Guardian Angels Health & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Hibbing, Minnesota.
- Location
- 1500 East Third Avenue, Hibbing, Minnesota 55746
- CMS Provider Number
- 245239
- Inspections on file
- 25
- Latest survey
- August 20, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Guardian Angels Health & Rehab Center during CMS and state inspections, most recent first.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist as required.
Surveyors found that milk and other beverages were served from a cart without proper cooling, resulting in milk temperatures above required guidelines on two occasions. The dietary aide confirmed the milk was not safe to serve and disposed of it after temperature checks. The DON stated that food and beverages are expected to be served at safe temperatures, but temperature logs were not provided.
A resident under droplet precautions had a nasal swab specimen placed on a medication cart without proper surface sanitization, and an LPN was unclear about hand hygiene between tasks. Laundry staff transported uncovered soiled linens through the facility, used the same gloves across multiple areas, and entered clean laundry zones without changing PPE. The facility also lacked a comprehensive water management program, with incomplete records and insufficient monitoring of water features and system flow.
The facility did not ensure an active antibiotic stewardship program or perform required antibiotic time-outs for three residents who received antibiotics for infections such as upper respiratory infection and UTI. Nursing staff showed inconsistent knowledge of infection assessment criteria, and documentation of antibiotic reviews was missing, despite facility policy requiring these reviews.
Insufficient staffing led to residents not receiving timely assistance with ADLs, toileting, and hygiene, with some left in soiled clothing or not repositioned for hours. Staff reported being responsible for up to 30 residents, resulting in missed care such as nail care, catheter care, and incomplete care plans. Food requests were not always honored, and a resident was left unsupervised during a nebulizer treatment without required assessments, all due to inadequate staffing levels.
The facility did not complete required monitoring for side effects of antipsychotic medications, such as AIMS assessments and orthostatic blood pressure checks, for several residents with significant cognitive and psychiatric conditions. Additionally, PRN psychotropic medication orders for multiple residents lacked required stop dates and were not limited to 14 days as per facility policy, with no documented physician evaluation for continued use. These deficiencies were confirmed through record review and staff interviews.
Medications and biologicals were not securely stored in locked compartments, with some cupboards left unlocked or lacking locks, and the medication room was left open and unattended by staff. The medication refrigerator, containing immunizations, insulin, and controlled drugs, was found at 48°F, above the safe range, with incomplete temperature logs and multiple missed entries. Several medications required destruction and replacement due to unsafe storage conditions.
Multiple residents requiring assistance with ADLs, including toileting, hygiene, and repositioning, did not receive necessary care as outlined in their care plans. Observations and staff interviews revealed that residents were left in the same position for extended periods, did not receive scheduled nail or catheter care, and were sometimes left in soiled briefs overnight. Staff consistently cited inadequate staffing as a reason for missed care tasks.
The facility did not consistently track or intervene for bowel movements in two residents with orders for bowel management, failed to monitor and document oxygen saturation and administration as ordered for a resident with respiratory conditions, and did not complete or document required weekly skin checks for a resident with a chronic skin condition. These deficiencies were identified through observation, interviews, and record review.
A resident with a history of heart disease and moderate cognitive function was denied a requested second serving of watermelon during a meal, despite facility policy allowing seconds unless restricted by diet. Staff did not verify food availability with the kitchen, and later it was confirmed that more watermelon was available. Staff interviews revealed inconsistent understanding of the policy, and the incident was attributed in part to staff being rushed.
Two residents were allowed to self-administer medications without proper assessment or care plan authorization. One resident with COPD and cognitive impairment was left unsupervised during a nebulizer treatment, and another was left with a cup of medications at the bedside. Staff confirmed that required assessments for self-administration were not completed, and facility policy for SAM was not followed.
The facility did not timely review and revise care plans for two residents after significant changes, including a fall and new medication orders. One resident's care plan was not updated with new fall prevention interventions after a post-fall assessment, and another resident's care plan did not reflect recent changes in antidepressant and anticoagulant therapy. Facility policy requires ongoing care plan updates, but this was not followed.
A resident dependent on tube feeding had their feeding pump paused and tubing disconnected by nurse aides who were not trained or authorized to perform these tasks. The uncapped tubing was left hanging and later touched the floor before being wiped with a tissue and reconnected to the resident. Staff interviews and facility policy confirmed that only licensed staff should manage tube feeding pumps and connections, and nurse aides had not received the necessary training or competency checks.
Two residents with significant medical conditions were not educated on or offered pneumococcal and influenza vaccinations upon admission, and their immunization histories were not documented in the EMR as required by facility policy. Review of records and staff interviews confirmed that vaccination reconciliation and documentation steps were not completed for these individuals.
Two residents with complex medical conditions were admitted without documentation of COVID-19 vaccination status, and there was no evidence they were educated on or offered the vaccine as required by facility policy. A registered nurse confirmed that the necessary vaccination reconciliation and documentation were not completed for these residents.
Surveyors found that two residents did not have accessible or properly functioning bathroom call lights—one was missing a cord entirely, and another had a frayed cord. Maintenance confirmed these issues and acknowledged the safety concern, while facility policy required call lights to be within reach but did not address the condition of the cords.
A resident with chronic pain syndrome experienced unmanaged severe pain due to a delay in receiving prescribed pain medication. Despite multiple requests and communication to nursing staff, the resident waited five hours for pain relief, resulting in severe pain and disturbed sleep. The delay required the resident to take two doses of narcotic medication to manage the pain effectively.
A resident with multiple medical conditions fell from a mechanical lift due to improper use of a toileting sling, resulting in serious brain injuries. The nursing assistants involved had not received proper training on sling use, leading to the resident's arms being placed inside the sling and the waist buckle not being secured, causing the fall.
The facility failed to secure the medication storage area on the 400 hallway, leaving it open and unattended on multiple occasions. Staff interviews revealed confusion about responsibility for securing the area, with some believing the presence of a nearby nurse manager was sufficient. The ADON clarified that all medication storage doors should be locked when not attended by a licensed nurse, as per facility policy.
A facility failed to document a resident's contracture in the right hand upon admission and during subsequent assessments. The resident had diagnoses including bilateral lower extremity amputations and minimal cognitive impairment. Despite the resident stating the contracture had been present for over two years, it was not documented in the medical records. Staff interviews revealed the oversight, and the importance of accurate assessments was emphasized by the ADON.
The facility failed to accurately assess and care plan for two residents, leading to deficiencies in their care plans. One resident receiving hospice services was not documented as such in their care plan, while another resident, who was continent, was inaccurately documented as incontinent. These discrepancies were confirmed by nursing staff and highlighted the need for accurate assessments and care planning.
The facility failed to follow provider orders for weight monitoring for two residents with impaired cognition and multiple diagnoses. One resident's care plan did not address weight monitoring despite orders, and the other lacked specific orders, resulting in missing weight entries over several weeks. Staff interviews revealed lapses in the process, including reliance on nursing assistants to record weights and issues with documentation during staff absences.
A facility failed to document a rationale for extending a PRN psychotropic medication beyond 14 days for a resident with severe cognitive impairment and multiple diagnoses. The resident received Ativan for anxiety and hallucinations 14 times over two weeks without a specified end date. The assistant director of nursing confirmed that the order should have been reviewed in a monthly pharmacy meeting, but it lacked a documented rationale from the provider, as required by CMS guidelines.
The facility failed to implement enhanced barrier precautions (EBP) for residents with indwelling catheters and a chronic wound. A nursing assistant did not use PPE for a resident with a catheter, despite signage indicating EBP. Another resident with a catheter was not initially provided PPE during repositioning. Additionally, a resident with a stage 3 pressure ulcer lacked EBP, with staff uncertain about the requirement, despite facility policy indicating the need for such precautions.
The facility failed to post required nurse staffing data daily, including over the weekend, affecting all residents, staff, and visitors. The nurse staffing data was not updated for several days, with the responsibility for posting assigned to a scheduler who was absent. Interviews revealed that the data sheets were sometimes not posted on weekends, contrary to the facility's policy requiring daily updates.
Failure to Provide Required Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Maintain Safe Food and Beverage Temperatures
Penalty
Summary
Surveyors observed that the facility failed to monitor and maintain safe temperatures for food and beverages served to residents. On two consecutive days, a beverage cart containing milk, various juices, and ice water was positioned in the dining area without any ice or cooling device. The milk on the cart was measured at 44.5°F and 41.5°F on separate occasions, both above the facility's policy requirement of 40°F or below for cold food items. The dietary aide acknowledged that the milk was above the guideline for serving cold beverages and disposed of it each time after the temperature was checked. The facility's policy, as well as the FDA Food Code, require that milk and other temperature-controlled foods be maintained at or below 40°F and 41°F, respectively, to prevent food-borne illness. The director of nursing confirmed the expectation that food and beverages be served at proper temperatures. Temperature logs for fridges, freezers, and meals were requested by surveyors but were not provided by the facility.
Infection Control, Laundry Handling, and Water Management Deficiencies
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices in several key areas. For one resident with chronic kidney disease, vancomycin resistance, and congestive heart failure, an LPN collected a nasal swab specimen while the resident was under droplet precautions. The LPN placed the specimen tube on the medication cart, did not sanitize the cart surface before placing other residents' medication bottles on the same area, and was unclear about hand hygiene practices between tasks. The specimen remained on the cart for an extended period, and the infection prevention RN later confirmed that the medication cart was not an appropriate location for collected specimens and that surfaces should have been sanitized to prevent contamination. In the laundry area, staff did not follow proper procedures for handling soiled linens. Laundry personnel transported uncovered bins of dirty linen through the facility, wore the same gloves while collecting soiled items from multiple locations, and entered the clean laundry area with contaminated gloves. The staff did not consistently use required personal protective equipment such as gowns or face shields, and dirty laundry was brought through the clean side of the laundry area, contrary to facility policy. The policy required separation of clean and soiled linens, use of PPE, and specific handling procedures to reduce environmental contamination, but these were not followed during the observed process. The facility also lacked an active water management program as required by its own policy. Observations revealed that water features, such as a fishpond and a fountain, were present, but there was no consistent water testing or documentation of water system flow, mixing valves, or shut-off points. Maintenance staff were unable to provide complete records of water feature maintenance or testing, and the facility's water management map was incomplete, lacking necessary details about the water system. The policy required mapping and monitoring to prevent hazards such as Legionella, but these measures were not fully implemented.
Failure to Implement Antibiotic Stewardship Program and Perform Antibiotic Time-Outs
Penalty
Summary
The facility failed to maintain an active antibiotic stewardship program and did not perform antibiotic time-outs for three of five residents reviewed for antibiotic use. For one resident with severely impaired cognition and a diagnosis of Alzheimer's dementia, an order for azithromycin was initiated for an upper respiratory infection, but no antibiotic time-out was documented. Another resident with moderately impaired cognition and multiple diagnoses, including UTI and heart failure, received Macrobid for a suspected UTI, despite negative culture results and absence of UTI symptoms, without an antibiotic time-out recorded. A third resident with intact cognition and a history of UTI, heart disease, and diabetes was prescribed Levaquin for a UTI, but the medical record lacked documentation of an antibiotic time-out for this course of therapy. Interviews with nursing staff revealed inconsistent knowledge and application of infection criteria, such as McGeer's, and a lack of awareness regarding the facility's chosen criteria for infection assessment. The facility's infection control software relied on user input to trigger antibiotic time-outs, but this process was not consistently followed. The facility's policy required antibiotic reviews (time-outs) 48-72 hours after initiation, but these were not found in the records of the affected residents. Staff interviews confirmed the absence of required antibiotic time-outs and inconsistent posting and understanding of infection assessment criteria.
Failure to Provide Sufficient Nursing Staff Resulting in Missed Resident Care and Supervision
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in multiple deficiencies in care. Staff and family interviews, as well as direct observations, revealed that residents were left unattended for extended periods, did not receive timely assistance with activities of daily living (ADLs), and were not consistently offered toileting or position changes. For example, one resident was left in the same pajamas for several days, was not checked on after returning from the hospital, and did not receive assistance with toileting or morning care until prompted by family. Staff reported being responsible for up to 30 residents at a time, leading to delays in care, missed check and changes, and incomplete ADL support. Documentation showed that on several days, staffing levels were below the facility's own assessment and schedule, with shifts missing both licensed and nursing assistant hours. Specific residents experienced lapses in care, such as not receiving scheduled nail care, being left in soiled briefs for extended periods, and not being repositioned or toileted according to their care plans. One resident's brief was found to have the same staff initials from the previous day, indicating it had not been changed overnight, and staff confirmed that short staffing made it impossible to complete all required checks and changes. Another resident did not receive catheter care or morning hygiene due to staff being unable to complete all tasks, and care plans were found to be incomplete or missing essential information. Staff interviews confirmed that these lapses were directly related to inadequate staffing and high resident-to-staff ratios. Additional deficiencies included failure to respond to residents' food preferences and requests, as staff did not check for available food options or offer seconds, despite facility policy allowing for it. During medication administration, a resident was left unsupervised during a nebulizer treatment, contrary to care plan instructions, and was not assessed for self-administration. The nurse responsible stated she was too busy to remain with the resident or return promptly, and did not complete required post-treatment assessments. These events were corroborated by family and staff interviews, as well as direct observation, and were attributed to insufficient staffing and high workload.
Failure to Monitor Psychotropic Medication Use and Lapse in PRN Order Management
Penalty
Summary
The facility failed to ensure that residents receiving psychotropic medications were properly monitored and that as-needed (PRN) psychotropic medication orders included required end dates, as outlined in facility policy. For multiple residents, including those with severe cognitive impairment, Alzheimer's disease, depression, psychotic disorder, and other significant medical conditions, there was a lack of documented assessments for extrapyramidal symptoms (EPS) using the Abnormal Involuntary Movement Scale (AIMS) or similar tools, as well as missing orthostatic blood pressure monitoring. These assessments are necessary to monitor for side effects of antipsychotic medications, such as tardive dyskinesia and orthostatic hypotension, but records showed that these were not completed as required by policy and physician orders. Additionally, the facility did not ensure that PRN psychotropic medication orders, such as lorazepam, clonazepam, and buspirone, included stop dates or were limited to 14 days as required by the facility's psychotropic medication policy. In several cases, PRN orders remained active without an end date, and there was no documentation of physician evaluation or rationale for extending the orders beyond the policy limit. Interviews with nursing staff and the DON confirmed that these omissions were not in line with facility expectations and policy requirements. The deficiencies were identified through review of medical records, care plans, medication administration records, and staff interviews. The lack of required monitoring and documentation for residents prescribed antipsychotic and other psychotropic medications, as well as the absence of stop dates for PRN orders, constituted a failure to prevent unnecessary medication use and to monitor for adverse effects, as required by both facility policy and standard clinical practice.
Failure to Secure Medications and Maintain Safe Refrigeration Temperatures
Penalty
Summary
The facility failed to ensure that medications and biologicals in the medication room were securely stored and maintained at safe refrigeration temperatures. During an observation, it was found that some storage cupboards in the medication room were either not locked or lacked locks entirely, including cupboards containing stock medications and bins labeled for medication destruction. Additionally, the medication room was observed being left open and unattended by staff, contrary to facility policy requiring medication rooms to be locked when not in use. The medication refrigerator, which contained immunizations, GLP-1 injectables, insulin, and controlled medications, was found to be locked but had an internal temperature of 48 degrees Fahrenheit, exceeding the safe storage range. The temperature log for the fridge was incomplete, with several missed entries over multiple months. The facility's policy required that all compartments containing drugs and biologicals be locked when not in use and that medication refrigerator temperatures be maintained between 36 to 46 degrees Fahrenheit. Despite these requirements, the medication fridge was repeatedly found out of range, and temperature documentation was inconsistent. The consulting pharmacist later recommended destruction and replacement of several medications stored in the fridge due to the unsafe temperature. No residents were reported to have received medications from the affected fridge after the temperature deviation was discovered.
Failure to Provide Assistance with Activities of Daily Living for Multiple Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for four out of five residents reviewed, resulting in unmet care needs. One resident with dementia, heart failure, and macular degeneration required substantial to maximum assistance with ADLs and was at risk for pressure ulcers. Despite care plans specifying nail care and scheduled toileting, the resident was observed with dirty, untrimmed fingernails and left seated in the same position for over three hours without repositioning or being offered toileting. Staff interviews confirmed that toileting and repositioning were not consistently provided, and nail care was not documented or performed as required. Staff cited inadequate staffing as a barrier to providing timely care. Another resident, dependent on staff for all ADLs and always incontinent of bowel, was reportedly left in soiled briefs overnight and through multiple shifts, as evidenced by staff initials remaining on the brief from the previous day. Multiple nursing assistants reported being unable to complete regular check and changes due to chronic understaffing, particularly during evening shifts. The director of nursing confirmed that the expectation was for residents to be checked and changed every two hours, but this was not consistently achieved. Additional deficiencies were noted for two other residents. One resident with multiple medical conditions, including an indwelling catheter, did not receive morning hygiene or catheter care, and the care plan lacked documentation for ADL status and catheter care. Staff confirmed that due to time constraints, only minimal care was provided, and catheter care was omitted. Another resident requiring maximum assistance for personal hygiene and dressing did not receive scheduled bathing or shaving, with staff and the resident attributing the missed care to short staffing. Documentation of refusals and care provided was incomplete or missing.
Failure to Monitor and Intervene for Bowel Movements, Oxygen Saturation, and Skin Integrity
Penalty
Summary
The facility failed to provide appropriate treatment and care according to provider orders and resident needs for several residents. For one resident with multiple diagnoses including COPD, heart failure, and dementia, the facility did not track bowel movements or provide interventions when bowel movements were not recorded for several days, despite orders for bowel management and the resident's report of chronic constipation. Additionally, the care plan did not address oxygen or bowel management, and there was a lack of documentation regarding oxygen administration, including whether oxygen was used and at what liter flow, even though there was an order to monitor daily oxygen saturation and adjust oxygen to maintain saturation above 90%. Another resident with severe cognitive impairment and Parkinson's disease had provider orders for prune juice and PRN MiraLAX if no bowel movement occurred in 48 hours. However, bowel movements were infrequently recorded, and the medication administration records did not show that MiraLAX was administered as ordered, despite daily sign-offs indicating monitoring. Family members also reported ongoing issues with constipation for this resident, and staff interviews confirmed the expectation for bowel movement tracking and intervention, which was not consistently met. A third resident with livedoid vasculitis and moderate cognitive impairment had an order for weekly skin checks to be documented in the electronic health record. However, there was no evidence of completed skin assessments in the resident's record, despite facility policy and staff statements that weekly skin checks were expected. The resident was also known to refuse baths, which may have impacted the completion of skin checks, but the required documentation and monitoring were not present.
Failure to Provide Requested Second Helping of Food
Penalty
Summary
A deficiency occurred when a resident, identified as having heart disease, hypertension, hyperlipidemia, and being moderately cognitively intact, was not provided a requested second helping of food during a meal. The resident's care plan indicated a potential for altered nutrition and included interventions such as monitoring food and fluid intake and offering snacks. During meal service, the resident requested more watermelon, but a nursing assistant informed her that there was no more available without checking with the kitchen. The dietary aide later confirmed that there was additional watermelon available and that residents could have seconds if permitted by their diet. Staff interviews revealed inconsistent understanding of the policy regarding second servings, with the nursing assistant stating residents only receive one serving, while the LPN and RN indicated that seconds are allowed unless restricted by diet. The facility's policy emphasized treating residents with dignity and offering choices at mealtime, including what to eat. The failure to provide the requested second helping was attributed by one staff member to being rushed due to staffing issues, and the dietary manager was responsible for monitoring meal service for preferences and portion sizes.
Failure to Assess and Supervise Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that two residents did not self-administer medications (SAM) as assessed and according to their care plans. One resident with chronic obstructive pulmonary disease (COPD), mild cognitive impairment, and supraventricular tachycardia required partial to moderate assistance with activities of daily living and was not assessed to self-administer medications. Despite this, an LPN set up a nebulizer treatment for the resident and left the room, not returning for 34 minutes. During this time, the resident was observed repeatedly holding the nebulizer mouthpiece, with no staff supervision or assessment of respiratory status, oxygen saturation, or lung sounds as required by the medication order and care plan. Family members also reported that staff did not stay with the resident during treatments and noted instances where used nebulizer equipment was left unattended for hours. Another resident, admitted with a fracture, hyperthyroidism, and recent orthopedic surgery, was also not assessed for self-administration of medications. The care plan did not indicate the resident could self-administer, and there was no provider order for SAM. However, the resident was observed with a cup of medications left at the bedside by a nurse, and the resident stated the nurse had left them there. The medication administration record confirmed multiple medications were given that morning, but there was no documentation of a SAM assessment. Interviews with staff, including the LPN and DON, confirmed that neither resident had been assessed for self-administration of medications prior to being left alone with their treatments or medications. The facility's policy required a SAM assessment and interdisciplinary team review before allowing residents to self-administer medications, including evaluation of cognitive and physical status, medication appropriateness, storage, monitoring, and documentation. These procedures were not followed for the two residents involved.
Failure to Timely Update Care Plans After Significant Changes
Penalty
Summary
The facility failed to ensure timely review and revision of care plans for two residents following significant changes in their conditions and treatments. For one resident with a history of stroke, dysphagia, muscle weakness, and epilepsy, the care plan was not updated after a fall from a recliner, despite a post-fall assessment and identification of the root cause and new intervention. The care plan had last been revised prior to the fall, and staff confirmed that the necessary updates to fall prevention interventions were not made after the incident and interdisciplinary review. For another resident with multiple chronic conditions, including congestive heart failure, diabetes, chronic kidney disease, and severe depression, the care plan did not reflect recent medication changes, such as the initiation of new antidepressant and anticoagulant therapies. The care plan was last revised before these medication orders were implemented. Facility policy requires care plans to be updated on an ongoing basis as needed, especially following significant changes, but this was not done for either resident.
Untrained Nurse Aides Managed Tube Feeding, Breaching Facility Policy
Penalty
Summary
The facility failed to ensure that only competent, trained staff managed tube feeding pumps and tubing for a resident who was dependent on enteral nutrition. The resident, who had a history of stroke, dysphagia, muscle weakness, and epilepsy, was dependent for activities of daily living and received more than half of their nutrition through tube feeding. During morning care, two nurse aides (NAs) paused and disconnected the resident's tube feeding, leaving the uncapped end of the tubing hanging over the pole and later allowing it to touch the floor. One NA wiped the tubing with a tissue before reconnecting it to the resident and restarting the pump, despite not having received formal training on tube feeding management or pump operation. The NA expressed uncertainty about proper infection control procedures and indicated that nurses had only shown them how to pause the pump. Interviews with multiple staff members, including NAs, LPNs, an RN, and the DON, confirmed that NAs were not trained or authorized to operate tube feeding pumps or to connect/disconnect tube feeding tubing. Facility policy specified that only licensed staff should perform these tasks, and there was no record of NAs receiving education or competency checks related to tube feeding management. The deficiency was identified through observation, interview, and record review, demonstrating a lack of adherence to facility policy and proper staff training regarding tube feeding care.
Failure to Offer and Document Flu and Pneumonia Vaccinations Upon Admission
Penalty
Summary
The facility failed to ensure that residents were educated on and offered pneumococcal and influenza vaccinations upon admission, as required by policy. Specifically, one resident admitted prior to 3/31/25 with diagnoses including kidney failure, heart disease, and urinary tract infection did not have any documented vaccination history or evidence of being offered or educated about pneumococcal and influenza vaccines. Another resident admitted after 3/31/25 with a history of kidney transplant, chronic kidney disease, and immunodeficiency also lacked documentation of vaccination history or evidence of being offered or educated about pneumococcal vaccination. During interviews and document reviews, it was confirmed that the facility's process included vaccination reconciliation within 48 hours of admission and checking the Minnesota Immunization Information Connection (MIIC) for immunization history. However, for both residents, there was no vaccine data present in their records. The facility's policy required obtaining immunization history upon admission, sharing unknown or incomplete histories with the attending physician, and documenting this information in the electronic medical record, but these steps were not completed for the residents in question.
Failure to Educate and Offer COVID-19 Vaccination Upon Admission
Penalty
Summary
The facility failed to ensure that residents were educated on and offered COVID-19 vaccinations upon admission, as required by policy. Specifically, two residents with significant medical histories, including kidney failure, heart disease, urinary tract infection, status post-kidney transplant, chronic kidney disease, and immunodeficiency, were admitted without documentation of their COVID-19 vaccination status. Immunization Audit Reports for both residents did not identify any vaccination history, and there was no evidence that the required education or vaccine offer was provided at admission. During an interview, a registered nurse confirmed that vaccination reconciliation, including checking the Minnesota Immunization Information Connection (MIIC) and documenting immunization history, was part of the admission process. However, upon review, the nurse acknowledged that there was no vaccine data for the two residents in question. The facility's policy required that immunization history be obtained and documented in the electronic medical record, and that any unknown or incomplete vaccination histories be communicated to the attending physician for appropriate orders, which was not done in these cases.
Inaccessible and Damaged Bathroom Call Lights
Penalty
Summary
The facility failed to ensure that a working call system was available and accessible in each resident's bathroom and bathing area. Specifically, one resident's bathroom call light was found to be missing a cord, making it unusable from the bathroom floor, while another resident's bathroom call light cord was frayed and visibly damaged. Maintenance staff confirmed these issues, acknowledging that the missing and damaged cords posed a safety concern, as residents would be unable to call for help if needed. The facility's call light policy required staff to position call lights within reach and orient residents to their use, but did not address the condition or presence of call light cords.
Failure in Timely Pain Management for Resident
Penalty
Summary
The facility failed to provide appropriate pain management for a resident with chronic pain syndrome, leading to unmanaged severe pain and disturbed sleep. The resident, who was cognitively intact, had a care plan that included administering medications as ordered and using non-pharmacological interventions like applying cold or heat and repositioning. Despite having orders for hydrocodone-acetaminophen to be given as needed every six hours, the resident experienced a significant delay in receiving pain medication on a particular evening. On the evening in question, the resident activated the call light multiple times over several hours, requesting pain medication for severe flank pain. Nursing staff, including a nursing assistant and two LPNs, were informed of the resident's request, but the medication was not administered until five hours later. During this time, the resident reported escalating pain, describing it as feeling like someone was ripping his side open and rating it a 13/10 on the pain scale. The delay in administering the medication resulted in the resident needing two doses to manage the pain effectively. Interviews with staff revealed communication breakdowns and a lack of timely response to the resident's pain management needs. The nursing assistant informed one LPN of the resident's request, but did not follow up when the medication was not provided. Another LPN was also informed but did not ensure the medication was administered promptly. The director of nursing acknowledged that staff should follow provider orders and care plans when a resident requests assistance, highlighting the deficiency in pain management practices.
Removal Plan
- Facility investigation was coordinated with interviews of staff and residents on unit.
- Pain management policy was reviewed.
- Staff was educated on the pain management policy and expectations if a resident was in pain.
- Audits monitoring pain management practices started.
- LPN-A was provided education for pain management, resident rights, and customer service.
Improper Use of Toileting Sling Leads to Resident Injury
Penalty
Summary
The facility failed to safely use a toileting sling according to the manufacturer's recommendations, resulting in a resident falling from a mechanical lift and sustaining serious injuries, including subarachnoid and subdural brain bleeds. The resident, who had diagnoses of hemiplegia, abnormal involuntary movements, epilepsy, and a malignant neoplasm of the frontal lobe, required total assistance from two staff members for transfers using a mechanical lift with a medium toileting sling. On the day of the incident, a nursing assistant instructed the resident to place her arms inside the sling, contrary to proper procedure, and did not buckle the sling around the resident's waist. As a result, the resident fell from the sling during the transfer, hitting her head on the lift and the floor. The nursing assistants involved in the incident admitted to not having received proper training on the use of mechanical lifts and sling placements prior to the event. One of the nursing assistants acknowledged that she was aware the procedure was incorrect but did not intervene. The mechanical lift company representative confirmed that improper use of the sling, such as not buckling it or having the resident's arms inside, increased the risk of falling. The facility's medical director attributed the resident's injuries to the incorrect application of the toileting sling.
Removal Plan
- Reviewed policies on use of mechanical lifts, including proper placement and size of the slings.
- Re-assessed all residents who utilize a mechanical lift to ensure they have the proper size sling.
- Re-educated all staff who use the mechanical lift on the policy and procedure and did competency testing.
- Completed audits observing staff transferring residents with mechanical lifts results will then be brought to QAPI committee.
Unauthorized Access to Medication Storage Area
Penalty
Summary
The facility failed to ensure that unauthorized staff, visitors, and residents did not have access to the medication storage area, which had the potential to affect all residents on the 400 hallway. During observations, the medication storage area door was found open on multiple occasions without any staff present to monitor access. At 7:18 a.m. and 8:33 a.m. on 7/16/24, the door was open with no staff around, and the nurse manager was in her office with her back to the door. This lack of supervision allowed for potential unauthorized access to medications. Interviews with staff revealed a misunderstanding of responsibility regarding securing the medication storage area. RN-C confirmed the room was open and stated it was the responsibility of the nurse working the cart to secure the room. LPN-B admitted to leaving the door open while administering medications, believing the presence of the nurse manager nearby was sufficient security. However, the assistant director of nursing clarified that the expectation was for all medication storage area doors to remain shut and secured when not attended by a licensed nurse. The facility's policy, last reviewed on 4/11/23, required the medication room to be locked and the door closed at all times when unattended.
Failure to Document Resident's Contracture
Penalty
Summary
The facility failed to comprehensively assess and document a resident's contracture in the right hand upon admission and during subsequent assessments. The resident, identified as R8, was admitted with diagnoses including bilateral lower extremity amputations, anemia, and renal insufficiency, and was noted to have minimal cognitive impairment. The admission Minimal Data Set (MDS) and assessment indicated no functional limitations or impairments in the upper extremities, including the shoulder, elbow, wrist, or hand. However, during an observation, R8 was found to have a contracture in the right hand and fingers, which the resident stated had been present for over two years. Interviews with facility staff, including a registered nurse and the MDS coordinator, revealed that the contracture was not documented in R8's medical records at the time of admission. The registered nurse confirmed the presence of the contracture upon visiting R8's room, and the MDS coordinator acknowledged the lack of documentation regarding the contracture. The assistant director of nursing emphasized the importance of complete and accurate assessments to ensure the MDS is filled out correctly. The facility's policy on MDS 3.0 Assessment, last reviewed in October 2021, mandates comprehensive, accurate, and standardized assessments of each resident.
Inaccurate Care Plans for Hospice and Continence
Penalty
Summary
The facility failed to comprehensively assess and care plan services for two residents, leading to inaccuracies in their care plans. Resident R162, who was admitted on 7/3/24 with impaired cognition and diagnoses of lung and colon cancer, was receiving hospice services. However, the care plan dated 7/3/24 did not include a focus on hospice care and coordination, despite the resident being on hospice services since 2/1/24. This omission was confirmed by RN-A and acknowledged by the Director of Nursing, who stated that hospice care should have been included in the care plan for proper coordination of care. Resident R8, who had minimal cognitive impairment and was always continent of bowel and bladder, was inaccurately documented in the care plan dated 6/4/24 as being always incontinent of bowel. This discrepancy was noted despite the admission assessments and MDS indicating the resident's continence. RN-C acknowledged the error upon reviewing R8's medical record, and the Assistant Director of Nursing emphasized the importance of building care plans based on accurate assessments and resident needs. The facility's policy on Person Centered Care Planning, last reviewed on 4/20/23, mandates that care plans include accurate assessments of resident needs.
Failure to Follow Weight Monitoring Orders
Penalty
Summary
The facility failed to adhere to provider orders for weight monitoring for two residents, R42 and R33, who were under review for unnecessary medications. Resident R42, with impaired cognition and multiple diagnoses including Alzheimer's dementia and diabetes, had a care plan that did not address weight monitoring despite provider orders for weekly weights starting in May 2024. The electronic medical record showed no weight entries from late June to mid-July 2024. Interviews revealed that the nursing assistants were responsible for weighing residents and recording the data, which was then supposed to be entered into the electronic medical record by the nurse. However, there were lapses in this process, partly due to the dietician's absence on vacation and the resident's occasional refusal to be weighed. Resident R33, also with impaired cognition and diagnosed with diabetes and Parkinson's disease, had a care plan indicating weekly weight monitoring due to congestive heart failure. However, the provider orders lacked specific instructions for weights, and the electronic medical record showed missing weights for several weeks between April and July 2024. Interviews with staff confirmed that weights were supposed to be recorded weekly on the resident's bath day, but there were acknowledged gaps in documentation. The facility's Weight Monitoring Program policy required weekly weight tracking, which was not consistently followed, leading to the deficiency.
Failure to Document Rationale for Extended PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to document a rationale for the continuation of a PRN psychotropic medication beyond 14 days for a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease and dementia. The resident had a physician order for Ativan, a psychotropic medication, to be administered as needed for anxiety and hallucinations, with no specified end date. The medication was administered 14 times over a two-week period. During an interview, the assistant director of nursing acknowledged that the interdisciplinary team should have discussed the PRN order in their monthly pharmacy review meeting. The order lacked a documented rationale from the provider for its extended use, which is required by the State Operations Manual from the Centers for Medicare & Medicaid Services.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for residents with indwelling catheters and a chronic wound, as observed during a survey. One resident with an indwelling urinary catheter was not provided with the required personal protective equipment (PPE) by a nursing assistant during personal care activities, despite clear signage indicating the need for EBP. The nursing assistant admitted to not wearing a gown and gloves, acknowledging the importance of these precautions for infection control. Another resident with an indwelling urinary catheter also did not receive the necessary EBP during repositioning by a nursing assistant. Although PPE supplies were available outside the room, the nursing assistant initially failed to don a gown and gloves. It was only after observing another nursing assistant wearing PPE that the first assistant corrected her actions, confirming the requirement for PPE during such activities. Additionally, a resident with a stage 3 pressure ulcer did not have EBP implemented, as evidenced by the absence of signage and PPE outside the room. The registered nurse and assistant director of nursing were uncertain about the necessity of EBP for this resident, despite the facility's policy indicating that chronic wounds require such precautions. The assistant director confirmed the resident's pressure ulcer and the lack of EBP orders, acknowledging the oversight.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that required nurse staffing data was posted daily before each shift, including over the weekend, which had the potential to affect all 61 residents, staff, and visitors who wished to review this information. During an observation on 7/14/24, it was noted that the nurse staffing data posting was dated 7/11/24, indicating that the information had not been updated for several days. The administrator confirmed that the updated nurse staff data sheets were not posted at the beginning of the shifts on 7/12/24, 7/13/24, or 7/14/24. The responsibility for posting the data sheets was assigned to the scheduler, who was not present at the facility on those dates. Interviews revealed that the scheduler typically leaves completed nurse staff data sheets in the supervisors' book when not at the facility, with the expectation that the director or assistant director of nursing would post them on weekdays and the charge nurse on weekends. However, it was acknowledged by both the scheduler and the assistant director of nursing that the sheets were sometimes not posted on weekends, remaining in the supervisors' book until Monday mornings. The facility's policy, dated 12/18, requires daily posting of staffing levels for review by residents and families, which was not adhered to in this instance.
Latest citations in Minnesota
A resident with intact cognition and multiple diagnoses, including AFib, HF, stroke, anxiety, and depression, was permitted to self-administer nebulizer treatments after staff setup without an IDT self-administration assessment. The EMR lacked documentation of the resident’s competency and safety to manage the nebulizer, including understanding the medication, following directions, operating the equipment, recognizing side effects, and storing the medication and equipment. Staff and the DON confirmed the assessment had not been completed before the self-administration order was implemented.
Failure to Assess and Monitor Antipsychotic Use: A resident with severe cognitive impairment, dementia, anxiety, and mood disorder received Risperidone for agitation and paranoia, but the EMR did not show an AIMS assessment on admission or timely target behavior monitoring. The RN case manager and DON confirmed that baseline AIMS and ongoing behavior monitoring should have been in place when the antipsychotic was started, but the resident’s record lacked measurable target behaviors and documentation of medication effectiveness.
Incomplete Care Plans for Anticoagulant Therapy and Cardiac-Related Needs: The facility failed to include key diagnoses, devices, and medication-related risks in care plans for two residents. One resident’s plan did not address Eliquis use, cardiac conditions, pacemaker presence, or condom catheter care, and another resident’s plan did not address Eliquis therapy or related bleeding-risk monitoring. The DON and RN case manager confirmed these items should have been care planned.
Failure to provide scheduled bathing and grooming assistance: Two residents with intact cognition and ADL dependence did not receive bathing as documented on a weekly schedule, and one resident also had unaddressed facial hair and greasy, unkempt hair. Records did not show consistent weekly baths, additional refusals, or reasons for missed care, and staff interviews confirmed residents were expected to receive at least weekly bathing unless they refused and that facial hair should be shaved when noticed.
A resident with intact cognition and multiple diagnoses, including BPH and stroke, had a physician order for a condom catheter at bedtime, but the EMR lacked orders or instructions for cleaning, disinfecting, monitoring, or changing the drainage bag. During observation, the bag was seen hanging in the bathroom, and an LPN, RN case manager, and DON all confirmed the absence of documented guidance for the catheter drainage bag care.
Failure to preserve dignity occurred when staff placed a brief on a cognitively intact resident who was continent of bowel and bladder. The resident stated the brief made him feel like a baby, and a NA confirmed she applied it even though he was not incontinent; RN and DON both verified the resident was continent and that briefs should not be placed on continent residents.
Failure to provide restorative ambulation and respond to a decline in mobility: A resident with dementia, weakness, chronic pain, and limited physical mobility was care planned for daily ambulation with a FWW and staff assist of 1, but the rehab record repeatedly showed ambulation as not applicable and staff interviews confirmed the task was often not done. The resident stated she could no longer walk, staff reported she had not walked for weeks and now required a sit-to-stand lift with assist of 2 for transfers, and the chart lacked an ADL decline assessment or revision of the ambulation care plan.
A resident with mild cognitive impairment, hemiplegia, hemiparesis, and limited ROM had restorative orders for PROM, stretching, and hand splints, but staff did not consistently offer or complete the interventions. Documentation showed the splints were sometimes marked not applicable instead of refused, and leg stretches were completed only a few times with no explanation for missed care. Staff interviews confirmed the restorative tasks often were not done, and the DON stated the resident’s restorative program needed to be updated.
Dirty can opener and contaminated dry storage bins: The DCS observed four labeled dry-goods bins with dirty rims, dry matter on the bin walls, and a scoop left inside a flour bin with flour on it. The attached can opener also had dry red matter on the blade, and the cook said it had been used that morning to open cream of corn for lunch. The DCS verified the findings and stated the can opener should be washed after each use and the dry bins and scoops should be kept clean.
Dignified Medication Administration Not Maintained: A resident with severe dementia, hallucinations, anxiety, PTSD, and delusional disorder was observed during med pass in the dining room. An RN attempted to administer meds by pouring them from a plastic cup into the resident’s mouth, continued despite the resident pulling away and moving her head, and then raised her voice and questioned why the resident would not take the meds after one pill was spit out and thrown on the floor. The resident stated the nurse was not being nice, and the RN left with the refused meds.
Missing Self-Administration Assessment for Nebulizer Use
Penalty
Summary
The facility failed to ensure an interdisciplinary team (IDT) assessment was completed before allowing a resident to self-administer nebulizer treatments. The resident had intact cognition and required assistance with ADLs, and diagnoses included atrial fibrillation, heart failure, BPH, stroke, malnutrition, anxiety disorder, and depression. Physician orders showed Ipratropium-Albuterol nebulizer treatments three times daily, and the EMR later included an order permitting the resident to self-administer nebulizer treatments after staff setup, but there was no evidence that an IDT self-administration assessment had been completed first. The record also lacked documentation showing the resident’s competency and safety to self-administer the nebulizer medication and treatment, including the ability to understand the medication purpose, follow directions, safely operate the equipment, recognize side effects or adverse reactions, and ensure safe administration and storage. During observation, the resident had nebulizer equipment and medication available in the room. The resident stated staff set up the medication cup and left while the treatment ran, then returned to ensure the machine was turned off; staff cleaned the nebulizer mask afterward. An LPN and RN confirmed the treatment was set up by staff, and the RN and DON stated a self-administration assessment should have been completed before the resident was permitted to self-administer medications.
Failure to Assess and Monitor Antipsychotic Use
Penalty
Summary
The facility failed to ensure that a resident receiving psychotropic medications was adequately assessed and monitored. R3’s admission MDS identified severe cognitive impairment and the need for assistance with ADLs, with diagnoses including non-traumatic brain dysfunction, unspecified dementia without behavioral, psychological, mood, or anxiety disturbances, non-Alzheimer’s dementia, anxiety disorder, and mood affective disorder. The resident’s physician orders included Risperidone 0.25 mg, two tablets by mouth every four hours PRN for agitation and paranoia, with a maximum of three PRN doses in 24 hours, and Risperidone 0.5 mg, one tablet by mouth three times daily for paranoia/agitation. R3’s EMR did not show that an AIMS assessment was completed upon admission despite the resident receiving antipsychotic medication, and the assessment was only completed after surveyor request. The record also lacked evidence that target behavior monitoring had been initiated for the antipsychotic use, with no measurable target behaviors documented, including frequency, duration, severity, precipitating factors, or response to interventions for agitation and paranoia. Interviews with the RN case manager and DON confirmed that AIMS assessment and behavior monitoring should have been completed upon admission or initiation of antipsychotic medications, and both acknowledged that target behavior monitoring had not been initiated.
Incomplete Care Plans for Anticoagulant Therapy and Cardiac-Related Needs
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents with significant medical conditions and medication-related needs. One resident had intact cognition and diagnoses including atrial fibrillation, heart failure, BPH, stroke, malnutrition, anxiety disorder, depression, and a cardiac pacemaker, and was receiving Eliquis. The resident also had a physician order for a condom catheter at bedtime and removal when getting up for the day. The comprehensive care plan printed 5/20/26 did not identify interventions or monitoring related to anticoagulant use, including bleeding risk, adverse effect monitoring, or staff awareness of anticoagulant precautions, and it also lacked interventions related to the resident’s cardiac conditions, pacemaker, and condom catheter use, including skin integrity monitoring and resident-specific catheter care preferences. A second resident with severe cognitive impairment and diagnoses including non-traumatic brain dysfunction, unspecified dementia, non-Alzheimer’s dementia, anxiety disorder, and mood affective disorder was also receiving Eliquis. The resident’s comprehensive care plan printed 5/19/26 did not include anticoagulant therapy, bleeding risk precautions, monitoring for adverse effects, or other interventions related to anticoagulant medication use. During interviews, the RN case manager and DON confirmed that anticoagulant therapy, the condom catheter, cardiac conditions, and pacemaker presence should have been addressed on the care plans and acknowledged that these items were not included.
Failure to Provide Scheduled Bathing and Grooming Assistance
Penalty
Summary
The facility failed to ensure that two residents who required assistance with activities of daily living received routine bathing and grooming services needed to maintain personal hygiene and dignity. R2’s MDS identified intact cognition and a need for ADL assistance, and the care plan directed staff to assist with dressing, grooming, bathing, and oral care while honoring personal hygiene preferences. R21’s MDS also identified intact cognition and a need for ADL assistance, and the care plan directed staff to assist with dressing, grooming, bathing, and oral care. R2’s bathing record showed a weekly bathing schedule, but the documentation did not show bathing was completed every week as scheduled. Baths were documented on several dates, but the time between some baths exceeded one week, and the record did not show additional refusals or reasons why scheduled baths were missed. During observation, R2’s hair was messy and greasy, and long white chin hairs were present. R2 stated she did not get baths very often because the facility was short staffed and said she did not have access to tweezers, a shaver, or a mirror. The EMR did not document that grooming assistance had been offered or provided for facial hair care. R21’s bathing record also showed a weekly bathing schedule, but the documentation did not show bathing was completed every week as scheduled. The record showed one refusal and several baths, but some intervals between baths exceeded one week, and there was no documentation of additional refusals or reasons for missed baths. R21 stated she had been in the facility since mid-April and had yet to have a bath or shower, and said staff were waiting for physician approval because of wounds, though that had been a while. R21 also stated she had only had her hair washed once with a shampoo shower cap while in bed. Staff interviews confirmed residents were expected to receive at least one bath weekly unless they refused, refusals should be documented, and facial hair should be addressed when noticed.
Missing Orders and Documentation for Condom Catheter Drainage Bag Care
Penalty
Summary
The facility failed to ensure appropriate care and services were provided for management of a resident’s external urinary catheter system. The resident had intact cognition and required assistance with ADLs, and diagnoses included atrial fibrillation, heart failure, BPH, stroke, malnutrition, anxiety disorder, and depression. Physician orders dated 4/29/26 indicated use of a condom catheter at bedtime, but the electronic medical record did not contain physician orders or documented instructions for cleaning, disinfecting, monitoring, or routinely changing the associated catheter drainage bag. During observation on 5/19/26 at 11:57 a.m., the resident’s catheter drainage bag was seen hanging on the side rail in the bathroom. Record review and observation did not identify documentation that the drainage bag was routinely cleaned, disinfected, monitored, or replaced according to accepted standards of practice. An LPN confirmed there were no physician orders addressing when the drainage bag should be changed or instructions for cleaning or disinfecting it. An RN case manager stated the drainage bag should have been changed weekly, but no orders related to changing, cleaning, or disinfecting were present. The DON stated the facility expected clear physician orders and nursing instructions for catheter care, cleaning, monitoring, and replacement schedules, and confirmed the facility could not provide evidence that such orders or guidance were in place for the resident’s condom catheter drainage bag care.
Failure to Preserve Dignity by Placing a Brief on a Continent Resident
Penalty
Summary
The facility failed to provide services in a dignified manner for 1 resident who was cognitively intact and had diagnoses including renal insufficiency, DM, and hypertension. The resident’s MDS identified him as continent of bowel and bladder and needing staff assistance with ADLs including bed mobility, transfers, and toileting. A bowel and bladder assessment also identified the resident as continent, and the care plan stated he was aware of the need to void or defecate and would request to use the toilet as needed. During interview, the resident stated staff put diapers on him even though he was not incontinent and said it made him feel like a baby. During observation, a NA placed a brief on the resident, and the resident showed the surveyor the brief and stated it had just been put on him a few minutes earlier. The NA verified she placed a brief on the resident that morning even though he was not incontinent and said she was unsure why she did so. RN-A confirmed the resident was continent and stated staff put a brief on him out of habit. The DON stated staff should not place a brief on residents who are continent and that it was important to maintain the resident’s dignity.
Failure to Provide Restorative Ambulation and Address Decline in Mobility
Penalty
Summary
The facility failed to provide restorative ambulation services and failed to respond to a decline in ambulation status for one resident who had mild cognitive impairment, dementia, hypertension, diabetes, weakness, and chronic pain. The resident’s care plan and restorative documentation directed daily ambulation with a front wheeled walker and staff assistance of one, and the resident was also identified as having limited physical mobility and being at risk for falls due to weakness, chronic pain, and an unsteadied gait and balance. However, the nursing rehab point-of-care record repeatedly documented ambulation as “not applicable,” with only one entry showing the resident ambulated for 15 minutes and one entry showing refusal. The resident stated she could no longer walk and that staff needed to help her get into bed and her wheelchair. Staff interviews confirmed the ambulation task was not being completed. A nursing assistant stated aides were responsible for ambulation but were not completing it, and another nursing assistant stated ambulation was supposed to be done but was not done very often; that staff documented it as not applicable when it did not get done; and that the resident had not walked at all for several weeks and was using a sit-to-stand lift with assist of two for all transfers. An RN stated the task just did not get done and that no plan had been created to fix it. The DON stated the resident’s condition had changed and a therapy evaluation should have been requested, and also stated the care plan needed revision because the resident would not be transferred with an assist of one. The resident’s medical record lacked an assessment for ADL decline, including any revision to the ambulation care plan.
Failure to Complete and Document Restorative ROM and Splinting
Penalty
Summary
The facility failed to ensure range of motion (ROM) was completed in accordance with therapy recommendations to maintain mobility for one resident with mild cognitive impairment who was dependent on staff for all care areas and had diagnoses including diabetes, hemiplegia, and hemiparesis. The resident’s care plan identified limited physical mobility, fall risk, weakness, contractures, and limited ROM, and included restorative nursing interventions for bilateral lower extremity passive ROM to active ROM, passive hamstring and heel cord stretches, PROM to both hands, and splint use for the hands. The resident’s restorative documentation from 4/20/26 through 5/19/26 showed the hand splints were worn 41 times and marked not applicable 20 times out of 90 opportunities, but the documentation did not identify refusals to wear the splints. The leg stretches were completed 3 times out of 30 opportunities, and the documentation did not identify why the stretches were not performed or whether they were refused. The resident’s untitled nurse aide care sheet also identified a restorative program and encouragement to participate in the Well Fit program. During interviews, a nursing assistant stated staff were supposed to encourage participation in the Well Fit program and complete PROM and AROM, but it did not get done very often and was often documented as not applicable because it was not offered. An RN stated nursing assistants were responsible for restorative programs but they did not get done, and no plan had been created to fix the issue. The DON stated staff should have offered the tasks and documented refusals, but believed staff may have stopped offering after repeated refusals; the DON also stated the restorative program needed to be updated and that staff were documenting tasks as not applicable, which she was unaware of.
Dirty can opener and contaminated dry storage bins
Penalty
Summary
The facility failed to keep 1 of 1 commercial can opener clean and sanitary and failed to store dry goods removed from original packaging in a manner that reduced the risk of cross-contamination. During an initial tour with the Director of Culinary Services (DCS), four white plastic bins in the food preparation area were observed on the floor and labeled for flour, white sugar, rice, and powdered sugar. The flour bin was about one-third full and had a black scoop partially covered with flour, including the handle. The bin labeled white sugar had yellowish-tan dry matter on the right lateral wall, and the front wall had red dry matter measuring 6-7 cm in diameter. The rims around the lids of all four bins were dirty with dark dust-like particles, and the DCS verified these findings and stated the scoop should not be left inside the bins and needed to be clean inside and out. The attached [NAME] brand can opener was also observed with its blade halfway covered with dry, red-colored matter. On a later kitchen tour, the can opener blade still had dry red matter, which had been pushed upward by 0.2 cm, and a small light amber particle was noted below it. The cook stated he had used the can opener that morning to open a can of cream of corn used for lunch. The DCS verified the dry matter on the can opener and stated it should be washed every time it was used to prevent cross contamination. Facility policy stated dry storage areas would be maintained to keep food safe and free of infestation or contamination, and the sample cleaning schedule stated can openers should be clean after each use.
Dignified Medication Administration Not Maintained
Penalty
Summary
The facility failed to provide a dignified experience for 1 of 2 residents, R20, during medication administration. R20’s records showed severely impaired cognition, inattention, disorganized thinking, verbal behaviors toward others, and diagnoses including severe dementia with psychotic disturbance, visual hallucinations, generalized anxiety disorder, PTSD, and delusional disorder. Her care plan identified mood, behavior, and sleep alterations related to Alzheimer’s disease, dementia, generalized anxiety disorder, paranoia, public outbursts, and accusations that people were throwing medications down her throat, and it directed staff to redirect and reapproach when she was resistive or combative, use a calm approach, provide reassurance, and offer comfort items. During observation, RN-A brought medications to R20 in the dining room and attempted to pour them from a small plastic cup into her mouth. When R20 removed one medication, Divalproex, and threw it on the floor, RN-A attempted again to pour the remaining medications into her mouth while R20 moved her head back and forth and tried to pull away. RN-A then raised her voice, stated the resident’s name, told her she needed to take her medications, pulled her chair back from the table, picked up the Divalproex from the floor, placed it in a separate cup, and asked why she would not take her medications. R20 responded that it was because the nurse was not being nice. RN-A then left with the remaining refused medications and stated R20 would take them later and that she always had a behavior when taking her morning medications.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
