Resulting in Major Injury
Penalty
Summary
The facility failed to comprehensively assess falls for root cause, implement appropriate interventions, and update or revise care plans to prevent or reduce the risk of falls with major injury for two residents who experienced multiple falls. One resident, with a history of stroke, hemiplegia, and cognitive impairment, experienced several unwitnessed falls, including one that resulted in a subarachnoid hemorrhage and hospitalization. Despite documented risk factors such as impulsivity, incontinence, and poor safety awareness, the resident's care plan was not consistently updated to reflect these risks or to include interventions recommended by therapy staff. Incident reports and progress notes repeatedly lacked evidence of comprehensive fall investigations or causal analyses, and interventions such as supervision, use of fall mats, and toileting schedules were either not implemented or not documented in the care plan. Another resident, diagnosed with Huntington's disease and a history of falls, also experienced multiple unwitnessed falls. The care plan for this resident identified high fall risk but did not include specific interventions tailored to the resident's needs, such as regular toileting or ensuring the call light was within reach. After each fall, there was no indication that a comprehensive analysis was conducted to identify causal factors, nor was the care plan revised to address the circumstances of the falls. Documentation was inconsistent, and staff interviews revealed a lack of awareness regarding current fall prevention interventions for these residents. Staff interviews further revealed that nursing assistants and other clinical staff were often unaware of the specific fall prevention interventions in place for high-risk residents. There was confusion about where to find care plan information, and some staff were not trained on how to update care plans or conduct root cause analyses after falls. The facility's own policy required individualized, resident-centered fall prevention plans and prompt documentation and care plan updates after each fall, but these procedures were not followed, resulting in repeated falls and a major injury for one resident.
Removal Plan
- R1 had an updated fall risk assessment completed.
- R1's falls had a root cause analysis and appropriate fall prevention interventions added to the clinical chart.
- Interdisciplinary team reviewed R1's falls and root cause analysis to ensure appropriate fall interventions in place based on resident needs and resident's status based on the individual falls and root cause analysis.
- R1's care plan updated to include current fall interventions and fall risk level.
- All high risk fall residents who had a fall had a root cause analysis completed and care plans were updated to remove/negate the risk of falls based on potential risks of falls.
- Staff were re-educated on the facility's falls and fall risk, managing, fall risk assessment, assessing falls and their causes, falls-clinical protocol, baseline care plan, and comprehensive care plan policies.
- All clinician staff was re-educated on the facility policies, ensuring licensed staff adding immediate intervention post fall, updating care plan.
- Agency nursing staff orientation checklist update to include education on fall prevention policies and procedures.
Failure to Ensure Nursing Assistant Certification Status
Penalty
Summary
The facility failed to ensure that four of seven employed nursing assistants maintained current certification with the state nursing assistant registry. Review of the registry and facility employee records showed that these nursing assistants had expired certificates but continued to be scheduled and worked shifts during the period their certifications were not valid. This lapse had the potential to affect all thirty-two residents residing in the facility. Interviews with the Director of Nursing (DON) and the administrator revealed a lack of awareness regarding the expired certifications and an absence of a process to verify the current status of licensed or certified staff. The DON stated she was not responsible for monitoring certification status and was unsure who held that responsibility. The administrator acknowledged that there was no system in place to ensure verification of credentials and accepted ultimate responsibility for the oversight. Review of the facility's policy indicated that the Human Resources Director or designee was responsible for maintaining and verifying certification status, but this was not followed.
Failure to Analyze and Respond to Increased Resident Falls
Penalty
Summary
The facility failed to ensure its Quality Assurance and Performance Improvement (QAPI) committee effectively identified, investigated, analyzed, and responded to resident care issues, specifically regarding a high number of falls. Over several months, QAPI meeting minutes consistently documented falls as isolated incidents, with no trends identified, despite a significant increase in the number of falls in September. The committee did not comprehensively analyze the data or develop an action plan in response to the sudden rise in falls, and inaccuracies were noted in the documentation of fall incidents, including underreporting the number of falls and failing to identify multiple falls by the same resident. One resident experienced multiple falls since admission, culminating in a fall that resulted in a subarachnoid hemorrhage and hospitalization, which was classified as an immediate jeopardy event. The QAPI committee's meeting minutes did not reflect a thorough review or root cause analysis of the increased falls, nor did they document any systematic approach to identifying quality deficits in the fall management program. Although the medical director raised concerns and suggested forming an interdisciplinary team to address the issue, no formal action plan or investigation was initiated by the committee. Interviews with facility leadership confirmed that, despite recognizing a sharp increase in falls, the QAPI committee did not take steps to analyze or investigate the underlying causes. The facility's own policy outlines a systematic approach to performance improvement, including data analysis, root cause identification, and corrective action planning, but these processes were not followed in response to the increase in falls. As a result, the facility did not address the quality concern in a timely or effective manner.
Failure to Ensure Call Lights Accessible for Residents at Risk for Falls
Penalty
Summary
The facility failed to ensure that call lights were accessible and within reach for two of three residents reviewed for falls. One resident with Parkinson's disease and dementia, who required extensive assistance for all transfers and was at risk for falls, was observed sitting in his wheelchair with his call light on the floor behind him, out of reach. The resident requested assistance from the surveyor to pick up a glass, and stated he did not have his call button. A nursing assistant confirmed that the call light should have been within the resident's reach due to his agitation and risk of self-transfer. Another resident with Alzheimer's disease, severe cognitive impairment, and limited physical mobility was observed sitting in a recliner with her call light on the floor next to her foot, not within reach. She requested help from the surveyor to pick up items from the floor and explained she could not find her call button. A nursing assistant confirmed the call light was not within reach and should have been accessible. The facility's policy requires staff to ensure call lights are within reach and secured as needed, but this was not followed in these instances.
Failure to Timely Report Serious Fall Injury to State Agency
Penalty
Summary
The facility failed to timely report a fall with serious injury to the State Agency (SA) for a resident with a history of multiple falls and significant neurological impairment, including hemiplegia and hemiparesis following a stroke. The resident experienced several falls over a short period, with no comprehensive analysis or implementation of appropriate interventions to prevent further incidents. On one occasion, the resident was found on the floor with a head injury and was subsequently sent to the emergency department, where a brain bleed was identified. Despite this serious injury, there was no evidence that a comprehensive fall investigation or analysis was completed by the facility. Interviews revealed that staff were unclear about reporting requirements, with an LPN assuming that the assistant director of nursing (ADON) would notify the administrator and being unaware of the obligation to report to the SA. The administrator and director of nursing (DON) both acknowledged that the incident should have been reported to the SA within two hours of learning about the brain bleed, but this did not occur. The facility's own policy required prompt reporting of serious injuries, but this was not followed in this case.
Inaccurate MDS Assessment for Resident with Multiple Falls
Penalty
Summary
The facility failed to accurately complete a Minimum Data Set (MDS) assessment for a resident with a history of falls. The resident, who had diagnoses of hemiplegia and hemiparesis following a stroke, experienced three documented falls after admission. Incident reports and progress notes detailed unwitnessed falls from a wheelchair and bed, with specific dates and circumstances recorded in the resident's medical record. Despite this documentation, the 5-day MDS assessment for the resident was incorrectly coded to indicate that no falls had occurred since admission. The MDS Coordinator/registered nurse acknowledged during an interview that the assessment was inaccurate and that the falls had been missed during the review of risk management reports and progress notes. Facility policy requires that MDS assessments consistently reflect information in progress notes and other records, which was not followed in this instance.
Failure to Timely Update Baseline Care Plan for Fall Risk and Transfer Needs
Penalty
Summary
The facility failed to develop and implement an adequate baseline care plan within 48 hours of admission for a resident with significant fall risk factors. The resident, who had hemiplegia and hemiparesis following a stroke, was assessed as being at moderate risk for falls according to the Morse Fall Scale. Despite this, the temporary care plan did not include a focus area or interventions for fall prevention, nor did it address a toileting program for the resident's incontinence. The care plan also failed to specify the resident's transfer status, even though therapy notes and recommendations indicated changes in required transfer methods and equipment. Multiple staff interviews and document reviews revealed that the care plan was not updated in a timely manner to reflect changes in the resident's condition and therapy recommendations. Nursing assistants were unable to locate current transfer instructions in the electronic health record or on the therapy clipboard, leading to confusion about the appropriate transfer method. The physical therapist confirmed that updated transfer recommendations were communicated to nursing, but these were not incorporated into the care plan as expected. The director of nursing acknowledged that the care plan had not been updated to include fall risk, fall prevention interventions, or the resident's new transfer status. The facility's own policy requires that a baseline care plan be developed within 48 hours of admission, including interventions to address health and safety concerns such as fall risk. However, the resident's care plan did not meet these requirements, as it lacked essential information needed to prevent decline or injury. This failure resulted in staff not having access to up-to-date instructions for safe care, particularly regarding fall prevention and transfer assistance.
Failure to Provide Individualized Continence Care and Assessment
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent a decline in continence and urinary symptoms for a resident diagnosed with Huntington's disease. Upon admission, the resident was continent of bowel and bladder, but began experiencing fluctuating symptoms of incontinence, urgency, and frequency. The facility's continence evaluation assessment lacked detailed information regarding the circumstances and type of incontinence, and did not document interventions or treatments that had previously improved the resident's condition. The assessment inconsistently identified the type of incontinence and omitted a summary, while the resident's risk factors, such as cognitive impairment and use of antipsychotics, were not fully addressed. Documentation revealed that the resident experienced a change in continence status, with multiple episodes of incontinence and urinary urgency noted over several weeks. Despite these changes, the care plan addressing urinary continence was not initiated until several weeks after the initial assessment, and it did not include individualized goals or interventions to prevent further decline or manage urinary symptoms. The care plan focused on activities of daily living and fall prevention, but lacked a comprehensive bladder assessment or a voiding diary to inform an appropriate toileting schedule. Incident reports indicated that toileting was a causal factor in several falls, yet there was no evidence of a thorough assessment to determine the type of incontinence or to develop a tailored toileting program. Interviews with staff revealed a lack of awareness regarding the resident's specific toileting needs, with staff following a standard two-hour toileting schedule for all residents rather than an individualized plan. The resident reported feeling unsupported, stating that staff did not offer regular toileting assistance and that she sometimes attempted to toilet herself, resulting in falls and emotional distress. The facility's incontinence policy required appropriate treatment and services to maintain continence, but the documentation and staff interviews demonstrated that these standards were not met for this resident.
Failure to Perform Proper Hand Hygiene During Resident Care
Penalty
Summary
A nursing assistant (NA) failed to follow proper hand hygiene protocols during toileting and incontinence care for a resident with hemiplegia and hemiparesis following a stroke, who was dependent for all transfers and toileting. The NA applied gloves without performing hand hygiene before care, cleaned the resident after a bowel movement using wet wipes, and then proceeded to pull up the resident's pants and handle the wheelchair with the same soiled gloves. The NA did not remove gloves or perform hand hygiene between these tasks, despite being prompted by the surveyor. The NA only washed her hands after completing all care tasks and handling the resident's blanket. Interviews with the NA, a registered nurse (RN), and the director of nursing (DON) confirmed that the expected protocol was not followed, as hand hygiene should have been performed before and after glove use, and gloves should have been changed after peri care. The facility's hand hygiene policy also indicated that hand hygiene is required when moving from a contaminated to a clean body site during resident care. The failure to adhere to these procedures was observed and documented during the survey.
Failure to Ensure Safe Mechanical Lift Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when facility staff failed to ensure safe transfers for a resident requiring maximum assistance and the use of a mechanical lift. During a transfer from a wheelchair to a shower chair, staff did not follow manufacturer instructions or facility protocol for applying and securing the sling to the mechanical lift. Instead of removing an ill-fitting sling, staff placed a second sling under the resident and attached both to the lift, which is contrary to proper procedure. The slings were not properly secured, and the staff did not verify that all straps were correctly attached before lifting the resident. As a result of these actions, the sling became unhooked from the mechanical lift during the transfer, causing the resident to fall to the floor. The resident sustained a hematoma to the back of the head and multiple fractures to the left ribs, as well as a severe compression fracture at the T12 vertebra. The resident, who had a history of spondylosis, muscle weakness, and pain, experienced significant pain and limited mobility following the incident. The incident was witnessed and described by both the resident and the staff involved, who acknowledged not following proper procedures and failing to double-check the sling attachments. Documentation and interviews confirmed that the staff involved did not adhere to the facility's policy for mechanical lift use, including ensuring the correct sling size and secure attachment. The improper use of two slings, failure to remove the incorrect sling, and lack of verification of secure connections directly led to the resident's fall and subsequent injuries. The event was identified as an Immediate Jeopardy situation due to the severity of harm caused by the unsafe transfer.
Removal Plan
- NAR's immediately removed from the floor and given education on mechanical lifts, safe transfers, and sling safety with return demonstration.
- All nursing staff education on mechanical lifts, safe transfers, and sling safety with return demonstration until all staff were trained and completed.
- Disciplinary action for NAR's involved in the incident.
- Mandatory staff meeting regarding mechanical lifts and sling safety completed.
- Audits will be completed bi-weekly and reviewed with the Quality Assurance and Performance Improvement team.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was onsite for at least 8 consecutive hours per day, 7 days a week, as required. Review of the payroll based journal (PBJ) staffing report for the first quarter of 2025 revealed multiple days with either no RN hours reported or insufficient RN coverage. Specifically, there were several dates with no RN coverage at all, and at least one date with only 4 hours of RN coverage. Facility payroll and staffing schedules confirmed these gaps in RN coverage. Interviews with facility staff, including the regional nurse consultant, assistant director of nursing (ADON), and staffing coordinator, confirmed the lack of RN coverage on the identified dates. The staffing coordinator acknowledged ongoing difficulties in maintaining RN coverage, particularly on weekends, and stated that only two RNs were employed at the facility, with one working full time overnight and the other recently starting on evenings. The facility's own policy requires an RN to provide services for at least 8 consecutive hours every 24 hours, 7 days a week.
Failure to Respect Resident's Rights and Personal Property
Penalty
Summary
A resident with no cognitive impairment and minimal assistance needs reported that the previous facility administrator entered his room without permission, searched his personal belongings, and confiscated items including vape pens, cups, and dishes. The administrator stated the search was conducted due to suspicions that the resident was making moonshine with orange peels, water, or mouthwash, and possibly had illegal substances. The resident expressed feelings of mistrust and social isolation following the incident, stating that staff entered his room whenever they wanted. A certified nursing assistant confirmed that the previous administration had searched the resident's room without consent and confiscated his vape pens, with no law enforcement involvement. The current DON and administrator acknowledged that documentation in the resident's chart indicated staff had entered the room and removed property without permission. Facility policy requires staff to knock and request permission before entering a resident's room and to respect residents' private space and belongings at all times.
Failure to Accommodate Resident Bathing Preferences
Penalty
Summary
The facility failed to honor and facilitate a resident's preference for showering/bathing days, as required by regulations supporting resident self-determination and choice. The resident, who was cognitively intact and required substantial to maximal assistance for bathing, expressed a clear preference to receive showers or baths on Mondays, Wednesdays, and Fridays. Despite communicating this preference upon admission and being assured it could be accommodated, the resident routinely received showers or baths only on Tuesdays and Fridays, and occasionally on a Saturday, as documented in the treatment administration record. The resident reported rarely receiving showers or baths three times per week as preferred. Review of the resident's care plan revealed it lacked documentation of personal preferences for showering or bathing, containing only information related to a potential nutritional deficit. Interviews with facility staff, including a CNA and the ADON, indicated uncertainty about who was responsible for documenting resident preferences, especially following a change in leadership. The ADON confirmed that the baseline care plan should have included the resident's showering/bathing preferences, but this was not done, and a comprehensive care plan was not in place for the resident. Facility policy requires that a baseline care plan addressing immediate needs, including preferences, be developed upon admission.
Failure to Develop Person-Centered Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered, comprehensive care plans for two residents who were reviewed for care planning. For one resident, the admission Minimum Data Set (MDS) assessment indicated multiple complex medical conditions, including atrial fibrillation, heart failure, hypertension, peripheral vascular disease, renal insufficiency, diabetes, anxiety, and schizophrenia, as well as a history of falls and frequent incontinence. Although several care areas were triggered by the MDS and documented as addressed, the resident's record lacked a comprehensive, person-centered care plan. The temporary care plan provided to nursing assistants only included basic information such as diagnoses, diet, and assistance needs, but did not constitute a full care plan as required. For the second resident, the admission MDS assessment also identified significant functional impairments, including the need for assistance with eating, oral hygiene, toileting, dressing, and mobility, as well as frequent bowel incontinence and the presence of an indwelling catheter. Multiple care areas were triggered, but the only care plan item documented was a potential nutritional deficit, with no comprehensive care plan completed at the time of the survey. Interviews with staff confirmed that comprehensive care plans had not been developed for either resident, despite facility policy requiring such plans to be completed within 21 days of admission.
Failure to Provide Quarterly Trust Account Statements
Penalty
Summary
The facility failed to provide residents or their representatives with quarterly statements for trust accounts, as required by facility policy. During a recertification survey, a complaint regarding access to funds led to the discovery that the business office manager and the administrator both confirmed that quarterly statements were not being sent out. Document review showed that the facility's own policy mandates the availability of individual accounting records through quarterly statements and upon request, but this practice was not being followed. This deficiency had the potential to affect all residents with trust accounts at the care center. No specific residents or their medical histories were mentioned in the report, and the deficiency was identified through interviews and document review during the survey process.
Mechanical Lifts Not Maintained Properly
Penalty
Summary
The facility failed to maintain two mechanical lifts in proper working condition, as observed during a survey. The Volara brand mechanical sit-to-stand lift, identified as B01-18, had non-functional handlebar switches and a remote with a malfunctioning button for lowering a resident. Additionally, the wheels of this lift were clogged with hair, making it difficult to maneuver. Another full-body mechanical lift, A02-16, had a remote with buttons held together by electrical tape, and its wheels were similarly clogged with hair. Despite these issues, the lifts were still in use, and the maintenance director acknowledged the need for repairs but had not yet addressed them. The maintenance records for the lifts indicated weekly checks in August 2024, but these records did not specify whether repairs or cleaning were completed. The last documented inspection by the lift company was in June 2021. The facility's administrator expected the lifts to be in proper working order, but the maintenance director stated that staff needed to inform him of repair needs through an electronic request system. The manufacturer's manual for the lifts emphasized regular cleaning and inspection, which was not adhered to, contributing to the deficiency.
Incomplete Facility Assessment of Staffing Needs
Penalty
Summary
The facility failed to ensure that its Facility Assessment accurately identified the staffing needs based on the care requirements of its resident population. The assessment, which was intended to determine the necessary resources for competent resident care during both regular operations and emergencies, was found to be incomplete. Specifically, the Overall Staffing Needs table lacked details on the number of staff members required in various nursing roles, and the Staffing Needs as per Resident Unit table was entirely blank. Additionally, the Staffing Needs as per Shift table was incomplete, failing to specify the ratio of staff to residents or the hours per resident day of direct care needed for nursing positions across different shifts. During an interview, the administrator acknowledged the deficiencies in the Facility Assessment, noting that the tables were intended to indicate the number of registered nurses and nursing assistants needed to be fully staffed. However, she admitted to misunderstanding the Information About Nurse Staffing Plans section, which led to the incomplete documentation. The administrator also mentioned that the Facility Assessment had been recently updated with her supervisor's involvement, but she was unable to provide evidence that the assessment accurately identified the facility's staffing needs to ensure sufficient care for residents.
Failure to Implement Ambulation Program for Resident
Penalty
Summary
The facility failed to provide an ambulation program for a resident (R2) with a history of falls, as ordered by physical therapy. R2's care plan indicated a need for ambulation three times a day with a two-wheeled walker and contact guard assistance, following therapy recommendations. However, a review of R2's records between July 14 and August 14 showed no documentation of the ambulation program being completed or offered. Interviews with R2 and staff revealed that the resident was not asked to walk, and staff were often too busy to assist with walking programs. Staff interviews indicated a lack of awareness and time to complete the walking program. Nursing assistants and an LPN stated that walks were not done due to being busy and not knowing who was supposed to be walked. The physical therapist confirmed that walking recommendations were given to nursing staff, who were expected to continue the program. The director of nursing also expected staff to follow therapy recommendations. Despite these expectations, there was no documentation or tracking of the walking program, and the facility's Walking Program policy was not provided.
Incomplete Medical Record Documentation
Penalty
Summary
The facility failed to maintain a complete and accurately documented medical record for a resident, as required by professional standards. The deficiency was identified during a review of the resident's treatment administration record (TAR) and electronic health record (EHR). The resident had a provider order for a weekly Body Audit assessment to be completed every Friday. The TAR indicated that the assessments were completed on specific dates in July and August, but the EHR only contained records for some of these dates, specifically missing records for 7/19, 7/26, and 8/2. Interviews with facility staff, including an LPN and the DON, revealed that the Body Audit assessments were supposed to be documented in the EHR on the scheduled days. The DON confirmed that the assessments were charted as completed in the TAR but were not found in the EHR, indicating a discrepancy in the medical records. The facility's policy on online documentation did not address the maintenance of complete and accurate medical records, contributing to the deficiency.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure proper infection control procedures were followed for two residents, R3 and R4, when staff did not adhere to enhanced barrier precautions (EBP) during care and treatment. R3, who had severe cognitive impairment, a stage 4 pressure ulcer, and an indwelling bladder catheter, required EBP for wound treatment and catheter care. However, during observations, LPN-A and NA-A did not wear gowns while performing these tasks, despite signage indicating the need for EBP. Both staff members admitted to not using EBP, citing reasons such as forgetfulness, being too busy, and not recalling training on EBP. Similarly, R4, who had dementia, chronic pain syndrome, and an unstageable pressure ulcer, also required EBP for wound care and toileting assistance. Observations revealed that LPN-A, NA-A, and NA-B did not wear gowns during these activities, and there was no signage or supply cart for EBP in R4's room. Interviews with the staff indicated a lack of consistent use of EBP and uncertainty about training. The director of infection prevention and quality assurance confirmed that EBP should be used for catheters, chronic wounds, and other specified conditions.
Inaccurate Staffing Data Submission to CMS
Penalty
Summary
The facility failed to submit accurate and complete staffing data to CMS for the first quarter of the Federal Fiscal Year 2024. The CMS Payroll Based Journal (PBJ) Staffing Report indicated excessively low weekend staffing, which was triggered by the data submitted by the facility. However, a review of daily staff postings and census data for this period did not show significant differences between weekend and weekday staffing levels. Additionally, staffing schedules and staff timecards confirmed that licensed nursing staff were present on the weekends during the referenced time period. During interviews, the Director of Nursing (DON) stated that staffing needs were determined based on resident acuity and census, and that weekend staffing levels were the same as weekdays. The administrator admitted that the facility incorrectly reported staffing data to CMS by not including agency pool staff hours and miscoded staffing hours, leading to the appearance of low weekend staffing. A facility policy for staff reporting was requested but not received.
Failure to Offer Pneumococcal and Influenza Vaccinations
Penalty
Summary
The facility failed to ensure that three residents were offered and/or provided the pneumococcal vaccine series as recommended by the CDC. Specifically, residents with diagnoses such as stroke, COPD, diabetes mellitus, and other medically complex conditions were not given the pneumococcal vaccine, and there was no documentation indicating that the vaccine was offered or refused. Additionally, two residents were not offered the influenza vaccine, and there was no record of consent or declination for these vaccinations. The infection preventionist (IP) and the director of nursing (DON) acknowledged the oversight and confirmed that the facility is responsible for offering these vaccinations to eligible residents. The facility's policies on pneumococcal and influenza vaccinations indicated that all residents should be offered these vaccines, with consents and declinations documented in the resident records. However, the review revealed that these policies were not followed for the residents in question. The IP admitted to being unaware of the recent CDC recommendations for pneumonia vaccinations and confirmed that the necessary consents and declinations were missing from the records. The DON emphasized the importance of vaccinations and stated that they should be addressed during the admission process.
Failure to Provide Bed Hold Notification
Penalty
Summary
The facility failed to provide a written notification of the bed hold policy to a resident or their representative during a hospitalization. The resident, who had multiple diagnoses including hypothyroidism, traumatic brain injury, and dementia, was sent to the emergency room after experiencing nausea and emesis. Despite attempts to contact the resident's representative via phone, the facility was unable to reach them and decided to send the bed hold policy via mail. However, there was no evidence in the resident's medical record that the bed hold form was ever provided or signed by the resident or their representative before or during the hospitalization. Interviews with facility staff, including an LPN and the Director of Nursing (DON), revealed that the standard procedure was to obtain a signed bed hold form before a resident is sent to the hospital. The DON stated that if verbal consent could not be obtained, a copy of the bed hold form should be mailed within 24 hours. Despite searching, the facility could not locate the bed hold form for this resident. Additionally, the facility's bed hold policy was requested but not provided to the surveyor.
Failure to Provide Adequate Facial Grooming for Dependent Resident
Penalty
Summary
The facility failed to provide adequate facial grooming for a resident (R24) who was dependent on staff for personal hygiene tasks. R24, who has severe cognitive impairment and is diagnosed with dementia, was observed multiple times over several days with unshaven facial hair, despite expressing a preference to be clean-shaven. The resident's care plan indicated that staff should assist with personal hygiene daily, but observations and interviews revealed that R24's facial grooming needs were not consistently met. Staff reported that the resident's electric shaver was broken, causing discomfort when used, and there was a lack of documentation regarding the broken shaver or any refusal of care by the resident. Interviews with various staff members, including nursing assistants and a trained medication aide, indicated that R24's grooming was neglected due to the broken shaver and inconsistent staff assignments. Some staff members were unaware of the issue, while others mentioned that the resident's facial hair had been growing for months. The facility had disposable razors available, but these were not utilized to address the resident's grooming needs. The Director of Nursing (DON) and the social worker were also unaware of the broken shaver, and there was no specific policy regarding ADLs, only an expectation for staff to follow standards of care. The resident's family member confirmed that R24 was typically clean-shaven and that the current state of facial hair was unusual and likely bothersome to the resident. Despite multiple observations and interviews highlighting the issue, the resident remained unshaven until the evening or night shift on the final day of observation. The facility's failure to provide consistent and adequate grooming care for R24, despite the resident's dependency and expressed preference, constitutes a deficiency in meeting the resident's personal hygiene needs.
Failure to Offer COVID-19 Vaccine to Eligible Resident
Penalty
Summary
The facility failed to offer the COVID-19 vaccine to a resident eligible to receive the vaccine. Resident 7, who was moderately cognitively impaired and had medically complex conditions including diabetes mellitus and a pulmonary disease, was admitted on a specified date. The facility's documentation indicated that Resident 7 had not received any of the COVID-19 vaccination series. During interviews, the infection preventionist (IP) and the director of nursing (DON) confirmed that the vaccination status should be reviewed during the admission process, and the COVID-19 vaccine should be offered with proper consent and documentation. However, the IP was unable to find any records indicating that the COVID-19 vaccine had been offered, administered, or declined by Resident 7. The facility's policy, dated April 1, 2024, stated that all residents should be provided the opportunity and encouraged to receive the COVID-19 vaccinations upon admission. Despite this policy, the IP and DON acknowledged that the necessary steps for offering and documenting the COVID-19 vaccine for Resident 7 were not followed. The IP provided a blank consent form as an example of what should have been completed and uploaded into the resident's record during the admission process. The failure to offer and document the COVID-19 vaccination for Resident 7 was identified as a deficiency during the survey.
Failure to Notify Physician of Skin Injury
Penalty
Summary
The facility failed to ensure physician notification of a skin injury that required treatment for a resident with multiple health conditions, including chronic right heart failure, type 2 diabetes mellitus with foot ulcer, and a stage 2 pressure ulcer. The resident's care plan identified several skin issues, including a pressure injury on the left buttock and a diabetic ulcer on the right great toe. On a specific date, a registered nurse and nursing assistant noted an old bandage on the resident's left lower leg, which covered a wound of unknown cause. The wound appeared to be healing but was not documented or reported to the physician at that time. The resident's skin integrity log later identified the wound as a facility-acquired abrasion, but there was no evidence that the physician was notified between the initial observation and a later date. A family member discovered the wound during a visit and brought it to the physician's attention, who then ordered a treatment plan. However, the dressing was not changed as ordered, and the resident experienced significant pain during wound care. The clinical manager confirmed that the process for the resident's leg wound had not been followed properly. Interviews with staff revealed that the nurses did not always follow the protocol for documenting and reporting skin alterations. The director of nursing stated that body audits should be completed weekly, and any skin alterations should be reported immediately. The facility's policies required physician notification for new skin alterations and weekly documentation by the wound nurse, but these procedures were not followed in this case.
Failure to Revise Care Plan for Resident with New Diagnosis of Nonthrombocytopenic Purpura
Penalty
Summary
The facility failed to revise the care plan for a resident who developed substantial bruising due to a new diagnosis of nonthrombocytopenic purpura. The resident's admission record indicated diagnoses including chronic pain and nonthrombocytopenic purpura. Despite the resident's quarterly Minimum Data Set (MDS) identifying no cognitive impairment and dependence on staff for various activities, the care plan dated 4/6/23 did not include interventions for the risk of bruising or monitoring for such conditions. The resident's progress notes and weekly body audits documented multiple instances of bruising and other skin alterations, yet the care plan was not updated to address these issues. On 1/4/24, a progress note directed the addition of a diagnosis for senile purpura due to easy bruising, but the care plan was not revised to include this new diagnosis. Subsequent progress notes and body audits continued to document significant bruising and other skin issues, including a large hematoma that led to a hospital transfer on 2/14/24. Despite these ongoing issues, the care plan remained unchanged, and no new interventions were implemented to address the resident's condition. Interviews with the clinical manager and the director of nursing revealed a lack of awareness and responsibility for updating the care plan. The clinical manager admitted to not updating the care plan despite entering the new diagnosis into the computer system. The director of nursing acknowledged that the care plan should have been updated with new diagnoses and interventions but was unaware that this had not been done. The facility's document on person-centered care plans indicated that care plans should be developed, reviewed, and revised as needed, but this process was not followed in this case.
Failure to Assess and Monitor Pressure Ulcers
Penalty
Summary
The facility failed to complete a comprehensive pressure ulcer risk assessment, monitor pressure ulcers, notify the physician, and follow physician orders for a resident with multiple skin conditions. The resident had a history of chronic right heart failure, acute respiratory failure, type 2 diabetes with diabetic polyneuropathy, and pressure ulcers. Despite these conditions, the facility did not update the resident's care plan after new skin impairments were identified, nor did they conduct weekly comprehensive assessments and ongoing monitoring as required. The resident's care plan had not been revised since 9/20/23, even though new skin issues were documented on 3/4/24, 3/7/24, and 3/9/24. The facility's documentation and communication were inconsistent and incomplete. For instance, a weekly body audit on 3/4/24 identified redness on the resident's buttocks but lacked further description, etiology, measurement, and a treatment plan. Similarly, a progress note on 3/7/24 documented a suspected deep tissue injury on the right heel, but the facility's skin integrity log form did not match the progress note. Additionally, a wound on the resident's left lower leg was discovered on 3/9/24, but it was not comprehensively assessed, monitored, or treated until 3/19/24, ten days after it was identified. The facility also failed to follow physician orders for skin treatments, as evidenced by the treatment administration record (TAR) showing discrepancies in the start dates and application of prescribed treatments. Interviews with staff revealed a lack of adherence to protocols and policies. The licensed practical nurse (LPN) admitted to not notifying the doctor about the leg injury and stated that comprehensive skin assessments were not being completed weekly. The clinical manager (CM) acknowledged that the weekly body audits and skin integrity logs did not always match and were not comprehensive. The director of nursing (DON) confirmed that the body audits were supposed to be comprehensive skin assessments but were often missing details such as wound descriptions, measurements, and locations. The facility's policies on weekly skin assessments and skin management were not followed, leading to inadequate care and monitoring of the resident's pressure ulcers and other skin conditions.
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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